Left ventricular hypertrophy screening using a hand-held ultrasound device

Screening of Native Valvular Heart Disease Using a Pocket-Sized Transthoracic Echocardiographic Device

BACKGROUND

The authors assessed the performance of pocket-sized transthoracic echocardiography (pTTE) compared with standard transthoracic echocardiography (sTTE) and auscultation for early screening of valvular heart disease (VHD). Early diagnosis of significant VHD is a challenge, but it enables appropriate follow-up and implementation of the best therapeutic strategy.

METHODS

sTTE, pTTE, and auscultation were performed by three different experienced physicians on 284 unselected patients. All cases of VHD detected by each of these three techniques were noted. sTTE was the gold standard. Each physician performed one examination and was blinded to the results of other examinations.

RESULTS

We diagnosed a total of 301 cases of VHD, with a large predominance of regurgitant lesions: 269 cases (89.3%) of regurgitant VHD and 32 (10.7%) of stenotic VHD. pTTE was highly sensitive (85.7%) and specific (97.9%) for screening for VHD, while auscultation detected only 54.1%. All significant cases of VHD (at least mild severity) were detected on pTTE. The weighted κ coefficient between pTTE and sTTE for the assessment of mitral regurgitation was 0.71 (95% CI, 0.70-0.72), indicating good agreement. The weighted κ coefficients between pTTE and sTTE for the assessment of aortic regurgitation and aortic stenosis were 0.97 (95% CI, 0.96-0.98) and 0.98 (95% CI, 0.97-0.99), respectively, indicating excellent agreement.

CONCLUSIONS

pTTE performed by physicians with level III competency in echocardiography is reliable for identifying significant VHD and should be proposed as a new screening tool.

Digital devices for teaching cardiac auscultation - a randomized pilot study

BACKGROUND

Competent cardiac auscultation is a declining skill. Digital stethoscopes and hand-held echocardiography (HHE) are modern devices which may improve the accuracy of heart murmur recognition and diagnosis. Their incremental value compared to conventional examination has not been evaluated in depth.

OBJECTIVES

Our aim was to quantify the utility of digital stethoscopes and HHE as teaching aids to improve medical students' diagnostic accuracy in the evaluation of heart murmurs using a novel clinically weighted scoring system.

DESIGN

This pilot study involved eight medical students and eight patients with heart murmurs. Four patients were examined at 2 sessions, 1 week apart. Medical students were randomised into two groups: the 'intervention group' examined patients with a standard and digital stethoscope, and then received demonstration of the valvular lesion with HHE to illustrate the diagnosis. The 'control group' used a standard stethoscope only and were taught using traditional methods. Students' scores were compared to a 'gold standard' derived from a consensus of auscultation findings of three cardiologists.

RESULTS

Overall the mean percent correct of total possible score was 65.4% (SD8.4). Using a mixed models ANOVA approach to repeated measures, the mean [95% CI] increase from training to validation period for the control group was 2.5% [-11.5, 16.5] P(Tukey) = 0.95 and 15.8% [1.7,29.8] P(Tukey) = 0.027 for the intervention group. Between the validation and training sessions for both groups, there was an increase of 9.1% [1.82, 16.4] in scores (p = 0.018). The mean [95% CI] difference in scores of the control and intervention groups was 1.9% [-5.4, 9.2] (p = 0.59). The Cohen's effect size estimate was 0.9.

CONCLUSION

Digital stethoscopes and hand-held echo may be useful devices for teaching cardiac auscultation. This pilot study provides a novel study design, a heart murmur grading system, and data that will help develop definitive studies to assess new teaching techniques for cardiac auscultation using digital technology.

Cardiovascular Ultrasound Combined With Non-invasive Screening for the Detection of Undiagnosed Cardiovascular Disease: A Literature Review

Non-invasive screenings have been widely utilized in the United States and worldwide to provide early identification of cardiovascular disease, allowing for earlier diagnosis and treatment. Screening sonography detects valve disease, cardiac dysfunction, and carotid disease in 5% to 20% of the population. This review discusses the current data regarding cardiovascular screening, the methodologies, and the resources required for performance of screenings. Cardiac and carotid sonography is highly accurate and discovers cardiovascular diseases that impact quality of life and risk of future events. Screenings are performed in a variety of settings and accuracy depends on the quality of personnel performing the non-invasive testing, the equipment utilized, and the personnel interpreting the studies. Despite the potential benefit for disease detection, population screening to detect cardiovascular disease is not widely supported by national organizations due to the theoretical cost of further testing and lack of cost versus benefit data. Additional studies are necessary to compare costs and benefits of non-invasive cardiovascular screening in the community setting.

Clinical utility and diagnostic accuracy of palm-held, mini-sized ultrasonocardiographic scanner in congenital heart disease

BACKGROUND/PURPOSE

To investigate whether a palm-held ultrasonocardiographic scanner would be useful for screening and follow-up in congenital heart disease (CHD).

METHODS

We retrospectively reviewed the echocardiographic images from June 1, 2014 to November 1, 2014. All patients underwent two ultrasonographic examinations including palm-held scanner examination and standard echocardiography. To compare the quality of the two instruments, we developed a diagnostic scoring system ranging from 1 point to 10 points, with 10 points indicating the best quality. Two experienced echocardiographers retrospectively reviewed all recorded images blindedly and gave each examination a score. Comparisons of diagnostic score between two equipments were performed.

RESULTS

A total of 262 patients' images were reviewed. All cardiac lesions could be detected with both instruments. The mean diagnostic score of palm-held scanner and standard echocardiography were 8.20±0.53 versus 9.64±0.37 (p<0.05) in color image and 7.00±1.05 versus 8.56±1.14 (p<0.05) in gray-scale two-dimensional image, respectively. When we compared the score between the two instruments in individual CHDs, we found standard echocardiography had better quality except for detecting muscular ventricular septal defect and pulmonary regurgitation.

CONCLUSION

The diagnostic sensitivity of palm-held scanner in detecting CHD was very good. Despite both instruments having a high diagnostic score in detecting CHD, standard echocardiography had better quality. Traditional echocardiography is still the standard tool for CHD evaluation. However, the palm-held scanner can support physical examination for initial screening and follow-up, and offer cardiologists an opportunity to visualize and listen to the heart at any time.

