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

Guidance for performance, utilization, and education of cardiac and lung point-of-care ultrasonography from the Japanese Society of Echocardiography

In recent years, bedside ultrasound examinations have been used in many clinical departments and are called point-of-care ultrasound (POCUS). Regarding POCUS in the cardiac field, a protocol called focus (focused) cardiac ultrasound (FoCUS) has been developed in Europe and the United States, is being used clinically, and an educational syllabus has been created. According to them, FoCUS is defined as a point-of-care cardiac ultrasound examination using standardized limited sections and protocols. FoCUS is primarily intended to be performed by non-cardiologists, and in order to avoid making mistakes in judgment, it is important to be familiar with its limitations and it is necessary to understand pathological conditions that can only be diagnosed using conventional comprehensive echocardiography. The Japanese Society of Echocardiography has edited this clinical guideline because we believe that FoCUS should be used effectively and appropriately in Japan, and that appropriate education is essential to popularize FoCUS in Japan. Furthermore, lung POCUS has recently come into clinical use. Lung POCUS is useful for the diagnosis and follow-up of heart failure when used in conjunction with FoCUS, and is especially useful in primary care where chest X-rays are not available. The working group that created this manual agreed that it is desirable to educate patients about lung POCUS in conjunction with FoCUS, so we decided to include the basic techniques of lung POCUS and how to use them in this manuscript.

Impact of physician performed point of care ultrasound (POCUS) during first outpatient cardiology consultation on patient management and downstream testing

BACKGROUND

Goal directed point of care ultrasound (POCUS) is a bedside tool to assist with clinical diagnosis. We examined the impact of POCUS performed by consulting cardiologist (CC) during initial cardiology consult on clinical management and downstream testing.

METHODS

Sixty-nine study patients (pts) seen in a general cardiology outpatient clinic of a tertiary center by an expert imaging CC were compared to a control group of 65 pts seen by three different CCs without POCUS during the same time-period, in whom the first standard echo (SE) was performed after the initial visit.

RESULTS

Baseline characteristics were similar between the two groups for age, cardiac risk factors, and referral diagnoses. Echo findings on POCUS and by SE (mean delay of 17.2 days after visit) in the control group were comparable for RV size and function and for valvular heart disease. More patients with lower LVEF, higher LV filling pressures, new regional wall motion abnormalities, and increased aortic root size were present among POCUS group resulting in greater yield of echo abnormalities. There were more cardiovascular medication changes at the first visit (15.3% vs. 5.7%, p < .01), less referral for noninvasive stress testing (10% vs. 29%, p < .01), more advanced cardiac testing and subspecialty referrals (29% vs. 18% pts, p = .06), in the study compared to the control group after cardiology visit.

CONCLUSION

POCUS at time of consultation detects more abnormal echo findings, results in more medication adjustments, less referral for noninvasive stress testing, earlier referral for advanced cardiac diagnostic imaging, and subspecialty cardiac referrals.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Point-of-Care Ultrasonography in Patients With Acute Dyspnea: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians

BACKGROUND

Dyspnea is a common and often debilitating symptom with a complex diagnostic work-up.

PURPOSE

To evaluate the benefits, harms, and diagnostic test accuracy of point-of-care ultrasonography (POCUS) in patients with acute dyspnea. (PROSPERO: CRD42019126419).

DATA SOURCES

Searches of multiple electronic databases without language limitations (January 2004 to August 2020) and reference lists of pertinent articles and reviews.

STUDY SELECTION

Five randomized controlled trials (RCTs) and 44 prospective cohort-type studies in patients with acute dyspnea evaluated POCUS as a diagnostic tool to determine the underlying cause of dyspnea. Two investigators independently screened the literature for inclusion.

DATA EXTRACTION

Data abstraction by a single investigator was confirmed by a second investigator; 2 investigators independently rated risk of bias and determined certainty of evidence.

DATA SYNTHESIS

Point-of-care ultrasonography, when added to a standard diagnostic pathway, led to statistically significantly more correct diagnoses in patients with dyspnea than the standard diagnostic pathway alone. In-hospital mortality and length of hospital stay did not differ significantly between patients who did or did not receive POCUS in addition to standard diagnostic tests. Finally, POCUS consistently improved the sensitivities of standard diagnostic pathways to detect congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax; specificities increased in most but not all studies.

