Focused Cardiac Ultrasonography.

Focused cardiac ultrasonography (FCU) is the use of ultrasonography as an adjunct to physical examination at the point of care. There are ample data supporting the fact that noncardiology trained users using small ultrasonography devices can assess left ventricular (LV) enlargement, LV systolic dysfunction, right ventricular (RV) enlargement, left atrial (LA) enlargement, LV hypertrophy, pericardial effusion, and right atrial (RA) pressure elevation more accurately than performing a physical examination. In addition, FCU-trained providers may have skills to perform ultrasonography imaging of body systems outside the heart to supplement their cardiac evaluation. FCU training, including didactic education, proctored imaging, independent imaging, and image interpretation, has been established by several specialties and medical schools. Cardiologists should embrace FCU in their facilities, as the clinical value to patient care is clear. Cardiologists have the responsibility to maintain excellence in the practice of echocardiography while enabling the use of ultrasonography by other medical professionals to augment their clinical assessments conventionally based on physical examination alone.

Focused cardiac ultrasound as a predictor of readmission in acute decompensated heart failure.

Acute decompensated heart failure (ADHF) is a common reason for admission to the hospital, and readmission is frequent. Multiple factors contribute to rehospitalizations, but inadequate assessment of volume status leading to persistent congestion is an important factor. We sought to determine if focused cardiac ultrasound (FCU) of the inferior vena cava (IVC), as a surrogate of volume status, would predict readmission of ADHF patients after index hospitalization. Patients admitted with a primary diagnosis of ADHF were prospectively enrolled. All patients underwent FCU of the IVC on admission and then daily. 82 patients were enrolled. Patients demonstrated improvement in heart failure physical examination findings and symptoms during the hospitalization. There was a reduction in the size of the IVC and a significant increase in patients with small collapsible vena cava. Logistic regression analysis of physical examination, patient symptoms, and IVC parameters at discharge demonstrated IVC collapsibility and patient reported dyspnea improvement as the only significant variables to predict readmission or emergency department visit. FCU assessment of IVC size and collapsibility may be useful in patients with ADHF to predict risk of being readmitted within 30 days of hospital discharge.

A clinical pathway for heart failure reduces admissions from the ED without increasing congestion in the ED.

BACKGROUND: A multidisciplinary team at a major academic medical center established an Acutely Decompensated Heart Failure Clinical Pathway (ADHFCP) program to reduce inpatient readmission rates among patients with heart failure which, among several interventions, included an immediate consultation from a cardiologist familiar with an ADHFCP patient when the patient presented at the Emergency Department (ED). This study analyzed how that program impacted utilization of services in the ED and its subsequent effect on rates of admission from the ED and on disposition times. METHODS: ADHFCP inpatient visits were retrospectively risk stratified and matched with non-program inpatient visits to create a control group. A Cox survival model analyzed the ADHFCP's impact on patients' likelihood to visit the ED. Multivariable ANOVA evaluated the impact of the program on the patients' likelihood of being admitted when presenting at the ED. The ADHFCP's impact on bed-to-disposition time in the ED was evaluated by Wilcoxon's rank-sum test, as were doses of diuretics administered in the ED. RESULTS: The survival analysis showed no impact of the ADHFCP on patients' likelihood of visiting the ED, but ADHFCP patients presenting to the ED were 13.1 (95% CI: 3.6-22.6) percentage points less likely to be admitted. There was no difference in bed-to-disposition times, but ADHFCP patients received diuretics more frequently and at higher doses. CONCLUSIONS: Improved communication between cardiologists and ED physicians through the establishment of an explicit pathway to coordinate the care of heart failure patients may decrease that population's likelihood of admission without increasing ED disposition times.

2D and 3D Echocardiography-Derived Indices of Left Ventricular Function and Shape: Relationship With Mortality.

