Focused transthoracic echocardiography by sports medicine physicians: measurements relevant to hypertrophic cardiomyopathy

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Feasibility of a Novel Strategy for Cardiovascular Screening During the Preparticipation Physical Examination

OBJECTIVE

To determine the feasibility of simultaneously conducting history and physical (H&P), limb-lead electrocardiogram (ECG), and preparticipation echocardiography by frontline providers (PEFP) at one screening station.

METHODS

This cross-sectional study compares limb-lead versus 12-lead ECG as part of a preparticipation physical examination (PPE) including H&P and PEFP conducted in year 1 and year 2 on 2 cohorts (n = 36, n = 53, respectively) of college athletes at one institution. Year 1 screening was conducted at 3 stations, one station per screening component. Time to complete each station was recorded, and total time for screening was the summation of times for each station. Year 2 screening was conducted at one station; timing began when the patient entered the room and ended when all 3 components of screening were complete. An unpaired t test was used to compare the mean time difference between years 1 and 2 screening stations.

RESULTS

Year 1 screening time was significantly longer than time to complete cardiac screening using the year 2 protocol (10.51 ± 1.98 vs 3.96 ± 1.43 minutes, respectively; P < 0.001). Five athletes in year 1 and 3 athletes in year 2 were referred to cardiology for further evaluation; all athletes were ultimately cleared to participate.

CONCLUSIONS

A comprehensive PPE can be completed in a timely fashion using a single screening station and limb-lead ECG to improve efficiency, while still allowing providers to gather information on history, physical examination, heart rhythm, and heart structure. This strategy may serve as a potential solution in the longstanding debate over best practices for PPEs.

Potential role of an athlete-focused echocardiogram in sports eligibility

Sudden cardiac death (SCD) of an athlete is a rare but tragic event and sport activity might play a trigger role in athletes with underlying structural or electrical heart diseases. Preparticipation screenings (PPs) have been conceived for the potential to prevent SCD in young athletes by early identification of cardiac diseases. The European Society of Cardiology protocol for PPs includes history collection, physical examination and baseline electrocardiogram, while further examinations are reserved to individuals with abnormalities at first-line evaluation. Nevertheless, transthoracic echocardiography has been hypothesized to have a primary role in the PPs. This review aims to describe how to approach an athlete-focused echocardiogram, highlighting what is crucial to focus on for the different diseases (cardiomyopathies, valvulopathies, congenital heart disease, myocarditis and pericarditis) and when is needed to pay attention to overlap diagnostic zone ("grey zone") with the athlete's heart. Once properly tested, focused echocardiography by sports medicine physicians may become standard practice in larger screening practices, potentially available during first-line evaluation.

The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update)

Recent technological advances in echocardiography, with progressive miniaturization of ultrasound machines, have led to the development of handheld ultrasound devices (HUD). These devices, no larger than some mobile phones, can be used to perform partial, focused exams as an extension to the physical examination. The European Association of Cardiovascular Imaging (EACVI) acknowledges that the dissemination of appropriate HUD use is inevitable and desirable, because of its potential impact on patient management. However, as a scientific society of cardiac imaging, our role is to provide guidance in order to optimize patient benefit and minimize drawbacks from inappropriate use of this technology. This document provides updated recommendations for the use of HUD, including nomenclature, appropriateness, indications, operators, clinical environments, data management and storage, educational needs, and training of potential users. It also addresses gaps in evidence, controversial issues, and future technological developments.

Feasibility and Reliability of Nonexpert POCUS for Cardiovascular Preparticipation Screening of Varsity Athletes: The SHARP Protocol

BACKGROUND

Point of care ultrasound (POCUS) is a potential adjunctive cardiovascular preparticipation screening modality for young competitive athletes. A novel cardiac POCUS screening protocol, Screening the Heart of the Athlete Research Program (SHARP), was developed for nonexpert examiners to assess common structural etiologies associated with sudden cardiac arrest/death (SCA/D).

METHODS

Assessment of primary outcomes of feasibility, and reliability of obtained measurements, performed by comparison to formal transthoracic echocardiogram was undertaken. Inter-rater reliability was based on Intraclass correlation coefficients (ICC) defined as moderate for 0.40 to 0.59, good for 0.60 to 0.79, and excellent for 0.80 or greater. Electrocardiograms (ECGs) were also obtained. Identification of disease or other abnormalities was a secondary outcome.