Early markers of right heart involvement in regular smokers by Pocket Size Imaging Device

PURPOSE

To test the diagnostic power of Pocket Size Imaging Device (PSID) in detecting early signs of right heart (RH) involvement in regular smokers (RS) free of overt cardiac involvement.

METHODS

One-hundred-forty-three regular smokers and 51 healthy controls, comparable for age and sex, underwent physical exam (PE), PSID exam and standard echocardiography. Based on a simplified Boston score, ≥1 of clinical signs (jugular venous distension, hepatomegaly, peripheral pitting oedema and abnormal pulmonary sounds) were considered indicative of RH involvement. A composite score (1 to 4) obtained by summing the points of four quantitative RH abnormalities detectable by PSID (inferior vena cava [IVC] dilatation, reduced IVC respiratory variation, right ventricular dilatation and right atrial dilatation), was generated and ≥1 of PSID abnormal signs was considered indicative of RH involvement.

RESULTS

Boston score was not significantly different between the two groups. By using PSID, smokers exhibited greater IVC diameter (p < 0.0001), right atrial diameter (p < 0.002) and higher PSID score (p < 0.005) than controls. Compared to PE, the additional diagnostic power of PSID (≥1 abnormal sign of both Boston and PSID score) was 44.9% in smokers. By dividing smokers in tertiles according to number of cigarettes per day, the third tertile showed the largest values of both IVC and right atrial dimension. Differences were confirmed by standard echocardiography. Reproducibility of PSID measurements and concordance of linear measurements between PSID and standard echo measurements was very good except for concordance of right ventricular basal diameter.

CONCLUSIONS

PSID detects early ultrasound signs of RH involvement in regular otherwise healthy smokers in comparison with PE.

Pocket-size echocardiograph--a valuable tool for nonexperts or just a portable device for echocardiographers?

PURPOSE

The diagnostic value of examinations performed with the use of pocket-size echocardiograph by medical professionals with different levels of experience remains to be determined. The aim of this study was to assess the diagnostic value of bedside echocardiographic examinations performed with the use of pocket-size echocardiograph by experienced cardiologist and medical students.

MATERIAL/METHODS

The study group comprised 90 patients (63 men, 27 women; mean age 64±14 years) admitted to the cardiac intensive care unit and 30 patients from an out-patient clinic (21 men, 9 women; mean age 62±17 years). All patients underwent bedside echocardiographic examination performed with pocket-size echocardiograph by two briefly trained medical students (n=90 patients) or cardiologist (n=30 patients). Major findings were recorded using a simplified questionnaire. Within 24 hours standard echocardiographic examination was performed in all patients by another cardiologist using a full sized echocardiograph. The study group was divided into 4 subgroups: A / B - first / second half of in-patients examined by students, group C - inpatients examined by cardiologist, group D- out-patients examined by students.

RESULTS

The agreement between standard transthoracic echocardiography (sTTE) and major findings on bedside transthoracic echocardiography (bTTE) was fair to moderate (kappa 0.293-0.57) in group A, moderate to very good (kappa 0.535-1.00) in group B, good to very good (kappa 0.734-1.00) in group C and moderate to very good (kappa 0.590-1.00) in group D.

CONCLUSIONS

Pocket-size echocardiograph enables an expert echocardiographer to perform reliable bedside examinations. When used by briefly trained medical students it provides an acceptable diagnostic value with notable learning curve effect.

Diagnostic accuracy and cost-effectiveness of a pocket-sized transthoracic echocardiographic imaging device

BACKGROUND

The recently introduced pocket-sized portable transthoracic echocardiography (pTTE) is accurate for measurement of cardiac chamber size and function as well as for assessment of valvular regurgitation. This study aimed to compare the diagnostic accuracy of the pocket-sized pTTE with the standard TTE (sTTE) and assess its cost-effectiveness.

HYPOTHESIS

The use of pocket-sized pTTE, as an initial screening tool, may be feasible, accurate and cost-effective in the diagnostic strategy of cardiac abnormalities.

METHODS

The study subjects were 200 patients scheduled for sTTE and an electrocardiogram (ECG). Each patient underwent pTTE examination with the Vscan (GE Medical Systems, Milwaukee, WI) immediately after sTTE. The findings of pTTE and the ECG were compared with the results of sTTE. Cost-effectiveness was calculated.

RESULTS

There was a strong agreement in the detection of abnormal findings between pTTE and sTTE (agreement = 90%), whereas the agreement between the ECG and sTTE was 65%. When pTTE or the ECG was used as an initial screening tool prior to sTTE, similar cost reduction was obtained (approximately 30%) by reducing the number of referrals for sTTE. However, the negative predictive value of a diagnostic strategy with pTTE (92%) was superior to that with an ECG (67%).

CONCLUSIONS

This study demonstrates that the pocket-sized pTTE provides accurate detection of cardiac structural and functional abnormalities beyond the ECG. In addition, the use of pTTE as an initial screening tool prior to sTTE is cost-effective, suggesting that the pocket-sized pTTE is poised to alter the current diagnostic strategy in clinical practice.

[Diagnostic usefulness of pocket echography performed in hypertensive patients by a general practitioner]

BACKGROUND AND OBJECTIVE

Conventional echocardiography is the technique of choice for assessing cardiac involvement in arterial hypertension. Nevertheless, its availability in primary care is very limited. This study aimed to define the diagnostic usefulness of pocket echocardiography performed by a general practitioner (GP) in patients with arterial hypertension.

PATIENTS AND METHOD

Cross-sectional study of a random sample of 393 patients with arterial hypertension. A GP appropriately trained in the technique performed an examination with a pocket echocardiograph and semiquantitatively assessed the different findings. The studies were blindly re-assessed by an expert cardiologist and analyzed quantitatively by computer software. Dimensions of the left ventricle, left atrium and ascending aorta were assessed, together with interventricular septum thickness and presence of valve lesions.

