Hand-carried cardiac ultrasound as a tool to screen for important cardiovascular disease in an underserved minority health care clinic

Point-of-care ultrasound to assess left ventricular ejection fraction in heart failure in unselected patients in primary care: a systematic review

BACKGROUND

Heart failure (HF) is the most frequent cardiovascular pathology in primary care. Echocardiography is the gold standard for diagnosis, follow-up, and prognosis of HF. Point-of-care ultrasound (POCUS) is of growing interest in daily practice.

AIM

This study aimed to systematically review the literature to evaluate left ventricular ejection fraction (LVEF) assessment of unselected patients in primary care by non-expert physicians with cardiac POCUS (cPOCUS).

METHODS

We searched in Medline, Embase, and Pubmed up to January 2024 for interventional and non-interventional studies assessing LVEF with cPOCUS in unselected patients with suspected or diagnosed HF in hospital or outpatient settings, performed by non-expert physicians.

RESULTS

Forty-two studies were included, involving 6598 patients, of whom 60.2% were outpatients. LVEF was assessed by 351 non-expert physicians after an initial ultrasound training course. The LVEF was mainly assessed by visual estimation (90.2%). The most frequent views were parasternal long/short axis, and apical 4-chamber. The median time of cPOCUS was 8 minutes. A strong agreement was found (κ = 0.72 [0.63; 0.83]) compared to experts when using different types of ultrasound devices (hand-held and standard), and agreement was excellent (κ = 0.84 [0.71; 0.89]) with the same device. Training course combined a median of 4.5 hours for theory and 25 cPOCUS for practice.

CONCLUSION

The use of cPOCUS by non-expert physicians after a short training course appears to be an accurate complementary tool for LVEF assessment in daily practice. Its diffusion in primary care could optimize patient management, without replacing specialist assessment.

Point-of-Care Ultrasound in Detection, Severity and Mechanism of Significant Valvular Heart Disease and Clinical Management

BACKGROUND

Early diagnosis of significant valvular heart disease (VHD) enables appropriate implementation of the best therapeutic strategy and follow-up. Cardiac auscultation remains suboptimal in early detection of VHD. The aim of this study was to evaluate the utility of point-of-care ultrasound (POCUS) for early detection of VHD and its severity.

METHODS

All consecutive patients with VHD who did not have a standard echocardiogram prior to first outpatient cardiology consultation underwent history and physical examination followed by POCUS study by an experienced physician in a general cardiology clinic from June 2017 to August 2022 at our institution. Subsequent standard transthoracic echocardiography (sTTE) was performed as the gold standard. Comparison was performed between POCUS and sTTE for the presence and severity of VHD. sTTE was performed by registered cardiac sonographers and interpreted by another cardiologist blinded to the POCUS results.

RESULTS

A total of 77 patients were studied (ge 72 ± 11 years, 58.4% males). A total of 89 significant valvular abnormalities were diagnosed. There were 39 (43.8%) cases of regurgitant VHD, 16 (18.0%) of stenotic VHD and 34 (38.2%) had evaluation for prosthetic valve function. The sensitivity (90.9%; 82.4%; 83.3%; 100%) and specificity (100%; 96.7%; 100%; 100%) were high for detecting ≥ moderate aortic regurgitation (AR), mitral regurgitation (MR), aortic stenosis (AS) and prosthetic valvular abnormality, respectively. The weighted κ coefficient between POCUS and sTTE for the assessment of ≥ moderate MR, AR and AS was 0.81 (95% CI, 0.65-0.97), 0.94 (95% CI, 0.84-1.00) and 0.88 (95% CI, 0.76-1.0), respectively, indicating excellent agreement.

CONCLUSIONS

POCUS can identify patients with significant VHD and may serve as a powerful screening tool for early detection of significant VHD in the outpatient clinical practice with downstream impact on clinical management of significant VHD.

Effects of a focused training on first-year osteopathic medical students' ability to incorporate point-of-care ultrasound in assessment of the anterior knee

CONTEXT

Patients frequently present to the outpatient clinic, urgent care, or emergency department with a painful, swollen knee. Differentiating the underlying etiology can be a challenge for both medical students and seasoned clinicians alike. Because this scenario can represent a time-sensitive emergency, developing skills to diagnose the underlying cause quickly and accurately is essential for proper management, whether the patient would benefit from osteopathic manipulation, prompt administration of antibiotics, or a more invasive procedure like joint aspiration or surgery.

