Appropriateness criteria for cardiovascular imaging use in heart failure: report of literature review

Reasonable requests: echocardiography referral forms as a measure of coherent clinical communication

BACKGROUND

Well performed clinical communication is a cornerstone of collaborative care in medicine but may be confounded by inconsistent intentions of the messenger and biased interpretation by the recipient. A comparison of the findings of electronic echocardiography reports with clinician-completed standardised request forms provided an opportunity to assess communication quality.

AIM

The study aimed to determine clinician aptitude to complete written echocardiography referral forms by assessing the completeness, appropriateness, accuracy, and coherency of the reported clinical findings, conclusions and requests made on the referral forms. The study explored factors that may influence the quality of communication through this referral medium.

METHODS

A retrospective cohort study was conducted on patients who underwent trans-thoracic echocardiography imaging at Cecilia Makiwane Hospital in East London over 26 months. Paper echocardiography request forms that recorded the requesting clinician's findings on examination, the provisional clinical diagnosis, and the specific echocardiographic information sought, were compared with the actual findings on echocardiography.

RESULTS

Of 613 request forms reviewed, 97 cases were excluded due to illegibility or because they lacked analysable information or requester details, leaving 516 forms suitable for study. No pathology was found on echocardiography in 31%. Of the murmurs expected from the echocardiography findings, only half were recorded on the request form (sensitivity and positive predictive value both 52%.). Only 35% of request forms that mentioned a mitral systolic murmur gave a working diagnosis of mitral regurgitation and only 38% of request forms that mentioned an aortic systolic murmur considered aortic stenosis. Clinically suspected cardiomyopathy (CMO) had a PPV of 43% and echocardiographic CMO was missed clinically in 41%. Apex beat displacement reported clinically was not associated with echocardiographic LV dilatation in 65% of cases. One-third (34%) of forms reporting murmurs did not request valve function assessment and 17% considering cardiomyopathy did not request left ventricular function assessment.

CONCLUSION

Echocardiography request forms highlight vulnerabilities in clinical communication. Specifically, important clinical features were missing and more concerningly, included when unlikely to be present. There was a lack of concordance between recorded clinical findings and postulated diagnoses. Clinicians sometimes appeared unclear about the value or appropriateness of the requested assistance. Greater emphasis on teaching examination and communication skills may foster safer and more efficient use of scarce resources.

Detection of left ventricular systolic dysfunction using an artificial intelligence-enabled chest X-ray

BACKGROUND

Assessment of left ventricular systolic dysfunction provides essential information related to the prognosis and management of cardiovascular diseases. The aim of this study is to develop a deep-learning model (DLM) to identify LVEF≤35% via chest X-ray (CXR-EF≤35%) features and investigate the performance and clinical implications.

METHODS

This study collected 90,547 CXRs with the corresponding LVEF by transthoracic echocardiogram from the outpatient department in an academic medical center. Among these, 77,227 CXRs were used to develop a CXR-EF≤35%. Another 13,320 CXRs were used to validate the performance, which was evaluated by the area under the receiver operating characteristic curve (AUC). Furthermore, CXR-EF≤35% was tested to assess the long-term risks of developing LVEF≤35% and cardiovascular outcomes, which were evaluated by Kaplan-Meier survival analysis and the Cox proportional hazards model.

RESULTS

The AUCs of CXR-EF≤35% for the detection of LVEF≤35% were 0.888 and 0.867 in internal and external validation cohort. Patients with baseline LVEF>50%, detected as LVEF≤35% by CXR-EF≤35% were at higher risk of long-term developing LVEF≤35% (HR_i:3.91, 95% CI, 2.98-5.14; HR_e:2.49, 95%CI, 1.89-3.27). Furthermore, patients detected as LVEF≤35% by CXR-EF≤35% had significantly higher future risks of all-cause mortality (HR_i:1.40, 95%CI, 1.15-1.71; HR_e:1.38, 95%CI, 1.15-1.66), cardiovascular mortality (HR_i:3.02, 95%CI, 1.84-4.98; HR_e:2.60, 95%CI, 1.77-3.82), and new-onset atrial fibrillation (HR_i:2.81, 95%CI, 2.15-3.66; HR_e:2.93, 95%CI, 2.34-3.67) compared to those detected as no LVEF≤35%.

CONCLUSION

CXR-EF≤35% may serve as a screening tool for early detecting LVEF≤35% and independently contribute to predictions of long-term developing LVEF≤35% and cardiovascular outcomes. Further prospective studies are needed to confirm the model performance.

