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(Chest. 2004;126:693-701.)
© 2004 American College of Chest Physicians

Hand-Carried Ultrasound Improves the Bedside Cardiovascular Examination*

Sergio L. Kobal, MD; Shaul Atar, MD and Robert J. Siegel, MD

* From the Division of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA.

Correspondence to: Robert J. Siegel, MD, Cardiac Non-Invasive Laboratory, Room 5335, Cedars-Sinai Medical Center, Los Angeles, CA 90048; e-mail: siegel{at}cshs.org


   Abstract
TOP
 Abstract
Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
 References
 
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.

Key Words: cardiovascular disease • diagnostic techniques • echocardiography • hand-carried cardiac ultrasound


   Introduction
TOP
 Abstract
 Introduction
HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
 References
 
The diagnostic accuracy of the physical examination is problematic, even when performed by experts.123 New generations of doctors rely to a great extent on laboratory data and imaging techniques for making cardiovascular diagnoses. Echocardiography offers precise anatomic and functional information on the cardiovascular system, and is the most commonly used technique for diagnosing cardiovascular diseases.4 However, their cost and size, and the need for considerable expertise to acquire and interpret the ultrasound studies limit the use of standard, cart-based echocardiography (StdEcho) machines.

The hand-carried cardiac ultrasound (HCU) unit is a portable echocardiography device that is battery-operated, lightweight, and the size of a laptop computer. These relatively low-cost units can be used to identify cardiovascular pathologies during routine encounters at the bedside or in the outpatient clinic.5 Thus, this technology extends the physician’s diagnostic capabilities beyond the limits of the physical examination with the potential for more accurate diagnoses and rapid treatment decisions.


   HCU
TOP
 Abstract
 Introduction
 HCU
Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
 References
 
In 1978, Ligtvoet et al6 described the technical features of the first "ultrasonic stethoscope," a battery-operated device housed in a 25-cm long, 1.5-kg box. In the same journal, Roelandt et al7 published their clinical experience with this device. The imaging capability of this miniaturized system was satisfactory. However, it would take another 20 years for the medical industry to develop microprocessor technology to integrate high-resolution, two-dimensional (2D), Doppler imaging into small hand-carried units.8 The principal differences between HCU and StdEcho are summarized in Table 1 .


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  		Table 1. Major Differences Between Ultrasound Systems

 

   Clinical Experience With HCU
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
 References
 
HCU as an Extension of the Physical Examination
The accuracy of physicians’ cardiovascular physical examinations has been extensively reported in the past. Mangione and Nieman9 found that only 56% of cardiology fellows and 39% of medical residents were proficient in the auscultation of 12 cardiac findings. This inaccuracy extended to board-certified cardiologists, who missed 59% of the cardiovascular findings in their physical examinations.10 A number of published studies have demonstrated a remarkable increase in diagnostic accuracy by both cardiologists and noncardiologists when they added a brief cardiac ultrasound study to their conventional physical examination. The addition of a short ultrasound study with the HCU device to the physical examination by four board-certified cardiologists increased their diagnostic accuracy by 39%.10 More recently, Spencer et al11 proved that a routine ultrasound study with an HCU unit could identify unsuspected clinically significant pathology in 40% of patients in a medical department. Rugolotto et al12 found that a 6-min examination with an HCU unit in 55 patients in an ICU changed 40% of their initial diagnoses or diagnostic likelihood and modified the management of 24% of the patients. Severe left ventricular (LV) dysfunction, severe aortic stenosis, and pericardial effusion with tamponade were among the 22 unexpected pathologies found by the HCU operator. Bruce et al13 demonstrated that a 5-min study with an HCU unit expedited patient triage regardless of the encounter location (inpatient triage, 25%; outpatient triage, 15%) or the experience of the operator, and identified unexpected significant pathology in 19% of the population studied. Recently, Fedson et al14 showed that 39% of the patients admitted to an internal medicine department, who had no indication for an echocardiographic study based on history and physical examination findings, had clinically significant cardiac findings diagnosed by nonexpert physicians operating an HCU device.