RESULTS

The study took less than 5min and the quality was good-acceptable in 98%. Analysis showed very good concordance (weighted kappa>0,83) in dimensions of the left ventricle, left atrium and ascending aorta, interventricular septum thickness, aortic regurgitation and aortic valve sclerosis, and good concordance (weighted kappa>0,71) in mitral regurgitation and mitral valve calcification. Only 6 (2.6%) of the significant lesions were diagnosed by the GP.

CONCLUSIONS

Pocket echocardiography in primary care performed by a GP, as an extension of the clinical assessment of patients with arterial hypertension, provides an early diagnosis of significant cardiac lesions which may improve therapeutic management.

Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department

BACKGROUND

We aimed to investigate the potential benefit of adding a routine cardiac and abdominal diagnostic examination by pocket-sized ultrasound device in patients admitted to a medical department.

METHODS

A random sample of 196 patients admitted to the medical department at a non-university hospital in Norway between March and September 2010 was studied. The patients underwent cardiac and abdominal screening with a pocket-sized ultrasound device with B-mode and color flow imaging after a principal diagnosis was set. Three internists/cardiologists experienced in ultrasonography performed the examinations. Diagnostic corrections were made and findings were confirmed by high-end echocardiography and examinations at the radiologic department.

RESULTS

196 patients were included (male=56.6%, mean±SD; 68.1±15.0 years old). The time spent doing the ultrasound screening was mean±SD 4.3±1.6 min for the cardiac screening and 2.5±1.1 min for the abdominal screening. In 36 (18.4%) patients this examination resulted in a major change in the primary diagnosis. In 38 (19.4%) patients the diagnosis was verified and in 18 (9.2%) patients an important additional diagnosis was made.

CONCLUSION

By adding a pocket-sized ultrasound examination of <10 min to usual care, we corrected the diagnosis in almost 1 of 5 patients admitted to a medical department, resulting in a completely different treatment strategy without delay in many of the patients. Routinely adding a cardiac and abdominal ultrasound screening has the potential to rearrange inpatients workflow and diagnosis.

Diagnostic utility and clinical usefulness of the pocket echocardiographic device

BACKGROUND

The pocket echocardiograph (PE) with color Doppler imaging belongs to a new class of diagnostic tools, the feasibility and accuracy of which is not well established. The aim of this study was to assess the feasibility and diagnostic value of transthoracic echocardiography (TTE) performed with the use of PE by a cardiology resident (2nd year of training) and by an experienced cardiologist.

METHODS

The study population comprised 220 consecutive patients (142 men, mean age 63 ± 8 years), 110 of whom were admitted to our intensive cardiac care unit (ICU) and 110 patients referred for TTE from the outpatient clinic. All patients had PE TTE performed by a resident (60 ICU patients, 60 outpatients) or a cardiologist (50 ICU patients, 50 outpatients). Within 24 h of PE TTE, all subjects had a standard TTE (sTTE) performed by an experienced echocardiographer.

RESULTS

96% of patients had echocardiographic measurements completed by both PE TTE and sTTE. The dimensions measured with PE TTE by the resident and the cardiologist showed good to excellent correlation with sTTE (r = 0.64-0.96, P < 0.001). The agreement in detection of various pathologies between PE TTE performed by the resident and sTTE examinations was moderate to very good, whereas it was good to excellent if PE TTE was performed by the experienced cardiologist.

CONCLUSION

The diagnostic accuracy of the PE in basic assessment of cardiac morphology and function as compared to standard echocardiography is moderate to very good for a cardiology resident and good to excellent for an experienced cardiologist. (Echocardiography 2012;29:1-6).

[Suitability and performance of echocardiogram in primary care]

OBJECTIVE

The echocardiogram (ECC) is not available to all Spanish General Practitioners (GP) despite its proven benefits in prevalent diseases, such as hypertension and heart failure.

STUDY OBJECTIVE

To analyse the clinical adequacy of the application, performance, and diagnostic and therapeutic decisions of ECC indicated by the GP.

DESIGN

Descriptive, cross-sectional, retrospective, multicentre study.

SETTING

Primary care. Four health centres (HC).

PARTICIPANTS

A total of 684 patients over 18 years who had an ECC performed in 2006-2007.

MAIN MEASUREMENTS

A review of medical records and the ECC report. The socio-demographic variables, clinical and diagnostic performance were also evaluated.

RESULTS

The majority of patients (62.3%) were ≥ 65 years, of which 61.8% were female The most frequent reasons for performing ECC were (but not limited to): heart failure: 30%, suspected valvular disease: 26%; suspected cardiomyopathy: 24.3%. Adequacy of the ECC: 84% (95% CI: 81.09-86.7%) with differences by age (p=.02), HC teaching (p<.001), comorbidity (p<.001) and abnormal ECC (p<.001). A disease was found in 80% of ECC, with differences according to age (p<.001), comorbidity (p=0.02), cardiovascular risk factors (p<.001) and degree of appropriateness of ECC (p=.001). The most common findings (but not limited to) included: valvular heart disease (61.6%) left ventricular hypertrophy (43%) diastolic dysfunction (28.2%). The results of the ECC helped make decisions in 35.2%, with 17.1% referred to cardiology, 10.5% treatment change and 9.6% other tests.

CONCLUSIONS

We found that the application of ECC was highly appropriate. The results of ECC drive clinical decisions in a high percentage of cases. The ECC should be accessible to all GP.

Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography

BACKGROUND

The aim of this study was to investigate the imaging capabilities of recent hand-held ultrasound scanners.

METHODS

Three hundred forty-nine patients were scanned with hand-held ultrasound (HAND) and high-end echocardiography (HIGH). Segmental endocardial border delineation was scored (2 = good, 1 = poor, 0 = invisible) to describe image quality. Assessments of left ventricular (LV) dimensions, regional and global LV function, and grades of valve disease were compared.

RESULTS

The mean endocardial visibility grades were 1.6 ± 0.5 with HAND and 1.7 ± 0.4 with HIGH (P < .01). Regional wall motion was scored very similarly (κ = 0.73, P < .01). Ejection fraction assessment (bias = 1.8%, 1.96 × SD = 8.3%) and LV measurements (r = 0.99, P < .01; interventricular septum: bias = 0.91 mm, 1.96 × SD = 2.1 mm; LV end-diastolic diameter: bias = 0.5 mm, 1.96 × SD = 4.1 mm; LV posterior wall: bias = 0.61 mm, 1.96 × SD = 2.4 mm) showed negligible deviations. No pericardial effusion or valve stenosis was missed. Regurgitations missed by HAND were all graded "minimal" on HIGH. Regurgitations were mildly overestimated by HAND. Overall concordance for detection of regurgitations was very good (κ = 0.9, P < .01).