RESULTS

Fifty varsity athletes at our institution underwent the SHARP protocol, with 19 undergoing formal transthoracic echocardiogram and ECG for comparison. POCUS image quality was good to excellent. Feasibility of assessing for hypertrophic cardiomyopathy, aortic root dilatation, and left-ventricular function was deemed highly possible but limited in 20% for right-ventricular assessment. Reliability was good for measurements of interventricular septal thickness (0.67), end diastolic left-ventricular diameter (0.61), aortic root diameter (0.63), and moderate for left-ventricular posterior wall thickness (0.42). No cardiovascular abnormalities were detected.

CONCLUSIONS

A novel, comprehensive SHARP POCUS protocol performed by nonexpert practitioners demonstrated feasibility and reliability to assess varsity level athletes for common structural etiologies associated with SCA/D. Further large athlete screening cohort studies are required to validate the SHARP protocol and the role of cardiac POCUS as a screening modality.

Monitoring Morphologic Changes in Male Rowers Using Limited Portable Echocardiography Performed by a Frontline Physician

Athletes' hearts have been studied for adaptive changes in response to exercise. Physiologic changes are normal responses to intense athletic training regimens, whereas pathologic changes predispose athletes to sudden cardiac death. The two alterations overlap in clinical presentation. Research continues to investigate the upper limits of cardiac remodeling to aid clinical decision making. Studying normal changes that occur in response to exercise will advance physicians' understanding of physiologic responses to exercise and potentially improve clinical distinction. To expand this body of knowledge, we present an observational case series that describes morphologic changes in athlete's hearts concurrent with performance measurements.

4107 Limited Echocardiogram Examinations Performed by Intensivists: A Surgeon-Driven Multidisciplinary Program

Limited transthoracic echocardiogram (LTTE) has been introduced as a tool to direct resuscitation. At our institution, a multidisciplinary training program was instituted. Our hypothesis is that in spite all efforts for multidisciplinary training, certification, and credentialing, limited echocardiograms are under billed for. A training program was implemented in August 2010. This was followed by a process of credentialing and adding LTTE to the billing privileges for providers. Institutional Review Board approval was obtained to review all the studies performed from August 2010 to October 2014. About 4107 LTTEs were performed during the study period. Only 685 examinations were billed for (16.6%). The total amount billed for all the studies was $80,819.00. The number of studies billed for and performed in the emergency department (ED) were 342, and 343 studies were billed while performed in the intensive care unit (ICU). Our institution received payment at a higher rate when the studies were performed in the ICU (71.7%) versus ED (49.4%), P < 0.0001. The total actual reimbursement for the ED was $6487.29 and for the ICU was $8213.95 for a total of $14,701.24. The mean reimbursement amount was $35.59. If all of the studies were billed for and reimbursed at the average payment amount, the institution would have received $146,168.13. A multidisciplinary approach is pivotal for the success of intensivist-driven bedside echocardiogram programs. Education regarding credentialing and billing is a necessary addition to ensure sustainability of such efforts.

Sports Ultrasound: Applications Beyond the Musculoskeletal System

BACKGROUND

Traditionally, ultrasound has been used to evaluate musculoskeletal injuries in athletes; however, ultrasound applications extend well beyond musculoskeletal conditions, many of which are pertinent to athletes.

EVIDENCE ACQUISITION

Articles were identified in PubMed using the search terms ultrasound, echocardiogram, preparticipation physical examination, glycogen, focused assessment with sonography of trauma, optic nerve, and vocal cord dysfunction. No date restrictions were placed on the literature search.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Several potential applications of nonmusculoskeletal ultrasound in sports medicine are presented, including extended Focused Assessment with Sonography for Trauma (eFAST), limited echocardiographic screening during preparticipation physical examinations, assessment of muscle glycogen stores, optic nerve sheath diameter measurements in athletes with increased intracranial pressure, and assessment of vocal cord dysfunction in athletes.

CONCLUSION

Ultrasound can potentially be used to assist athletes with monitoring their muscle glycogen stores and the diagnosis of multiple nonmusculoskeletal conditions within sports medicine.