Echocardiographic Experience of the User
The diagnostic accuracy of an HCU depends on the technical features of the ultrasound equipment, and on the skills of the user in acquiring and interpreting the images. Table 2 summarizes the studies1012131415161718192021222324 that assessed the accuracy of the HCU device in identifying a variety of parameters using 2D imaging, and StdEcho was used for validation. Compared to the StdEcho device, the HCU unit has been found to be accurate for the detection of global LV dysfunction and pericardial effusion, even in the hands of relatively inexperienced personnel.161920 For instance, agreement in the assessment of LV systolic function graded on a scale of 1 (normal) to 4 (severely reduced) between the StdEcho and HCU devices operated by expert cardiologists was found in 96% of the cases.12 Kimura et al25 showed that a brief training session (1 h) in the use of the HCU that was given to 13 medical residents improved their detection of asymptomatic LV dysfunction by 40%. Internists who received 3 h of echocardiography training were able to correctly categorize the LV ejection fraction as < 55% or ≥ 55% in 83% of cases.16 Cardiac fellows with 6 weeks of training in portable echocardiographic studies correctly assessed normal/abnormal LV function in 100% of patients studied, as confirmed with StdEcho.20 In contrast, the diagnosis of segmental wall motion abnormalities and right ventricular dysfunction requires a higher level of expertise. For instance, the rate of agreement in diagnoses between those made with the HCU device and those made with the StdEcho device in the assessment of regional wall motion by cardiologists with limited echocardiographic training was 80% vs 96%, respectively, when assessments were performed by experienced echocardiologists.13 Medical residents misdiagnosed 56% of the cases of right ventricular dysfunction compared to 26% of misdiagnoses by experienced cardiologists.19


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  		Table 2. HCU Diagnostic Accuracy*

 
When assessing valvular lesions, the level of expertise of the HCU unit operator is of major importance. We assessed the accuracy of an HCU device (OptiGo; Philips Medical Systems; Andover, MA) in the diagnosis of valvular regurgitation in 120 hospitalized patients.26 The HCU device operators had level 2 echocardiographic training (defined as at least 150 studies performed and 300 studies interpreted under supervision). Valvular regurgitation was scored from 0 (none) to 3 (severe), and the StdEcho device was used for validation. The StdEcho device identified 312 regurgitant jets, and 53% were clinically significant (moderate regurgitation, 91 jets; severe regurgitation, 75 jets). HCU device operators identified a regurgitant lesion in 99% of those valves with clinically significant lesions and correctly assessed the severity in 83% of the cases. Bruce et al13 compared the utility of the HCU unit when used by cardiologists with and without significant echocardiographic experience. The agreement of the HCU unit with the StdEcho device for the assessment of valve function was 93% (64 of 69 valves). Of note, the less experienced cardiologists performed assessments in four of the five cases with discordant results. Similarly, Alexander et al16 found that in studies performed by medical residents or cardiac fellows, the concordance for the evaluation of moderate or greater mitral regurgitation was 79%.When assessing clinically significant aortic regurgitation, residents missed 19% of the cases, and cardiologists recognized all of them.19

Physicians with limited training performed a study with the HCU device on hospitalized patients in a general ward as a complement to the physical examination. They had a high rate of false-positive results, leading to a positive predictive value of 32%. The HCU unit operator failed, principally, to assess correctly the grade of valvular regurgitation in 20 of 28 patients, mainly by overestimating its severity.14

Technical Limitations
State-of-the-art echocardiography machines use different image modalities, probe frequencies, and vertical and horizontal gain controls to enhance image acquisition and to overcome many technical difficulties. Some of the HCU units (eg, the OptiGo) have few settings to control the 2D general gain and depth. Some units (eg, SonoHeart; Sonosite, Inc; Bothell, WA; and Terason 2000; Teratech Corp; Burlington, MA) have power color-flow Doppler imaging, which is nonaliasing (ie, it measures the mean amplitude but not the frequency shifts from the motion signal of blood cells), so the diagnosis of turbulent jets, which is frequently found in cases of valvular lesions and intracardiac shunts, is more difficult. Spectral Doppler, imaging, which is present in some of the currently available HCU devices (ie, SonoHeart and Terason 2000), but not all of them, has limited capability.

