A prospective observational cross sectional study with Focused cardiac ultrasound (FOCUS) conducted by the family physicians at patients with a high risk of cardiovascular diseases.

Mihai Iacob

Keywords: Point of Care Ultrasonography (POCUS), Clinical Ultrasonography, Focused CardiaC Ultrasound(FOCUS)

Background:

FOCUS is a complement of the clinical exam, for the evaluation of the structural and functional abnormalities of the heart, to the hemodynamic critical patient. Just a few studies have assessed the value and accuracy of focused cardiac ultrasound (FOCUS) performed by family physicians. This study aimed to evaluate the diagnostic accuracy of FOCUS performed by family doctors compared to echocardiography performed by a cardiologist at the patients with a high risk of cardiovascular diseases.

Research questions:

How can we improve the rapid evaluation of the critical hemodynamic patient in primary healthcare?

Method:

We made FOCUS on the patients which present after clinical-examination the suspicion of cardiac pathology (cardiomegaly, valvulopathy, pericarditis, endocarditis, congenital malformations, aneurysms, and arrhythmias) and use the five-standard-cardiac-scans: Subxiphoid-view, Parasternal-long/short axis, Apical-four-chamber-view, and IVC-assessment. We conducted a prospective-observational-cross-sectional-study of 1780 patients with high-cardiovascular-risk. High-risk-patients identified on inclusion-criteria, were first examined by a family-doctor with expertise, subsequently compared with ultrasound review by cardiologists, to determine the accuracy of this application. We have developed a Computerized-Diagnostic-Algorithm of the cardiac-pathology detected by non-cardiologists. The agreement between family-physicians and cardiologists on each finding, was evaluated using Cohen’s kappa coefficient with 95%CI.

Results:

We identified 585 patients with cardiac-pathology and subsequently confirmed by the cardiologist. We did the descriptive-statistical-analysis of the echocardiographic-cases detected. The accuracy of FOCUS-screening in primary care, was 96.07% with a sensitivity:95.12% and specificity:96.57%,p<0.001, for all 1780 emergency-patients which were subsequently confirmed by the cardiologist as the"Gold-Standard"method. The prevalence of cardiac-pathology was:34.55% with 95%CI:32.34% at 36.81%. Reports of the two-groups for identifying cardiac-pathology showed 95%-agreement(k=0.88;95%CI=0.81–0.95),standard-error:0,037.

Conclusions:

FOCUS performed by trained-family-physicians is comparable to echocardiography performed by cardiologists. It could be a reliable tool and screening-test for the initial diagnosis of patients suspected of cardiac-abnormalities and we propose as a complementary-diagnostic tool followed by referral to the cardiologist.

Points for discussion:

How can we evaluate the structural, functional and hemodynamic abnormalities of the heart to the high-risk patients of cardiovascular diseases?

Will it be possible soon, practice of the Cardiac Focused Ultrasound (FOCUS), by family doctors who were trained in specialized centers, for conducting Rapid Cardiac Assessment?

Will it be possible to use echocardiography with the stethoscope in the evaluation of heart disease by future family physicians?