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FELLOWS-IN-TRAINING & EARLY CAREER PAGE

Handheld Ultrasound and Diagnosisof Cardiovascular Diseaseat the Bedside

Brandon Wiley, MD, Bibhu Mohanty, MD

I n 1903, Dr. William Osler advocated for reform ofmedical education to emphasize bedside teach-ing, recommending “no teaching without a pa-

tient for a text and the best teaching is that taughtby the patient himself” (1). More than a century later,new voices in the profession echo that sentiment,suggesting that diagnosis has again strayed from thebedside. Some propose that technology has usurpedthe clinical examination at the expense of patientcare and the cognitive development of practitioners.Proponents of bedside medicine lament that wardrounds have been reduced to examining a patient’selectronic medical record and clicking computerizedorder sets based on results of myriad prior diagnostictests.

Inspection of jugular venous pulsations, palpationof the precordium, and auscultation of heart tonesare multisensory experiences that require the physi-cian to integrate observation, touch, and hearing inthe context of the patient’s clinical history andsymptoms. The medical history provides a frameworkfor developing a logical differential diagnosis. Forexample, in evaluation of chest pain syndromes, athorough history characterizing the quality, severity,location, duration, and tempo of symptoms canguide diagnosis, risk stratification, and management.Incorporation of Bayesian theory can enhance diag-nostic accuracy based on rational statistical infer-ence, thereby increasing the predictive power ofancillary testing. By reducing false-positive results,costly testing can be avoided.

“Bedside” treatment extends to all physical in-teractions with our patients, which are integral foran appropriate diagnosis and care plan. Correctly

From the Zena and Michael A. Wiener Cardiovascular Institute, Icahn

School of Medicine at Mount Sinai, New York, New York.

elicited and interpreted findings from a physical ex-amination reveal the underlying pathology and directthe selection of diagnostics and therapy. “Layinghands” on a patient with heart failure to assess thewarmth of extremities is a valid gauge of cardiac in-dex and the need for inotropic augmentation. Evalu-ation of jugular venous pressure and hepatojugularreflux provides a noninvasive evaluation of ventric-ular filling pressures. The assessment of the intensity,radiation, and timing of murmurs distinguishes thetype and severity of valvular lesions. Combiningauscultation with a thorough history and physicalexamination is crucial in the evaluation of patientswith valvular heart disease because astute clinicalassessment for the presence of symptoms can makethe difference between a strategy of “watchful wait-ing” and the need for surgical intervention.

Perhaps most importantly, patients view the ex-amination as an important part of the medical pro-cess. Performing a physical examination positivelyinfluences patient perceptions, impacts their satis-faction with providers, and improves understandingof disease. A patient survey found that 95% viewedbedside rounds positively, and 66% understood theirillness better as a result (2). Thus, the bedside ex-amination has tangible healing power derived fromstrengthening the doctor-patient relationship byplacing the patient—not diagnostic data—at the centerof the evaluation in a collaborative manner with thephysician. In Dr. Osler’s words, “The good physiciantreats the disease; the great physician treats the pa-tient who has the disease” (3).

Although there is evidence correlating physicalexamination findings with pathological diagnoses,the declining practice of the traditional examinationhas eroded its reproducibility and accuracy. Con-temporary studies of auscultation proficiency, evenwith the use of electronic stethoscopes, have been

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disappointing. One potential solution for the de-ficiencies of the physical examination is incorporationof point-of-care ultrasound in the bedside evaluation.In well-trained hands, handheld ultrasound (HHU)is recognized to be accurate and reproducible forassessment of cardiac structure and function by theAmerican Society of Echocardiography (4).

Using HHU in conjunction with the physical ex-amination has been demonstrated to improve detec-tion of cardiac abnormalities by at least 31.5% (5). Theadditive benefit of improved sensitivity and accuracyafforded by incorporation of HHU into the physicalexamination has been demonstrated across thespectrum of doctors, from medical trainees to expe-rienced cardiologists (6,7). Specifically, HHU per-forms well in the evaluation of left ventricularsystolic dysfunction, a cardiac abnormality that isdifficult to detect by the traditional physical exami-nation when the patient is asymptomatic. In theoutpatient cardiology clinic, HHU improved thenumber of diagnoses made from 23.3% to 74.6%,leading to rapid clinical decisions and fewer tests (8).Outpatient protocols have also been developed thatleverage the ability of HHU to detect subclinical car-diovascular disease and thus provide prompt andcost-effective cardiovascular risk screening (9).