CONCLUSIONS

Handheld echocardiography was feasible and missed no relevant findings. Given the future implementation of spectral Doppler capabilities, this handheld scanner can safely be used in clinical routine.

Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study

Miniaturization has evolved in the creation of a pocket-size imaging device which can be utilized as an ultrasound stethoscope. This study assessed the additional diagnostic power of pocket size device by both experts operators and trainees in comparison with physical examination and its appropriateness of use in comparison with standard echo machine in a non-cardiologic population.

Three hundred four consecutive non cardiologic outpatients underwent a sequential assessment including physical examination, pocket size imaging device and standard Doppler-echo exam. Pocket size device was used by both expert operators and trainees (who received specific training before the beginning of the study). All the operators were requested to give only visual, qualitative insights on specific issues. All standard Doppler-echo exams were performed by expert operators.

One hundred two pocket size device exams were performed by experts and two hundred two by trainees. The time duration of the pocket size device exam was 304 ± 117 sec. Diagnosis of cardiac abnormalities was made in 38.2% of cases by physical examination and in 69.7% of cases by physical examination + pocket size device (additional diagnostic power = 31.5%, p < 0.0001). The overall K between pocket size device and standard Doppler-echo was 0.67 in the pooled population (0.84 by experts and 0.58 by trainees). K was suboptimal for trainees in the eyeball evaluation of ejection fraction, left atrial dilation and right ventricular dilation. Overall sensitivity was 91% and specificity 76%. Sensitivity and specificity were lower in trainees than in experts.

In conclusion, pocket size device showed a relevant additional diagnostic value in comparison with physical examination. Sensitivity and specificity were good in experts and suboptimal in trainees. Specificity was particularly influenced by the level of experience. Training programs are needed for pocket size device users.

Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination

BACKGROUND

The aim of this study was to assess the usefulness of a new miniaturized echocardiographic system (MS) to perform bedside echocardiography in initial outpatient cardiology consultations, in addition to physical examination.

METHODS

One hundred eighty-nine patients referred for initial cardiology outpatient consultations at two tertiary hospitals in two countries were studied. Each patient was submitted to physical examination followed by MS assessment. Scanning time, the number of examinations with abnormal results after physical examination and the MS, and the information obtained by physical examination alone and followed by the MS (in terms of its importance in reaching a diagnosis, in the necessity of performing routine echocardiography, and in the decision to release the patient from the outpatient clinic) were assessed.

RESULTS

The scanning time with the MS was 180 ± 86 seconds. Its use after physical examination led to diagnoses in 141 patients (74.6%) and to an additional 37 patients (19.6%) being released from the outpatient clinic. After physical examination followed by MS assessment, only 64 patients (33.9%) were sent to the echocardiography lab. The MS modified the decision of whether to send a patient to the echocardiography lab, with referral determined by the MS in 27 patients (14.3%) and no referral determined by the MS in 58 patients (30.7%).

CONCLUSIONS

The new MS caused a negligible increase in the duration of consultations. It showed additive clinical value over physical examination, increasing the number of diagnoses, reducing the use of unnecessary routine echocardiography, increasing the number of adequate echocardiographic studies, and determining a large number of releases from the outpatient clinic.

A hand-carried cardiac ultrasound device in the outpatient cardiology clinic reduces the need for standard echocardiography

OBJECTIVE

To assess the potential value and cost-effectiveness of a hand-carried ultrasound (HCU) device in an outpatient cardiology clinic.

METHODS

222 consecutive patients were prospectively enrolled in the study. When standard echocardiography (SE) was specifically indicated on the basis of clinical history, electrocardiogram and physical examination, the same cardiologist (level-2 or level-3 trained) immediately performed an HCU examination. The cardiologist then reassessed the clinical situation to confirm or cancel the SE request according to the information provided by HCU. The SE examination was performed by a sonographer and examined in a blinded fashion by a cardiologist expert in echocardiography. Findings from the two examinations were compared.

RESULTS

HCU was performed in 108/222 patients, and a definite diagnosis was established in 34 of them (31%), making SE examination potentially avoidable. In the 74 patients with inconclusive HCU results and for whom SE was still indicated, the decision was mainly dictated by the lack of spectral Doppler modality in the HCU system. The overall agreement between HCU and SE for diagnosis of normal/abnormal echocardiograms was 73% (kappa = 0.4). On the basis of the potentially avoided SE examinations and the obviated need for a second cardiac consultation, a total cost saving of euro2142 per 100 patients referred for echocardiography was estimated.

CONCLUSIONS

The use of a simple HCU device in the outpatient cardiology clinic allowed reliable diagnosis in one third of the patients referred for echocardiography, which translates into cost and time saving benefits.

Hypertensive patients with false-positive thallium-201 scintigraphic results in the infero-posterior wall are in high risk for coronary artery disease development

BACKGROUND

It has been previously postulated that Thallium-201 (Tl201) scintigraphy is characterized by relatively low specificity in hypertensive patients. This study was undertaken to assess any possible influence of false-positive scintigraphic results on the prognosis of hypertensive patients.

METHODS

The study group comprised 179 consecutive hypertensive patients (128 men and 51 women), aged 50+/-7 years, who underwent exercise Tl(201) scintigraphy and coronary angiography (patients with normal scintigraphic results underwent coronary angiography due to persistent angina-like symptoms). All patients with normal coronary arteries underwent a second Tl201 scintigraphy within 36+/-6 months. Patients with reversible ischemia in the second scintigraphy underwent also a second coronary angiography.

RESULTS

Coronary artery disease (CAD) was detected in 78 (44%) patients, while the rest 101 (56%) patients had normal coronary arteries. Abnormal scintigraphic results were revealed in 66 (85%) patients with CAD and in 38 (38%) patients without CAD. Twenty-two (58%) of the 38 hypertensive patients with false-positive scintigraphic results presented reversible ischemia of the infero-posterior wall of the left ventricle. Coronary artery disease was detected in 7 (32%) of these patients during the follow-up period.