OBJECTIVES: This study hypothesized that left ventricular (LV) ejection fraction (EF) and global longitudinal strain (GLS) derived from 3-dimensional echocardiographic (3DE) images would better predict mortality than those obtained by 2-dimensional echocardiographic (2DE) measurements, and that 3DE-based LV shape analysis may have added prognostic value. BACKGROUND: Previous studies have shown that both LVEF and GLS derived from 2DE images predict mortality. Recently, 3DE measurements of these parameters were found to be more accurate and reproducible because of independence of imaging plane and geometric assumptions. Also, 3DE analysis offers an opportunity to accurately quantify LV shape. METHODS: We retrospectively studied 416 inpatients (60 ± 18 years of age) referred for transthoracic echocardiography between 2006 and 2010, who had good-quality 2DE and 3DE images were available. Mortality data through 2016 were collected. Both 2DE and 3DE images were analyzed to measure LVEF and GLS. Additionally, 3DE-derived LV endocardial surface information was analyzed to obtain global shape indices (sphericity and conicity) and regional curvature (anterior, septal, inferior, lateral walls). Cardiovascular (CV) mortality risks related to these indices were determined using Cox regression. RESULTS: Of the 416 patients, 208 (50%) died, including 114 (27%) CV-related deaths over a mean follow-up period of 5 ± 3 years. Cox regression revealed that age and body surface area, all 4 LV function indices (2D EF, 3D EF, 2D GLS, 3D GLS), and regional shape indices (septal and inferior wall curvatures) were independently associated with increased risk of CV mortality. GLS was the strongest prognosticator of CV mortality, superior to EF for both 2DE and 3DE analyses, and 2D EF was the weakest among the 4 functional indices. A 1% decrease in GLS magnitude was associated with an 11.3% increase in CV mortality risk. CONCLUSIONS: GLS predicts mortality better than EF by both 3DE and 2DE analysis, whereas 3D EF is a better predictor than 2D EF. Also, LV shape indices provide additional risk assessment.

Cardiology Consultation in the Emergency Department Reduces Re-hospitalizations for Low-Socioeconomic Patients with Acute Decompensated Heart Failure.

BACKGROUND: Re-hospitalization after discharge for acute decompensated heart failure is a common problem. Low-socioeconomic urban patients suffer high rates of re-hospitalization and often over-utilize the emergency department (ED) for their care. We hypothesized that early consultation with a cardiologist in the ED can reduce re-hospitalization and health care costs for low-socioeconomic urban patients with acute decompensated heart failure. METHODS: There were 392 patients treated at our center for acute decompensated heart failure who received standardized education and follow-up. Patients who returned to the ED received early consultation with a cardiologist; 392 patients who received usual care served as controls. Thirty- and 90-day re-hospitalization, ED re-visits, heart failure symptoms, mortality, and health care costs were recorded. RESULTS: Despite guideline-based education and follow-up, the rate of ED re-visits was not different between the groups. However, the rate of re-hospitalization was significantly lower in patients receiving the intervention compared with controls (odds ratio 0.592), driven by a reduction in the risk of readmission from the ED (0.56 vs 0.79, respectively). Patients receiving the intervention accumulated 14% fewer re-hospitalized days than controls and 57% lower 30-day total health care cost. Despite the reduction in health care resource consumption, mortality was unchanged. After accounting for the total cost of intervention delivery, the health care cost savings was substantially greater than the cost of intervention delivery. CONCLUSION: Early consultation with a cardiologist in the ED as an adjunct to guideline-based follow-up is associated with reduced re-hospitalization and health care cost for low-socioeconomic urban patients with acute decompensated heart failure.

Myocardial strain may be useful in differentiating Takotsubo cardiomyopathy from left anterior descending coronary artery ischemia.

BACKGROUND: Stress-induced cardiomyopathy (SCM) is characterized by transient apical wall motion abnormalities of the left ventricle (LV) in the absence of obstructive coronary artery disease. Although the echocardiographic findings of SCM mimic those of left anterior descending coronary artery ischemia or infarction (LAD), the regional LV wall motion pattern and degree of RV involvement may differ. METHODS: We sought to systematically assess regional LV and RV function with myocardial strain imaging to assess if ventricular involvement may differ between SCM and LAD. RESULTS: This was a retrospective cohort study, with 3 groups: patients with SCM (n=55), patients with LAD (n=36), and 37 normal subjects. All the patients had a comprehensive transthoracic echocardiographic examination, including assessment of longitudinal strain (LS). Global LV longitudinal strain was markedly decreased in both the SCM and LAD groups. However, SCM patients differed by more severe involvement the mid-inferolateral, mid-inferior, apical-lateral, and apical-inferior segments. When compared to the LAD patients, SCM patients had significantly more RV involvement both visually and quantitatively (27-42% versus 0-25%). Predictors of SCM included visually reduced RV systolic function, abnormal TAPSE, RVS' and RV LS in the apical segment. Of the LV variables, regional LS in the mid-inferior and apical-inferior segments could differentiate the groups. CONCLUSIONS: Our results suggest that RV involvement and the pattern of LV regional LS abnormalities may help differentiate SCM from LAD disease during echocardiographic imaging.

