Introduction
Experienced echocardiographers can quickly glean diagnostic information from limited
echocardiographic views. The use of limited cardiac ultrasound, particularly as a
screening tool, is increasing. During the COVID-19 pandemic, limited cardiac ultrasound
has the major advantage of reducing exposure time between sonographer and patient.
The sensitivity and negative predictive value of a “screening” echocardiogram with
highly limited views is uncertain.
Aim/Method
We examined the accuracy of limited echocardiography in 203 consecutive, de novo studies.
We used six images: parasternal long axis, with colour Doppler over the mitral valve,
and aortic valve, and apical four-chamber with colour Doppler over the mitral valve,
and tricuspid valve. We compared the interpretation of 12 subjects with the final
echocardiogram report, (gold standard). The subjects comprised four experienced echocardiography-specialised
cardiologists, four experienced cardiologists with non-imaging subspecialty interests,
and four senior cardiac sonographers. Studies were graded as: (1) normal or (2) needs
full study (due to inadequate images or abnormality detected). Sensitivity, specificity,
negative predictive value, positive predictive value and accuracy are reported.
Results
Forty-one per cent (41%) of studies were normal by the gold standard report. Overall,
a screening echocardiogram had a sensitivity of 71.2%, specificity of 57.1% to detect
an abnormal echocardiogram, negative predictive value 58.4%, positive predictive value
of 70.2%, and accuracy of 65.4%. When inadequate images were excluded, overall accuracy
was nearly identical at 64.6%. The overall accuracy between the three groups of interpreters
was similar: 66.5% (95% CI 63.1–69.7) for echocardiography-specialised cardiologists,
65.3% (95% CI 61.9–68.5) for non-echocardiography specialised cardiologists, and 64.4%
(95% CI 61.0–67.7) for sonographers. These groups are all highly experienced practitioners.
There was no difference in sensitivity or specificity comparing echocardiography-specialised
cardiologists with cardiologists of other subspecialty experience. Comparing cardiologists
to sonographers, cardiologists had lower sensitivity (echocardiography specialists
67.6%, 95% CI 63.2–71.8, non-echocardiography specialists 62.0%, 95% CI 57.4–66.4)
compared to sonographers (84.0% [95% CI 80.4–87.2, p<0.05]), but cardiologists had
higher specificities (64.9% [95% CI 59.5–70.0] for the echocardiography specialists,
and 69.9% [95% CI 64.7–74.8] for non echocardiography specialists), compared to 36.6%
(95% CI 31.4–42.0, p<0.05) for the sonographer group. When looking at only the studies
considered to be interpretable, cardiologists had higher positive predictive value
(echocardiography specialists 73.7%, 95% CI 69.0–78.1, non echocardiography specialists
74.1%, 95% CI 68.8–79.9), as compared to sonographers (64.3%, 95% CI 59.8–68.5%).
Conclusions
Limited cardiac ultrasound as a screening tool for a normal heart had a sensitivity
of only 71%, when performed and interpreted by experienced personnel, raising questions
regarding the safety of this practice. Caution is especially recommended in extrapolating
its use to non-specialised settings.
Keywords
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Article info
Publication history
Published online: October 13, 2021
Accepted:
August 19,
2021
Received in revised form:
August 1,
2021
Received:
May 13,
2021
Identification
Copyright
Crown Copyright © 2021 Published by Elsevier B.V. on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
