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.