Skip to main content

01.12.2018 | Letter | Ausgabe 1/2018 Open Access

Critical Care 1/2018

Letter on “Pre-hospital transthoracic echocardiography for early identification of non-ST-elevation myocardial infarction in patients with acute coronary syndrome”

Critical Care > Ausgabe 1/2018
Guido Tavazzi, Aleksandar N Neskovic, Bogdan A Popescu, Gabriele Via
Wichtige Hinweise
Acute coronary syndrome
Focus cardiac ultrasound
Myocardial infarction
Non-ST-elevation acute coronary syndrome
Non-ST-segment myocardial infarction
Regional wall motion abnormality
Transthoracic echocardiography
We read with interest the manuscript by Bergmann et al. [ 1] but believe it is fraught by several conceptual and methodological flaws, the main ones being:
  • The authors used interchangeably the terms “transthoracic echocardiography”, “focus echocardiography”, and “focus cardiac ultrasound”(FoCUS) without the clear distinction required by the potential major clinical implications [ 2]; the screening for regional wall motion abnormalities (RWMA) is in fact clearly considered by international consensus beyond the scope of the limited training and application that FoCUS entails [ 3, 4], and the level of echocardiographic education/competence of emergency physicians was not detailed.
  • The authors state: “A diagnosis of NSTEMI was based on the combination of ACS symptoms, lack of ST-segment elevation, and RWMA. Myocardial infarction was excluded in the absence of the latter.” Non-transmural infarctions compromising a small amount of necrotic myocardium may not be detectable on 2D-echo. It has been shown that RWMA detectable by echocardiography occur if resting coronary flow is reduced by > 50%, if > 20% of myocardial thickness is jeopardized by actual ischemia/necrosis, or if at least 1–6% of the left ventricle mass is involved [ 5].
  • Previous myocardial infarction is indicated as an exclusion criterion. But a screening for myocardial scars or signs of pre-existing left ventricle disease was omitted from the exam, and a subsequent re-reading of the images by a blinded expert was omitted too, which may have led to potential false positives in non-ST-segment myocardial infarction (NSTEMI) diagnosis.
It remains obscure how the authors can conclude that “No evidence of myocardial infarction was found in any patient with NSTE-ACS without RWMA in the pre-hospital TTE” and later state that NSTEMI was conclusively diagnosed in two patients without RWMA [ 1]. We agree, as recommendations do [ 2], that pre-hospital ultrasound has the potential to lead to earlier diagnosis and faster treatment in acute cardiac patients. But, based on questionable methodology and unclear data, this study conveys the equivocal message that FoCUS has sufficient diagnostic accuracy for NSTEMI.

Availability of data and materials

Data sharing is not applicable to this article as no datasets were generated or analyzed during the current study.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://​creativecommons.​org/​licenses/​by/​4.​0/​), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://​creativecommons.​org/​publicdomain/​zero/​1.​0/​) applies to the data made available in this article, unless otherwise stated.
Über diesen Artikel

Weitere Artikel der Ausgabe 1/2018

Critical Care 1/2018 Zur Ausgabe

Neu im Fachgebiet AINS

Mail Icon II Newsletter

Bestellen Sie unseren kostenlosen Newsletter Update AINS und bleiben Sie gut informiert – ganz bequem per eMail.