Point-of-care ultrasound: Closing guideline gaps in screening for valvular heart disease

A call to consider an aortic stenosis screening program

Aortic stenosis (AS) is the most common age-related valvular condition with a prevalence of 13.1% in patients older than 75 years of age. Based on the severity of AS and symptoms, current guidelines recommend interval monitoring with transthoracic echocardiogram (TTE). However, no guidelines exist regarding screening asymptomatic persons for AS. Prevalence of AS is comparable to conditions such as colorectal cancer, lung cancer, breast cancer, and abdominal aortic aneurysm where dedicated screening programs are offered resulting in reduction of overall morbidity and mortality. We review recent advancements in treatment options, and we propose an AS screening program for high-risk individuals without known history of AS including all persons over age 75 and persons aged 70 years and older with dialysis dependent end-stage renal disease (ESRD).

The future of valvular heart disease assessment and therapy

Valvular heart disease (VHD) is becoming more prevalent in an ageing population, leading to challenges in diagnosis and management. This two-part Series offers a comprehensive review of changing concepts in VHD, covering diagnosis, intervention timing, novel management strategies, and the current state of research. The first paper highlights the remarkable progress made in imaging and transcatheter techniques, effectively addressing the treatment paradox wherein populations at the highest risk of VHD often receive the least treatment. These advances have attracted the attention of clinicians, researchers, engineers, device manufacturers, and investors, leading to the exploration and proposal of treatment approaches grounded in pathophysiology and multidisciplinary strategies for VHD management. This Series paper focuses on innovations involving computational, pharmacological, and bioengineering approaches that are transforming the diagnosis and management of patients with VHD. Artificial intelligence and digital methods are enhancing screening, diagnosis, and planning procedures, and the integration of imaging and clinical data is improving the classification of VHD severity. The emergence of artificial intelligence techniques, including so-called digital twins-eg, computer-generated replicas of the heart-is aiding the development of new strategies for enhanced risk stratification, prognostication, and individualised therapeutic targeting. Various new molecular targets and novel pharmacological strategies are being developed, including multiomics-ie, analytical methods used to integrate complex biological big data to find novel pathways to halt the progression of VHD. In addition, efforts have been undertaken to engineer heart valve tissue and provide a living valve conduit capable of growth and biological integration. Overall, these advances emphasise the importance of early detection, personalised management, and cutting-edge interventions to optimise outcomes amid the evolving landscape of VHD. Although several challenges must be overcome, these breakthroughs represent opportunities to advance patient-centred investigations.

Multimodality Cardiac Imaging and the Imaging Workforce in the United States: Diversity, Disparities, and Future Directions

Innovations in cardiac imaging have fundamentally advanced the understanding and treatment of cardiovascular disease. These advances in noninvasive cardiac imaging have also expanded the role of the cardiac imager and dramatically increased the demand for imagers who are cross-trained in multiple modalities. However, we hypothesize that there is significant variation in the availability of cardiac imaging expertise and a disparity in the adoption of advanced imaging technologies across the United States. To evaluate this, we have brought together the leaders of cardiovascular imaging societies, imaging trainees, as well as collaborated with national imaging accreditation commissions and imaging certification boards to assess the state of cardiac imaging and the diversity of the imaging workforce in the United States. Aggregate data confirm the presence of critical gaps, such as limited access to imaging and imaging expertise in rural communities, as well as disparities in the imaging workforce, notably among women and underrepresented minorities. Based on these results, we have proposed solutions to promote and maintain a robust and diverse community of cardiac imagers and improve equity and accessibility for cardiac imaging technologies.