Experienced sonographers operating an HCU device in an ICU failed to identify 17 of 99 significant clinical findings, of which 11 were due to the poor sensitivity of the color-flow Doppler mode of the HCU device.27 Four patients (ie, pulmonary hypertension, three patients; LV outflow tract obstruction, one patient) were missed because of the lack of spectral Doppler. On the other hand, Vourvouri et al28 demonstrated that cardiologists using an HCU unit were able to answer a clinical question for which patients were referred for cardiac consultation in almost 79% of cases, reducing considerably the cost and time of a medical diagnosis. The most frequent reason that led to the subsequent referral for study using StdEcho device was to evaluate the severity of a valvular lesion and the diagnosis of pulmonary hypertension (20 of 23 patients), which require the use of spectral Doppler mode, which was not present in the HCU device used in the study.


   HCU Technical Features
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
Clinical Application of the...
 Present and Future
 Conclusions
 References
 
Four HCU devices for cardiovascular diagnosis are commercially available. OptiGo (Philips Medical Systems) weighs 2.9 kg and has a screen display of 6.5 inches. Figure 1 was obtained from a patient with a systolic murmur, documented by the OptiGo color-flow Doppler device as severe mitral regurgitation. The image from the HCU device in Figure 2 demonstrates a mild-to-moderate pericardial effusion (the "*") in a postoperative patient with pleuritic chest pain. The SonoHeart (Sonosite) is another HCU device that weighs 2.6 kg including battery and has a screen display of 5 inches. A smaller device manufactured by Sonosite (iLook) weighs 1.6 kg and provides only 2D images. The Terason 2000 device (Teratech Corp) is conceptually different from the other HCU devices because the ultrasound system is housed in the probe (weight, 1.3 kg), which connects to any laptop personal computer, which may be used as an image monitor. All of these systems are battery-operated, and offer 2D and color-flow Doppler imaging. Images can be frozen, and electronic calipers allow simple measurements. Images can be stored, printed, or transferred to a personal computer. The second generation of these portable devices (ie, the SonoHeart Elite and the Terason 2000) incorporate tissue harmonic imaging, spectral and pulse Doppler, M-mode and ECG settings, and the possibility of videotape recording using a video cassette recorder and loop recording. The technical features of the HCU devices are listed in Table 3 .



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  		Figure 1. A regurgitant jet into the left atrium (LA) during systole due to severe mitral regurgitation is identified by color Doppler imaging with a four-chamber view. RA = right atrium; RV = right ventricle.

 


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  		Figure 2. An apical four-chamber view demonstrates a small-to-moderate pericardial effusion. * = pericardial effusion.

 

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  		Table 3. Principal Features of the Available HCU Devices

 

   Clinical Application of the HCU Unit
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
Present and Future
 Conclusions
 References
 
An examination with an HCU device is particularly suitable in three specific environments (Table 4 ).


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  		Table 4. HCU Device Setting

 
Emergency and Critical Care Medicine
Noncardiologists were the first to use point-of-care bedside echocardiography. This limited, focused ultrasound examination was initially performed by the medical personnel directly involved in patient care to answer a specific clinical question. Emergency and critical care physicians, after brief training in ultrasonography, have used compact ultrasound units as a complement to their physical examination to triage patients with chest trauma,29 to identify treatable causes of pulseless cardiac activity,3031 and to diagnose pericardial effusion and pulmonary embolism.3233 Croft et al34 showed that after a focused ultrasound examination, emergency physicians changed their first diagnosis in 26% of the patients studied, and their management in 18%. Most emergency medicine residencies in the United States now offer formal instruction in bedside ultrasound examination, and medical organizations have developed policies for the training and adequate application of emergency bedside ultrasound examinations.35