Monitoring Ionizing Radiation Exposure for Cardiotoxic Effects of Breast Cancer Treatment.

Serial assessments of left ventricular ejection fraction (LVEF) are customary in patients with breast cancer receiving trastuzumab. Radionuclide angiography (RNA) is often used; however, a typical monitoring schedule could include 5 scans in a year. We evaluated the proportion of imaging-related ionizing radiation attributable to RNA in 115 patients with breast cancer, from 3 medical centers in the United States, Ireland, and Japan, who completed 12 months of trastuzumab treatment. Estimated radiation dose (ERD) was used to calculate exposure associated with imaging procedures spanning the 18 months before and after trastuzumab therapy. In addition, 20 cardiologists and oncologists from participating centers were surveyed for their opinions regarding the contribution of RNA to overall radiation exposure during trastuzumab treatment. When RNA was used to monitor LVEF, the mean ERD from imaging was substantial (34 ± 24.3 mSv), with the majority attributable solely to RNA (24.7 ± 14.8 mSv, 72.6%). Actual ERD associated with RNA in this population differed significantly from the perception in surveyed cardiologists and oncologists; 70% of respondents believed that RNA typically accounted for 0% to 20% of overall radiation exposure from imaging; RNA actually accounted for more than 70% of ERD. In conclusion, RNA was used to monitor LVEF in most patients in this cohort during and after trastuzumab therapy. This significantly increased ERD and accounted for a greater proportion of radiation than that perceived by surveyed physicians. ERD should be taken into account when choosing a method of LVEF surveillance. Alternative techniques that do not use radiation should be strongly considered.

Outpatient Use of Focused Cardiac Ultrasound to Assess the Inferior Vena Cava in Patients With Heart Failure.

Accurate assessment of volume status is critical in the management of patients with heart failure (HF). We studied the utility of a pocket-sized ultrasound device in an outpatient cardiology clinic as a tool to guide volume assessment. Inferior vena cava (IVC) size and collapsibility were assessed in 95 patients by residents briefly trained in focused cardiac ultrasound (FCU). Cardiologist assessment of volume status and changes in diuretic medication were also recorded. Patients were followed for occurrence of 30-day events. There was a 94% success rate of obtaining IVC size and collapsibility, and agreement between visual and calculated IVC parameters was excellent. Most patients were euvolemic by both FCU IVC and clinical bedside assessment (51%) and had no change in diuretic dose. Thirty-two percent had discrepant FCU IVC and clinical volume assessments. In clinically hypervolemic patients, the FCU evaluation of the IVC suggested that the wrong diuretic management plan might have been made 46% of the time. At 30 days, 14 events occurred. The incidence of events increased significantly with FCU IVC imaging categorization, from 11% to 23% to 36% in patients with normal, intermediate, and plethoric IVCs. By comparison, when grouped in a binary manner, there was no significant difference in event rates for patients who were deemed to be clinically volume overloaded. Assessment of volume status in an outpatient cardiology clinic using FCU imaging of the IVC is feasible in a high percentage of patients. A group of patients were identified with volume status discordant between FCU IVC and routine clinic assessment, suggesting that IVC parameters may provide a valuable supplement to the in-office physical examination.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Focused cardiac ultrasound: where do we stand?

Focused cardiac ultrasound (FCU) is a bedside examination of the heart performed with a small, portable ultrasound platform by a physician as an adjunct to their physical examination. The goal is to recognize a narrow list of abnormalities that are both detectable by physicians with limited ultrasound training and have high clinical assessment value. Results from the FCU examination are integrated with traditional bedside assessment (physical examination and history) to provide early management plans and patient triage in settings when echocardiography cannot be obtained or is not immediately available.

Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.