CONCLUSIONS

Hypertensive patients with normal coronary arteries and false-positive scintigraphic results usually present with reversible ischemia of the infero-posterior wall of the left ventricle. This group of patients seems to be at increased risk of developing CAD in a long-term follow-up period.

Efficacy of Ultrasound-assisted Stress Testing Using a Hand-carried Ultrasound Device for Diagnosis of Coronary Artery Disease

BACKGROUND

Exercise echocardiography is an effective means of noninvasively detecting coronary artery disease (CAD), and hand-carried cardiac ultrasound (HCU) devices are now being used to diagnose CAD in emergency rooms and at bedsides.

OBJECTIVE

To compare the efficacies of exercise echocardiography with an HCU device (EchoCG-HCU) and exercise electrocardiography (ECG) in the diagnosis of CAD.

METHODS

Fifty-eight patients underwent symptom-limited treadmill exercise testing. Two-dimensional echocardiographic images were obtained from standard parasternal and apical windows at rest and immediately after exercise using an HCU device (180 PLUS SonoSite Inc, Bothell, Wash). Wall motion was scored for each of 16 left ventricular segments using a 5-point grading system. The development of new or worsening wall motion was considered to be indicative of ischemia.

RESULTS

When identifying CAD using exercise ECG, the sensitivity ws 63%, the specificity was 72%, and the diagnostic accuracy was 69%. By comparison, with exercise EchoCG-HCU the sensitivity was 68%, the specificity was 90%, and the diagnostic accuracy was 83%. Moreover, the specificity of exercise EchoCG-HCU was significantly higher than that of exercise ECG (p < .05).

CONCLUSION

Exercise EchoCG-HCU is at least as useful as exercise ECG for diagnosing CAD.

Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination

This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p <0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p <0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p <0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p <0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.

Hand-held echocardiography: its use and usefulness

In recent years, several echocardiographic hand-held devices have been developed and are now available for a growing number of cardiologists. After the first clinical use 25 years ago, hand-held echocardiography (HHE) is now earning important commercial positions. Their transportability permits echo performance out the echo-labs and offers the possibility to make diagnosis in intensive care unit, emergency room, outpatient clinic, at the bedside, and even in ambulance. Experiences in the clinical setting have demonstrated the ability of HHE to detect multiple diseases including abdominal aortic aneurysms, left ventricular hypertrophy, regional wall motion abnormalities, pericardial and pleural effusions. At the present time, four varieties of HHE have to be recognized: the first includes high-cost, miniaturized machines, similar to the most advanced instrumentations, provided by new tools and imaging transfer systems; a second intermediate, middle-cost variety encompasses devices corresponding to standard echocardiography, but not miniaturized; according to the definition of the American Society of Echocardiography, a third and a fourth category comprise machines of weight lower than 2.7 kg, battery supplied and appropriately defined as "portable cardioschopes", which can be utilized as a technical refinement of physical examination. The use of HHE opens main controversy concerning their diagnostic accuracy, the opportunity to establish in which clinical settings they should be used and the identification of both potential users and required competence level. Preliminary experiences show the possibility to improve and anticipate diagnosis of several cardiovascular diseases but also the need to plan specific ultrasound training to avoid incorrect use of HHE.

The Use of Hand-carried Ultrasound in the Hospital Setting-A Cost-effective Analysis

OBJECTIVES

We sought to assess the accuracy of hand-carried ultrasound (HCU) in the prediction of a normal study, and its cost-effectiveness in reducing the number of standard departmental echocardiograms (SDE) performed on hospital inpatients.

METHODS

The setting was a district general hospital. Participants were 157 consecutive inpatients, mean age 68 (range: 18-97) years, 95 men (61%), referred for SDE. HCU was performed at the bedside as part of the clinical assessment. SDE was performed routinely. Main outcome measures were: (1) assessment of the accuracy of HCU in detection of a normal or abnormal study as determined by SDE; and (2) a cost-effectiveness analysis.

RESULTS

Indications for echocardiography were: left ventricular (LV) function assessment, n = 101 (64.3%); valvular abnormalities, n = 11 (7%); arrhythmia, n = 4 (2.6%); miscellaneous, n = 10 (6.4%); and no reason stated, 31 (19.7%). The sensitivity, specificity, and positive and negative predictive values of HCU predicting a completely normal scan were 74%, 96%, 94%, and 81%, respectively, and of predicting normal LV function in requests specific for LV function assessment were 81%, 100%, 100%, and 77%, respectively. If either all inpatients or those with requests for LV function assessment underwent HCU initially, and only those with abnormal scans underwent further SDE, there would be a 29% and 22% reduction in departmental workload and a cost saving of pound sterling 23,000 and pound sterling 30,000, respectively.

CONCLUSION

HCU is an accurate method of identifying patients with normal hearts as determined by SDE. Its routine use is cost-effective and can significantly reduce the number of SDE that need be performed.

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.

Hand-held echocardiography: added value in clinical cardiological assessment

BACKGROUND

The ultrasonic industry has recently produced echocardiographic Hand Held Devices (miniaturized, compact and battery-equipped echocardiographic systems). Their potential usefulness has been successfully assessed in a wide range of clinical conditions. The aim of the study was to verify if the routine use of a basic model of echocardiographic Hand Held Device (HHD) could be an important diagnostic tool during outpatient cardiologic consulting or in non-cardiologic hospital sections.

METHODS

87 consecutive patients were included in this study; they underwent routine physical examination, resting ECG and echocardiographic evaluation using a basic model of HHD performed by trained echocardiographists; the cardiologist, whenever possible, formulated a diagnosis. The percentage of subjects in whom the findings were judged reasonably adequate for final diagnostic and therapeutic conclusions was used to quantify the "conclusiveness" of HHD evaluation. Successively, all patients underwent a second echocardiographic evaluation, by an examiner with similar echocardiographic experience, performed using a Standard Echo Device (SED). The agreement between the first and the second echocardiographic exam was also assessed.