The HCU device is well-suited for use in small, crowded places like the emergency department and ICU. However, lung disease, mechanical ventilation, chest and abdominal tubes, and noncooperative patients are all factors that can affect the quality of the ultrasound imaging. It is precisely in the difficult environment of the ICUs that the accuracy of HCU results is of paramount importance when decisions on management and treatment are made regarding the care of critically ill patients. Goodkin et al27 demonstrated that a first-generation HCU device in the setting of an ICU, even when the studies were performed by experienced sonographers and interpreted by echocardiographers, missed 31% of the findings. On the other hand, Firstenberg et al36 demonstrated that in critically ill patients the HCU device identified 27 of 30 pathologic findings, and the image was satisfactory in all patients. It is reasonable to conclude that experience in echocardiography is desirable in order to overcome the adverse conditions of scanning the heart and interpreting the results in critically ill patients.

The diagnostic utility of using the HCU device in critically ill patients can extend beyond the cardiovascular system. The HCU device can assist physicians in the diagnosis of pulmonary pathologies such as pneumothorax or hydropneumothorax, and can help to determine bladder urine volume in anuric patients. The HCU device is also useful in guiding and monitoring invasive therapeutic procedures such as the drainage of pleural and pericardial effusions,37 and the insertion of central lines and intracardiac electrodes and catheters.38

Community Screening
The cost/benefit ratio of screening programs depends on the incidence of the disease under investigation, whether its detection and treatment change patient outcome, and the existence of reliable and inexpensive diagnostic methods. Asymptomatic patients with LV dysfunction or those with aortic abdominal aneurysms can benefit from early detection and treatment. The diagnosis of LV hypertrophy in hypertensive patients and of hypertrophic cardiomyopathy in athletes can be used to identify a population that is at high-risk for cardiac mortality. The HCU device has been proven to be a reliable tool in assessing the prevalence of LV dysfunction in the community,21 in assessing LV hypertrophy and aortic abdominal aneurysm in hypertensive and older patients,2324 and in assessing hypertrophic cardiomyopathy in athletes.39 In these studies,212324 the degree of concordance between results obtained with the HCU and StdEcho devices was 93 to 98%. Therefore, these data suggest that the HCU device is an ideal noninvasive screening tool because it offers high sensitivity and specificity. However, more studies are required to validate the impact of screening on the clinical outcomes of the different at-risk populations in order to assess the cost/benefit ratio of such a diagnostic method.

Remote Areas
Due to its size and use of battery power, the HCU device can be used in remote places with difficult access, as is the case in many rural areas in developing countries. In Gambia, we used a portable ultrasound (ie, SonoHeart) to examine 1997 people. Of those people, 17% had hypertension, LV hypertrophy was found in 65%.40 The HCU device allowed the identification of a high-risk hypertensive population by diagnosing LV hypertrophy. It is precisely this population that can derive maximal benefit from antihypertensive treatment. We evaluated the diagnostic utility of an HCU device on patients who were referred for cardiac consultation to an outpatient clinic in a rural area of Mexico. The HCU device identified 69 major cardiac findings, including nine cases of congenital heart disease in 88 patients, and helped to elucidate a clinical problem in 89% of them (78 of 88 patients), obviating the need for further comprehensive echocardiographic evaluation (unpublished data). In developing countries, medical care personnel may have infrequent opportunities to diagnose cardiovascular disease. By adding a brief ultrasound study with a portable device to the initial encounter, disease may be recognized and treated more efficiently, and in a timely manner. In areas with reduced medical personnel, ultrasound studies using an HCU device could be obtained by nurses or other community health workers, with remote interpretation obtained when needed.


   Present and Future
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
Conclusions
 References
 
The HCU device has a high level of diagnostic accuracy in the identification of global LV systolic dysfunction,121318192021 LV hypertrophy,121723 and pericardial effusion,121314161718 but it is less precise in assessing regional wall motion abnormalities,1319 right ventricular dysfunction,1319 and valvular lesions.13141626 The limited diagnostic capability of the HCU device compared to the StdEcho device is due not only to the technical limitations of the portable device but also to the different levels of expertise of those acquiring and interpreting the images from the StdEcho device and other portable systems. Thus, studies obtained with portable devices cannot replace comprehensive echocardiographic studies.