OBJECTIVES

The objectives are to determine the effects of a focused ultrasound training on first-year osteopathic medical students' ability to identify normal sonographic anatomy of the anterior knee and to differentiate between three common pathologies: joint effusion, prepatellar bursitis, and cellulitis.

METHODS

First-year osteopathic medical students voluntarily participated in this cross-sectional study. The study protocol included a focused ultrasound training (online materials, brief didactic and single hands-on sessions) followed by a hands-on assessment. A written test and 5-point Likert scale questionnaire were administered before and after the focused training. Nine weeks later, students completed a follow-up written test. The proportion of students who correctly identified common pathologies on written tests before (pretest) and after (posttest) training and on the follow-up written test were compared utilizing the Fisher's exact test. A t test was utilized to compare data from the pretraining and posttraining questionnaires.

RESULTS

Of 101 students completing the written pretest and pretraining questionnaire, 95 (94.1 %) completed the written posttest and posttraining questionnaire, and 84 (83.2 %) completed the follow-up written test. Students had limited previous experience with ultrasound; 90 (89.1 %) students had performed six or fewer ultrasound examinations before the focused ultrasound training. On written tests, students accurately identified joint effusion (22.8 % [23/101] pretest, 65.3 % [62/95] posttest, 33.3 % [28/84] follow-up test), prepatellar bursitis (14.9 % [15/101] pretest, 46.3 % [44/95] posttest, 36.9 % [31/84] follow-up test), and cellulitis (38.6 % [39/101] pretest, 90.5 % [86/95] posttest, 73.8 % [62/84] follow-up test). Differences were found between pretest and posttest for identification of all three pathologies (all p<0.001) and between the pretest and 9-week follow-up test for identification of prepatellar bursitis and cellulitis (both p≤0.001). For questionnaires, (where 1=strongly agree, 5=strongly disagree), the mean (standard deviation [SD]) confidence for correctly identifying normal sonographic anatomy of the anterior knee was 3.50 (1.01) at pretraining and 1.59 (0.72) at posttraining. Student confidence in the ability to differentiate joint effusion, prepatellar bursitis, and cellulitis utilizing ultrasound increased from 4.33 (0.78) at pretraining to 1.99 (0.78) at posttraining. For the hands-on assessment, 78.3 % (595 correct/760 aggregated responses) of the time students correctly identified specific sonographic landmarks of the anterior knee. When the evaluation combined real-time scanning with a prerecorded sonographic video clip of the anterior knee, 71.4 % (20/28) accurately identified joint effusion, 60.9 % (14/23) correctly diagnosed prepatellar bursitis, 93.3 % (28/30) recognized cellulitis, and 47.1 % (8/17) diagnosed the normal knee.

CONCLUSIONS

Our focused training was effective at immediately increasing basic knowledge, as well as confidence of first-year osteopathic medical students when assessing the anterior knee with point-of-care ultrasound. However, spaced repetition and deliberate practice may be useful for learning retention.

The Evolution of Cardiovascular Ultrasound: A Review of Cardiac Point-of-Care Ultrasound (POCUS) Across Specialties

The use of cardiac point-of-care ultrasound (POCUS) is now widespread in clinics, emergency departments, and all areas of the hospital. Users include medical trainees, advanced practice practitioners, and attending physicians in many specialties and sub-specialties. Opportunities to learn cardiac POCUS and requirements for training vary across specialties as does the scope of the cardiac POCUS examination. In this review, we describe both a brief history of how cardiac POCUS emerged from echocardiography and the state of the art across a variety of medical fields.

Starting a Free Ultrasound Clinic for the Underserved: Considerations and Overcoming Challenges

Many radiologists are interested in providing affordable care to underserved populations but are unsure how to accomplish it. We present a model for providing imaging services to the underserved with an emphasis on the challenges we encountered and strategies we used to overcome them. In partnership with our medical school's student-run free clinic, we developed a community-based ultrasound service that provides diagnostic ultrasound examinations to an uninsured urban population to address the need of timely access to care and integrated follow-up care. Image storage and reporting were fully integrated with our existing imaging informatics and electronic medical record systems. Radiology residents play a central role in the operation of the service while gaining hands-on ultrasound experience, in partnership with volunteer sonographers, radiology attendings, and medical students.