The rapid technological developments of the past decade and the changes in echocardiographic practice brought about by these developments have resulted in the need for updated recommendations to the previously published guidelines for cardiac chamber quantification, which was the goal of the joint writing group assembled by the American Society of Echocardiography and the European Association of Cardiovascular Imaging. This document provides updated normal values for all four cardiac chambers, including three-dimensional echocardiography and myocardial deformation, when possible, on the basis of considerably larger numbers of normal subjects, compiled from multiple databases. In addition, this document attempts to eliminate several minor discrepancies that existed between previously published guidelines.

Automated mutual exclusion rules discovery for structured observational codes in echocardiography reporting.

Structured reporting in medicine has been argued to support and enhance machine-assisted processing and communication of pertinent information. Retrospective studies showed that structured echocardiography reports, constructed through point-and-click selection of finding codes (FCs), contain pair-wise contradictory FCs (e.g., "No tricuspid regurgitation" and "Severe regurgitation") downgrading report quality and reliability thereof. In a prospective study, contradictions were detected automatically using an extensive rule set that encodes mutual exclusion patterns between FCs. Rules creation is a labor and knowledge-intensive task that could benefit from automation. We propose a machine-learning approach to discover mutual exclusion rules in a corpus of 101,211 structured echocardiography reports through semantic and statistical analysis. Ground truth is derived from the extensive prospectively evaluated rule set. On the unseen test set, F-measure (0.439) and above-chance level AUC (0.885) show that our approach can potentially support the manual rules creation process. Our methods discovered previously unknown rules per expert review.

Identifying errors and inconsistencies in real time while using facilitated echocardiographic reporting.

BACKGROUND: Facilitated reporting using a discrete set of finding codes (FCs) is a common method of generating echocardiographic reports. METHODS: The investigators developed a tool that allows echocardiographic reports to be evaluated in real time for errors, omissions, and inconsistencies on the basis of a defined group of "rules" applied to the FCs present in the report. At the time of report finalization, conflicts were displayed for the interpreting physicians, and their responses to each rule conflict were logged. RESULTS: Over the course of 1 year, 7,986 transthoracic echocardiographic reports were analyzed prospectively during study interpretation. Overall, 30 ± 4.7 FCs were used to generate finalized reports. An average of 2.4 ± 2.0 conflicts were detected per finalized study. Eighty-three percent of studies had at least one conflict identified. There was no significant correlation between physician experience and conflict rates, but time of day (earlier) and rate at which studies were being finalized (faster) were both correlated with increased conflict rate. Overall, physicians ignored identified conflicts 52% of the time and altered their readings to eliminate the conflicts 48% of the time. Overall, at least one change was made in 54% of all finalized studies. There was a small but significant trend for physicians to produce more conflicts over time as the tool was used. CONCLUSIONS: This study demonstrates that facilitated reporting of echocardiographic studies, using a discrete set of FCs, allows the generation of rules that can be used to identify discrepancies in echocardiographic reports before finalization. Conflicts are common in clinical practice, and the identification of these conflicts in real time allowed readers to review their interpretations and frequently resulted in alterations to echocardiographic reports.

Cardiac sarcoidosis detected by late gadolinium enhancement and prevalence of atrial arrhythmias.

Cardiovascular magnetic resonance (CMR) imaging is being increasingly used to help identify patients with cardiac sarcoidosis (CS). Whereas ventricular arrhythmias have been well studied in this population, atrial arrhythmias have not been thoroughly investigated. We sought to better characterize the arrhythmia burden of a cohort of patients diagnosed with CS by CMR imaging. Patients with biopsy-proven extracardiac sarcoidosis were referred to the University of Chicago for evaluation of the presence of CS. CMR imaging was used to categorize the patients into 2 groups; those with and those without late gadolinium enhancement (LGE) for comparison of arrhythmic events. Arrhythmic evaluation included Holter monitor, event recorder, electrophysiology testing, or implantable cardioverter-defibrillator (ICD) interrogation; 192 consecutive patients were evaluated with CMR imaging, 57 of whom did not have ambulatory monitoring results and thus were excluded. LGE was present in 44 patients. Atrial arrhythmias were documented in 16 patients (36%) with myocardial LGE and in 11 patients (12%) without myocardial LGE (p = 0.002). Ventricular arrhythmias were documented in 27% of patients with myocardial LGE and 2.2% of LGE-negative patients (p = 0.00076). Of 26 LGE-positive patients with ICDs, 8 (30.8%) received therapies, 3 (11.5%) of which were inappropriate for atrial arrhythmias. In conclusion, atrial arrhythmias were documented more frequently than ventricular arrhythmias in patients with sarcoidosis with cardiac involvement and were 3 times more prevalent than in patients with sarcoidosis without cardiac involvement. Risk-benefit assessment of anticoagulation for primary prevention of stroke should be performed for patients with CS. In patients receiving implantable defibrillators, programming to minimize inappropriate ICD shocks for atrial arrhythmias must be considered.