The impact of this new technology on patient care must be assessed by comparing bedside diagnostic accuracy based on the traditional physical examination to that of the physical examination complemented with a short ultrasound study performed with the HCU device. By adding a brief ultrasound study to the physical examination in one study,10 cardiologists increased their diagnostic accuracy by almost 40%.The additional value of the HCU device is considerable for those conditions with imperceptible or barely detectable clinical manifestations such as ventricular dysfunction or pericardial effusion. However, any hemodynamic compromise occurring as a result of a pericardial effusion requires the assessment of pulsus paradoxus and jugular venous pressure. The diagnosis of pericarditis relies on the auscultation of a pericardial friction rub regardless of the presence of effusion. Auscultation of pulmonary rales and a third heart sound in patients with congestive heart failure has therapeutic implications, regardless of the severity of the ventricular dysfunction. The functional capacity of cardiac patients, which is of paramount importance in deciding on treatment and management, is obtained from the patient’s history. Thus, the maximal benefit of the use of the HCU device on patient care will be achieved by complementing the information obtained from the history and physical examination.

It is likely that smaller and less expensive HCU units, and the capacity for long distance consultation through high-resolution network transmission will become available in the near future. Improvements in image storage will allow the comparison of studies at different points in time and may be used to guide therapy, as in heart failure patients.

Appropriate Use
Due to the diversity of settings where an HCU device can be used, and to the different levels of difficulty present in the use of each one, there is concern about the minimal level of training required to get maximal benefit from the utilization of this technology. The expertise of the HCU user will affect the rate of false-positive results obtained when HCU studies are performed in populations with a low prevalence of cardiovascular disease,14 and it will affect the number of false-negative cases when studies are performed in the ICU setting.27

The American Society of Echocardiography and the American College of Cardiology/American Heart Association41 recommend a minimum of level 2 training in echocardiography (defined as at least 150 studies performed and 300 studies interpreted under supervision) for the use of an HCU device as an extension of the physical examination (ie, a focused or limited study). As these devices become equipped with more diagnostic elements, the degree to which they add information to the clinical evaluation will depend mainly on the user’s level of expertise more than on device-related limitations.

Unresolved Issues Regarding the Future Use of the HCU Device
The HCU device has the potential to modify traditional medical practices by complementing the physical examination with real-time cardiovascular imaging. However, financial, organizational, and liability issues are still to be resolved. Spevack et al42 considered that the training alone of 32,000 American emergency department physicians and 10,000 pulmonary and critical care specialists would cost approximately $2.1 billion. Another $50 million would be required to provide the 5,000 ICUs in the United States with one portable unit. The current price of the device is an obstacle to physicians purchasing them for their personal use. On the other hand, Vourvouri et al28 have demonstrated that, based on the HCU device results, the cardiac consultant reduced by one third the cost of the medical diagnosis and shortened significantly the time to diagnosis.

As the use of HCU devices becomes more popular and routine, the following several organizational and liability issues will need to be addressed: (1) who will be responsible for the training and continuing education of users?; (2) should HCU training be extended to paramedic personnel, emergency medicine technicians, and nurses?; and (3) will the certification of users be needed or desirable?


   Conclusions
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
References
 
Portable cardiac ultrasound technology is able to assist physicians in the assessment of the cardiovascular system at the initial patient examination. When operated by experienced personnel, the HCU device renders its maximum benefit.

Use of the HCU device can lead to considerable savings of cost and time, as physicians will be able to more selectively order tests based on what is found during the physical examination and after completing a brief ultrasound study. Thus, the HCU device has the potential to help promote better and more efficient health-care delivery.


   Footnotes
 
Abbreviations: 2D = two-dimensional; HCU = hand-carried cardiac ultrasound; LV = left ventricle, ventricular; StdEcho = standard, cart-based echocardiography

Received for publication September 12, 2003. Accepted for publication April 16, 2004.


   References
TOP
 Abstract
 Introduction
 HCU
 Clinical Experience With HCU
 HCU Technical Features
 Clinical Application of the...
 Present and Future
 Conclusions
 References
 

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