1. Answer: C. The American Society of Echocardiography defines FCU as “A focused examination of the cardiovascular system performed by a physician by using ultrasound as an adjunct to the physical examination to recognize specific ultrasonic signs that represent a narrow list of potential diagnoses in specific clinical settings.” FCU does not obviate the need for cardiac physical examination (Answer A is incorrect), rather is used in combination with data gathered from other sources at the bedside to make an initial diagnostic impression. FCU is also not meant to evaluate or exclude all cardiac abnormalities (Answer B is incorrect). FCU should only be used to rapidly assess for and diagnose or exclude a defined list of abnormalities within the practitioner’s scope of training. One of the great strengths of FCU is that the practitioner, who acquires the images, interprets them in real time at the bedside—facilitating rapid patient evaluation (Answer D is incorrect).

2. Answer: B. All users of cardiac ultrasound need to understand the fundamentals of cardiac ultrasound physics. With FCU, the goal is to gain expertise to acquire reliable images from a limited number of views and subjectively interpret these images for prechosen targets. Subsequent referral for echocardiography is usually indicated to delineate and quantify all findings, including incidental or associated findings, that may go unrecognized by FCU. A physician with FCU expertise does not have the image acquisition or interpretation training to identify all structures, image from all acoustic windows, or use advanced ultrasound techniques.

3. Answer: C. Parasternal imaging is generally preferred for inexperienced imagers who perform FCU. It is easier to learn how to acquire (Answer A is incorrect), and it can be done in a supine patient without need for patient positioning in a left lateral decubitus position (Answer D is incorrect). While LV systolic function can be assessed from both views, foreshortening of the LV leading to overestimation of LVEF is common among inexperienced users from the apical window. RV enlargement, if present, can be diagnosed from the subcostal and parasternal views. However, absence of RV enlargement in these views can be misleading and a true on-axis apical image is more reliable for assessing RV size.

4. Answer: A. Assessment of LV systolic function, LA size, RV size, and pericardial effusion have all been validated as assessable by a practitioner with FCU level image acquisition and interpretation training. Pathologies that are complex or unusual should not be expected to be diagnosed by a physician solely trained in FCU. In addition, some pathologies are subtle and are difficult to recognize (aortic dissection, hypertrophic cardiomyopathy, LV regional wall motion abnormalities, cardiac masses, RV hypertrophy, LV thrombus, and valvular vegetations). Other abnormalities require assimilation of data from multiple views to correctly define (RV systolic function).

5. Answer: C. FCU is an ideal tool when there is a need for urgent cardiac evaluation. In hemodynamically unstable or cardiac arrest patients, prompt bedside assessment may impact therapy in terms of the use of volume repletion or vasopressors. In patients with chest trauma or findings consistent with pericardial tamponade, FCU can readily be used to identify the presence or absence of pericardial effusion. Stroke patients have less urgent need for evaluation and the clinically relevant ultrasound findings may be beyond the acquisition and interpretive abilities of an FCU trained physician.

6. Answer: C. While helpful in making the diagnosis of CHF, physical examination, CXR, and BNP have a poor ability to differentiate systolic from diastolic heart failure. EKG, while suggestive if there are extensive Q-waves, also lacks the ability to differentiate types of heart failure. FCU has excellent ability to detect LV systolic function even when performed by physicians with as few as 20-30 prior examinations.

7. Answer: D. It would be impractical to use traditional echocardiography to assess a patient at the bedside every day or multiple times a day for a period of time, such as during hospitalization. In addition, there are few ultrasound parameters that would be useful to follow on such a frequent basis. Although a pericardial effusion may need serial assessment, repeated evaluation of this is best reserved for those with echocardiographic training to assess the hemodynamic effects of the effusion and serially compare images, which may be difficult with FCU systems. Knowledge of patient volume status (at least as measured by RA pressure) is frequently assessed by physical examination and, therefore, suitable for FCU. FCU assessment of the IVC is both more feasible and accurate than physical examination for detecting elevated central venous pressure. LV systolic function may need reassessment by FCU if a patient’s hemodynamic status changes but rarely requires frequent serial evaluation.

