© 2004 by European Society of Cardiology
Copyright © 2004, The European Society of Cardiology
The cardiologist's view
Dr. Sloth raises several important issues worthy of consideration. Hand-carried ultrasound (HCU) devices provide an opportunity for widespread application of echocardiography (and ultrasound imaging in general) at the point-of-care permitting earlier diagnosis, triage and therapy.1 Moreover, the introduction of this technology comes at a time when the focus of medicine is shifting from cure to prevention necessitating earlier diagnosis often long before disease is clinically manifest. Examples include detection of asymptomatic left ventricular dysfunction and abdominal aortic aneurysms.2,3 These important clinical conditions can easily be missed on physical examination. Even left atrial enlargement, a parameter that cannot be determined by physical examination has been shown to be an important prognostic risk factor for cardiovascular disease.4
Regarding the use of echocardiography, we agree completely with Dr. Sloth's recommendations that echocardiography should only be performed when clinically indicated. However, as a portable screening tool in a new era of preclinical diagnosis, it may be indicated as part of the general physical examination to screen for asymptomatic, clinically occult disease. Dr. Sloth's perception that the "advertised expansion was not founded on new and scientifically-based data" is interesting. There are several studies evaluating the use of these devices performed by qualified echocardiographers1,3,5–9 and fewer by less well-trained health care providers.10,11 Point-of-care ultrasound at the patient's bedside in the intensive care unit can potentially provide an immediate window to the heart assisting in timely diagnosis and facilitating management. Studies comparing HCU with standard echocardiography in this setting, however, have reported that HCU is limited by decreased image quality and that it may miss important diagnoses even when used in experienced hands.9 Regarding assessment of effusions, we have found that HCU can play an important role not only in assessment but also guidance of treatment of both pleural and pericardial effusions.7 We also agree that there are expanded roles for ultrasound imaging in the outpatient and inpatient settings and intensive care unit.1 Moreover, the use of point-of-care ultrasound extends beyond the field of cardiology and, with the right training, may be used for other applications such as breast, thyroid and abdominal imaging.
Although there is a good argument for broad use of these devices by all health care providers, controversy exists which is principally related to concern that inadequate training will result in misuse, misinformation, and ultimately poor patient outcome.
Widespread application of the technology will mandate appropriate training and credentialing. Echocardiography is not just a technology but rather a highly operator-dependent technique. Misinformation can have significant deleterious consequences. Also, HCU devices do not "make transthoracic echocardiography easier" to perform or interpret. In fact, because these studies are being done at the patient's bedside or outpatient examination room, the environment is generally not ergonomic making the technique more challenging. A thorough training in image acquisition, image interpretation as well as understanding the technique/device specific limitations is necessary. After all, an echocardiographic machine is an echocardiographic machine irrespective of its size.
Guidelines have been set forth by the American Society of Echocardiography, American College of Cardiology and American Heart Association outlining necessary training before these devices can be used clinically for cardiac applications.12 These recommendations may be too stringent or not appropriate when this technique is only applied to evaluate discreet clinical questions such as abdominal aortic caliber or presence of a pleural effusion. Guidelines from the American College of Emergency Physicians have taken a pragmatic approach but there is concern that diagnostic competency is compromised.13 Therefore, consensus in the medical community is needed regarding (1) the appropriate focused use of these devices to address specific clinical questions and (2) the training and credentialing required to use them in this manner.
There are significant barriers to training. Physicians already established in busy clinical practice find it difficult to comply with the time commitment to achieve the ASE recommended training. To address this we and others have advocated introduction of ultrasound technology early in medical school or residency training much like the use of the stethoscope.14 It is therefore unlikely that within five years "everyone will have a pocket machine." These devices are currently too expensive (particularly since there is no reimbursement when used as an extension of the physical examination), and the training required to use these devices responsibly will most likely preclude such widespread use in this short time frame.
In conclusion, HCU permits the widespread application of ultrasound technology, overcoming the limitations of the physical examination, to enhance early diagnosis. It is up to the medical community to ensure that this in done in a responsible fashion mandating appropriate training, credentialing, and recertification to ensure ongoing competence in this significantly operator-dependent technique, the sooner the better.
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- Bruce C.J., et al. Utility of hand-carried ultrasound devices used by cardiologists with and without significant echocardiographic experience in the cardiology inpatient and outpatient settings. American Journal of Cardiology (2002) 90(11):1273–1275.[CrossRef][Web of Science][Medline]
- Vourvouri E.C. Screening for left ventricular dysfunction using a hand-carried cardiac ultrasound device. The European Journal of Heart Failure (2003) 5:767–774.[CrossRef]
- Bruce C.J., et al. Personal ultrasound imager: abdominal aortic aneurysm screening. Journal of the American Society of Echocardiography (2000) 13(7):674–679.[CrossRef][Web of Science][Medline]
- Tsang T.S., et al. Prediction of risk for first age-related cardiovascular events in an elderly population: the incremental value of echocardiography. Journal of the American College of Cardiology (2003) 42(7):1199–1205. [see comment].
[Abstract/Free Full Text] - Vourvouri E., et al. Experience with an Ultrasound Stethoscope. Journal of the American Society of Echocardiography (2002) 15:80–85.[CrossRef][Web of Science][Medline]
- Spencer K., et al. Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient. Journal of the American College of Cardiology (2001) 37:2013–2018.
[Abstract/Free Full Text] - Osranek M., et al. Hand-carried ultrasound-guided pericardiocentesis and thoracentesis. Journal of the American Society of Echocardiography (2003) 16(5):480–484.[CrossRef][Web of Science][Medline]
- Gorcsan J. Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology. In: Journal of the American Society of Echocardiography (2004) 17(1).
- Goodkin G.M., et al. How useful is hand-carried bedside echocardiography in critically ill patients? In: Journal of the American College of Cardiology (2001) 37(8):2019–2022. [see comment].
[Abstract/Free Full Text] - DeCara J.M., et al. The use of small personal ultrasound devices by internists without formal training in echocardiography. In: European Journal of Echocardiography (2003) 4(2):141–147. [see comment].[CrossRef][Medline]
- Alexander J.H., et al. Feasibility of point-of-care echocardiography by internal medicine house staff. American Heart Journal (2004) 147(3):476–481.[CrossRef][Web of Science][Medline]
- Seward J.B., et al. Hand-carried cardiac ultrasound (HCU) device: recommendations regarding new technology. A report from the Echocardiography Task Force on New Technology of the Nomenclature and Standards Committee of the American Society of Echocardiography. Journal of the American Society of Echocardiography (2002) 15(4):369–373.[CrossRef][Web of Science][Medline]
- , et al. American College of Emergency Physicians. American College of Emergency Physicians. ACEP emergency ultrasound guidelines-2001. Annals of Emergency Medicine (2001) 38(4):470–481.[CrossRef][Medline]
- Wittich C.M., et al. Teaching cardiovascular anatomy to medical students by using a handheld ultrasound device. JAMA (2002) 288(9):1062–1063.
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