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Letter to the Editor
Accuracy of cardiac ultrasound performed by a noncardiologist resident
Fiabilidad diagnóstica de la ecocardioscopia realizada por un residente no cardiólogo
Miguel Ángel López Zúñigaa,
Corresponding author
, Miriam A. Martín Torob, Tomás Vallejo Palominoc, Alba M. Castillo Fernándeza, Álvaro Campos Caleroa, Ascensión M. Vílchez Parrasa, María I. Villa Garcíaa, Desirée V. Gerez Neiraa, Justo Martinez Colmeneroa, Francisco Padilla Morenoa
a Servicio de Medicina Interna, Complejo Hospitalario de Jaén, Jaén, Spain
b Servicio de Cardiología, Complejo Hospitalario de Jaén, Jaén, Spain
c Servicio de Radiología, Complejo Hospitalario de Jaén, Jaén, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Bedside ultrasound has been postulated as an extension of the physical examination&#44; with diagnostic and clinical benefits&#44; improving the doctor&#8211;patient relationship&#46; Specifically&#44; echocardiography has been shown to improve the detection of heart disease when compared to auscultation&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> It can also allow a faster and more accurate diagnosis&#44; limiting errors&#44; as well as a daily clinical follow-up&#44; allowing immediate therapeutic decision-making&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> This paper is aimed at analyzing the diagnostic reliability of echocardiographic assessment performed by &#8220;non-cardiologist&#8221; residents in different clinical settings&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">We conducted a prospective observational study which included consecutive patients hospitalized in an internal medicine service who were requested a cardiac ultrasound scheduled according to clinical indication&#46; We included 200 patients&#44; but we lost 15 of them &#40;7&#46;5&#37;&#41; &#40;2 exitus&#44; 5 discharged prior to TTE completion and in 8 cases the reason is unknown&#41;&#46; To the remaining 185&#44; a resident internist&#44; with a basic training in clinical ultrasound&#44; performed a cardiac ultrasound &#40;with a Vscan with Dual probe&#44; General Electric&#41;&#46; The results were compared with the result of the regulated echocardiography performed by a cardiologist in the prior 48<span class="elsevierStyleHsp" style=""></span>h or after&#44; comparing functional and structural parameters&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Cardiac ultrasounds were requested due to congestive heart failure &#40;37&#46;1&#37;&#41;&#44; dyspnea of unknown origin &#40;14&#46;1&#37;&#41;&#44; febrile syndrome with no obvious focus of infection &#40;8&#46;8&#37;&#41;&#44; in 5&#46;3&#37; for suspected pulmonary hypertension&#44; and below 5&#37; for onset of atrial fibrillation&#44; syncope or chest pain&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> lists the consistency and diagnostic accuracy of cardiac ultrasound compared with the regulated study&#46; We could notice a good or very good consistency &#40;<span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;61&#41;&#44; a sensitivity and specificity &#62;90&#37; and a Youden&#39;s <span class="elsevierStyleItalic">J</span><span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>0&#46;6 in a large number of the parameters analyzed&#44; including the most useful clinical parameters such as the right and left ventricular ejection fractions&#44; the presence of pericardial effusion&#44; hypertrophy of the left ventricle&#44; the diameter of the inferior vena cava and the absence of a significant valvular disease&#44; as well as the aortic root dilation&#44; and others&#46; Since the main purpose of this assay is to differentiate the normality of the pathological situations&#44; this accuracy is supported by a negative predictive value of 80&#37; in almost every parameter studied&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The low prevalence of the observed feature and the asymmetry of the marginal totals&#44; influence the kappa coefficient<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> by limiting it&#44; so that&#44; given a low prevalence&#44; the results obtained acquire even greater importance&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The reported data are slightly lower than those obtained by L&#243;pez-Palmero et al&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> &#40;internists&#41; or Prinz et al&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> &#40;cardiologists&#41;&#46; This is most likely due to the greater experience of these professionals and the variability in the indication of echocardiography of this study compared to the previous ones&#44; a fact that promotes a low prevalence&#44; and the consequences of this on the kappa coefficient&#44; as previously mentioned&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In view of these results&#44; cardiac ultrasound carried out by &#8220;non-cardiologists&#8221; with a short learning curve&#44; should be interpreted as a reliable selection tool&#44; which would allow the clinician to improve diagnostic performance&#46; Always&#44; after a specific training period and without substituting the regulated echocardiography carried out by cardiologists in cases where definite diagnosis is necessary&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Therefore&#44; the use of cardiac ultrasound can be postulated as a fifth cornerstone of the physical examination&#44; useful when evaluating the patient&#46; We can conclude that a resident can include echocardiography reliably to the physical examination after a limited period of training&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; L&#243;pez Z&#250;&#241;iga M&#193;&#44; Mart&#237;n Toro MA&#44; Vallejo Palomino T&#44; Castillo Fern&#225;ndez AM&#44; Campos Calero &#193;&#44; V&#237;lchez Parras AM&#44; et al&#46; Fiabilidad diagn&#243;stica de la ecocardioscopia realizada por un residente no cardi&#243;logo&#46; Med Clin &#40;Barc&#41;&#46; 2019&#59;153&#58;43&#8211;44&#46;</p>"
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          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">RA&#58; right atrium&#59; LA&#58; left atrium&#59; <span class="elsevierStyleItalic">E</span>&#58; specificity&#59; AoS&#58; aortic stenosis&#59; MS&#58; mitral stenosis&#59; AoI&#58; aortic insufficiency&#59; MI&#58; mitral insufficiency&#59; TI&#58; tricuspid insufficiency&#59; LVP&#58; left ventricle pressure&#59; <span class="elsevierStyleItalic">S</span>&#58; sensitivity&#59; IVC&#58; inferior vena cava&#59; RV&#58; right ventricle&#59; NPV&#58; negative predictive value&#59; PPV&#58; positive predictive value&#59; &#37; CC&#58; percentage of correct classification&#46;</p>"
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                  \t\t\t\t">Unaffected mitral valve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Metallic mitral valve&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Aorta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Unaffected aorta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">98&#46;6&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">94&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Metallic aorta&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;74 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">100&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t">Double aortic injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;39 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">33&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">99&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Tricuspid valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;68 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">73&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Unaffected tricuspid valve&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;68 &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">76&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">93&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  """
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Consistency&#44; validity&#44; safety&#44; Youden&#39;s <span class="elsevierStyleItalic">J</span> statistic and prevalence of the cohort&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
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              "etiqueta" => "1"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Positioning document on incorporating point-of-care ultrasound in Internal Medicine departments"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "J&#46; Torres Macho"
                            1 => "F&#46;J&#46; Garc&#237;a S&#225;nchez"
                            2 => "P&#46; Garmilla Ezquerra"
                            3 => "L&#46; Beltr&#225;n Romero"
                            4 => "J&#46; Canora Lebrato"
                            5 => "J&#46;M&#46; Casas Rojo"
                          ]
                        ]
                      ]
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ISSN: 23870206
Original language: English
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