Point-of-Care Ultrasound for the Diagnosis of Frequent Cardiovascular Diseases: A Review

Point-of-care ultrasound (POCUS) has emerged as an indispensable diagnostic tool in cardiology, particularly within the emergency department. This narrative synthesis provides a comprehensive exploration of POCUS applications in cardiovascular diseases, elucidating its multifaceted roles and addressing challenges. The review delves into the technical attributes of POCUS, emphasizing its non-invasive nature, radiation-free qualities, and suitability for non-radiologists. It navigates through educational strategies, stressing the importance of structured programs for the seamless integration of POCUS into clinical practice. Highlighting its efficacy, the synthesis discusses POCUS applications in various scenarios such as dyspnea, chest pain, cardiac arrest, aortic dissection, pericardial effusion, and pulmonary embolism. Beyond acute care, the review explores the role of POCUS in outpatient and inpatient settings, focusing on chronic and acute heart failure, valvular heart diseases, and more. Acknowledging operator-dependent challenges and the need for continuous education, the review underscores the transformative potential of POCUS across diverse healthcare settings. This narrative synthesis accentuates POCUS as a valuable and versatile diagnostic tool in cardiology, offering efficiency, safety, and cost-effectiveness. Despite challenges, POCUS stands out as a transformative addition to clinical practices, poised to enhance patient outcomes and reshape the landscape of cardiovascular diagnostics.

Diagnostic Accuracy of Cardiac Point-of-Care Ultrasound in a Tertiary Medical Intensive Care Unit

Objective

Critical care echocardiography (CCE) is a useful tool for managing critically ill patients in intensive care. However, concerns exist regarding the accuracy of CCE examinations because of operator dependence. We sought to evaluate the accuracy of CCE examinations compared with cardiology-performed transthoracic echocardiogram (TTE).

Design Setting and Subjects

We retrospectively reviewed charts of patients in a medical ICU in a large academic medical center in the United States. We compared CCE examinations performed by a fellow and reviewed by a staff physician between May 5, 2020, and December 31, 2021, to TTE obtained within 24 hours of the CCE examination.

Intervention Measurements and Main Results

We developed a standardized process for documentation of all CCE examinations performed in the medical ICU. We assessed agreement (kappa statistic), sensitivity and specificity of CCE examination compared with TTE. Features included left ventricle (LV) systolic function, right ventricle (RV) size, RV systolic function, pericardial effusion, mitral insufficiency, tricuspid insufficiency, and aortic insufficiency. The study analyzed 504 pairs of CCE and TTE examinations. Kappa statistics for detecting LV and RV systolic dysfunction, pericardial effusion, and RV size ranged from 0.60 to 0.74. CCE showed high sensitivity and specificity for detecting LV and RV systolic dysfunction and pericardial effusion, with values ranging from 0.85 to 0.99. The kappa statistic for detecting RV dilation was 0.59, with a sensitivity of 0.71 and a specificity of 0.85. In contrast, CCE examinations were nondiagnostic for mitral, tricuspid, or aortic insufficiency in 60-70% of cases, whereas TTE examinations were nondiagnostic in 20-30% of cases. Kappa statistics for mitral, tricuspid, and aortic insufficiency ranged from 0.32 to 0.42.

Conclusions

CCE is a reliable tool for assessing LV and RV systolic function, pericardial effusion, and RV size. However, CCE may be limited in its ability to detect mitral, tricuspid, or aortic insufficiency.

Building Consensus on the Point-of-Care Ultrasound Skills Required for Effective Healthcare Service Delivery at District Hospitals in South Africa: A Delphi Study

BACKGROUND

Despite the widespread availability of ultrasound machines in South African district hospitals, there are no guidelines on the competency in point-of-care ultrasound (POCUS) use required by generalist doctors in this setting. This study aimed to define the required POCUS competencies by means of consensus via the Delphi method.

METHODS

An online Delphi process was initiated in June 2022, using the existing American Academy of Family Physicians' ultrasound curriculum (84 skillsets) as the starting questionnaire. Panelists were selected across the country, including two from district hospitals in each province and two from each academic family medicine department in South Africa (N = 36). In each iterative round, the participants were asked to identify which POCUS skillsets were essential, optional (region-specific), or non-essential for South African district hospitals. This process continued until consensus (>70% agreement) was achieved on all of the skillsets.

RESULTS

Consensus was achieved on 81 of the 84 skillsets after 5 iterative rounds (96.4%), with 3 skillsets that could not achieve consensus (defined as <5% change over more than 2 consecutive rounds). The final consensus identified 38 essential, 28 optional, and 15 non-essential POCUS skillsets for the South African district hospital context.

CONCLUSIONS

The list of essential POCUS skillsets provided by this study highlights the predominance of obstetric- and trauma-based skillsets required for generalist healthcare workers in South African district hospitals. The findings will require priority setting and revalidation prior to their implementation across the country.