LIMITATIONS

Most studies assessed diagnostic test accuracy, which has limited utility for clinical decision making. Studies rarely reported on the proportion of indeterminate sonography results, and no evidence is available on adverse health outcomes of false-positive or false-negative POCUS results.

CONCLUSION

Point-of-care ultrasonography can improve the correctness of diagnosis in patients with acute dyspnea.

PRIMARY FUNDING SOURCE

American College of Physicians.

Appropriate Use of Point-of-Care Ultrasonography in Patients With Acute Dyspnea in Emergency Department or Inpatient Settings: A Clinical Guideline From the American College of Physicians

DESCRIPTION

The American College of Physicians (ACP) developed this guideline to provide clinical recommendations on the appropriate use of point-of-care ultrasonography (POCUS) in patients with acute dyspnea in emergency department (ED) or inpatient settings to improve the diagnostic, treatment, and health outcomes of those with suspected congestive heart failure, pneumonia, pulmonary embolism, pleural effusion, or pneumothorax.

METHODS

The ACP Clinical Guidelines Committee based this guideline on a systematic review on the benefits, harms, and diagnostic test accuracy of POCUS; patient values and preferences; and costs of POCUS. The systematic review evaluated health outcomes, diagnostic timeliness, treatment decisions, and test accuracy. The critical health, diagnostic, and treatment outcomes evaluated were in-hospital mortality, time to diagnosis, and time to treatment. The important outcomes evaluated were intensive care unit admissions, correctness of diagnosis, disease-specific outcomes, hospital readmissions, length of hospital stay, and quality of life. The critical test accuracy outcomes included false-positive results for suspected pneumonia, pneumothorax, and pulmonary embolism and false-negative results for suspected congestive heart failure, pneumonia, pneumothorax, and pulmonary embolism. Important test accuracy outcomes included false-positive results for suspected congestive heart failure and false-negative and false-positive results for suspected pleural effusion. This guideline was developed using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) method.

TARGET AUDIENCE AND PATIENT POPULATION

The target audience is all clinicians, and the target patient population is adult patients with acute dyspnea in ED or inpatient settings.

RECOMMENDATION

ACP suggests that clinicians may use point-of-care ultrasonography in addition to the standard diagnostic pathway when there is diagnostic uncertainty in patients with acute dyspnea in emergency department or inpatient settings (conditional recommendation; low-certainty evidence).

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.

Accuracy and Efficacy of Hand-Held Echocardiography in Diagnosing Valve Disease: A Systematic Review

In recent years, advances in technology have enabled hand-held echocardiography (HHE) to generate high-quality 2-dimensional and color Doppler images. As these devices become smaller, simpler, and more affordable, the question of whether HHE can augment or replace auscultation as the primary mode of cardiovascular diagnosis has become increasingly more relevant. If widely implemented, HHE has the potential for significant cost savings and better resource utilization. This review examines studies comparing the sensitivities of auscultation, HHE, and standard echocardiography in detecting various valvular lesions and discusses why current evidence supports the use of HHE to augment the physical examination, which can lead to more reliable and rapid bedside diagnoses, triage, and appropriate treatment of structural cardiac abnormalities.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Focused Cardiac Ultrasound in Place of Repeat Echocardiography: Reliability and Cost Implications

BACKGROUND

Health care systems are increasingly moving toward models that emphasize the delivery of high-quality health care at lower costs. Rates of repeat echocardiography (two or more transthoracic echocardiographic studies performed within a short interval) are high and can contribute substantially to the cost of providing cardiovascular care. Certain findings from handheld ultrasound scans performed by echocardiographers have been shown to correlate well with findings on transthoracic echocardiography (TTE). It therefore may be feasible and cost effective to use expert focused cardiac ultrasound (eFCU) in place of repeat TTE for highly selected indications in certain settings. The aim of this study was to determine the reliability and cost implications of using eFCU in place of repeat TTE in selected inpatients.