Point-of-Care Ultrasound

Purpose of the Review

Point-of-care ultrasound using small ultrasound devices has expanded beyond emergency and critical care medicine to many other subspecialties. Awareness of the strengths and limitations of the technology and knowledge of the appropriate settings and common indications for point-of-care ultrasound is important.

Recent Findings

Point-of-care ultrasound is widely embraced as an extension of the physical exam and is employed in acute care and medical education settings. Echocardiography laboratories involved in education must individualize training to the intended scope of practice of the user. Advances in artificial intelligence may assist in image acquisition and interpretation by novice users.

Summary

Point-of-care ultrasound is widely available in a variety of clinical settings. The field has advanced substantially in the past 2 decades and will likely continue to expand with advancement in technology, reduced cost, and improved opportunities to assist new users.

Utility of expert focused cardiac ultrasound in paediatric cardiology outreach clinics

OBJECTIVE

This prospective observational study evaluates the utility of expert focused cardiac ultrasound (eFCU) with spectral Doppler to inform decision making in established patients with specific, selected congenital cardiac defects in outreach clinics. Secondary objectives include determining if the addition of eFCU expands capacity in paediatric cardiology outreach clinics and if it improves the patient experience.

METHODS

Patients aged 2 months to 19 years old with a diagnosis of ventricular septal defect, atrial septal defect, atrioventricular septal defect, patent ductus arteriosus, aortic valve stenosis, or pulmonary valve stenosis with the need for follow-up echocardiography in an outreach clinic from August 2017 to June 2018 were studied. A novel assessment tool was used to determine the success of eFCU.

RESULTS

Forty-two patients from 11 clinics underwent eFCU with one unsuccessful exam making the failure rate 2.3% (95% CI 0.0006-0.1256). Addition of eFCU led to a significant increase in volume of patients able to be seen 19 versus 15.5 (p < 0.01). A majority of parents/patients reported a positive experience with eFCU.

CONCLUSION

Expert focused cardiac ultrasound with spectral Doppler can be used successfully for follow-up in patients with select CHD and the addition of eFCU permits increased patient capacity in outreach clinics and has the potential to improve the patient experience.

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Focused cardiac ultrasound (FoCUS)—a simplified, qualitative version of echocardiography—is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20–30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

Hospital Medicine Point of Care Ultrasound Credentialing: An Example Protocol

Though the use of point-of-care ultrasound (POCUS) has increased over the last decade, formal hospital credentialing for POCUS may still be a challenge for hospitalists. This document details the Hospital Medicine Department Ultrasound Credentialing Policy from Regions Hospital, which is part of the HealthPartners organization in Saint Paul, Minnesota. National organizations from internal medicine and hospital medicine (HM) have not published recommended guidelines for POCUS credentialing. Revised guidelines for POCUS have been published by the American College of Emergency Physicians, though these are not likely intended to guide hospitalists when working with credentialing committees and medical boards. This document describes the scope of ultrasound in HM and our training, credentialing, and quality assurance program. This report is intended to be used as a guide for hospitalists as they work with their own credentialing committees and will require modification for each institution. However, the overall process described here should assist in the establishment of POCUS at various institutions.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.

Focused Cardiac Ultrasound in Place of Repeat Echocardiography: Reliability and Cost Implications

BACKGROUND

Health care systems are increasingly moving toward models that emphasize the delivery of high-quality health care at lower costs. Rates of repeat echocardiography (two or more transthoracic echocardiographic studies performed within a short interval) are high and can contribute substantially to the cost of providing cardiovascular care. Certain findings from handheld ultrasound scans performed by echocardiographers have been shown to correlate well with findings on transthoracic echocardiography (TTE). It therefore may be feasible and cost effective to use expert focused cardiac ultrasound (eFCU) in place of repeat TTE for highly selected indications in certain settings. The aim of this study was to determine the reliability and cost implications of using eFCU in place of repeat TTE in selected inpatients.

METHODS

Inpatients who underwent repeat TTE (prior TTE within 30 days) ordered for the assessment of ventricular function, pericardial effusion, or inferior vena cava collapse were prospectively enrolled. Subjects underwent eFCU in addition to TTE, and results were compared for correlation using the weighted κ statistic. The potential cost savings of using eFCU in place of TTE were modeled from the provider perspective (i.e., physicians and hospitals).