RESULTS

Mean examination time was 6.7 +/- 1.5 min. using HHD vs. 13.6 +/- 2.4 min. using SED. The echocardiographic examination performed using HHD was considered satisfactory in 74/87 patients (85.1% conclusiveness). Among the 74 patients for whom the examination was conclusive, the diagnosis was concordant with that obtained with the SED examination in 62 cases (83.8% agreement).

CONCLUSION

HHD may generally allow a reliable cardiologic basic evaluation of outpatient or subjects admitted to non-cardiologic sections, more specifically in particular subgroups of patients, with a gain in terms of time, shortening patient waiting lists and reducing healthy costs.

The value of portable ultrasound for evaluation of cardiomegaly patients presenting at the emergency department

OBJECTIVES

The purpose of this study was to evaluate the value of a hand-carried portable ultrasound device in the emergency department for patients with cardiomegaly and evaluate its impact on diagnosis and treatment. We compared the results of the portable ultrasound with the results of physical examination and with standard echocardiograph (SE) in the cardiomegaly patients in emergency department.

BACKGROUND

Recently, small portable ultrasound devices have been introduced, and they need more extensive study to evaluate their application.

METHODS

We used the OptiGo (Agilent Technologies, Andover, MA) portable device to evaluate emergency patients, and compared it with two SE devices available for this study, the Hewlett Packard (Sono 5500; Andover, MA) or the Vingmed (System V; Horten, Norway). Each of 100 patients was studied by physical examination first then examined with the portable ultrasound and standard echocardiography. The yields from physical examination and portable echocardiography were compared and results of the standard and portable were also compared.

RESULTS

There were a total of 243 cardiovascular findings detected by the standard echocardiographic examination in the 100 patients studied. Cardiac examination failed to detect 40% of the overall findings but the portable device missed only 17% of all findings. The portable device evaluated 201 conditions correctly (83%) and missed relevant clinical findings in 37 (17%) as compared to standard echocardiography, but in only 12 (5%) were these findings of major importance As an overall measure of diagnostic value, the portable device would have added to clinical judgment, thus boosting diagnostic accuracy from 62% to 83%.

CONCLUSIONS

Portable ultrasound technology can provide rapid, readily available and important clinical information for emergency physicians in the management of emergency patients with cardiomegaly.

Hand-held miniaturized cardiac ultrasound instruments for rapid and effective bedside diagnosis and patient screening

RATIONALE, AIMS AND OBJECTIVES

Technological progress in recent years has made it possible that ultrasound industry can now offer affordable, portable and battery-operated ultrasound systems the size of a laptop computer. The purpose of this study was to compare these hand-carried ultrasound instruments with standard echocardiography in order to investigate the facility of a rapid bedside diagnosis in patients with suspected or known cardiovascular disease.

METHODS

Fifty consecutive patients were studied with miniaturized ultrasound equipment (SonoHeart) and a conventional scanner (Acuson Sequoia) in a blinded manner. All studies were performed by three board-certified cardiologists skilled and experienced in echocardiographic practice. Investigators were not aware of any previous medical reports.

RESULTS

With the new system, adequate images could be obtained in all patients. Left ventricular and left atrial diameters measured with the hand-held system correlated well with those obtained with conventional scanning: r = 0.87, mean difference 3.12 +/- 2.7 mm and r = 0.84, mean difference 2.8 + 2.4 mm, respectively. The presence of left ventricular dysfunction, regional wall motion abnormalities, relevant valvular regurgitation (moderate or more) or valve stenosis was correctly diagnosed in all patients. However, there was a tendency towards underestimating the extent of wall motion abnormalities particularly in patients difficult to image. Discrepancies also frequently occurred in patients with trivial or mild regurgitation, where false-positive and false-negative findings were described.

CONCLUSION

Currently available hand-held echocardiography systems can facilitate rapid bedside diagnosis and patient screening. However, this recent development in echocardiography also raises a number of questions and its actual impact on general clinical practice still remains to be evaluated.

Evaluation of a hand carried cardiac ultrasound device in an outpatient cardiology clinic

OBJECTIVE

To determine the diagnostic potential of a hand carried cardiac ultrasound (HCU) device (OptiGo, Philips Medical Systems) in a cardiology outpatient clinic and to compare the HCU diagnosis with the clinical diagnosis and diagnosis with a full featured standard echocardiography (SE) system.

METHODS

300 consecutive patients took part in the study. The HCU examination was performed by an experienced echocardiographer before patients visited the cardiologist. The echocardiographer noted whether the HCU device was able to confirm or reject the referral diagnosis, which abnormality was detected, and whether SE investigation was necessary. Physical examination by a cardiologist followed and thereafter, whenever required, a complete study with an SE was carried out. The HCU data were compared with the clinical diagnosis of the cardiologist and the SE diagnosis in a blinded manner.

RESULTS

The cardiologist referred 203 of 300 patients for an SE study and 13 patients for transoesophageal echocardiography. In 84 patients no further examination was considered necessary. HCU echocardiography was able to confirm or reject the suspected clinical diagnosis in 159 of 203 (78%) patients. In 44 of 203 (22%) patients SE Doppler was needed. Agreement between the HCU device and the SE system for the detection of major abnormalities was excellent (98%). The HCU device missed 4% of the major findings. Among the 84 patients not referred for an SE, the HCU device detected unsuspected major abnormalities missed with the physical examination in 14 (17%).

CONCLUSION

Integration of an HCU device with the physical examination augments the yield of information.

Hand-carried ultrasound performed at bedside in cardiology inpatient setting - a comparative study with comprehensive echocardiography

Background

Hand-carried ultrasound (HCU) devices have been demonstrated to improve the diagnosis of cardiac diseases over physical examination, and have the potential to broaden the versatility in ultrasound application. The role of these devices in the assessment of hospitalized patients is not completely established. In this study we sought to perform a direct comparison between bedside evaluation using HCU and comprehensive echocardiography (CE), in cardiology inpatient setting.

Methods

We studied 44 consecutive patients (mean age 54 ± 18 years, 25 men) who underwent bedside echocardiography using HCU and CE. HCU was performed by a cardiologist with level-2 training in the performance and interpretation of echocardiography, using two-dimensional imaging, color Doppler, and simple calliper measurements. CE was performed by an experienced echocardiographer (level-3 training) and considered as the gold standard.

