Every great advance of science opens our eyes to facts that we had failed before to observe and makes new demands on our powers of interpretation. The extension of the material of science into regions where our great-grandfathers could see nothing at all is one of the most remarkable features of modern progress. —Karl Pearson, The Grammar of Science
Rene Laennec introduced the stethoscope in 1816, and it has been the instrument of choice for the bedside diagnosis of heart disease for over 200 years. It was the first diagnostic instrument to improve bedside diagnosis and is an icon of medicine. There is good evidence that we have a much better bedside technology today to diagnosis heart disease: the handheld ultrasound device (HHU). The stethoscope lacks the sensitivity and specificity for the accurate diagnosis of most heart diseases.1,2 Experience, and clinical studies, report that current practicing cardiologists lack the skills to effectively use the stethoscope as a diagnostic instrument and often complete an abbreviated, incomplete cardiac physical examination.3 The superior ability of the echocardiogram to determine the morphology and function of the heart has supplanted the clinician’s confidence in the utility of the auscultatory examination. The HHU has evolved through several generations into a small, easy-to-use device with a high sensitivity and specificity for diagnosing cardiac function, congestive heart failure, valvular heart disease, pericardial effusion, and unexpected cardiac disease. It is time for HHU to be a routine part of the bedside clinical examination for most medical practitioners, physician assistants, nurse practitioners, and especially cardiologists.4 What are the restraints that are preventing this from happening?
THE VALUE OF HHU
HHU devices have gone through three generations of advances to become smaller, lightweight, and with increased diagnostic capabilities. The American Society of Echocardiography published guidelines for their use and described the focused cardiac ultrasound exam as goal oriented in specific clinical settings to supplement the physical examination.5 In skilled hands, a focused HHU exam can be completed in 5 minutes. The routine use of HHU will permit an earlier initiation of appropriate therapies or targeted diagnostic tests.
An editorial on HHU in 2023 commented, “The advantages of ultrasonography are unquestionable, and its widespread application requires no justification.”5 The authors noted that the visual stethoscope was a theoretical concept first mentioned and then implemented in a real diagnostic device in the 1970s. Pioneering and groundbreaking ideas often require the technology to catch up, and not until the beginning of the 2000s was a pocket-sized imaging ultrasonography device suitable for cardiac imaging introduced. Despite current technological advances, there is significant reluctance to use HHU in the routine cardiovascular exam. This parallels Laennec’s own experience when he introduced the stethoscope; although its value was appreciated, there was reluctance to use the new technology.
In 2022, Sam Jenkins and colleagues reviewed current HHU.6 They critiqued four devices, which varied in price from $2000 to $6000, weighed from 108 to 393 grams, had from one to three probes, had charge times from 60 to 120 minutes of continuous use, and stored images on iCloud. Many have suggested that the cost of the device is an issue, and fellows in training cannot afford them. While the cost is a significant concern, quality devices are affordable for practicing cardiologists, and I have interviewed cardiology trainees who feel that if the cost is spread out over time, they could acquire them.
Several studies have reported on the effectiveness of HHU in diagnosing heart disease.2,5,7,8 They reported the sensitivity and specificity for left ventricular dilation, left ventricular function, left ventricular hypertrophy, inferior vena cava dilation, pericardial effusion, left atrial dilation, valvular heart disease, and right ventricular dilation and function. Sensitivities were as high as 70% to 100% and specificities, 80% to 94%. They concluded: “The simplicity of use, availability at the patient’s bedside, easy transportability, and relatively low cost have encouraged physicians to use these devices for prompt medical decision making.” They report that “other additive values are short time acquisition (<5 minutes), rapid diagnosis in symptomatic patients, and detection of clinically significant pathologies in asymptomatic individuals.”
OBSTACLES TO THE IMPLEMENTATION OF HHU IN THE ROUTINE CARDIAC EXAM
For HHU to become routine, education and training need to be standardized. This means that training programs will need to institute a hands-on experience in the skillful completion of an echocardiographic examination. What is the training and experience necessary to competently complete an exam in 5 minutes? Most studies suggest that for a cardiologist, a relatively brief time is required, but other physicians and nurses will need an intensive training program. Should HHU be a focused exam to identify a normal heart, and any suspected pathology be documented and recorded with usual diagnostic studies? The answer is yes, HHU will not replace the diagnostic transthoracic echocardiogram at this time.
There must be incentive to use HHU. In the current US healthcare model of fee for service, there is no reward for spending more time at the bedside to arrive at a quick diagnosis. Although the immediate knowledge from imaging expedites care, some cardiologists question the viability and sustainability in a clinical practice or hospital where revenue currently depends on referrals to the more established diagnostic modalities (comprehensive or limited echocardiography). This permits the time and effort to be accounted for and built into the reimbursement scheme. There is a worrisome delay in diagnosis when the prompt acquisition of a scheduled echocardiogram is not available. This occurs both in the hospital and as an outpatient in many communities and can be related to a shortage of skilled ultrasound technicians and available laboratories. Whether the routine use of HHU would increase, decrease, or have no effect on the cost of patient care, cardiology department revenues, and hospital revenue is not known. This seems to be a decisive question for many concerned with implementing its routine use. There is good evidence that HHU is in the best interest of the patient and therefore should be implemented as essential in the bedside examination.
Disclosure statement/Funding
The authors report no funding or conflicts of interest.
References
- 1.Richardson TR , Moody JM Jr. The bedside cardiac exam: the Bedside Cardiac Exam: consistency in a sea of change. Curr Probl Cardiol. 2000;25(11):783–825. doi: 10.1067/mcd.2000.109835. [DOI] [PubMed] [Google Scholar]
- 2.Wiley B, Mohanty B.. Handheld ultrasound and the diagnosis of cardiovascular disease at the bedside. J Am Coll Cardiol. 2014;64(2):229–230. doi: 10.1016/j.jacc.2014.05.011. [DOI] [PubMed] [Google Scholar]
- 3.Silverman B, Gertz A.. Present role of the precordial examination in patient care. Am J Cardiol. 2015;115(2):253–255. doi: 10.1016/j.amjcard.2014.10.031. [DOI] [PubMed] [Google Scholar]
- 4.Chamsi-Pasha MA, Sengupta PP, Zoghbi WA.. Handheld echocardiography: current state and future perspectives. Ciculation. 2017;136(22):2178–2188. doi: 10.1161/CIRCULATIONAHA.117.026622. [DOI] [PubMed] [Google Scholar]
- 5.Filpiak-Strzecka D, Lipiec P, Kasprzak JD.. Handheld ultrasound in cardiology: current perspectives. Adv Clin Exp Med. 2023;32(2):267–274. doi: 10.17219/acem/158565. [DOI] [PubMed] [Google Scholar]
- 6.Jenkins S, Shiha MG, Yones E, et al. Cardiovascular examination using the handheld cardiac ultrasound. J Echocardiogr. 2022;20(1):1–9. doi: 10.1007/s12574-021-00540-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Savino K, Ambrosio G.. Handheld ultrasound and focused cardiovascular echography: use and information. Medicina (Kaunas). 2019;55(8):423. doi: 10.3390/medicina55080423. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Giusca S, Jurcut R, Ticulescu R, et al. Accuracy of handheld echocardiography for bedside diagnostic evaluation in a tertiary cardiology center: Comparison with standard echocardiography. Echocardiology. 2011;28(2):136–141. doi: 10.1011/j.1540-8175.2010.01310x. [DOI] [PubMed] [Google Scholar]