Ischaemic heart disease: acute coronary syndrome

Transthoracic echocardiography (TTE) is a non-invasive and accessible tool that should be widely used in the evaluation of patients with suspected or known acute coronary syndrome (ACS). Its role is crucial in the management of patients with suspected ACS without electrocardiographic changes or elevation of cardiac markers, allowing the formulation of differential diagnosis between cardiac and extracardiac aetiologies. If the ACS is confirmed, initial assessment of regional and global left and right ventricle contractile function is fundamental in establishing the management strategy and may help in the risk stratification of these patients. TTE can also characterize the ischaemic myocardium in the acute phase, exposing any myocardial regional wall motion abnormalities. Furthermore, TTE is an excellent tool for the initial assessment of the aetiology of cardiogenic shock. It provides additional information regarding the haemodynamic status of the patient, including filling pressures and stroke volume, and it may rule out other causes of shock; thus, immediate TTE, or transoesophageal echocardiography if necessary, should be performed when cardiogenic shock is suspected. In the chronic phase, TTE plays an important role in characterizing myocardial infarction scar and its extent. TTE can accurately differentiate viable myocardium from scar tissue, and may guide revascularization if needed, improving patient care.