Results

There were no significant differences in cardiac chamber dimensions and left ventricular ejection fraction determined by the two techniques. The agreement between HCU and CE for the detection of segmental wall motion abnormalities was 83% (Kappa = 0.58). There was good agreement for detecting significant mitral valve regurgitation (Kappa = 0.85), aortic regurgitation (kappa = 0.89), and tricuspid regurgitation (Kappa = 0.74). A complete evaluation of patients with stenotic and prosthetic dysfunctional valves, as well as pulmonary hypertension, was not possible using HCU due to its technical limitations in determining hemodynamic parameters.

Conclusion

Bedside evaluation using HCU is helpful for assessing cardiac chamber dimensions, left ventricular global and segmental function, and significant valvular regurgitation. However, it has limitations regarding hemodynamic assessment, an important issue in the cardiology inpatient setting.

Ultrasound stethoscopy

Miniaturization and digital techniques have resulted in the development of high-resolution, battery-powered personal ultrasound devices with excellent grey-scale and color blood flow imaging capabilities. These devices are appropriately called "ultrasound stethoscopes" and are practical to use. They extend our physical perception during a clinical examination by "seeing the invisible pathology" and allow the user to address specific clinical problems anywhere at the point-of-care. Murmurs and abnormal precordial movements can be directly related to cardiac structural, functional, and flow abnormalities. A cardiac abnormality (pericardial effusion, dilated heart, valvular disease, mass lesion) is rapidly confirmed during the clinical examination and often a specific diagnosis is made. The device can effectively assist in the initial evaluation and rapid diagnosis of potentially life-threatening conditions or in situations where quick decision-making is essential. Overall, they strengthen our clinical diagnostic accuracy and also add quantitative information. The ultrasound stethoscope allows rapid screening for left ventricular dysfunction and occult aortic abdominal aneurysm and left ventricular hypertrophy in patients with hypertension. Training may become an important issue and should focus on criteria of normalcy and identifying specific and major cardiac disorders. There is no doubt, however, that these devices will revolutionize the physical cardiac examination and diagnosis.

Hand-Carried Ultrasound Improves the Bedside Cardiovascular Examination

OBJECTIVES

We assessed the clinical utility of hand-carried cardiac ultrasound (HCU) devices to assist physicians in the diagnosis of cardiovascular disease.

MATERIALS AND METHODS

We reviewed 42 articles published from 1978 to 2004.

RESULTS

The capability and simplicity of the HCU device assist physicians in the diagnosis of cardiovascular disease at the initial patients contact. HCU is particularly useful in the setting of emergency or critical care, community screening, or in remote areas with limited access to health care.

CONCLUSION

The inherent limitations of the physical examination as well as the reduced focus and training in physical diagnosis of current and recent medical school graduates has set the stage for the HCU device to modify traditional medical practices by complementing the physical examination with real-time cardiovascular imaging.

Utility and diagnostic accuracy of hand-carried ultrasound for emergency room evaluation of chest pain

This study examined the utility and accuracy of immediate hand-carried echocardiography in patients presenting to the emergency room with chest pain and a normal or nondiagnostic electrocardiogram. Hand-carried echocardiography was highly concordant (kappa = 0.8) with troponin T tests as well as the discharge diagnosis of acute coronary syndrome, had a 100% sensitivity for the detection of acute coronary syndrome, 93% specificity, and 71% and 100% positive and negative predictive values, respectively.

Feasibility of point-of-care echocardiography by internal medicine house staff

OBJECTIVE

To determine whether internal medicine house staff with limited training in echocardiography can use point-of-care echocardiography to make simple, clinically important diagnoses.

BACKGROUND

Availability of small, portable ultrasound devices could make point-of-care echocardiography widely available. The training required to perform point-of-care echocardiography has not been established.

METHODS

Medical house staff participated in a 3-hour point-of-care echocardiography training program. Patients scheduled for standard echocardiography as part of clinical care underwent point-of-care echocardiography within 24 hours to assess four common clinically important diagnoses. Each standard echocardiogram was interpreted twice. Agreement (kappa) was calculated between point-of-care and standard echocardiography by using standard echocardiography as the gold standard and between the two interpretations of standard echocardiography.

RESULTS

Agreement (kappa) between point-of-care echocardiography and standard echocardiography was 75% (0.51) for left ventricular dysfunction (ejection fraction <55%), 79% (0.31) for moderate or severe mitral regurgitation, 92% (0.32) for aortic valve thickening or immobility, and 98% (0.51) for moderate or large pericardial effusion. Agreement between the two interpretations of standard echocardiography was 83% (0.63) for left ventricular dysfunction, 92% (0.68) for moderate or severe mitral regurgitation, 95% (0.62) for aortic valve thickening or immobility, and 97% (0.53) for moderate or large pericardial effusion.

CONCLUSIONS

Medical house staff with limited training in echocardiography can use point-of-care echocardiography to assess left ventricular function and pericardial effusion with moderate accuracy that is lower than that of standard echocardiography. Assessment of valvular disease and other diagnoses likely requires more training and/or experience in echocardiography.

Making an Impossible Mission Possible

Cardiovascular disease (CVD) is widespread in developing countries. Hypertension is a major contributor of CVD. Left ventricular hypertrophy (LVH) is a risk marker in hypertensive populations. Identification of LVH and treatment of high-risk patients can result in more effective use of the limited resources. LVH is diagnosed by echocardiography, often unavailable in developing countries. In Gambia, we used a hand-carried ultrasound (HCU) to examine 1,997 people. Seventeen percent had hypertension; of these, LVH was found in 65%. The battery-powered HCU permits clinicians to detect LVH in areas with limited access to diagnostic equipment, allowing identification of a high-risk hypertensive population.

Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology

To test the hypothesis that hand-carried ultrasound (HCU) may influence patient treatment on consultative cardiology rounds, 235 patients who were hospitalized (aged 65 +/- 10 years) were studied. First, routine treatment decisions regarding diagnostic workup and therapy were made from patient history, physical examination, 12-lead electrocardiogram, and chart data. Second, a goal-directed HCU study was performed in <10 minutes focusing on left ventricular global and regional function, wall thickness, and presence of pericardial effusion, followed by a reassessment of treatment decisions. HCU data influenced treatment decisions in 149 patients (63%); 50% had a change in medical therapy and 22% had a change in their diagnostic workup (most with changes in both). In all, 12 patients (5%) had an immediate change in the decision for cardiac catheterization or pericardiocentesis. Overall agreement for the above findings with subsequent full-size system echocardiography ranged from 92% to 100% (kappa 0.91-0.96). Goal-directed HCU has the potential to influence bedside patient treatment decisions and expedite health care.

Community screening for left ventricular hypertrophy in patients with hypertension using hand-held echocardiography

Left ventricular (LV) hypertrophy (LVH) confers increased cardiovascular risk on patients with hypertension. Echocardiography using new hand-held devices might allow community-based cost-effective screening for LVH in a targeted hypertensive population. Thus, the aim of this study was to test the validity of hand-held ultrasound devices to screen for LVH in the community. Accordingly, 189 patients with hypertension attending a community-based heart failure screening program underwent echocardiography by both hand-held and standard devices by an experienced echocardiographer. LVH was defined as LV mass index >/=134 g.m(-2) for men and >/=110 g.m(-2) for women using the Devereux-modified American Society of Echocardiography cube equation. No significant differences were noted between the 2 devices in the measurement of LV wall thickness or LV mass index. Agreement for estimation of LVH between the 2 devices was 86% (kappa = 0.63). The sensitivity, specificity, and positive and negative predictive values of the hand-held device for predicting LVH were 72%, 91%, 73%, and 90%, respectively. Thus, hand-held echocardiography devices accurately assessed LVH and may be used for community-based screening for LVH in targeted patients with hypertension.

Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device

BACKGROUND

The hand-carried cardiac ultrasound (HCU) device is a recently introduced imaging device, which may be potentially useful in the primary care setting.

AIM

To test the screening potential of a HCU for the detection of left ventricular (LV) dysfunction by evaluating LV ejection fraction (LVEF) and inferior vena cava (IVC) collapse. Standard echocardiographic system (SE) and plasma brain natriuretic peptide (BNP) measurements were used as a reference.

METHODS

Eighty-eight consecutive patients (56 male, aged 59+/-12 years) with suspected LV dysfunction were enrolled in the study. The HCU-LVEF was visually estimated and the SE-LVEF was derived by the Simpson's biplane method. A LVEF <40% represented LV dysfunction. An IVC collapse of <50% and BNP levels > or =15 pmol/l were considered abnormal. The correlation of HCU-LVEF, HCU-IVC and BNP to the SE-LVEF and SE-IVC was analysed independently using 2x2 tables.

RESULTS

Six patients were excluded because of poor echo images. 19/82 patients had LV dysfunction. The HCU and BNP could identify 17 and 18 out of these 19 patients, respectively. The agreement for LVEF and IVC collapse between SE and HCU was 96% for both parameters. The sensitivity of IVC collapse, HCU-LVEF and BNP in identifying patients with LV dysfunction was 26, 89 and 94%, respectively.

CONCLUSION

A HCU device can reliably be used as a screening tool for LV dysfunction.

Portable spectral Doppler echocardiographic device: overcoming limitations

BACKGROUND

There is evidence that new portable echocardiographic devices are useful in evaluating heart anatomy and function, but a lack of Doppler modes has up to now been an important limitation in obtaining haemodynamic data.

OBJECTIVES

To report the Doppler capabilities of a new hand held echocardiographic device.

DESIGN

Blinded comparison of two types of echocardiography machine.

SETTING

Tertiary care centre.

PATIENTS

98 consecutive patients were randomly imaged with the hand held device, with a standard platform as reference.

OUTCOME MEASURES

Pulsed wave transmitral Doppler inflow tract velocities, deceleration time, and continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation peak velocities were recorded.

RESULTS

There was excellent agreement between the hand held device and standard echocardiography for the evaluation of diastolic E and A waves, E/A ratio, and deceleration time with pulsed wave Doppler (intraclass correlation coefficients of 0.97, 0.93, 0.90, and 0.78, respectively). In addition, good agreement was found between continuous wave Doppler measurements of aortic ejection and tricuspid regurgitation velocities (intraclass correlation coefficients of 0.96 and 0.80). However, there was a significant difference between patients with tricuspid regurgitation measured with the hand held device (25.5%) and by standard echocardiography (65.3%), resulting in misdiagnosis of eight patients with pronounced pulmonary hypertension.

CONCLUSIONS

New hand held devices with Doppler capabilities overcome previous limitations in evaluating haemodynamic variables. With colour Doppler they are now suitable for the complete evaluation of valvar disease and diastolic function. However, important limitations remain in the evaluation of pulmonary pressures.

Clinical utility and cost effectiveness of a personal ultrasound imager for cardiac evaluation during consultation rounds in patients with suspected cardiac disease

OBJECTIVE

To assess the clinical utility and cost effectiveness of a personal ultrasound imager (PUI) during consultation rounds for cardiac evaluation of patients with suspected cardiac disease.

METHODS

107 unselected patients from non-cardiac departments (55% men) were enrolled in the study. After the physical examination the consultant cardiologist performed an echocardiographic study with a PUI. The final report was given instantly to the referring physician. All patients subsequently underwent a study with a standard echocardiographic device (SED). For each patient the consultant cardiologist noted whether the findings of the PUI were adequate for final diagnosis. The total cost when full echocardiography was used was compared with the cost when the PUI was used. The time interval from request to diagnosis was also compared.

RESULTS

In 84 (78.5%) patients no further examination with an SED was regarded as necessary. Twenty three patients (21.5%) required a further detailed examination with the SED because of the need for haemodynamic information. There was an excellent agreement for the detection of abnormalities between the two devices (96%). The total cost was euro;132 per patient with the SED and euro;75 per patient with the PUI. According to this study, the use of the PUI can lead to a 33.4% reduction of total cost. The mean time from request to diagnosis at the authors' institution was four days for the SED and instantly for the PUI, for additional potential cost savings.

CONCLUSIONS

Immediate echocardiographic assessment during consultation rounds can lead to significant cost savings and can shorten the time to diagnosis.