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Handheld Echo: Kona, 2016
Anthony DeMaria
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HAND-HELD ECHOCARDIOGRAPHY
• Emergency imaging–eg cardiopulmonary arrest
• Limited exams (screening, focused)–eg pre-athletic participation
• Extended physical examination– the “ultrasonic stethoscope”
• A harbinger of ultimate miniaturization
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Specific Examinations: Inpatient evaluation
Seven Sites…Simple…Supported by literature…Suitable for the inpatient
1 12 2
3 34
5
67 7
77
High frequencyLow frequencyDopplerd
2. pneumothorax1. internal jugular
4. cardiac parasternal3. pleural effusion
5. cardiac subcostal6. bladder7. deep leg veins
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Missed Findings: POC Echo vs Physical
Spencer, Lang et.al; JACC,2001
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HANDHELD ECHO: CARDIAC EMERGENCIES
• Pericardial effusion/tamponade
• Profound LV dysfunction
• Mechanical lesions– cardiac rupture– papillary muscle rupture
• Dissection
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The Limited (Focused) Exam and Handheld Echo
• Instrument size not critical, but useful
• Focused exam to save time/cost
• Focused exam for specific conditions
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Requirements for a Focused Exam
• A focused exam can be defined
• The exam retains diagnostic accuracy
• The exam will not miss important findings
• The exam saves significant time/money
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Echo exam = 30 min; 50% is Doppler
Kimura et al; JASE;2004
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Incidental Findings are Related to Patient Characteristics
• Age of patient
• Outpatient vs Inpatient
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FOCUSED ECHO: THE MVP EXAMPLE
• MVP frequently suspected
• MVP usually not present
• Accurately diagnosed in PLA view
• Pt population young, ambulatory and with few incidental findings
• Echo limited to PLA saves time/cost
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Kimura et al; AJM: 108, 2000
Focused Echo in MVP
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Kimura et al; AJM: 108, 2000
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Handheld Echo Will Complement/Replace the Stethescope for Physical Exam
• The PE is indirect, imprecise, limited• Accuracy of performing PE is limited• Handheld is comparable to standard echo• Handheld is superior to PE (for all organs)• Trainees can master basic handheld skills• Handheld units will be smaller/cheaper
• A handheld exam will supplant the PE as the primary cost-effective cardiac screen
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Accuracy of Current PE• St Clair AnnIntMed 1992 63 res 50-60% error
MR, AR, MS
• Mangione JAMA 1997 453 res 80% error• Roldan AJC 1996 15 card 20% error• Jost AmJMed 2000 20 card 21% error• March MayoProc 2005 17 card 66% error
All MDs had 76% error
• Criley ArchIntMed 2006 860 MDs 42% errorCards fellows best at 30% errorNo difference for intern to faculty
Functionalmurmurs
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ULTRASOUND PHYSICAL: ASSUMPTIONS
• A hand-held echograph is available– Gray scale and color flow minimum
• Non-sonographers can master echo exam
• Non-echocardiographers can master diagnosis
• The exam is Screening and is not a replacement for full echo
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“ULTRASOUND STETHESCOPE”: LVEF EXAMPLE
• Physical exam limited in assessing EF
• Echo gives good visual EF estimate
• Echo exam of LV may be easier to master than physical exam
• Echo can provide directional changes
• Echo improves LV assessment by medical residents (Kimura et al)
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-6 -5 -4 -3 -2 -1 0 1
5
4
3
2
1
0
Improvement after Ultrasound Use
Total Net Error
DecreasingError
Increasing Error
Num
ber o
f pat
ient
s
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Conclusion:
•These findings suggest that a briefly-trained physician can perform a simplified bedside ultrasound exam using a hand-held device to improve detection of LV systolic dysfunction.
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Carotid Artery (I-M) Screening
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Detection of Abdominal Aortic Aneurysm
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Cardiovascular Limited Ultrasound Examination (CLUE)
• 196 pts in Medicine Clinic (40% new)• Risk stratified by NCEP guidelines
• HCU of carotid, heart, abd aorta
• 36% had undetected abnormalities• 20% had change in management
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Clinical recommendations made in patients (n=196) as a result of CLUE:
• Change LDL goal to <100mg/dl 31• Order echocardiogram7• Order carotid ultrasound 3• Order abdominal ultrasound1• TOTAL: 42
Kimura et al, AJC, 2007
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1.a. Perceived threat to standard ultrasound studies“low quality,” “cursory exam,” “nonstandard documentation”
b. Potential for abuse of current CPT billing codes
2a. still too expensive: >$10,000b. too bulky to carry, unlike stethoscope
a. lack of formal ultrasound training at level of primary-care.b. medico-legal implications unknown.
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ExamOperator
Instrument
LimitedNoviceStripped
FocusedExperienceBasic
CompleteExpertFull feature
Rei
mbu
rsem
ent
Variable Echo Reimbursement??