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Hand-held cardiac ultrasound examinations performed in primary care patients by nonexperts to identify reduced
G Nilsson1,2, L Söderström3, K Alverlind3
1Department of Public Health and Clinical Medicine, Umeå University, 90187 Umeå, Sweden. gunnar.nilsson@regionjh.se.
Insights
Focused cardiac ultrasound (FCU) using handheld devices showed poor agreement with expert assessments for identifying reduced left ventricular ejection fraction (LVEF). This highlights challenges in primary care settings for diagnosing heart failure with reduced LVEF.
Area of Science:
- Cardiology
- Medical Imaging
- Primary Care Medicine
Background:
- Early identification of patients with reduced left ventricular ejection fraction (LVEF) is crucial for managing suspected heart failure (HF).
- Focused cardiac ultrasound (FCU) with handheld devices offers a potential tool for primary care settings.
- The study aimed to evaluate FCU's effectiveness in identifying reduced LVEF and characterizing HF types in primary care.
Purpose of the Study:
- To determine if focused cardiac ultrasound (FCU) performed with a handheld device (Vscan 1.2) can identify patients with LVEF < 50%.
- To assess the distribution of heart failure (HF) types among patients with suspected HF in primary care clinics.
- To compare FCU findings by general practitioners (GPs) with conventional cardiac ultrasound by specialists.
Main Methods:
- 100 patients with suspected HF underwent FCU by GPs/registrars after training, compared to conventional cardiac ultrasound by specialists.
- Agreement on LVEF < 50% was assessed via visual global left ventricular function assessment.
- HF types were classified using reference examinations and NT-proBNP levels.
Main Results:
- FCU showed poor agreement (Cohen's κ = 0.22) with expert assessments for identifying reduced LVEF (sensitivity 47.4%, specificity 81.0%).
- Among false negatives, some had HF with LVEF < 40% or 40-49%.
- In patients with elevated NT-proBNP and HF criteria, HF with preserved LVEF (≥50%) predominated (53.2%).
Conclusions:
- There was poor agreement between non-experts using handheld devices and experts using standard ultrasound for identifying reduced LVEF.
- Limited GP experience and the low prevalence of reduced LVEF HF in primary care may explain the poor performance.
- Further training or refined protocols may be needed to improve FCU utility in primary care for HF detection.
Background:
Early identification of patients with reduced left ventricular ejection fraction (LVEF) could facilitate the care of patients with suspected heart failure (HF). We examined if (1) focused cardiac ultrasound (FCU) performed with a hand-held device (Vscan 1.2) could identify patients with LVEF < 50%, and (2) the distribution of HF types among patients with suspected HF seen at primary care clinics.
Methods:
FCU performed by general practitioners (GPs)/GP registrars after a training programme comprising 20 supervised FCU examinations were compared with the corresponding results from conventional cardiac ultrasound by specialists. The agreement between groups of estimated LVEF < 50%, after visual assessment of global left ventricular function, was compared. Types of HF were determined according to the outcomes from the reference examinations and serum levels of natriuretic peptides (NT-proBNP).
Results:
One hundred patients were examined by FCU that was performed by 1-4 independent examiners as well as by the reference method, contributing to 140 examinations (false positive rate, 19.0%; false negative rate, 52.6%; sensitivity, 47.4% [95% confidence interval [CI]: 27.3-68.3]; specificity, 81.0% [95% CI: 73.1-87.0]; Cohen's κ measure for agreement = 0.22 [95% CI: 0.03-0.40]). Among patients with false negative examinations, 1/7 had HF with LVEF < 40%, while the others had HF with LVEF 40-49% or did not meet the full criteria for HF. In patients with NT-proBNP > 125 ng/L and fulfilling the criteria for HF (68/94), HF with preserved LVEF (≥50%) predominated, followed by mid-range (40-49%) or reduced LVEF (< 40%) HF types (53.2, 11.7 and 7.4%, respectively).
Conclusions:
There was poor agreement between expert examiners using standard ultrasound equipment and non-experts using a handheld ultrasound device to identify patients with reduced LVEF. Asides from possible shortcomings of the training programme, the poor performance of non-experts could be explained by their limited experience in identifying left ventricular dysfunction because of the low percentage of patients with HF and reduced ejection fraction seen in the primary care setting.
Trial Registration:
The study was registered at ClinicalTrials.gov (NCT02939157). Registered 19 October 2016.
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