Use of bedside echocardiography in the care of critically ill patients - a joint consensus document of the Associação de Medicina Intensiva Brasileira, Associação Brasileira de Medicina de Emergência, and Sociedade Brasileira de Medicina Hospitalar. Part 1 - Competence in bedside echocardiography

The use of echocardiography by physicians who are not echocardiographers has become common throughout the world across highly diverse settings where the care of acutely ill patients is provided. Echocardiographic evaluation performed in a point-of-care manner can provide relevant information regarding the mechanism of causes of shock, for example, increasing the rates of correct diagnosis and allowing for faster informed decision-making than through evaluation methods. Considering that the accurate diagnosis of life-threatening situations is essential for professionals working with acutely ill patients, several international associations recommend that physicians responsible for critically ill patients acquire and develop the ability to perform bedside ultrasound examinations, including echocardiographic examinations. However, there is no consensus in the literature regarding which specific applications should be included in the list of skills for nonechocardiographer physicians. Taking into account the multiplicity of applications of echocardiography in different scenarios related to acutely ill patients; the differences in the published protocols, with regard to both the teaching methodology and competence verification; and the heterogeneity of training among highly diverse specialties responsible for their care at different levels, this consensus document aimed to reflect the position of representatives of related Brazilian medical societies on the subject and may thus serve as a starting point both for standardization among different specialties and for the transmission of knowledge and verification of the corresponding competencies.

Challenging Decision-Making Between Transcatheter Aortic Valve Implantation and Aortic Valve Surgery: A Case of a Jehovah's Witness Patient With Severe Symptomatic Aortic Stenosis Coexisting With Severe Mitral Regurgitation and Bicuspid Aortic Valve

A 73-year-old Jehovah's witness man with a bicuspid aortic valve and a history of epilepsy presented to the emergency room with chest pain and dyspnea. Echocardiography revealed normal left ventricular systolic function, but also revealed severe aortic stenosis and severe mitral regurgitation. Coronary angiography and computerized tomography angiography ruled out any significant coronary artery disease and aortic dissection, respectively. In view of his religious views, transcatheter aortic valve implantation was considered more suitable than aortic valve surgery and was successful with a stable postoperative state. This case reaffirms that autonomy should be maintained while considering the best interest of patients in decision-making.

Evaluating Medical Therapy for Calcific Aortic Stenosis: JACC State-of-the-Art Review

Despite numerous promising therapeutic targets, there are no proven medical treatments for calcific aortic stenosis (AS). Multiple stakeholders need to come together and several scientific, operational, and trial design challenges must be addressed to capitalize on the recent and emerging mechanistic insights into this prevalent heart valve disease. This review briefly discusses the pathobiology and most promising pharmacologic targets, screening, diagnosis and progression of AS, identification of subgroups that should be targeted in clinical trials, and the need to elicit the patient voice earlier rather than later in clinical trial design and implementation. Potential trial end points and tools for assessment and approaches to implementation and design of clinical trials are reviewed. The efficiencies and advantages offered by a clinical trial network and platform trial approach are highlighted. The objective is to provide practical guidance that will facilitate a series of trials to identify effective medical therapies for AS resulting in expansion of therapeutic options to complement mechanical solutions for late-stage disease.

Point-of-care ultrasound: Closing guideline gaps in screening for valvular heart disease

BACKGROUND

A linear increase in the number of valvular heart disease is expected due to the aging population, yet most patients with severe valvular heart disease remain undiagnosed.

HYPOTHESIS

POCUS can serve as a screening tool for valvular heart disease.

METHODS

We reviewed the literature to assess the strengths and limitations of POCUS in screening and diagnosing valvular heart disease.

RESULTS

POCUS is an accurate, affordable, accessible, and comprehensive tool. It has a fast learning curve and can prevent unnecessary and more expensive imaging. Challenges include training availability, lack of simplified screening protocols, and reimbursement. Large scale valvular screening data utilizing POCUS is not available.

CONCLUSION

POCUS can serve as a screening tool and guide the management of patients with valvular heart disease. More data is needed about its efficacy and cost-effectiveness in the screening of patients with valvular heart disease.