UOTW #36 Answer

Answer: Regional Wall Motion Abnormality due to LAD occlusion

Bedside echo performed identified global hypokinesis, with wall motion abnormalities worse in the septal and apical segments.  Thoracic ultrasound shows bilateral b-lines consistent with pulmonary edema.  These findings were confirmed by an complete echocardiography performed by the cardiology department a few hours later.  

An EKG was then performed that showed diffuse anterior-lateral STEMI with depressions in the inferior leads, with a troponin of 12.3.

The patient was then taken emergently to cath lab and found to have a 100% osital LAD lesion that was successfully stented with some difficulty.

• Ostial lesions are defined as arising within 3 mm of the vessel origin. These lesions have the reputation of being associated with lower successful PCI and higher complication rates when compared to non-ostial lesions.¹
• Various views can be used to identify regional wall motion abnormalities (RWMA), which can be seen as hypokinesis in relation to adjacent walls.
• When evaluating the heart for RWMA, it has been recommended to divide the heart into 17 segments for assessment of the myocardium and the left ventricular cavity², however a more simplified method may be more ideal of the point-of-care evaluation of a patient with suspected RWMA.
• A more simplified method has been suggested by Lang et al² which focuses on identification of the distribution of the right coronary artery (RCA), left anterior descending artery (LAD) and the circumflex artery (CX).

• Emergency physicians can be trained to identify these lesions with good accuracy. A study by Kerwin et al found that after a brief, 30 minute training module, median percentages correct improved from 67% to 87% when reviewing pre-recorded clips.³

1. Jokhi P, Curzen N. Percutaneous coronary intervention of ostial lesions. EuroIntervention. 2009;5:(4)511-4. [pubmed]
2. Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr. 2005;18:(12)1440-63. [pubmed]
3. Kerwin C, Tommaso L, Kulstad E. A brief training module improves recognition of echocardiographic wall-motion abnormalities by emergency medicine physicians. Emerg Med Int. 2011;2011:483242. [pubmed]