Artificial intelligence-enabled electrocardiogram screens low left ventricular ejection fraction with a degree of confidence

Background

Artificial intelligence-enabled electrocardiogram has become a substitute tool for echocardiography in left ventricular ejection fraction estimation. However, the direct use of artificial intelligence-enabled electrocardiogram may be not trustable due to the uncertainty of the prediction.

Objective

The study aimed to establish an artificial intelligence-enabled electrocardiogram with a degree of confidence to identify left ventricular dysfunction.

Methods

The study collected 76,081 and 11,771 electrocardiograms from an academic medical center and a community hospital to establish and validate the deep learning model, respectively. The proposed deep learning model provided the point estimation of the actual ejection fraction and its standard deviation derived from the maximum probability density function of a normal distribution. The primary analysis focused on the accuracy of identifying patients with left ventricular dysfunction (ejection fraction ≤ 40%). Since the standard deviation was an uncertainty indicator in a normal distribution, we used it as a degree of confidence in the artificial intelligence-enabled electrocardiogram. We further explored the clinical application of estimated standard deviation and followed up on the new-onset left ventricular dysfunction in patients with initially normal ejection fraction.

Results

The area under receiver operating characteristic curves (AUC) of detecting left ventricular dysfunction were 0.9549 and 0.9365 in internal and external validation sets. After excluding the cases with a lower degree of confidence, the artificial intelligence-enabled electrocardiogram performed better in the remaining cases in internal (AUC = 0.9759) and external (AUC = 0.9653) validation sets. For the application of future left ventricular dysfunction risk stratification in patients with initially normal ejection fraction, a 4.57-fold risk of future left ventricular dysfunction when the artificial intelligence-enabled electrocardiogram is positive in the internal validation set. The hazard ratio was increased to 8.67 after excluding the cases with a lower degree of confidence. This trend was also validated in the external validation set.

Conclusion

The deep learning model with a degree of confidence can provide advanced improvements in identifying left ventricular dysfunction and serve as a decision support and management-guided screening tool for prognosis.

Trends in Cardiovascular MRI and CT in the U.S. Medicare Population from 2012 to 2017

Purpose

To assess the characteristics and trends of cardiovascular MRI and CT practitioners and practice in the United States.

Materials and Methods

A retrospective cross-sectional analysis of 2012-2017 Medicare Part B physician payments from the Provider Utilization and Payment Data Physician and Other Supplier Public Use Files (POSPUF) was performed. Characteristics of cardiovascular MRI and CT, including the number of providers and examinations, provider sex and location, and physician reimbursement were analyzed. Variable means, standard deviations, and changes per year were reported and compared.

Results

In 2017, 582 physicians provided cardiovascular MRI services in 45 states, a 16.6% increase from 2016 and an 84.8% increase from 2012. A total of 1645 physicians provided cardiovascular CT services in 49 states, a 14.2% increase from 2016 and a 77.3% increase from 2012. Of the providers, 18.0% and 13.3% of cardiovascular MRI and CT providers were women, respectively, similar to providers' respective medical specialties. Only 1.0% of radiologists and 0.2% of cardiologists provided cardiovascular MRI services. A total of 3.2% of radiologists and 0.5% of cardiologists provided cardiovascular CT services. Both cardiovascular MRI use (+75.5%) and cardiovascular CT use (+97.4%) increased markedly over the 6-year study period.

Conclusion

Although the availability of cardiovascular MRI and CT is increasing, both are used less frequently in comparison with other cardiovascular imaging modalities.See also the commentary by Bierhals in this issue.Supplemental material is available for this article.© RSNA, 2021.

Multimodality imaging in the diagnosis, risk stratification, and management of patients with dilated cardiomyopathies: an expert consensus document from the European Association of Cardiovascular Imaging

Dilated cardiomyopathy (DCM) is defined by the presence of left ventricular or biventricular dilatation and systolic dysfunction in the absence of abnormal loading conditions or coronary artery disease sufficient to explain these changes. This is a heterogeneous disease frequently having a genetic background. Imaging is important for the diagnosis, the prognostic assessment and for guiding therapy. A multimodality imaging approach provides a comprehensive evaluation of all the issues related to this disease. The present document aims to provide recommendations for the use of multimodality imaging according to the clinical question. Selection of one or another imaging technique should be based on the clinical condition and context. Techniques are presented with the aim to underscore what is 'clinically relevant' and what are the tools that 'can be used'. There remain some gaps in evidence on the impact of multimodality imaging on the management and the treatment of DCM patients where ongoing research is important.

Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study

AIMS

Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival.

METHODS AND RESULTS

OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33).

CONCLUSIONS

This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.

Tongmai Yangxin intervening in myocardial remodeling after PCI for coronary heart disease: study protocol for a double-blind, randomized controlled trial

Background

Coronary heart disease (CHD) has become a common cardiovascular disease that seriously threatens the health of people. As reperfusion in the early phase and drug therapy, especially percutaneous coronary intervention (PCI), have become widely used in the clinic, the mortality of acute myocardial infarction in the short term has been reduced significantly. In addition, in 40%–56% of patients who experience myocardial infarction, cardiac dysfunction occurs and about 25%–33% develop heart failure.

Methods

This study was designed as a multicenter, double-blind, randomized, placebo-controlled, parallel-group, superiority trial. Participants were randomly assigned in a 1:1 ratio through a centrally controlled, computer-generated, simple randomization schedule. The primary outcome was left ventricular end-diastolic volume index = left ventricular end-diastolic volume/body surface area. The combined secondary outcomes include traditional Chinese medicine syndrome score, echocardiogram results, 6-minute walk test results, Seattle Angina Questionnaire score, cardiac magnetic resonance imaging results, biological indicators, dynamic electrocardiogram results, and experiment event rate. Assessments will be performed at baseline and at 4, 8, and 12 weeks after randomization.

Discussion

This trial will demonstrate that the addition of a Tongmai Yangxin pill (TMYX) to conventional treatment will intervene in the development of cardiac remodeling and cardiac dysfunction.

Trial registration

This study was registered in the Chinese Clinical Trial Registry on 7 May 2019. The registration number is ChiCRT1900023023 (http://www.chictr.org.cn/showproj.aspx?proj=12370).

Real-world clinical diagnostics of heart failure patients with reduced or preserved ejection fraction

Aims

The study aimed at investigating the use of guideline‐recommended diagnostic tools and medication in patients with heart failure (HF) in specialty care in Southwest Finland. We also compared the characteristics of the diagnosed and undiagnosed patients as well as laboratory tests, procedures, and treatments in everyday clinical practice.

Methods and results

Patients diagnosed with HF, cardiomyopathy, or hypertension‐induced heart disease (n = 20 878, primary cohort) or not diagnosed with HF but having a record of elevated N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) (>125 ng/L, n = 24 321, secondary cohort) were included in the study from the specialty care patient register of the Hospital District of Southwest Finland during the years 2005–2017. Among patients with an International Classification of Diseases, Tenth Revision (ICD‐10) code for HF, only 50% had ejection fraction (EF) data to be found by data mining from the electronic health records. Of these patients, 39% (n = 4042) had EF ≤ 40% [HF with reduced EF (HFrEF)] and 61% (n = 6347) had EF > 40%. Elevated NT‐proBNP together with EF > 40% narrowed down the number to 4590 patients, a population defined as HF with preserved EF (HFpEF) patients. HFpEF patients were further stratified into HF with mildly reduced EF (HFmrEF; EF 41–50%, n = 1468) and EF > 50% patients (n = 3122) to compare clinical characteristics. NT‐proBNP was higher within the HFrEF patients vs. HFpEF {4580 [inter‐quartile range (IQR): 2065–9765] vs. 2900 [2065–9765] ng/L, P < 0.001}. Baseline co‐morbidities differed between HFpEF and HFrEF groups. Further, HFpEF patients had more procedures and lab tests taken prior to diagnosis than had HFrEF patients. HFmrEF patients were found to resemble more HFrEF than EF > 50% patients. In 70% (n = 17 156) of patients in the secondary cohort, the NT‐proBNP concentrations were >300 ng/L, median was 1090 (IQR 551–2558) ng/L and EF 58.4 ± 12.1% (n with EF available = 6845). Reduced EF was present in 6.8% of patients lacking HF diagnosis.

Conclusions

Half of the patients with ICD‐10 code for HF did not have EF data available after a visit at specialty care. In particular, the diagnosis of HFpEF seems challenging, reflected as an increase in procedures and laboratory test preceding diagnosis compared with those in HFrEF patients. Also, a large proportion of patients did not have HF diagnosis, yet they presented elevated NT‐proBNP concentrations and clinical characteristics resembling those of HFpEF patients.