METHODS

Inpatients who underwent repeat TTE (prior TTE within 30 days) ordered for the assessment of ventricular function, pericardial effusion, or inferior vena cava collapse were prospectively enrolled. Subjects underwent eFCU in addition to TTE, and results were compared for correlation using the weighted κ statistic. The potential cost savings of using eFCU in place of TTE were modeled from the provider perspective (i.e., physicians and hospitals).

RESULTS

Over 45 days, 105 patients were enrolled. The majority of scans were performed for assessment of left ventricular function and pericardial effusions. eFCU showed excellent correlation with TTE for most parameters, including left ventricular systolic function (κ = 0.80) and the presence and size of pericardial effusions (κ = 0.81) (P < .001 for both). Adoption of this eFCU protocol could save between $41 and $64 per study, or between $34,512 and $53,871 annually at the authors' institution.

CONCLUSIONS

Findings from eFCU correlate well with those from TTE when used in the setting of repeat testing for assessment of ventricular function, pericardial effusion, and inferior vena cava collapse. The judicious use of eFCU in place of repeat inpatient TTE has the potential to deliver quality cardiac imaging at reduced cost.

Utility of hand-held echocardiography in outpatient pediatric cardiology management

Adult patient series have shown hand-held echocardiography (echo) units (HHE) to be accurate for rapid diagnosis and triage. This is the first study to evaluate the ability of HHE to inform decision making in outpatient pediatric cardiology. New pediatric cardiology patients in outpatient clinics staffed by six pediatric cardiologists (experience 1-17 years) were prospectively enrolled if an echocardiogram (echo) was ordered during their initial visit. After history and physical examination and before a standard echo, the cardiologists performed a bedside HHE examination (GE Vscan 1.7-3.8 MHz), documented findings, and made a clinical decision. Diagnoses and decisions based on HHE were compared with final management after the standard echo. The study enrolled 101 subjects (ages 9 days to 19 years). The cardiologists considered HHE imaging adequate for decision making for 80 of the 101 subjects. For 77 of the 80 subjects with acceptable HHE imaging (68/68 normal and 9/12 abnormal standard echoes), the HHE-based primary diagnoses and decisions agreed with the final management. The sensitivity of HHE was 75 % (95 % confidence interval [CI] 43-94 %) and the positive predictive value 100 % (95 % CI 66-100 %) for pediatric heart disease. The agreement between standard echocardiography and HHE imaging was substantial (κ = 0.82). Excluding one of the least experienced cardiologists, HHE provided the basis for correct cardiac diagnoses and management for all the subjects with acceptable HHE imaging (58/58 normal and 9/9 abnormal echoes). In outpatient pediatric cardiology, HHE has potential as a tool to complement physical examination. Further investigation is needed to evaluate how value improves with clinical experience.

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.

The Application of Hand-Held Ultrasound Scanner in Teaching of Telemedicine and Rural Medicine

Stethoscope, the symbol of modern medicine has been in place for more than 150 years. However, this reliable diagnostic instrument has started showing its age with the arrival of a newer diagnostic instrument: the hand-held ultrasound.

Hand-held ultrasound is rapidly expanding in many specialties but not yet in obstetrics and gynecology. There is a paucity of literature on the application of hand-held ultrasound in obstetrics and gynecology, in contrast to a large volume of literature published by other specialties. Several studies demonstrated that medical students and residents can improve the accuracy of their physical examinations with the use of hand-held ultrasound. Similarly, physical examinations performed by hospitalists with hand-carried ultrasound are more accurate than those performed without the instrument. Advances in technology have contributed to the improvement of image quality and portability. As a result, these devices become increasingly available in many clinical settings such as point of care, telemedicine and rural medicine. The quality of ultrasound images of the hand-held scanner is inferior to those of standard laptop ultrasound. However, the hand-held ultrasound requires much less time for setup.

Although there have been recommendations for training guidelines for operators of hand-held ultrasound, standards for optimal training to achieve level of competency have not been determined.

How to cite this article

Wright J, Noriega O, Ho H. The Application of Hand-Held Ultrasound Scanner in Teaching of Telemedicine and Rural Medicine. Donald School J Ultrasound Obstet Gynecol 2014;8(1):87-91.

