Complementing the physical examination with a point-of-care ultrasound study (POCUS) can improve patient triage. We aimed to study the impact of POCUS on the diagnosis and management of outpatients and hospitalized patients with suspected cardiac disease. In this multicenter study, a pocket-sized device was used to perform POCUS when the diagnosis or patient management was unclear based on anamnesis, physical examination, and basic diagnostic testing. Eighteen physicians (cardiac fellows 49%, cardiologists 30%, and echocardiographers 21%) performed physical examinations extended by POCUS on 207 patients (inpatients 83% and outpatients 17%). POCUS findings resulted in a change in the primary diagnosis in 14% of patients. In patients whose diagnosis remained unchanged, POCUS results reinforced the initial diagnosis in 48% of the cases. In 39% of the patients, the diagnostic plan was altered, including referral (16%) or deferral (23%) to other diagnostic techniques. Alteration in medical treatment (drug discontinuation or initiation) occurred in 11% of the patients, and in 7% POCUS results influenced the decision whether to perform a therapeutic procedure. Hospitalization or discharge was determined after POCUS in 11% of the patients. In conclusion, during patient triage, extension of the physical examination by POCUS can cause physicians to alter their initial diagnosis, resulting in an immediate change of diagnostic and therapeutic procedures. Based on POCUS results, physicians altered the diagnostic plan either by avoiding or referring patients to other diagnostic procedures in almost half of the studied population.
Bedside diagnosis of cardiovascular disease by both general practitioners and specialists is problematic. Small ultrasound units have been developed, and for the last 5 years, pocket-size ultrasound devices have been available. Several studies demonstrated a remarkable increase in the accuracy of cardiovascular diagnosis by medical students, residents, internists, and cardiologists when a brief ultrasound study was added to the conventional physical examination. Recommendations have been published for the use of these devices as complementary to the physical examination to address a specific clinical question. The impact of the extension of the physical cardiovascular examination by point-of-care ultrasound study (POCUS) was studied mainly in single-center studies and in small populations. The aim of the current multicenter study was to assess the impact of POCUS on the clinical decision making of physicians and on the management of patients in a variety of settings when it is performed by operators with different levels of expertise.
Methods
In different clinical settings, physicians (18 in total) with various levels of expertise in echocardiography performed 207 physical examinations extended by POCUS of patients with suspected acute cardiac disease. The portable device, V-Scan (GE Vingmed Ultrasound AS, Horten, Norway), provides 2-dimensional and color-coded flow image and allows simple linear measurements. The decision to perform a POCUS was left to the discretion of the physician in charge of the patient, with a focus on cases where diagnosis or patient management remained in doubt after anamnesis, physical examination, and simple diagnostic tests, such as ECG, blood tests, and chest x-ray. After the ultrasound study, physicians filled out a questionnaire that assessed the impact of POCUS on the diagnosis and management of the patient, including the presenting clinical problem, the rationale for the examination, main echocardiographic findings, impact on the diagnosis and diagnostic plan (the necessity or avoidance of other diagnostic procedures), on treatment plan (medical and procedural therapy), and on decisions regarding hospitalization or discharge.
Eight cardiology fellows (with minimum level 1 training as defined by the American Society of Echocardiography ), 5 board-certified cardiologists, and 5 echocardiographers performed the studies at 3 university medical centers. Global and regional ventricular wall motion was assessed qualitatively by eyeball estimation. Color Doppler was used to diagnose valve malfunction. Severity of valvular regurgitation was qualitatively estimated by assessment of the regurgitant jet area. Linear measurements of LV and RV size, LV wall thickness, and ascending aorta were performed according to guidelines. The ethics committees at the 3 participating centers approved the research protocol.
Statistical analysis was performed with the SPSS package (SPSS, Chicago, Illinois). The results are presented as the mean (SD) for continuous variables and as the total patients (percentage of total patients) for categorical data; t test was used for comparison of the continuous variables and chi-square test for categorical data, using Fisher’s exact test if needed. A 2-tailed p value ≤0.05 was considered significant.
Results
The study included 207 patients. Data on gender and age were available for 167 of them (56% male, mean age 63 ± 11 years). In 147 patients (71%), POCUS was performed in the intensive cardiac care unit and in the emergency department, in 35 patients (17%) POCUS was performed in the outpatient clinic, whereas in the remainder of patients POCUS was performed in medical and surgical wards. Cardiology fellows performed 102 (49%) of the POCUS examinations, cardiologists 61 (30%), and echocardiographers 44 (21%). The studies were completed in an average time of 6.9 ± 3.5 minutes.
The main reasons for performing POCUS were complaints of chest pain and dyspnea (see Table 1 ). In 35 cases, there were multiple reasons to include POCUS in the initial triage. The questions that the examinations aimed to address are reported in Table 2 , and their main findings are summarized in Table 3 . Based on the POCUS results, physicians changed their initial diagnosis in 29 (14%) of the studied patients. In 19 cases (9%), the diagnosis was changed from cardiac to noncardiac, in 6 cases (3%) the diagnosis was modified from one cardiac etiology to a different one, and in 4 cases (2%), the diagnosis was changed from noncardiac to cardiac. In almost half of patients whose initial diagnosis remained unchanged, the POCUS results reinforced physicians’ level of confidence in their diagnosis ( Figure 1 ).
