Diagnostic accuracy of handheld cardiac ultrasound device for assessment of left ventricular structure and function: systematic review and meta-analysis.

OBJECTIVE: Handheld ultrasound devices (HUD) has diagnostic value in the assessment of patients with suspected left ventricular (LV) dysfunction. This meta-analysis evaluates the diagnostic ability of HUD compared with transthoracic echocardiography (TTE) and assesses the importance of operator experience. METHODS: MEDLINE and EMBASE databases were searched in October 2020. Diagnostic studies using HUD and TTE imaging to determine LV dysfunction were included. Pooled sensitivities and specificities, and summary receiver operating characteristic curves were used to determine the diagnostic ability of HUD and evaluate the impact of operator experience on test accuracy. RESULTS: Thirty-three studies with 6062 participants were included in the meta-analysis. Experienced operators could predict reduced LV ejection fraction (LVEF), wall motion abnormality (WMA), LV dilatation and LV hypertrophy with pooled sensitivities of 88%, 85%, 89% and 85%, respectively, and pooled specificities of 96%, 95%, 98% and 91%, respectively. Non-experienced operators are able to detect cardiac abnormalities with reasonable sensitivity and specificity. There was a significant difference in the diagnostic accuracy between experienced and inexperienced users in LV dilatation, LVEF (moderate/severe) and WMA. The diagnostic OR for LVEF (moderate/severe), LV dilatation and WMA in an experienced hand was 276 (95% CI 58 to 1320), 225 (95% CI 87 to 578) and 90 (95% CI 31 to 265), respectively, compared with 41 (95% CI 18 to 94), 45 (95% CI 16 to 123) and 28 (95% CI 20 to 41), respectively, for inexperienced users. CONCLUSION: This meta-analysis is the first to establish HUD as a powerful modality for predicting LV size and function. Experienced operators are able to accurately diagnose cardiac disease using HUD. A cautious, supervised approach should be implemented when imaging is performed by inexperienced users. This study provides a strong rationale for considering HUD as an auxiliary tool to physical examination in secondary care, to aid clinical decision making when considering referral for TTE. TRIAL REGISTRATION NUMBER: CRD42020182429.

Outpatient management of heart valve disease following the COVID-19 pandemic: implications for present and future care.

The established processes for ensuring safe outpatient surveillance of patients with known heart valve disease (HVD), echocardiography for patients referred with new murmurs and timely delivery of surgical or transcatheter treatment for patients with severe disease have all been significantly impacted by the novel coronavirus pandemic. This has created a large backlog of work and upstaging of disease with consequent increases in risk and cost of treatment and potential for worse long-term outcomes. As countries emerge from lockdown but with COVID-19 endemic in society, precautions remain that restrict 'normal' practice. In this article, we propose a methodology for restructuring services for patients with HVD and provide recommendations pertaining to frequency of follow-up and use of echocardiography at present. It will be almost impossible to practice exactly as we did prior to the pandemic; thus, it is essential to prioritise patients with the greatest clinical need, such as those with symptomatic severe HVD. Local procedural waiting times will need to be considered, in addition to usual clinical characteristics in determining whether patients requiring intervention would be better suited having surgical or transcatheter treatment. We present guidance on the identification of stable patients with HVD that could have follow-up deferred safely and suggest certain patients that could be discharged from follow-up if waiting lists are triaged with appropriate clinical input. Finally, we propose that novel models of working enforced by the pandemic-such as increased use of virtual clinics-should be further developed and evaluated.

Stress echocardiography in the district hospital setting: a cost-saving analysis.

AIMS: Accurate and cost-effective techniques are required for investigating patients experiencing chest pain, given the significant workload this patient cohort represents. We determined the cost impact of stress echocardiography compared with myocardial perfusion scintigraphy and coronary angiography in the investigation of patients with chest pain deemed unsuitable for exercise treadmill testing. METHODS AND RESULTS: A total of 200 patients with chest pain-with a low-intermediate probability of coronary artery disease-consecutively referred for stress echocardiography were recruited. Referring clinicians were asked which management strategy they would have chosen were the stress echocardiography service unavailable. The cost saving of stress echocardiography, an accuracy analysis, and adverse outcomes at 6 and 24 months follow-up were determined. The total cost attributable to the stress echocardiography service was Pound Sterling 58 368. If unavailable, 78 (39%) patients would have been referred for angiography and 122 (61%) for perfusion scintigraphy at a cost of Pound Sterling 56 316 and Pound Sterling 42 090, respectively, with a total cost of Pound Sterling 98 406. This represents a cost saving of Pound Sterling 40 038. CONCLUSION: Stress echocardiography is a cost saving method for the investigation of chest pain in patients with low-intermediate risk of flow limiting coronary artery disease in the district hospital setting.