Advances in imaging: ultrasound in every physician's pocket

Advances in medical ultrasound have made the modality widely applicable and the new cart-based and pocket size devices have allowed for relevant point-of-care (POC) ultrasound examinations in many medical specialties. POC ultrasonography is performed as a real-time examination assisting the physician in diagnosis, procedure or screening of the patient without life threatening delays. The examination can be performed at the bedside or wherever the patient may be present. Structured and focused protocols for simple clinical questions have been developed and implemented in the following specialties: Anesthesiology, Cardiology, Critical Care Medicine, Dermatology, Emergency Medicine, Neonatology, Gynecology and Rheumatology and many others. POC ultrasound, as well as ultrasound in general, is very user dependent and the need for quality assurance, formal education and practical training is obvious. With this in mind, POC ultrasound now really has the potential for becoming the physician's new personal universal examination tool. Patients admitted to emergency departments will be able to receive organ or symptom-guided initial focused ultrasound triage as part of the physician's first encounter with the patient. This will allow for more accurate referral, correct diagnosis and relevant screening in turn leading to better overall treatment results.

Validation of the smallest pocket echoscopic device's diagnostic capabilities in heart investigation

We hypothesized that, based on greyscale imaging and color Doppler capabilities, a new pocket ultrasound device (PUD) could accurately record cardiologic diagnostic findings. One hundred patients referred for conventional clinical indications underwent a standard echocardiography. Subsequently, a second physician blinded to the results performed an evaluation using the PUD on the same patients. Study end-points were echocardiographic window quality; left ventricular (LV) morphology; function; hypertrophy; right ventricular, atrial and vena caval morphologies; aortic and mitral valvulopathies; and pericardial structure. Using a scale of three grades, concordance in image quality proved good with a kappa coefficient (κ) of 0.71. Concordances between systems were excellent for LV function and morphology (κ = 0.91 and 0.96). Concordance for LV hypertrophy was good (κ = 0.74). Concordances for mitral regurgitation grades were 0.90, 0.95 and 1.00, respectively. In conclusion, a new PUD enabled scanning examinations, which showed good concordance of basic and qualitative diagnostic capability to standard echocardiographic instruments.

The pocket echocardiograph: validation and feasibility

BACKGROUND

A new, miniaturized ultrasound device, the pocket echocardiograph (PE), is highly portable and can be carried inside a lab-coat pocket. Studies of this device are limited and have not examined the use by novice echocardiographers. We hypothesize that a novice echocardiographer can use PE to produce interpretable cardiac images, and that both novice and expert echocardiographers can use PE to accurately quantify ejection fraction.

METHODS

Unselected subjects (n = 40) in an echocardiography laboratory underwent blinded formal transthoracic echocardiography (TTE) and PE (Acuson P10, Siemens, Mountain View, CA, USA). A cardiology fellow with 2 months of echocardiography training acquired PE images. The fellow and an experienced echocardiographer interpreted the PE studies offline in a blinded fashion. To assess adequacy, studies were graded as technically adequate, limited, or inadequate. A visual estimation of ejection fraction was made. Comparisons were made to the formal reported TTE.

RESULTS

Subjects were heterogeneous, 43% male; age 64 ± 17 years, and ejection fraction 52.4%± 12.3%. All PE studies were interpretable, and the vast majority of PE and TTE images were considered technically adequate (77.5% and 85% respectively; P = 0.32). Ejection fraction showed a good correlation, bias, and limits of agreement for the fellow's interpretation (r = 0.78, -5.9%, ±16.6%) with stronger association for the experienced echocardiographer (r = 0.88, -0.8%, ±11.4%).

CONCLUSION

Novice echocardiographers using the PE can produce adequate quality images. Both expert and novice echocardiographers can use PE to quantify ejection fraction over a broad range of patients. The device's low cost and portability may greatly expand the availability of bedside echocardiography for routine or urgent cardiovascular assessment.

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.

Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?

OBJECTIVE

The traditional physical examination of the heart is relatively inaccurate. There is little information regarding whether cardiac hand-carried ultrasound performed by noncardiologists adds to the accuracy of physical examinations. The purpose of this study was to determine whether hand-carried ultrasound can add to the accuracy of hospitalists' cardiac physical examinations.

