Transthoracic Echocardiography for Detecting Adverse Cardiovascular Events in Patients With Chest Pain

Transthoracic echocardiography (TTE) is often performed among emergency department (ED) patients with chest pain to identify potential pathology. However, prior studies evaluating TTE in this population are limited. This study aims to evaluate the diagnostic performance of TTE for detecting major adverse cardiovascular events (MACE) in ED patients with chest pain.

We conducted a multisite observational cohort study of patients ≥18 years old without STEMI who presented to 5 U.S. EDs with chest pain (08/2020-08/2023). TTEs were performed by ED clinicians and reviewed by fellowship-trained ultrasonographers for clinically significant abnormalities, defined as focal wall motion abnormality (FWMA), dilated right ventricle, McConnell’s Sign, septal bowing, dilated aortic root, and pericardial effusion. The primary outcome was index MACE (composite of myocardial infarction [MI], pulmonary embolism [PE], aortic dissection [AD], cardiac tamponade [CT], or death), as determined by electronic health record data. Diagnostic yield was calculated based on the proportion of patients receiving TTE who had an abnormality. Number needed to test (NNT) was determined by the proportion of patients receiving TTE who had a true positive test for MACE. Negative and positive predictive values (NPV and PPV) as well as likelihood ratios (-LR and +LR) of TTE for MACE were calculated with 95% confidence intervals.

Among 1,025 patients with chest pain, 54.2% (556/1,025) were men, 55.1% (565/1,025) were White, and the median age was 55 years (IQR 40-68). During the index visit, MACE occurred 15.8% (162/1,025), with 120 MIs, 35 PEs, 2 ADs, 1 CT, and 8 deaths. The diagnostic yield of TTE was 16.0%, with 164/1,025 patients having at least one significant abnormality. Abnormalities included 43 FWMAs, 48 dilated right ventricles, 20 bowed septums, 6 McConnell’s Signs, 17 dilated aortic roots, and 72 pericardial effusions, with some patients having more than one finding. Among patients with an abnormal TTE, the true positive rate for MACE was 28.4% (46/162). This corresponds to an NNT of 22. The NPV and -LR of TTE for MACE were 28.0% (95%CI 21.3-35.6%) and 0.48 (95%CI 0.36-0.65). TTE had a PPV of 86.5% (95%CI 84.1-88.7%) and +LR 1.21 (95%CI 1.09-1.33) for MACE.

TTE had low diagnostic yield and poor -LR for MACE. These findings do not support bedside TTE for the evaluation of MACE in ED patients with chest pain.