Image-based resuscitation of the hypotensive patient with cardiac ultrasound: An evidence-based review

This article is a detailed review of the literature regarding the use of cardiac ultrasound for the resuscitation of hypotensive patients. In addition, figures regarding windows and description of how to perform the test are included.

Pre-participation and follow-up screening of athletes for endurance sport

Physical activity increases life expectancy and sport is a priori not harmful. Exhausted sporting activity (e.g. endurance running, triathlon, cycling or competitive sport) can lead under individual conditions to negative cardiac remodelling (pathological enlargement/function of cardiac cavities/structures) or in worst case to cardiac arrhythmias and sudden cardiac death (SCD). This individually disposition can be genetically determined or behaviourally/environmentally acquired. Overall competitive young male athletes suffer five-fold higher than non-competitive athletes from sudden death and athletes aged over 30 bear a potential for arrhythmias, atrial fibrillation or a 20-fold higher possibility for SCD as female athletes. Patients with diabetes, coronary disease, obesity or hypertension require different special managements. Screening of cardiorespiratory health for sport activities has a lot of faces. Basically there is a need for indicated examinations or possible preventive measures inside or outside of pre-competition screening. The costs of screening compared to expenditure of whole effort for sporting activities are acceptable or even negligible, but of course dependent on national/regional settings. The various causes and possibilities of screening will be discussed in this article as basic suggestion for an open discussion beyond national borders and settings.

Focused cardiac ultrasound: uncommon but critical diagnoses made at the point of care

Cardiovascular and respiratory conditions in acute care require rapid, critical decision making, often with limited clinical information. Focused cardiac ultrasound (FOCUS) can aid in diagnosis by providing information that may not be evident from a patient's medical history, physical examination, and ancillary tests. Eight cases are presented in which FOCUS drastically altered the management of patient care, shortened the differential diagnosis, or allowed for the development of a definitive diagnosis. In 3 cases, diagnoses that were not initially suspected were identified by FOCUS. In the remaining cases, uncommon yet critical diagnoses were established at early stages along the patients' courses of care.

Pocket-sized focused cardiac ultrasound: strengths and limitations

Focused cardiac ultrasound (FCU) has emerged in recent years and has created new possibilities in the clinical assessment of patients both in and out of hospital. The increasing portability of echocardiographic devices, with some now only the size of a smartphone, has widened the spectrum of potential indications and users, from the senior cardiologist to the medical student. However, many issues still need to be addressed, especially the acknowledgment of the advantages and limitations of using such devices for FCU, and the extent of training required in this rapidly evolving field. In recent years, an increasing number of studies involving FCU have been published with variable results. This review outlines the evidence for the use of FCU with pocket-echo to address specific questions in daily clinical practice.

International evidence-based recommendations for focused cardiac ultrasound

BACKGROUND

Focused cardiac ultrasound (FoCUS) is a simplified, clinician-performed application of echocardiography that is rapidly expanding in use, especially in emergency and critical care medicine. Performed by appropriately trained clinicians, typically not cardiologists, FoCUS ascertains the essential information needed in critical scenarios for time-sensitive clinical decision making. A need exists for quality evidence-based review and clinical recommendations on its use.

METHODS

The World Interactive Network Focused on Critical UltraSound conducted an international, multispecialty, evidence-based, methodologically rigorous consensus process on FoCUS. Thirty-three experts from 16 countries were involved. A systematic multiple-database, double-track literature search (January 1980 to September 2013) was performed. The Grading of Recommendation, Assessment, Development and Evaluation method was used to determine the quality of available evidence and subsequent development of the recommendations. Evidence-based panel judgment and consensus was collected and analyzed by means of the RAND appropriateness method.

RESULTS

During four conferences (in New Delhi, Milan, Boston, and Barcelona), 108 statements were elaborated and discussed. Face-to-face debates were held in two rounds using the modified Delphi technique. Disagreement occurred for 10 statements. Weak or conditional recommendations were made for two statements and strong or very strong recommendations for 96. These recommendations delineate the nature, applications, technique, potential benefits, clinical integration, education, and certification principles for FoCUS, both for adults and pediatric patients.