METHODS

During a focused training program in hand-carried echocardiography, 10 hospitalists performed cardiac examinations of 354 general medical inpatients first by physical examination and then by hand-carried ultrasound. Eligible inpatients included those for whom a conventional hospital echocardiogram was ordered. We measured how frequently the hospitalists' cardiac examination with or without hand-carried ultrasound matched or came within 1 scale level of an expert cardiologist's interpretation of the hospital echocardiogram.

RESULTS

Adding hand-carried ultrasound to the physical examination improved hospitalists' assessment of left ventricular function, cardiomegaly, and pericardial effusion. For left ventricular function, using hand-carried ultrasound increased the percentage of exact matches with the expert cardiologist's assessment from 46% to 59% (P=.005) and improved the percentage of within 1-level matches from 67% to 88% (P=.0001). The addition of hand-carried ultrasound failed to improve the assessments of aortic stenosis, aortic regurgitation, and mitral regurgitation.

CONCLUSION

Adding hand-carried ultrasound to physical examination increases the accuracy of hospitalists' assessment of left ventricular dysfunction, cardiomegaly, and pericardial effusion, and fails to improve assessment of valvular heart disease. The clinical benefit achieved by improved immediacy of this information has not been determined. An important limitation is that the study assessed only 1 level of training in hand-carried ultrasound.

The pocket echocardiograph: a useful new tool?

AIMS

Hand-carried ultrasound scanners are getting smaller. The Acuson P10 is the latest and smallest portable echocardiograph available on the market.

METHODS AND RESULTS

We tested the ability of this scanner to allow qualitative assessment of LV size and function in an unselected group of 30 patients [19 male, 11 female; mean age (SD) 64.7 (10.3) years] seen by a consultant cardiologist (accredited for advanced echocardiography) during a week on call in a regional cardiac tertiary facility. Patients had focused scans (parasternal long-axis and apical four chamber views) for a maximum of 4 min, and an assessment of LVEF (normal/abnormal) and LV dimension (LVD) (dilated/non-dilated) was recorded. Where available, this was compared with results of alternative imaging modalities. In 23 (77%) patients, it was possible to assess LVEF and LVD; of these, 19 (83%) had alternative imaging techniques, which confirmed the findings. It was possible to obtain a parasternal long-axis image in 28 (93%) patients and apical four-chamber views in 23 (77%). Clinical management was altered by the findings of the portable scan in two patients.

CONCLUSION

The 'pocket scanner' allows accurate qualitative assessment of left ventricular dimensions and function in a substantial proportion of patients seen in tertiary cardiology practice.

Cost effectiveness of the B type natriuretic peptide, electrocardiography, and portable echocardiography for the assessment of patients from the community with suspected heart failure

To analyze the cost efficiency of guidelines proposed by the European Society of Cardiology for investigation of patients in the community with suspected heart failure (HF). The guidelines recommend electrocardiography (ECG) and/or measurement of N-terminal pro B type natriuretic peptide (NTproBNP) prior to referral for echocardiography. Portable echocardiography is a new but validated technique for the evaluation of HF. Accordingly, 137 suspected HF patients (mean age 71+/-13 years) from the community underwent ECG and NTproBNP estimation prior to portable echocardiography. Cost effective analysis for ECG, NTproBNP, portable echocardiography and a combination of these; to define valvular heart disease, right ventricular dysfunction and left ventricular systolic and diastolic dysfunction were compared. The cost of abnormal NTproBNP followed by portable echocardiography, abnormal ECG followed by portable echocardiography and portable echocardiography alone for the detection per case of left ventricular systolic dysfunction were 313 euro, 310 euro, and 296 euro respectively and that for detection per case of any of the aforementioned cardiac abnormalities were 198 euro, 223 euro, and 170 euro respectively. Portable echocardiography alone for the assessment of suspected HF patients resulted in a cost reduction of up to 1083 euro for the detection per case of cardiac abnormality. While a strategy where initial NTproBNP estimation is cost effective in detecting any causes of heart failure, portable echocardiography remains the most costeffective strategy to assess patients from the community with suspected heart failure.

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.