The International Journal of Cardiovascular Imaging

, Volume 29, Issue 8, pp 1749–1757 | Cite as

The diagnostic accuracy of pocket-size cardiac ultrasound performed by unselected residents with minimal training

  • Vidar Ruddox
  • Thomas Muri Stokke
  • Thor Edvardsen
  • Jøran Hjelmesæth
  • Erlend Aune
  • Morten Bækkevar
  • Ingvild B. Norum
  • Jan Erik Otterstad
Original Paper


Pocket-size imaging devices may represent a tool for fast initial cardiac screening in the emergency setting. Pocket-size cardiac ultrasound (PCU) examinations performed by experienced echocardiographers yield acceptable diagnostic accuracy compared to standard echocardiogram (SE). However, the success of this method when used by unselected non-cardiologists remains unexplored. The current study studies the diagnostic accuracy of PCU when used by unselected internal medicine residents with minimal training. All residents were given a 2-hour introductory course in PCU (Vscan) and reported PCU results for up to 15 predefined cardiac landmarks. These were arbitrarily divided into 3 priority groups, such that left ventricle (LV) and pericardium were of first priority. Diagnostic accuracy [sensitivity/specificity and negative/positive predictive values (PPV/NPV)] and agreement were evaluated using a subsequent SE as reference. During a 9.2 months period a total of 303 patients were included in the study, the majority on the basis of presenting with chest pain or suspected heart failure. In the pooled LV and pericardial (1st priority) data, sensitivity/specificity/PPV/NPV were 61/92/70/89 % respectively. Similar specificities and NPVs were observed for the 11 remaining indices, as were lower sensitivities and PPVs. The best PCU sensitivity (76 %) was attained for the assessment of LV wall motion abnormalities. Overall agreement was k = 0.50. PCU examination performed by internal medicine residents with minimal training could provide a suitable means of ruling out cardiac pathology, as reflected in the high specificities and NPVs. It is not, however, a satisfactory tool for identifying patients with various cardiac disorders.


Pocket-size Echocardiography Accuracy Sensitivity Specificity Resident 



The authors thank Matthew McGee, Morbid Obesity Center, Vestfold Hospital Trust, for proofreading the manuscript.

Conflict of interest

The authors have declared that no competing interests exist.

Supplementary material

10554_2013_278_MOESM1_ESM.pdf (93 kb)
A flow chart showing those patients screened with PCU for the detection of a decreased left ventricle ejection fraction, subsequently found to be eligible for reference standard examination. (PDF 92 kb)
10554_2013_278_MOESM2_ESM.pdf (92 kb)
A flow chart showing those patients screened with PCU for detecting left ventricle dilation, subsequently found to be eligible for reference standard examination. (PDF 92 kb)
10554_2013_278_MOESM3_ESM.pdf (93 kb)
A flow chart showing those patients screened with PCU for the detection of left ventricle wall motion abnormalities, subsequently found to be eligible for reference standard examination. (PDF 93 kb)
10554_2013_278_MOESM4_ESM.pdf (92 kb)
A flow chart showing those patients screened with PCU for the detection of pericardial effusion, subsequently found to be eligible for reference standard examination. (PDF 91 kb)


