Echocardiography update for primary care physicians: a review

Improved Spatiotemporal Resolution in Echocardiography Using Mixed Geometry Imaging Sequences

Cardiac ultrasound seeks to image the most dynamic environment in the body-the moving heart. Many modern ultrasound imaging techniques address the tradeoff between spatial and temporal resolution using either narrow focused beams or with broad beam, synthetic aperture (SA) sequences that have been shown to suffer from motion artifacts. Retrospective encoding for conventional ultrasound sequences (REFoCUS) unifies the processing of these various geometric sequences, but the motion sensitivity of this approach has yet to be investigated. We hypothesize that a "mixed sequence" enabled by the REFoCUS method incorporating several beam geometries may better resolve cardiac motion over a wide field of view (FOV) and at a high frame rate. First, the motion sensitivity of REFoCUS was evaluated in simulation for several focused and broad transmit profiles. Focused transmissions resolve both lateral and axial motion much more effectively than broad transmissions, with performance similar to conventional beamforming techniques. Second, a mixed sequence was designed that insonifies the full field-of-view with plane wave (PW) transmissions and key moving targets with focused transmissions. This mixed sequence was tested in simulation and in vivo and was used to image the heart as well as the liver, a low-motion control. By combining a sparse PW sequence ( n=60 ) with a small group of targeted focused transmissions ( n = 10), the anterior mitral valve leaflet (AML) at its peak observed velocity was better resolved. We believe that mixed sequences have strong potential to resolve cardiac motion at clinically relevant frame rates.

Fragmented QRS Is Independently Predictive of Long-Term Adverse Clinical Outcomes in Asian Patients Hospitalized for Heart Failure: A Retrospective Cohort Study

Background: Fragmented QRS (fQRS) results from myocardial scarring and predicts cardiovascular mortality and ventricular arrhythmia (VA). We evaluated the prevalence and prognostic value of fQRS in Asian patients hospitalized for heart failure.

Methods and Results: This was a retrospective cohort study of adult patients hospitalized for heart failure between 1st January 2010 and 31st December 2016 at a tertiary center in Hong Kong. The baseline ECG was analyzed. QRS complexes (<120 ms) with fragmented morphology in ≥2 contiguous leads were defined as fQRS. The primary outcome was a composite of cardiovascular mortality, VA, and sudden cardiac death (SCD). The secondary outcomes were the components of the primary outcome, myocardial infarction, and new-onset atrial fibrillation. In total, 2,182 patients were included, of whom 179 (8.20%) had fQRS. The follow-up duration was 5.63 ± 4.09 years. fQRS in any leads was associated with a higher risk of the primary outcome (adjusted hazard ratio (HR) 1.428 [1.097, 1.859], p = 0.001), but not myocardial infarction or new-onset atrial fibrillation. fQRS in >2 contiguous leads was an independent predictor of SCD (HR 2.679 [1.252, 5.729], p = 0.011). In patients without ischaemic heart disease (N = 1,396), fQRS in any leads remained predictive of VA and SCD (adjusted HR 3.526 [1.399, 8.887], p = 0.008, and 1.873 [1.103, 3.181], p = 0.020, respectively), but not cardiovascular mortality (adjusted HR 1.064 [0.671, 1.686], p = 0.792).

Conclusion: fQRS is an independent predictor of cardiovascular mortality, VA, and SCD. Higher fQRS burden increased SCD risk. The implications of fQRS in heart failure patients without ischaemic heart disease require further studies.

The contribution of family physicians in coordinating care and improving access at district hospitals: The False Bay experience, South Africa

This short report describes three family physicians (FP)-led clinical governance interventions to strengthen the care access and coordination in an urban district hospital in Cape Town, South Africa. The actual experiences and their effects on health services are captured here. The report also describes a range of interventions from enhanced access to timely computer tomographic scans to determine definitive care, to creating a local referral forum between levels of care, which resulted in a renewed appreciation for the scope of services and illness burden managed by the district health system and to the establishment of an onsite echocardiology service at the local district hospital to enhance the identified burden of disease of the local community. Each of these interventions were planned and implemented based on local data in partnership with the team members at the different levels of care. By applying an inclusive and distributed leadership style as informed by care access to scarce resources was better coordinated for the local communities served. The importance of the building trusting relationships between FPs and referral hospital colleagues cannot be overemphasised. Family physicians should be integrated and collaborated in the clinical governance platforms across levels of care. The FP’s roles as primary care consultant and clinical governance leader are pivotal in enhancing service delivery efficiency and in providing quality healthcare.

Ten things to know about ten imaging studies: A preventive cardiology perspective ("ASPC top ten imaging")

Knowing the patient's current cardiovascular disease (CVD) status, as well as the patient's current and future CVD risk, helps the clinician make more informed patient-centered management recommendations towards the goal of preventing future CVD events. Imaging tests that can assist the clinician with the diagnosis and prognosis of CVD include imaging studies of the heart and vascular system, as well as imaging studies of other body organs applicable to CVD risk. The American Society for Preventive Cardiology (ASPC) has published "Ten Things to Know About Ten Cardiovascular Disease Risk Factors." Similarly, this "ASPC Top Ten Imaging" summarizes ten things to know about ten imaging studies related to assessing CVD and CVD risk, listed in tabular form. The ten imaging studies herein include: (1) coronary artery calcium imaging (CAC), (2) coronary computed tomography angiography (CCTA), (3) cardiac ultrasound (echocardiography), (4) nuclear myocardial perfusion imaging (MPI), (5) cardiac magnetic resonance (CMR), (6) cardiac catheterization [with or without intravascular ultrasound (IVUS) or coronary optical coherence tomography (OCT)], (7) dual x-ray absorptiometry (DXA) body composition, (8) hepatic imaging [ultrasound of liver, vibration-controlled transient elastography (VCTE), CT, MRI proton density fat fraction (PDFF), magnetic resonance spectroscopy (MRS)], (9) peripheral artery / endothelial function imaging (e.g., carotid ultrasound, peripheral doppler imaging, ultrasound flow-mediated dilation, other tests of endothelial function and peripheral vascular imaging) and (10) images of other body organs applicable to preventive cardiology (brain, kidney, ovary). Many cardiologists perform cardiovascular-related imaging. Many non-cardiologists perform applicable non-cardiovascular imaging. Cardiologists and non-cardiologists alike may benefit from a working knowledge of imaging studies applicable to the diagnosis and prognosis of CVD and CVD risk - both important in preventive cardiology.