CONCLUSIONS

This document presents the results of the first International Conference on FoCUS. For the first time, evidence-based clinical recommendations comprehensively address this branch of point-of-care ultrasound, providing a framework for FoCUS to standardize its application in different clinical settings around the world.

USEFUL: Ultrasound Exam for Underlying Lesions incorporated into physical exam

INTRODUCTION

The Ultrasound Screening Exam for Underlying Lesions (USEFUL) was developed in an attempt to establish a role for bedside ultrasound in the primary and preventive care setting. It is the purpose of our pilot study to determine if students were first capable of performing all of the various scans required of our USEFUL while defining such an ultrasound-assisted physical exam that would supplement the standard hands-on physical exam in the same head-to-toe structure. We also aimed to assess the time needed for an adequate exam and analyze if times improved with repetition and previous ultrasound training.

METHODS

Medical students with ranging levels of ultrasound training received a 25-minute presentation on our USEFUL followed by a 30-minute hands-on session. Following the hands-on session, the students were asked to perform a timed USEFUL on 2-3 standardized subjects. All images were documented as normal or abnormal with the understanding that an official detailed exam would be performed if an abnormality were to be found. All images were read and deemed adequate by board eligible emergency medicine ultrasound fellows.

RESULTS

Twenty-six exams were performed by 9 students. The average time spent by all students per USEFUL was 11 minutes and 19 seconds. Students who had received the University of California, Irvine School of Medicine's integrated ultrasound curriculum performed the USEFUL significantly faster (p< 0.0025). The time it took to complete the USEFUL ranged from 6 minutes and 32 seconds to 17 minutes, and improvement was seen with each USEFUL performed. The average time to complete the USEFUL on the first standardized patient was 13 minutes and 20 seconds, while 11 minutes and 2 seconds, and 9 minutes and 20 seconds were spent performing the exam on the second and third patient, respectively.

CONCLUSION

Students were able to effectively complete all scans required by the USEFUL in a timely manner. Students who have been a part of the integrated ultrasound in medicine curriculum performed the USEFUL significantly faster than students who had not. Students were able to significantly improve upon the time it took them to complete the USEFUL with successive attempts. Future endpoints are aimed at assessing the feasibility and outcomes of an ultrasound-assisted physical exam in a primary care setting and the exam's effect on doctor-patient satisfaction. [West J Emerg Med. 2014;15(3):260-266.].

Aortic root disease in athletes: aortic root dilation, anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome

Two professional athletes in the U.S. National Basketball Association required surgery for aortic root dilation in 2012. These cases have attracted attention in sports medicine to the importance of aortic root disease in athletes. In addition to aortic root dilation, other forms of aortic disease include anomalous coronary artery, bicuspid aortic valve, and Marfan's syndrome. In this review, electronic database literature searches were performed using the terms "aortic root" and "athletes." The literature search produced 122 manuscripts. Of these, 22 were on aortic root dilation, 21 on anomalous coronary arteries, 12 on bicuspid aortic valves, and 8 on Marfan's syndrome. Aortic root dilation is a condition involving pathologic dilation of the aortic root, which can lead to life-threatening sequelae. Prevalence of the condition among athletes and higher risk athletes in particular sports needs to be better delineated. Normative parameters for aortic root diameter in the general population are proportionate to anthropomorphic variables, but this has not been validated for athletes at the extremes of anthropomorphic indices. Although echocardiography is the favored screening modality, computed tomography (CT) and cardiac magnetic resonance imaging (MRI) are also used for diagnosis and surgical planning. Medical management has utilized beta-blockers, with more recent use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs), and statins. Indications for surgery are based on comorbidities, degree of dilation, and rate of progression. Management decisions for aortic root dilation in athletes are nuanced and will benefit from the development of evidence-based guidelines. Anomalous coronary artery is another form of aortic disease with relevance in athletes. Diagnosis has traditionally been through cardiac catheterization, but more recently has included evaluation with echocardiography, multislice CT, and MRI. Athletes with this condition should be restricted from participation in competitive sports, but can be cleared for participation 6 months after surgical repair. Bicuspid aortic valve is another form of aortic root disease with significance in athletes. Although echocardiography has traditionally been used for diagnosis, CT and MRI have proven more sensitive and specific. Management of bicuspid aortic valve consists of surveillance through echocardiography, medical therapy with beta-blockers and ARBs, and surgery. Guidelines for sports participation are based on the presence of aortic stenosis, aortic regurgitation, and aortic root dilation. Marfan's syndrome is a genetic disorder with a number of cardiac manifestations including aortic root dilation, aneurysm, and dissection. Medical management involves beta-blockers and ARBs. Thresholds for surgical management differ from the general population. With regard to sports participation, the most important consideration is early detection. Athletes with the stigmata of Marfan's syndrome or with family history should be tested. Further research should determine whether more aggressive screening is warranted in sports with taller athletes. Athletes with Marfan's syndrome should be restricted from activities involving collision and heavy contact, avoid isometric exercise, and only participate in activities with low intensity, low dynamic, and low static components. In summary, many forms of aortic root disease afflict athletes and need to be appreciated by sports medicine practitioners because of their potential to lead to tragic but preventable deaths in an otherwise healthy population.

