Point-of-Care Cardiac Ultrasound: Feasibility of Performance by Noncardiologists

Overcoming barriers in the use of artificial intelligence in point of care ultrasound

Point-of-care ultrasound is a portable, low-cost imaging technology focused on answering specific clinical questions in real time. Artificial intelligence amplifies its capabilities by aiding clinicians in the acquisition and interpretation of the images; however, there are growing concerns on its effectiveness and trustworthiness. Here, we address key issues such as population bias, explainability and training of artificial intelligence in this field and propose approaches to ensure clinical effectiveness.

Point-of-Care Thoracic Ultrasound in Children: New Advances in Pediatric Emergency Setting

Point-of-care thoracic ultrasound at the patient's bedside has increased significantly recently, especially in pediatric settings. Its low cost, rapidity, simplicity, and repeatability make it a practical examination to guide diagnosis and treatment choices, especially in pediatric emergency departments. The fields of application of this innovative imaging method are many and include primarily the study of lungs but also that of the heart, diaphragm, and vessels. This manuscript aims to describe the most important evidence for using thoracic ultrasound in the pediatric emergency setting.

Task shifting for point of care ultrasound in primary healthcare in low- and middle-income countries-a systematic review

Low-and middle-income countries (LMIC) are faced with healthcare challenges including lack of specialized healthcare workforce and limited diagnostic infrastructure. Task shifting for point-of-care ultrasound (POCUS) can overcome both shortcomings. This review aimed at identifying benefits and challenges of task shifting for POCUS in primary healthcare settings in LMIC. Medline and Embase were searched up to November 22nd, 2021. Publications reporting original data on POCUS performed by local ultrasound naïve healthcare providers in any medical field at primary healthcare were included. Data were analyzed descriptively. PROSPERO registration number CRD42021223302. Overall, 36 publications were included, most (n = 35) were prospective observational studies. Medical fields of POCUS application included obstetrics, gynecology, emergency medicine, infectious diseases, and cardiac, abdominal, and pulmonary conditions. POCUS was performed by midwives, nurses, clinical officers, physicians, technicians, and community health workers following varying periods of short-term training and using different ultrasound devices. Benefits of POCUS were yields of diagnostic images with adequate interpretation impacting patient management and outcome. High cost of face-to-face training, poor internet connectivity hindering telemedicine components, and unstable electrici'ty were among reported drawbacks for successful implementation of task shifting POCUS. At the primary care level in resource-limited settings task shifting for POCUS has the potential to expand diagnostic imaging capacity and impact patient management leading to meaningful health outcomes.

Handheld Echocardiography in a Clinical Practice Scenario: Concordances Compared to Standard Echocardiographic Reports

BACKGROUND

The purpose of this study was to assess the utility of a handheld device (HH) used during common daily practice and its agreement with the results of a standard echocardiography study (STD) performed by experienced sonographers and echocardiographer.

METHODS

A prospective follow-up was conducted in an adult outpatient echocardiography clinic. Experienced sonographers performed the STD and an experienced echocardiographer performed the HH. STD included 2-dimensional images, Doppler and hemodynamics analysis. Hemodynamic assessment was not performed with the HH device because the HH does not include such technology. The images were interpreted by blinded echocardiographers, and the agreement between the reports was analyzed.

RESULTS

A total of 108 patients were included; and the concordance for left ventricle (LV) ejection fraction (EF), wall motion score index, LV and right ventricle (RV) function, RV size, and mitral and aortic stenosis was excellent with κ values greater than 0.80. Wall motion abnormalities had good concordance (κ value 0.78). The agreement for LV hypertrophy, mitral and aortic regurgitation was moderate, and tricuspid and pulmonary regurgitation agreements were low (κ values of 0.26 and 0.25, respectively).

CONCLUSIONS

In a daily practice scenario with experienced hands, HH demonstrated good correlation for most echocardiography indications, such as ventricular size and function assessment and stenosis valve lesion analyses.

