Two-Dimensional Strain for Diagnosing Chest Pain in the Emergency Room (2DSPER): A Multicenter Prospective Study by the Israeli Echo Research Group

Avinoam Shiran ^1,2 David S. Blondheim ^2,3 Sara Shimoni ⁴ Mohamed Jabaren ⁵ David Rosenmann ⁶ Zvi Friedman ^2,12 Lilach Tamir Vanuk ¹² Alex Sagie ⁷ David Leibowitz ⁸ Marina Leitman ⁹ Micha Feinberg ¹⁰ Ronen Beeri ¹¹ Noah Liel-Cohen ¹³

¹Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel
²Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
³Cardiology, Hillel-Yaffe Medical Center, Hadera, Israel
⁴Cardiology, Kaplan Medical Center, Rehovot, Israel
⁵Cardiology, HaEemek Medical Center, Afula, Israel
⁶Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
⁷Cardiology, Rabin Medical Center, Petah Tikva, Israel
⁸Cardiology, Hadassah Har Hazofim Medical Center, Jerusalem, Israel
⁹Cardiology, Assaf Harofeh Medical Center, Zerifin, Israel
¹⁰Cardiology, Sheba Medical Center, Tel Hashomer, Israel
¹¹Cardiology, Hadassah Medical Center, Ein Kerem, Israel
¹²Ultrasound, GE Healthcare, Tirat Carmel, Israel
¹³Cardiology, Soroka Medical Center, Beer Sheva, Israel

Background: Echocardiographic two-dimensional left ventricular (LV) longitudinal strain (2DS) analysis has been suggested as a useful tool for detection of acute coronary syndromes (ACS). Our aim was to determine whether 2DS analysis could accurately rule out ACS in the emergency room (ER).

Methods: We prospectively enrolled 700 patients from 11 Israeli hospitals presenting to the ER with chest pain (CP) and suspected ACS but without diagnostic ECG or troponin elevation. An echocardiogram was performed within 24 hours of CP. Following a standard in-hospital evaluation a final diagnosis of ACS or no-ACS was made, and patients were followed for 6 months for MACE. 2DS analysis was performed in a core lab using EchoPac software. Histograms of peak LV systolic strain (PSS) were generated and the value identifying the 20% worst strain values (PSS20%) was determined. A pre-specified value of > -17% PSS20% was used to diagnose ACS.

Results: 2DS analysis was available for 606 patients (mean age 58±9 y, 70% males), of which 74 (12.2%) had ACS. Coronary anatomy was available in 67 (91%) patients with ACS and 95 (17.9%) patients without ACS. During follow-up (93% complete) MACE occurred in 4 (6%) patients with and in 4 (0.8%) without ACS. Abnormal 2DS was present in 60 patients with ACS (sensitivity 81%, negative predictive value 91%), but also in 392 patients without ACS (specificity 26%, positive predictive value 13%). Based on 2DS analysis alone, only 140 patients (23%) could have been safely discharged from the ER whereas 14 patients (2.3%) with ACS would have been missed and 392 (65%) would have had an unnecessary work-up.

Conclusions: In this large multicenter prospective study 2DS was not a useful tool to rule out ACS in the ER due to a high false positive rate.

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