RESULTS

Over 45 days, 105 patients were enrolled. The majority of scans were performed for assessment of left ventricular function and pericardial effusions. eFCU showed excellent correlation with TTE for most parameters, including left ventricular systolic function (κ = 0.80) and the presence and size of pericardial effusions (κ = 0.81) (P < .001 for both). Adoption of this eFCU protocol could save between $41 and $64 per study, or between $34,512 and $53,871 annually at the authors' institution.

CONCLUSIONS

Findings from eFCU correlate well with those from TTE when used in the setting of repeat testing for assessment of ventricular function, pericardial effusion, and inferior vena cava collapse. The judicious use of eFCU in place of repeat inpatient TTE has the potential to deliver quality cardiac imaging at reduced cost.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals

BACKGROUND

Heart disease is difficult to detect clinically and it has been suggested that echocardiography should be available to all patients with possible cardiac symptoms or signs.

AIM

To analyse the results of 2 years of open access echocardiography for the frequency of structural heart disease according to request.

DESIGN AND SETTING

Retrospective database analysis in a teaching hospital open access echocardiography service.

METHOD

Reports of all open access transthoracic echocardiograms between January 2011 and December 2012 were categorised as normal, having minor abnormalities, or significant abnormalities according to the indication.

RESULTS

There were 2343 open access echocardiograms performed and there were significant abnormalities in 29%, predominantly valve disease (n = 304, 13%), LV systolic dysfunction (n = 179, 8%), aortic dilatation (n = 80, 3%), or pulmonary hypertension (n = 91, 4%). If echocardiography had been targeted at a high-risk group, 267 with valve disease would have been detected (compared to 127 with murmur alone) and 139 with LV systolic dysfunction (compared to 91 with suspected heart failure alone). Most GP practices requested fewer than 10 studies, but 6 practices requested over 70 studies.

CONCLUSION

Open access echocardiograms are often abnormal but structural disease may not be suspected from the clinical request. Uptake by individual practices is patchy. A targeted expansion of echocardiography in patients with a high likelihood of disease is therefore likely to increase the detection of clinically important pathology.

Hospitalist use of hand-carried ultrasound: preparing for battle

Hand-carried ultrasound (HCU) is a burgeoning technology at a critical point in its development as a general diagnostic technique. Despite the known safety and accuracy of ultrasound in radiology and echocardiography, the use of HCU to augment physical diagnosis by all physicians has yet unrealized potential. In order to incorporate ultrasound into a diagnostic model of routine bedside application, simple imaging and training protocols must first be derived and validated. Simplified cardiac ultrasound exams have already been validated to detect evidence-based targets such as subclinical atherosclerosis, heart failure, and elevated central venous pressures. However, for general examination of the acutely ill patient, it is the internist-hospitalist who should derive a full-body ultrasound examination, balancing training requirements with the numerous clinical applications potentially available. As the hospital's leading diagnostician with ultrasound expertise available in-house, the hospitalist could develop HCU so as to triage and refer more appropriately and limit unnecessary testing and hospital stays. Active involvement by hospitalists now in the planning of outcome, validation, and training studies, will be invaluable in the formation of an "ultrasound-assisted" physical examination in the future and will promote competent, cost-effective applications of HCU within general medical practice.

Echocardiography for the clinician: a practical update

Echocardiography is the mainstay of cardiovascular diagnostics, and is the most performed test for the evaluation of cardiac function. Critical and costly management decisions are based on quantification of left ventricular volumes and ejection fraction. Recent advances in echocardiography, such as microsphere contrast echocardiography for left ventricular opacification and perfusion imaging, three-dimensional transthoracic and trans-oesophageal imaging, strain and tissue Doppler imaging, all contribute to improving accuracy and reproducibility of these important measurements. Such techniques are now routinely available on standard echocardiography equipment in Australian centres for daily use. Hand-carried ultrasound devices have been developed, which are portable, are affordable and offer increased availability of echocardiography to the wider community. Clinicians should be actively encouraged to adopt these technologies to improve the diagnostic quality and reproducability of echocardiography for our patients. This article provides an overview of important recent advances in echocardiographic imaging with an emphasis on their role in clinical practice today.

Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?

OBJECTIVE

The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations.

METHODS

During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram.

RESULTS

Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation.

CONCLUSION

Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.

The pocket echocardiograph: a useful new tool?