Comparison of Emergency Echocardiographic Results between Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome

INTRODUCTION

Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid disposition of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the diagnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident was evaluated in comparison with board-certified cardiologists.

METHODS

A prospective, cross-sectional study was implemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point-of-care echocardiography under the supervision of two cardiologists and the reports were compared with cardiologists as a reference test.

RESULTS

100 patients with the mean age of 54.1 ± 11.5 years were recruited (65% male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin (HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolute measure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89) based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between specialists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and pericardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART score with an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists.

CONCLUSION

This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in different ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists in determining left ventricular ejection fraction (LVEF) and pericardial effusion.

Ensuring competency in focused cardiac ultrasound: a systematic review of training programs

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a valuable skill for rapid assessment of cardiac function and volume status. Despite recent widespread adoption among physicians, there is limited data on the optimal training methods for teaching FoCUS and metrics for determining competency. We conducted a systematic review to gain insight on the optimal training strategies, including type and duration, that would allow physicians to achieve basic competency in FoCUS.

METHODS

Embase, PubMed, and Cochrane Library databases were searched from inception to June 2020. Included studies described standardized training programs for at least 5 medical students or physicians on adult FoCUS, followed by an assessment of competency relative to an expert. Data were extracted, and bias was assessed for each study.

RESULTS

Data were extracted from 23 studies on 292 learners. Existing FoCUS training programs remain varied in duration and type of training. Learners achieved near perfect agreement (κ > 0.8) with expert echocardiographers on detecting left ventricular systolic dysfunction and pericardial effusion with 6 h each of didactics and hands-on training. Substantial agreement (κ > 0.6) on could be achieved in half this time.

CONCLUSION

A short training program will allow most learners to achieve competency in detecting left ventricular systolic dysfunction and pericardial effusion by FoCUS. Additional training is necessary to ensure skill retention, improve efficiency in image acquisition, and detect other pathologies.

Focus-assessed transthoracic echocardiography: Implications in perioperative and intensive care

Transthoracic echocardiography is a potent and appealing diagnostic tool by virtue of rapidity, noninvasiveness, and repeatability. Focus-assessed transthoracic echocardiography (FATE) forms quick guidance to interpret the echocardiographic information and relates it to the clinical context. It can be applied in the perioperative period, intensive care units (ICUs), and emergency situations, in trauma and as resuscitation aids. FATE intents to assess cardiac function including contractility, chamber size and hypertrophy, valvular dysfunction, cardiac tamponade, and pericardial and pleural effusions. Thence, FATE has become a quintessential scanning tool perioperatively and in ICUs.

Cardiac ultrasound in resource-limited settings (CURLS): towards a wider use of basic echo applications in Africa

Background

Point-of-care ultrasound is increasingly being used as a diagnostic tool in resource-limited settings. The majority of existing ultrasound protocols have been developed and implemented in high-resource settings. In sub-Saharan Africa (SSA), patients with heart failure of various etiologies commonly present late in the disease process, with a similar syndrome of dyspnea, edema and cardiomegaly on chest X-ray. The causes of heart failure in SSA differ from those in high-resource settings. Point-of-care ultrasound has the potential to identify the underlying etiology of heart failure, and lead to targeted therapy. Based on a literature review and weighted score of disease prevalence, diagnostic impact and difficulty in performing the ultrasound, we propose a context-specific cardiac ultrasound protocol to help differentiate patients presenting with heart failure in SSA.

Results

Pericardial effusion, dilated cardiomyopathy, cor pulmonale, mitral valve disease, and left ventricular hypertrophy were identified as target conditions for a focused ultrasound protocol in patients with cardiac failure and cardiomegaly in SSA. By utilizing a simplified 5-question approach with all images obtained from the subxiphoid view, the protocol is suitable for use by health care professionals with limited ultrasound experience.