HHU’s portability and wireless transmission capa-bility provides the potential to improve global accessto cardiac assessment. Large studies in rural Indiahave combined HHU with remote image interpreta-tion to provide cardiac evaluation for thousands ofpatients (10). Smartphone software advances couldfurther the global impact by allowing real-timeinterpretative guidance.

Although HHU presents a tremendous resource forthe evaluation and detection of cardiovascular dis-ease, there are some challenges facing the wide-spread application of the devices at present. Without

adequate training, the sensitivity of HHU is temperedby suboptimal specificity. Thus, educational protocolsshould be developed for noncardiologists to ensuresafe and accurate implementation of the technology.

The traditional bedside evaluation allows thephysician to develop a logical hypothesis and ratio-nally direct care through a collaborative interactionthat strengthens the therapeutic patient–physicianrelationship. Portable HHU can be incorporated intothis bedside paradigm. When utilized by well-trainedoperators as an extension of the physical examina-tion, HHU has the potential to improve the efficacy ofbedside evaluation, provide valuable information toguide patient care, and increase access to cardiovas-cular assessment worldwide. HHU should not beviewed as another technological barrier thatthreatens to disrupt the sacred patient–physician in-teraction. Instead, this technology enables the visu-alization of cardiac anatomy and physiology while atthe bedside, in direct physical contact with the pa-tient. Like the stethoscope, HHU is a tool for thephysician’s legendary “black bag” that simply pro-vides diagnostic data. The true value of these data isdependent on the thoughtful and accurate interpre-tation by the practitioner in the context of the pa-tient’s clinical condition. In this sense, Dr. Osler’sdictum that the examination of a patient mustinclude contemplation still holds merit. It has beensaid that the most crucial part of the auscultatoryexam is “what exists between the ears of thelistener,” and the same can be said of a comprehen-sive evaluation with the assistance of HHU.

ADDRESS CORRESPONDENCE TO: Dr. BrandonWiley, Zena and Michael A. Wiener CardiovascularInstitute, Mount Sinai Medical Center, One Gustave L.Levy Place, New York, New York 10029. E-mail:Brandon.Wiley@mountsinai.org.

RE F E RENCE S

1. Osler W. On the need of a radical reform in ourmethods of teaching senior students. Med News1903;82:49–53.

2. Linfors EW, Neelon FA. Sounding boards. Thecase of bedside rounds. N Engl J Med 1980;303:1230–3.

3. Porter R. The Cambridge History of Medicine.New York, NY: Cambridge University Press, 2006.

4. Spencer KT, Kimura BJ, Korcarz CE, et al.Focused cardiac ultrasound: recommendationsfrom the American Society of Echocardiography.J Am Soc Echocardiogr 2013;26:567–81.

5. Galderisi M, Santoro A, Versiero M, et al.Improved cardiovascular diagnostic accuracy by

pocket size imaging device in non-cardiologicoutpatients: the NaUSiCa (Naples UltrasoundStethoscope in Cardiology) study. J CardiovascUltras 2010;8:51.

6. Kimura BJ, DeMaria AN. Technology insight:hand-carried ultrasound cardiac assessment—evolution, not revolution. Nat Clin Pract Car-diovasc Med 2005;2:217–23, quiz 224.

7. Panoulas VF, Daigeler AL, Malaweera AS, et al.Pocket-size hand-held cardiac ultrasound as anadjunct to clinical examination in the hands ofmedical students and junior doctors. Eur Heart JCardiovasc Imaging 2013;14:323–30.

8. Cardim N, Fernandez Golfin C, Ferreira D,et al. Usefulness of a new miniaturized

echocardiographic system in outpatient cardiol-ogy consultations as an extension of physicalexamination. J Am Soc Echocardiogr 2011;24:117–24.

9. Kimura BJ, Shaw DJ, Agan DL, et al. Value ofa cardiovascular limited ultrasound examinationusing a hand-carried ultrasound device on clinicalmanagement in an outpatient medical clinic. Am JCardiol 2007;100:321–5.

10. Singh S, Bansal M, Maheshwari P, et al.American Society of Echocardiography: RemoteEchocardiography with Web-Based Assess-ments for Referrals at a Distance (ASE-REWARD) study. J Am Soc Echocardiogr 2013;26:221–33.