AIMS

Hand-carried ultrasound scanners are getting smaller. The Acuson P10 is the latest and smallest portable echocardiograph available on the market.

METHODS AND RESULTS

We tested the ability of this scanner to allow qualitative assessment of LV size and function in an unselected group of 30 patients [19 male, 11 female; mean age (SD) 64.7 (10.3) years] seen by a consultant cardiologist (accredited for advanced echocardiography) during a week on call in a regional cardiac tertiary facility. Patients had focused scans (parasternal long-axis and apical four chamber views) for a maximum of 4 min, and an assessment of LVEF (normal/abnormal) and LV dimension (LVD) (dilated/non-dilated) was recorded. Where available, this was compared with results of alternative imaging modalities. In 23 (77%) patients, it was possible to assess LVEF and LVD; of these, 19 (83%) had alternative imaging techniques, which confirmed the findings. It was possible to obtain a parasternal long-axis image in 28 (93%) patients and apical four-chamber views in 23 (77%). Clinical management was altered by the findings of the portable scan in two patients.

CONCLUSION

The 'pocket scanner' allows accurate qualitative assessment of left ventricular dimensions and function in a substantial proportion of patients seen in tertiary cardiology practice.

Future potential of echocardiography in heart failure

Echocardiography represents a convenient, portable and noninvasive method to provide important anatomic and physiologic information to inform the management of heart failure patients. Traditional echo assessments include diagnostic, etiologic and prognostic data from ventricular size, geometry and performance. Newer echocardiographic techniques are receiving greater utilization, however, and promise to further enhance diagnostic abilities in heart failure. This article reviews traditional anatomic assessments, echo-based cardiac hemodynamics, 3D echocardiography, quantification of myocardial tissue mechanics and hand-carried echocardiography. These developments in echocardiography underlie future trends toward echo objectivity, improved imaging of patients with poor acoustic windows, miniaturization and simplicity in focused exams and the expanded application of old and new techniques.

A suggested curriculum in echocardiography for critical care physicians

Echocardiography is a powerful diagnostic and monitoring tool of cardiac performance, cardiac pathology, and extracardiac intrathoracic abnormalities. Numerous investigations in intensive care have shown its merit, being efficacious and safe. Because many obvious and/or unsuspected conditions can impact the hemodynamic status of critically ill patients, echocardiography is becoming an integral part of an intensivist's diagnostic and monitoring armamentarium. However, significant background information, cognitive, and technical skills are required to properly perform and interpret echocardiography images. Some education and training guidelines for echocardiography have been developed while others remain "in progress." This manuscript suggests a core curriculum and necessary training elements for intensivists. This curriculum does not segregate portable handheld surface echocardiography from the typical platforms of transthoracic echocardiography and transesophageal echocardiography, because hardware and software developments have bridged these technologies.

A comparison by medicine residents of physical examination versus hand-carried ultrasound for estimation of right atrial pressure

Physicians' ability to accurately estimate right atrial (RA) pressure from bedside evaluation of the jugular venous waveform is poor, particularly when performed by physicians in training. Conventional ultrasound measurement of the inferior vena cava (IVC) accurately predicts RA pressure, but the cost, lack of portability, and specialized training required to acquire and interpret the data render this modality impractical for routine clinical use. The objective of this study was to compare physical examination with hand-carried ultrasound (HCU) in the detection of elevated RA pressure (>10 mm Hg). After limited training (4 hours didactic and 20 studies), 4 internal medicine residents using an HCU device estimated RA pressure from images of the IVC in 40 consecutive patients <1 hour after right-sided cardiac catheterization. RA pressure was also estimated from examination of the jugular venous pulse (JVP) in 40 patients before right-sided cardiac catheterization. RA pressure was successfully estimated from HCU images of the IVC in 90% of patients, compared with 63% from JVP examination. The sensitivity for predicting RA pressure >10 mm Hg was 82% with HCU and 14% from JVP inspection. Specificities were similar between the techniques. Overall accuracies were 71% using HCU and 60% with JVP assessment. In conclusion, internal medicine residents with brief training in echocardiography can more frequently and more accurately predict elevated RA pressure using HCU measurements of the IVC than with physical examination of the JVP.