8. Answer: C. LV systolic dysfunction is an ideal target for screening. It is somewhat prevalent, even in a population of asymptomatic subjects, and has effective therapy even in the preclinical stage. BNP and EKG while having good sensitivity, have very poor specificity to screen for LV systolic dysfunction (Answers D and E are incorrect). While comprehensive echocardiography has excellent accuracy, its costs make it impractical as a screening tool. FCU, which can be performed rapidly at the bedside, has very good sensitivity and specificity for identifying reduced LVEF, even when performed by practitioners with limited training. FCU is clearly superior to physical examination for detecting low LV ejection fraction (Answer A is incorrect).

9. Answer: D. Successful implementation of an FCU practice must consider the abilities of the imager to acquire the required images and their training to interpret the findings (Answers B and C are incorrect). As with any clinical tool, inappropriate use of FCU beyond a defined scope of training may have adverse consequences on patient care. The risk of a false-negative FCU examination that leads to delayed treatment or a false-positive examination that results in unnecessary treatment must be recognized. Although easier to use, the simplified, miniaturized devices often used for FCU have reduced imaging abilities and may simply be inadequate to detect certain abnormalities (Answer A is incorrect). Physician specialty will strongly affect FCU protocols. Depending on the type of patients and clinical scenarios encountered, the ultrasound targets of the FCU examination may vary significantly (Answer E is incorrect). While patient gender and body size may affect the ability to acquire useable images, the protocol will not vary as the goals of the examination remain unchanged (Answer D is correct).

10. Answer: C. While emergency and critical care physicians have been early adopters of FCU, it is expected that physicians with diverse training backgrounds and specialties will find FCU useful (Answer B is incorrect). Depending on the physician’s scope of practice, the data they require when evaluating their patients may vary. This means that FCU protocols may vary by specialty (Answer A is incorrect). Although frequently used as a surrogate measure, the relationship between the number of studies performed and clinical competency has a weak relationship (Answer D is incorrect). FCU courses should include three core components—didactic, hands-on imaging, and case-based image interpretation. Didactic training can be delivered in any number of formats (lecture, online, DVD) (Answer E is incorrect).

11. Answer: A. While hands-on training on simulation dummies or in normal subjects may be useful (Answer C is incorrect) to learn basic views and gain confidence in imaging, there is no surrogate of imaging patients who are representative of the type of patients the physicians care for in their practice (Answer B is incorrect). Like many procedures in medicine, the technical hands-on skill generally lags and extinguishes faster than the didactic learning (Answer D is incorrect).

12. Answer: C. This subcostal image demonstrates a large pericardial effusion with collapse of the RV consistent with cardiac tamponade.

13. Answer: B. LV and RV systolic functions are preserved and there is no significant pericardial effusion. FCU assessment of the IVC from the subcostal window demonstrates a normal sized IVC with complete collapsibility with respiration, suggesting a right atrial pressure lower than 5 mm Hg. While FCU findings need to be used in conjunction with history, and physical examination in the evaluation of patients, these data strongly suggest that hypovolemia (Answer B) is more likely than the other causes listed as the etiology of hypotension.

14. Answer: D. Rapid bedside assessment of this hypotensive patient with FCU demonstrates no significant pericardial fluid, a small hyperdynamic LV and a very enlarged poorly contractile RV. While not enough to be used in isolation, when combined with the clinical picture, this is consistent with an acute RV syndrome, in this case pulmonary embolism. Recognition of this may not direct immediate therapy, but it can dramatically change the subsequent testing, away from left-sided congestive heart failure to a cause of acute RV injury.

15. Answer: B. The parasternal long-axis image demonstrates preserved LVEF and marked calcification of the aortic valve with impaired leaflet motion, all consistent with aortic stenosis. Comprehensive transthoracic echocardiography (TTE) is indicated for assessment of stenosis severity and evaluation for concomitant valvular heart disease.

16. Answer: C. Parasternal long- and short-axis images demonstrate preserved LV systolic function, no significant pericardial effusion with significant concentric hypertrophy and left atrial enlargement. These findings make diastolic heart failure likely. Comprehensive TTE is indicated for comprehensive evaluation of diastolic function and filling pressures, but these bedside images may allow more targeted therapy before the results of TTE are available.

17. Answer: A. While many findings on physical examination may suggest LV systolic dysfunction, FCU in 20-60 seconds performed at the bedside definitively determines that this patient has serious LV systolic dysfunction. Determination of LVEF at this point is not required to guide therapy, simply a determination of LV systolic function as clearly normal, reduced, or very reduced allows targeted management decisions.