Conclusions

The “Cardiac ultrasound for resource-limited settings (CURLS)” protocol is a context-specific algorithm designed to aid the clinician in diagnosing the five most clinically relevant etiologies of heart failure and cardiomegaly in SSA. The protocol has the potential to influence treatment decisions in patients who present with clinical signs of heart failure in resource-limited settings outside of the traditional referral institutions.

Point-of-Care Ultrasound to Identify Congenital Heart Disease in the Pediatric Emergency Department

The first presentation of congenital heart disease can be a diagnostic challenge in the emergency department. We report on 2 cases where point-of-care ultrasound identified gross cardiac abnormalities in 2 children and expedited disposition and downstream care.

Ultrasound Curricula in Undergraduate Medical Education: A Scoping Review

The clinical applications of point-of-care ultrasound (US) have expanded rapidly over the past decade. To promote early exposure to point-of-care US, there is widespread support for the integration of US curricula within undergraduate medical education. However, despite growing evidence and enthusiasm for point-of-care US education in undergraduate medical education, the curricular design and delivery across undergraduate medical education programs remain variable without widely adopted national standards and guidelines. This article highlights the educational and teaching applications of point-of-care US with a focus on outcomes. We then review the evidence on curricular design, delivery, and integration and the assessment of competency for point-of-care US in undergraduate medical education.

Hand-held cardiac ultrasound screening performed by family doctors with remote expert support interpretation

OBJECTIVE

To assess the usefulness of hand-held cardiac ultrasound (HCU) performed by family doctors (FDs) in primary care, with web-based remote expert support interpretation, in a cohort of patient with symptoms or physical examination signs suggestive of cardiovascular disease.

METHODS

This prospective observational study included 1312 consecutive patients, in three remote primary care areas, with symptoms or physical examination signs suggestive of cardiovascular disease. In 859 patients (group A), FDs had indicated conventional echocardiography (CE), and in 453 (Group B) the study was performed to complement the physical examination. HCU was carried out by 14 FDs after a short training period. The scans and preliminary FD reports were uploaded on a web-based program for remote expert support interpretation in <24 h.

RESULTS

Experts considered HCU to be inconclusive in 116 (8.8%) patients. FD and expert agreement on diagnosis was moderate (K=0.40-0.70) except in mitral stenosis (K=0.29) and in left atrial dilation (K=0.38). Diagnostic agreement between expert interpretation and CE was good (K=0.66-0.85) except in mitral stenosis (K=0.43). After remote expert interpretation, conventional echocardiograms were finally requested by FDs in only 276 (32.1%) patients, and discharges increased by 10.2%. Furthermore, significant heart diseases were diagnosed in 32 (7%) patients of group B.

CONCLUSIONS

HCU performed at the point of care by FDs with remote expert support interpretation using a web-based system is feasible, rapid and useful for detecting significant echocardiographic abnormalities and reducing the number of unnecessary echocardiographic studies.

Bioimaging and subclinical cardiovascular disease in low- and middle-income countries

Cardiovascular disease (CVD) is the leading cause of mortality worldwide and also exerts a significant economic burden, especially in low- and middle-income countries (LMICs). Detection of subclinical CVD, before an individual experiences a major event, may therefore offer the potential to prevent or delay morbidity and mortality, if combined with an appropriate care response. In this review, we discuss imaging technologies that can be used to detect subclinical atherosclerotic CVD (carotid ultrasound, coronary artery calcification) and nonatherosclerotic CVD (echocardiography). We review these imaging modalities, including aspects such as rationale, relevance, feasibility, utilization, and access in LMICs. The potential gains in detecting subclinical CVD may be substantial in LMICs, if earlier detection leads to earlier engagement with the health care system to prevent or delay cardiac events, morbidity, and premature mortality. Thus, dedicated studies examining the feasibility, utility, and cost-effectiveness of detecting subclinical CVD in LMICs are warranted.