Early screening for cardiovascular abnormalities with preparticipation echocardiography: utility of focused physician-operated echocardiography in preparticipation screening of athletes

OBJECTIVES

We have developed the Early Screening for Cardiovascular Abnormalities With Preparticipation Echocardiography protocol to improve false-positive rates, reduce referrals, and broaden the spectrum of disease that can be captured through preparticipation screening of athletes. This study documents the first application of this protocol and uses case analysis to discuss the potential utility of portable sonography in screening.

METHODS

Sixty-five male collegiate athletes, aged 18 to 25 years, were prospectively enrolled. Each athlete was screened with a history and physical examination, electrocardiography (ECG), and focused echocardiography performed by a noncardiologist sports medicine physician. The history and physical examination were based on the 12-element American Heart Association recommendations; 2010 European Society of Cardiology criteria were used to screen ECGs. Focused physician-operated echocardiography was performed to assess for hypertrophic cardiomyopathy and aortic root dilatation. Athletes screening positive were referred to a cardiologist.

RESULTS

Most of the athletes (n = 59) did not screen positive by any screening modality. Three athletes screened positive on ECG but had normal focused echocardiographic findings. Three athletes screened positive by history and physical examination but had normal ECG and focused echocardiographic findings. All athletes screening positive were referred to a cardiologist and eventually cleared for sports participation. No athlete screened positive by focused echocardiography alone. Focused echocardiography was able to reduce the referral rate for hypertrophic cardiomyopathy by 33% and obtained measurements statistically similar to those of formal echocardiography.

CONCLUSIONS

This study provides evidence that focused physician-operated echocardiography can improve false-positive rates and broaden the spectrum of disease that is detectable through preparticipation screening of athletes.

Focused physician-performed echocardiography in sports medicine: a potential screening tool for detecting aortic root dilatation in athletes

OBJECTIVES

The purpose of this study was to investigate whether sports medicine physicians can obtain accurate measurements of the aortic root in young athletes.

METHODS

Twenty male collegiate athletes, aged 18 to 21 years, were prospectively enrolled. Focused echocardiography was performed by a board-certified sports medicine physician and a medical student, followed by comprehensive echocardiography within 2 weeks by a cardiac sonographer. A left parasternal long-axis view was acquired to measure the aortic root diameter at the sinuses of Valsalva. Intraclass correlation coefficients (ICCs) were used to assess inter-rater reliability compared to a reference standard and intra-rater reliability of repeated measurements obtained by the sports medicine physician and medical student.

RESULTS

The ICCs between the sports medicine physician and cardiac sonographer and between the medical student and cardiac sonographer were strong: 0.80 and 0.76, respectively. Across all 3 readers, the ICC was 0.89, indicating strong inter-rater reliability and concordance. The ICC for the 2 measurements taken by the sports medicine physician for each athlete was 0.75, indicating strong intra-rater reliability. The medical student had moderate intra-rater reliability, with an ICC of 0.59.

CONCLUSIONS

Sports medicine physicians are able to obtain measurements of the aortic root by focused echocardiography that are consistent with those obtained by a cardiac sonographer. Focused physician-performed echocardiography may serve as a promising technique for detecting aortic root dilatation and may contribute in this manner to preparticipation cardiovascular screening for athletes.