Segmental Bioelectrical Impedance Spectroscopy to Monitor Fluid Status in Heart Failure

Bioelectrical impedance spectroscopy (BIS) measures body composition, including fluid status. Acute decompensated heart failure (ADHF) is associated with fluid overload in different body compartments. This investigation aimed to evaluate the feasibility of measuring and monitoring fluid accumulation in patients with ADHF using BIS. The extracellular impedance as a surrogate marker for fluid accumulation was measured in 67 participants (25 healthy reference volunteers and 42 patients admitted with ADHF) using BIS in the “transthoracic”, “foot-to-foot”, “whole-body” and “hand-to-hand” segments. At baseline, BIS showed significantly lower extracellular resistance values for the “whole-body” (P < 0.001), “foot-to-foot” (P = 0.03), “hand-to-hand” (P < 0.001) and “transthoracic” (P = 0.014) segments in patients with ADHF than the reference cohort, revealing a specific pattern for peripheral, central and general fluid accumulation. The “foot-to-foot” (AUC = 0.8, P < 0.001) and “hand-to-hand” (AUC = 0.74, P = 0.04) segments indicated compartments of fluid accumulation with good prediction. During cardiac recompensation, BIS values changed significantly and were in line with routine parameters for monitoring ADHF. Mean bodyweight change per day correlated moderately to good with BIS values in the “whole-body” (r = −0.4), “foot-to-foot” (r = −0.8) and “transthoracic” (r = −0.4) segments. Based on our analysis, we conclude that measuring and monitoring fluid accumulation in ADHF using segmental BIS is feasible and correlates with clinical parameters during recompensation.

EACVI survey on standardization of cardiac chambers quantification by transthoracic echocardiography

AIMS

To evaluate standard reporting of cardiac chambers size and function by transthoracic echocardiography (TTE), the EACVI Scientific Initiatives Committee performed a survey across European centres. In particular, the routine use of three-dimensional echocardiography (3DE) and speckle tracking-derived myocardial deformation imaging (STE) was explored.

METHODS AND RESULTS

A total of 96 European Echocardiography Laboratories from 22 different countries responded to the survey, which consisted of 20 questions. For most of the standard parameters of cardiac chamber size and function, answers from the centres were homogeneous and demonstrated good adherence to current recommendations. In particular, all centres assessed left ventricular (LV) and left atrial (LA) size combining diameter measurements with volumes obtained using the bi-plane Simpson's method. More variability was observed in the measurements of the right heart chambers and thoracic aorta. Interestingly, >90% of centres had access to 3DE and STE; however, the large majority of centres reserved the use of these techniques for selected cases, particularly for the measure of 3D LV volumes and ejection fraction and global longitudinal strain in patients being considered for cardiac device implantation, surgical intervention (valvular heart disease) or screened for cardiotoxicity. Only 10% of centres used 3DE for right ventricular and LA volumes. Also, <30% of the centres used LA strain imaging.

CONCLUSION

In Europe, a good adherence to current recommendations was observed for most of the standard parameters of cardiac chambers quantification by TTE. Advanced echocardiography modalities, such as 3DE and STE, are widely available but used only in selected cases.

Emerging Techniques for Cardiovascular PET

The application of positron emission tomography (PET) to cardiac disease has yielded tremendous developments in the evaluation of coronary artery, myocardial, and valvular heart disease over the past several decades. These advances have included development of new radiotracers, incremental technological improvements, and coupling of PET with other non-invasive cardiac imaging modalities. The current era has seen rapid, successive and wide-ranging advances in PET myocardial perfusion and metabolic imaging. This review will address emerging techniques in cardiovascular PET imaging, including the measurement of absolute myocardial blood flow (MBF), use of novel tracers, and other advances in heart failure, infection imaging, and valvular disease.

Low prevalence of relevant findings in inappropriate echocardiograms and discordant perceptions between cardiologists and patients

