Evaluating the Accuracy of Longitudinal Strain from Poor-Quality Echocardiograms in Identifying STEMI Culprit Vessels

PurposeLongitudinal strain is a valuable echocardiographic marker, yet its reliability in poor-quality images remains uncertain. Poor image quality is common in ST-segment elevation myocardial infarction (STEMI) patients, raising concerns about the utility of strain analysis in such cases. This study evaluated the accuracy of longitudinal strain in predicting the culprit vessel in STEMI patients with suboptimal echocardiographic imaging. MethodsA retrospective analysis of 50 consecutive STEMI patients was performed using echocardiograms acquired during index hospitalizations. Studies with discernable basal insertion points and apical caps were included, despite limited visualization of other segments. Longitudinal strain was quantified using the 4AS parameter, derived with TomTec LV AutoStrain software, and compared against clinical interpretations performed without strain analysis. Culprit vessel identification by strain and clinical interpretation was validated against coronary angiography findings. ResultsThe 4AS parameter correctly identified the culprit vessel in 48 of 50 cases (96%), significantly outperforming routine clinical interpretation, which was correct in 35 cases (70%; p = 0.0022). Strain performance was robust across varying image quality levels and coronary territories. ConclusionsLongitudinal strain, as measured by 4AS, accurately identified STEMI culprit vessels despite poor echocardiographic image quality, surpassing standard clinical interpretations. These findings suggest that strain analysis retains diagnostic utility even with low-quality images, supporting its integration into routine workflows for acute cardiac care.