  1. 1.
    Sicari R, Galderisi M, Voigt JU, Habib G, Zamorano JL, Lancellotti P, Badano LP (2011) The use of pocket-size imaging devices: a position statement of the European Association of Echocardiography. Eur J Echocardiogr 12(2):85–87. doi: 10.1093/ejechocard/jeq184 PubMedCrossRefGoogle Scholar
  2. 2.
    Andersen GN, Haugen BO, Graven T, Salvesen O, Mjolstad OC, Dalen H (2011) Feasibility and reliability of point-of-care pocket-sized echocardiography. Eur J Echocardiogr 12(9):665–670. doi: 10.1093/ejechocard/jer108 PubMedCrossRefGoogle Scholar
  3. 3.
    Galderisi M, Santoro A, Versiero M, Lomoriello VS, Esposito R, Raia R, Farina F, Schiattarella PL, Bonito M, Olibet M, de Simone G (2010) Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study. Cardiovasc Ultrasound 8:51. doi: 10.1186/1476-7120-8-51 PubMedCrossRefGoogle Scholar
  4. 4.
    Prinz C, Voigt JU (2011) Diagnostic accuracy of a hand-held ultrasound scanner in routine patients referred for echocardiography. J Am Soc Echocardiogr 24(2):111–116. doi: 10.1016/j.echo.2010.10.017 PubMedCrossRefGoogle Scholar
  5. 5.
    Kimura BJ, Amundson SA, Willis CL, Gilpin EA, DeMaria AN (2002) Usefulness of a hand-held ultrasound device for bedside examination of left ventricular function. Am J Cardiol 90(9):1038–1039PubMedCrossRefGoogle Scholar
  6. 6.
    Alexander JH, Peterson ED, Chen AY, Harding TM, Adams DB, Kisslo JA Jr (2004) Feasibility of point-of-care echocardiography by internal medicine house staff. Am Heart J 147(3):476–481. doi: 10.1016/j.ahj.2003.10.010 PubMedCrossRefGoogle Scholar
  7. 7.
    Wittich CM, Montgomery SC, Neben MA, Palmer BA, Callahan MJ, Seward JB, Pawlina W, Bruce CJ (2002) Teaching cardiovascular anatomy to medical students by using a handheld ultrasound device. JAMA 288(9):1062–1063PubMedCrossRefGoogle Scholar
  8. 8.
    Bossuyt PM, Reitsma JB, Bruns DE, Gatsonis CA, Glasziou PP, Irwig LM, Moher D, Rennie D, de Vet HC, Lijmer JG, Standards for Reporting of Diagnostic A (2003) The STARD statement for reporting studies of diagnostic accuracy: explanation and elaboration. Ann Intern Med 138(1):W1–W12PubMedGoogle Scholar
  9. 9.
    Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P, Varga A, Sicari R, Evangelista A, Nihoyannopoulos P, Zamorano JL, European Association of E, Document R, Derumeaux G, Kasprzak JD, Roelandt JR (2009) European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. Eur J Echocardiogr 10(8):893–905. doi: 10.1093/ejechocard/jep151 PubMedCrossRefGoogle Scholar
  10. 10.
    Aune E, Baekkevar M, Rodevand O, Otterstad JE (2010) Reference values for left ventricular volumes with real-time 3-dimensional echocardiography. Scand Cardiovasc J 44(1):24–30. doi: 10.3109/14017430903114446 PubMedCrossRefGoogle Scholar
  11. 11.
    Prinz C, Dohrmann J, van Buuren F, Bitter T, Bogunovic N, Horstkotte D, Faber L (2012) The importance of training in echocardiography: a validation study using pocket echocardiography. Journal Cardiovasc Med 13(11):700–707. doi: 10.2459/JCM.0b013e328356a55f CrossRefGoogle Scholar
  12. 12.
    Pelliccia F, Palmiero P, Maiello M, Losi MA, On behalf of the Italian chapter of the international society of cardiovascular U (2012) Italian chapter of the international society of cardiovascular ultrasound expert consensus document on training requirements for noncardiologists using hand-carried ultrasound devices. Echocardiography 29(6):745–750. doi: 10.1111/j.1540-8175.2012.01720.x PubMedCrossRefGoogle Scholar
  13. 13.
    Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D, Rahman S, Nihoyannopoulos P (2012) Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. doi: 10.1093/ehjci/jes140
  14. 14.
    Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E, Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS, Solomon SD, Spencer KT, Sutton MS, Stewart WJ, Chamber Quantification Writing G, American Society of Echocardiography’s G, Standards C, European Association of E (2005) Recommendations for chamber quantification: a report from the American society of echocardiography’s guidelines and standards committee and the chamber quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European society of cardiology. J Am Soc Echocardiogr 18(12):1440–1463. doi: 10.1016/j.echo.2005.10.005 PubMedCrossRefGoogle Scholar
  15. 15.
    Lancellotti P, Tribouilloy C, Hagendorff A, Popescu BA, Edvardsen T, Pierard LA, Badano L, Zamorano JL, Scientific Document Committee of the European Association of Cardiovascular Imaging: Thor Edvardsen OBBCEDRDMGPLDMKNRS (2013) Recommendations for the echocardiographic assessment of native valvular regurgitation: an executive summary from the European Association of cardiovascular imaging. Eur Heart J Cardiovasc Imaging 14(7):611–644. doi: 10.1093/ehjci/jet105 PubMedCrossRefGoogle Scholar
  16. 16.
    Otterstad JE, Froeland G, St John Sutton M, Holme I (1997) Accuracy and reproducibility of biplane two-dimensional echocardiographic measurements of left ventricular dimensions and function. Eur Heart J 18(3):507–513PubMedCrossRefGoogle Scholar
  17. 17.
    Skjaerpe T, Hegrenaes L, Hatle L (1985) Noninvasive estimation of valve area in patients with aortic stenosis by Doppler ultrasound and two-dimensional echocardiography. Circulation 72(4):810–818PubMedCrossRefGoogle Scholar
  18. 18.
    Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD, Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, Rakowski H, Stewart WJ, Waggoner A, Weissman NJ, American Society of E (2003) Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 16(7):777–802. doi: 10.1016/S0894-7317(03)00335-3 PubMedCrossRefGoogle Scholar
  19. 19.
    Lancellotti P, Moura L, Pierard LA, Agricola E, Popescu BA, Tribouilloy C, Hagendorff A, Monin JL, Badano L, Zamorano JL, European Association of E (2010) European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 2: mitral and tricuspid regurgitation (native valve disease). Eur J Echocardiogr 11(4):307–332. doi: 10.1093/ejechocard/jeq031 PubMedCrossRefGoogle Scholar
  20. 20.
    Lancellotti P, Tribouilloy C, Hagendorff A, Moura L, Popescu BA, Agricola E, Monin JL, Pierard LA, Badano L, Zamorano JL, European Association of E (2010) European Association of Echocardiography recommendations for the assessment of valvular regurgitation. Part 1: aortic and pulmonary regurgitation (native valve disease). Eur J Echocardiogr 11(3):223–244. doi: 10.1093/ejechocard/jeq030 PubMedCrossRefGoogle Scholar
  21. 21.
    Messika-Zeitoun D, Bellamy M, Avierinos JF, Breen J, Eusemann C, Rossi A, Behrenbeck T, Scott C, Tajik JA, Enriquez-Sarano M (2007) Left atrial remodelling in mitral regurgitation–methodologic approach, physiological determinants, and outcome implications: a prospective quantitative Doppler-echocardiographic and electron beam-computed tomographic study. Eur Heart J 28(14):1773–1781. doi: 10.1093/eurheartj/ehm199 PubMedCrossRefGoogle Scholar
  22. 22.
    Otterstad JE, Aune E, Beakkevar M, Froeland G, Knutsen K (2009) Normal values for volume and contractility of the 4 heart chambers based on measurements with 3 and 2-dimensional echocardiography. Hjerteforum 22:47–57Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2013

Authors and Affiliations

  • Vidar Ruddox
    • 1
    • 2
  • Thomas Muri Stokke
    • 2
    • 3
  • Thor Edvardsen
    • 2
    • 3
  • Jøran Hjelmesæth
    • 1
    • 4
    • 5
  • Erlend Aune
    • 3
  • Morten Bækkevar
    • 1
  • Ingvild B. Norum
    • 1
  • Jan Erik Otterstad
    • 1
  1. 1.Department of CardiologyVestfold Hospital TrustTønsbergNorway
  2. 2.University of OsloOsloNorway
  3. 3.Department of CardiologyOslo University Hospital, RikshospitaletOsloNorway
  4. 4.Morbid Obesity CenterVestfold Hospital TrustTønsbergNorway
  5. 5.Department of Endocrinology, Institute of Clinical Medicine, Morbid Obesity and Preventive MedicineUniversity of OsloOsloNorway

Personalised recommendations