Bicuspid aortic valve: inter-racial difference in frequency and aortic dimensions.

OBJECTIVES: The objective of this study was to examine the similarities and differences in Caucasian (C) and African-American (AA) patients with bicuspid aortic valve (BAV) with respect to morphology, severity of aortic stenosis/insufficiency, and aortic dilation. BACKGROUND: BAV is a common congenital valve abnormality, accounting for a large number of valve replacements. METHODS: A total of 229 patients with the diagnostic code BAV were identified retrospectively from our computerized adult echocardiographic database, which consists of 91,896 studies performed at the University of Chicago Medical Center from 1998 to 2009, representing 40,878 patients. Of those, 183 patients with BAV were included in this retrospective BAV single-center cohort study and reanalyzed with a comprehensive assessment of aortic dimensions, aortic valve morphology and function, clinical cardiovascular risk factors, and patient characteristics. RESULTS: Of the 183 patients with BAV, 138 were C and 45 were AA. Our echocardiographic database encompasses approximately 65% AA, 31% C, and 4% other races, for an estimated frequency of BAV in AA patients of 0.17% and a frequency in C patients of 1.1% (p = 0.001). There were no significant inter-racial differences regarding sex, height, weight, hyperlipidemia, diabetes, tobacco use, cardiac medications, and left ventricular ejection fraction. The AA cohort was older (age 50 ± 17 years vs. 43 ± 17 years, p < 0.05) and had a higher prevalence of hypertension (51% vs. 24%, p < 0.05). After adjusting for comorbidities, aortic dimensions were larger in C (C vs. AA: annulus, 2.4 ± 0.4 vs. 2.1 ± 0.4 cm; sinuses of Valsalva, 3.4 ± 0.7 vs. 3.1 ± 0.6 cm; sinotubular junction, 3.0 ± 0.6 vs. 2.6 ± 0.5 cm; and ascending aorta, 3.5 ± 0.7 vs. 3.2 ± 0.5 cm; all p values <0.05). CONCLUSIONS: This is the first study to report racial differences among patients with BAV with reduced aortic dimensions in AA patients despite the presence of more risk factors, suggestive of marked heterogeneity in the BAV population and indicating race as a potential disease modifier in BAV.

Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure.

BACKGROUND: The rapid detection of left ventricular systolic dysfunction (LVSD) is an important step in the clinical management of patients admitted with acute decompensated heart failure, because it allows the initiation of treatment specific to LVSD and avoidance of contraindicated therapies. The aim of this study was to determine whether internal medicine residents with limited ultrasound training could use hand-carried ultrasound (HCU) to identify LVSD. METHODS: Fifty patients admitted with acute decompensated heart failure were imaged from the parasternal window at the bedside with an HCU device by residents blinded to all clinical data, who had undergone limited cardiac ultrasound training (20 practice studies). Ejection fraction (EF) on HCU was graded as >40% or <40%. HCU EF and a number of physical exam findings and electrocardiographic and laboratory variables were compared for their ability to predict to formal echocardiographic left ventricular EF. RESULTS: The average formal EF was 32 ± 16% (range, 7%-70%), with 66% of patients having EFs < 40%. The residents' ability to detect an EF < 40% with HCU was excellent (sensitivity, 94%; specificity, 94%; negative predictive value, 88%; positive predictive value, 97%). Binary logistic regression demonstrated that HCU EF was the most powerful predictor of EF < 40%, with minimal additional value from clinical, exam, lab, and electrocardiographic variables. The time interval between clinical assessment and availability of formal echocardiographic results was 22 ± 17 hours. CONCLUSIONS: Residents with limited training in cardiac ultrasound were able to identify LVSD in patients with acute decompensated heart failure with superior accuracy compared with clinical, physical exam, lab, and electrocardiographic findings and an average of 22 hours before the results of formal echocardiography were available.