Rapid assessment of left ventricular systolic function in a pacemaker clinic using a hand-carried ultrasound device

OBJECTIVE

Pacemaker recipients with left ventricular (LV) dysfunction are potential candidates for upgrades to implantable defibrillators or cardiac resynchronization devices. This study sought to determine if a hand-carried ultrasound (HCU) device could be used for rapid, inexpensive identification of LV dysfunction in a busy pacemaker clinic.

MATERIALS AND METHODS

Eighty patients undergoing routine pacemaker check were enrolled. Patients underwent HCU imaging in the sitting position during device interrogation, by an internist who had 20 h of didactic training and 20 practice examinations. LV dysfunction was defined as ejection fraction (EF) <40%. Patients also underwent echocardiography limited to EF assessment by a sonographer using a full-feature platform.

RESULTS

The mean age was 75 +/- 13 years; 49% were female. Coronary artery disease was present in 29%; 82% were NYHA class I or II. At the time of HCU imaging, 48% of patients were receiving RV pacing. HCU images were interpretable in 91% (73/80) and required 3.7 +/- 0.9 min to complete. Based on the full-feature echo, LV dysfunction prevalence was 17/80 (21%); 25% of these patients were NYHA class I. The sensitivity of the HCU exam was 75%, specificity was 91%, negative predictive value was 93%, positive predictive value was 71%, and accuracy was 88%.

CONCLUSIONS

HCU screening in a pacemaker clinic by a non-cardiologist can rapidly and accurately identify pacemaker recipients with at least moderate LV dysfunction who might be candidates for device upgrades. Ventricular dyssynchrony associated with RV pacing does not limit HCU identification of LV dysfunction.

Handcarried ultrasound measurement of the inferior vena cava for assessment of intravascular volume status in the outpatient hemodialysis clinic

Accurate intravascular volume assessment is critical in the treatment of patients who receive chronic hemodialysis (HD) therapy. Clinically assessed dry weight is a poor surrogate of intravascular volume; however, ultrasound assessment of the inferior vena cava (IVC) is an effective tool for volume management. This study sought to determine the feasibility of using operators with limited ultrasound experience to assess IVC dimensions using hand-carried ultrasounds (HCU) in the outpatient clinical setting. The IVC was assessed in 89 consecutive patients at two outpatient clinics before and after HD. Intradialytic IVC was recorded during episodes of hypotension, chest pain, or cramping. High-quality IVC images were obtained in 79 of 89 patients. Despite that 89% of patients presented at or above dry weight, 39% of these patients were hypovolemic by HCU. Of the 75% of patients who left HD at or below goal weight, 10% were still hypervolemic by HCU standards. Hypovolemic patients had more episodes of chest pain and cramping (33 versus 14%, P = 0.06) and more episodes of hypotension (22 versus 3%, P = 0.02). The clinic with a higher prevalence of predialysis hypovolemia had significantly more intradialytic adverse events (58 versus 27%; P = 0.01). HCU measurement of the IVC is a feasible option for rapid assessment of intravascular volume status in an outpatient dialysis setting by operators with limited formal training in echocardiography. There is a poor relationship between dry weight goals and IVC collapsibility. Practice variation in the maintenance of volume status is correlated with significant differences in intradialysis adverse events.

Effectiveness of echocardiographic imaging by nurses to identify left ventricular systolic dysfunction in high-risk patients

Recognizing left ventricular (LV) systolic dysfunction is critical. The investigators sought to evaluate whether nurses could be trained to use a hand-carried ultrasound (HCU) device to screen for LV systolic dysfunction in high-risk patients. Sixty-three patients from an outpatient diabetes clinic underwent brief echocardiographic examinations by nurses using HCU devices. Of the 63 patients enrolled in the study, 3 (4.7%) had LV systolic dysfunction. The nurses correctly identified these 3 patients as having LV systolic dysfunction (sensitivity 100%, negative predictive value 100%). The identification of occult LV systolic dysfunction in diabetic patients may allow the initiation of therapies known to improve prognosis.

Technology Insight: hand-carried ultrasound cardiac assessment—evolution, not revolution

Hand-carried ultrasound devices can enhance the art of bedside physical examination by increasing diagnostic accuracy, detecting disease at an earlier stage, and improving triage and referral of patients. Although limitations of device cost and portability can be overcome with technologic advances, the shortage of standardized imaging and training opportunities now needs to be addressed to move the technique forward. Cardiologists are the best-qualified subspecialists to design and teach a simplified training program for bedside use of hand-carried ultrasound devices to assess the cardiovascular system.