Limitations:
This study represents a small cohort from a single institution. TTEs were done as part of routine care, and could have been performed several hours after HHU, as well as after coronary angiography or revascularization, by which time wall motion may have changed. This potentially could be a confounding factor, affecting accuracy of comparing wall motion on HHU with wall motion on TTE. The HHUs in our study were performed by 14 cardiology fellows, with first year fellows carrying out two-thirds of the studies. This increases interobserver variability which has previously been shown to contribute to disagreement between the HHU and TTE (15). Decision making regarding proceeding to angiography and timing of angiography may have been made based on factors other than HHU, including patient preference and other clinical characteristics.
It should be pointed out that the influence of HHU on cardiology fellows’ clinical management of each patient was a subjective report by each fellow as part of the checklist; however, other findings including higher rates of catheterization and shorter time-to-cath timeframes provide supporting evidence that validate the influence of HHU on fellows’ better clinical decisions.
Conclusion :
In summary, we found that cardiac HHU is a feasible method for cardiology fellows in-training in rapidly determining LVEF and wall motion abnormalities in critical situations of a suspected STEMI, when timing and accuracy of clinical decision making is paramount. We also found that cardiology fellows with higher level of training could obtain more accurate results from HHU with higher confidence in their interpretations. Additionally, the presence of WMAs on HHU was associated with higher rates of angiography and faster angiography, which may have important implications for the triage and early management of patients presenting with suspected STEMI.
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Figures captions :
FIGURE 1: (A and B) Linear correlation between standard TTE and HHU for (A) LVEF and (B) WMSI, with a concordance correlation coefficient of 0.71 for LVEF and 0.76 for WMSI. (C and D) Bland–Altman correlation between standard TTE and HHU for (C) LVEF and (D) WMSI. The dark horizontal line in the middle represents the mean of the difference between TTE and HHU. The light dashed lines represent 2 SDs away from the mean difference. (C) For LVEF, Bland–Altman correlation demonstrates a larger difference between the TTE and HHE within the mid-range of LVEF, whereas for WMSI, largest difference between the HHU and standard TTE occurred in the mid to upper to end of the reported range, between 1.5 and 2.5.
Abbreviations: HHU, handheld ultrasonography; LVEF, left ventricular ejection fraction; SD, standard deviation; TTE, transthoracic echocardiography; WMSI, wall motion score index.
FIGURE 2: Stratification of linear correlation between standard TTE and HHU for LVEF (A and B) and WMSI (C and D) based on (A and C) FIT =1 and (B and D) FIT ≥ 2, showing a concordance correlation coefficient of 0.64 versus 0.80 for A and B, and 0.70 versus 0.87 for C and D, respectively. Abbreviations: FIT, fellow in training.
Table 1: Clinical and echocardiographic characteristics of the study population. Data are presented as n (%), mean ± SD, or median (interquartile range).
Table 2: LV regional wall motion abnormality between HHU and standard TTE for each wall segment.
Table 3: Fellow-reported HHU image quality and reported effect of HHU results on clinical decisions. Data are presented as mean ± SD of scores to segmental endocardial border visualization (2 = good, 1 = poor, 0 = invisible), mean ± SD of scores to level of confidence interpreting the study (2 = confident, 1 = intermediate, 0 = uncertain), and n (%) for number of studies that influenced patient care.
Supplemental Figure 1: The survey used to collect echocardiographic data (ejection fraction, wall motion abnormalities, pericardial effusion, segmental endocardial border visualization, level of confidence, and influence of study on patient care) at the time of performing hand-held ultrasound in STEMI activation patients.
Supplemental Figure 2: Organization of the hand-held ultrasound studies based on wall motion abnormalities followed by their stratification based on cardiac catheterization results.
HHU, hand-held ultrasound; n, number of patients; WMA, wall motion abnormalities; Cath, cardiac catheterization; LAD, left anterior descending, LCx, left circumplex; RCA, right coronary artery; PCI, percutaneous intervention.