Complementary examinations are "inadequate" whenever the likelihood of benefits from their indication is lower than the negative results. The low benefit is a result of poor performance in detecting relevant changes that lead to improved behavior. However, inadequate examinations are prevalent and little is known about patients' notions of the usefulness of such indications. The aim of this study was to describe relevant findings in inappropriate echocardiograms and to assess the level of agreement between patients and cardiologists regarding their usefulness. Adults without known cardiovascular disease who were referred for echocardiogram by inappropriate criteria according to the American College of Cardiology were selected. Relevant findings were defined by any change in the degree of moderate to severe, according to the American Society of Echocardiography. We tested the level of agreement between the patients who underwent echocardiographic examination and the physicians who requested the exam through a standard questionnaire. Five hundred patients were included, with average age of 52±17 years (47% males). Only 17 patients had any relevant changes (3.4%, 95%CI=2 to 5.4%). The most frequent alterations included valve changes in 8 and diastolic dysfunction grade II in 6 patients. Eighty-seven examinations were performed to determine the level of agreement between patients and cardiologists. For the question "Is this test really necessary?", 92% of patients responded positively, compared with 5% of cardiologists (Kappa negative 0.04; P=0.01). The frequency of relevant findings was low in inadequate echocardiograms and patients and cardiologists had a different perception regarding its usefulness.

Appropriateness criteria for treatment of osteoporotic vertebral compression fractures

The purpose of this study was to review and summarise the literature on appropriateness criteria for treatment of osteoporotic vertebral compression fractures (OVCF), with appropriateness defined as a treatment where the expected benefits outweigh the expected harms, confirmed by available evidence and expert opinion. A comprehensive search of peer-reviewed publications (PubMed, EMBASE) and grey literature was performed. To be included for analysis, documents had to be a review article (e.g. clinical guideline or meta-analysis), focus on OVCF and make a statement on treatment appropriateness. Eleven publications fulfilled the eligibility criteria. Among the five publications that made recommendations about non-surgical management (NSM), there is agreement that conservative methods are appropriate in OVCF patients who have low level of pain, and that the majority of patients should be treated with conservative methods before other treatments are initiated. All publications made recommendations about vertebral augmentation procedures (VAP), i.e. vertebroplasty (VP) and/or balloon kyphoplasty (BKP). VAP are mostly considered appropriate in patients with high level of pain who do not respond to NSM. However, results cannot be generalised due to heterogeneity of treatment recommendations and patient selection. Although there is a consensus that NSM should be considered as the first-line treatment, there is more heterogeneity in treatment recommendations for VAP. This could most likely be explained by an insufficient clinical evidence base for VAP and heterogeneity of OVCF patients, leading to greater reliance on expert opinion affecting the quality of evidence in the primary sources.

Appropriate Use Criteria for Echocardiography: Evolving Applications in the Era of Value-Based Healthcare

The current climate in healthcare is increasingly emphasizing a value-based approach to diagnostic testing. Cardiac imaging, including echocardiography, has been a primary target of ongoing reforms in healthcare delivery and reimbursement. The Appropriate Use Criteria (AUC) for echocardiography is a physician-derived tool intended to guide utilization in optimal patient care. To date, the AUC have primarily been employed solely as justification for reimbursement, though evolving broader applications to guide clinical decision-making suggest a far more valuable role in the delivery of high-quality and high-value healthcare.

EuroEcho-Imaging 2015: highlights

The annual meeting of the European Association of Cardiovascular Imaging, EuroEcho-Imaging, was held in Seville, Spain, in December 2015. In the present paper, we present a summary of the 'Highlights' session.

The Role of Cardiovascular Magnetic Resonance Imaging in Heart Failure

Cardiovascular imaging is key for the assessment of patients with heart failure. Today, cardiovascular magnetic resonance imaging plays an established role in the assessment of patients with suspected and confirmed heart failure syndromes, in particular identifying aetiology. Its role in informing prognosis and guiding decisions around therapy are evolving. Key strengths include its accuracy; reproducibility; unrestricted field of view; lack of radiation; multiple abilities to characterise myocardial tissue, thrombus and scar; as well as unparalleled assessment of left and right ventricular volumes. T2* has an established role in the assessment and follow-up of iron overload cardiomyopathy and a role for T1 in specific therapies for cardiac amyloid and Anderson-Fabry disease is emerging.

Quality Markers in Cardiology. Main Markers to Measure Quality of Results (Outcomes) and Quality Measures Related to Better Results in Clinical Practice (Performance Metrics). INCARDIO (Indicadores de Calidad en Unidades Asistenciales del Área del Corazón): A SEC/SECTCV Consensus Position Paper

Cardiology practice requires complex organization that impacts overall outcomes and may differ substantially among hospitals and communities. The aim of this consensus document is to define quality markers in cardiology, including markers to measure the quality of results (outcomes metrics) and quality measures related to better results in clinical practice (performance metrics). The document is mainly intended for the Spanish health care system and may serve as a basis for similar documents in other countries.