The Era of Point-of-Care Ultrasound Has Arrived: Are Cardiologists Ready?

Dear editor,

Point-of-Care Ultrasound (POCUS) has become a vital tool for bedside diagnosis and management in patient care. Accordingly, POCUS is becoming an important educational component in medical school and residency training programs. Although POCUS protocols can be generalized and involve multiorgan assessment, the fundamental component of bedside ultrasound assessment is cardiac POCUS, or similarly termed “focused cardiac ultrasound.” A recent publication by Kirkpatrick et al defined three forms of focused cardiac ultrasound: Ultrasound-assisted physical examination, cardiac POCUS, and critical care echocardiography.¹ However, with significant overlap between these forms of focused cardiac ultrasound, distinguishing between them may be of lesser importance from a practical standpoint.

Traditionally, the providers involved in obtaining and interpreting bedside cardiac POCUS have been predominantly non-cardiologists, including specialists in critical care medicine, emergency medicine, and anesthesia. This emphasis on cardiac POCUS by non-cardiologists is reflected by the increasing number of publications and training courses on cardiac POCUS, which are almost exclusively led by various non-cardiology professional societies.^{2 , 3} In particular, cardiac POCUS in the setting of critical care is increasingly perceived as its own entity with a separate term “critical care echocardiography.” In fact, critical care echocardiography has been advocated as an essential component of training and is now officially acknowledged by the National Board of Echocardiography, which started to administer its first special competence examination in this imaging protocol beginning in 2019.

Although interest and training in POCUS has surged in the past decade, cardiologists have largely been at the periphery of this development, hesitant to adopt this concept. Perhaps this hesitancy stems from the concern that growth of bedside POCUS may encroach on the principal role of comprehensive transthoracic echocardiography (TTE) in cardiology training and practice, questioning if cardiologists are ready to participate and lead this field.

It is important to note that cardiac POCUS as a diagnostic modality is different than standard TTE. Although typical cardiac POCUS does not provide the advanced imaging features and hemodynamic data of TTE, it provides rapid evaluation and allows for rapid decision making, especially when standard TTE cannot be obtained or is not immediately available (Figure 1 ).^{1 , 4} This is particularly useful in the care of critically ill patients, including those in the cardiac intensive care unit, where cardiovascular specialists and trainees are pivotal providers of care. The role of cardiac POCUS has been more evident with the recent COVID-19 pandemic, given concerns for provider and equipment exposure.⁵ The potential for cardiac POCUS can extend even beyond the acute care setting. In ambulatory cardiology practice, cardiac POCUS can augment the physical examination and inform cardiologists of critical information (e.g., left ventricular function, severity of valvular disease, and volume status) in a timely manner. With the advancement in technology allowing for more portable and intelligent devices, the logistics of performing cardiac POCUS is becoming even more feasible.

Figure 1.

Cardiologist's application of cardiac POCUS. Yellow circle depicts potential timing of cardiac POCUS. Gray arrow highlights repeating nature of cardiac POCUS.

Increased adoption of cardiac POCUS by cardiologists will require a significant change in perception, as well as improved understanding of its practical applications and limitations. The performance of cardiac POCUS using newer devices adds minimal time to the patient encounter and provides instantaneous diagnostic information of high clinical value. However, a crucial issue is that the integration of cardiac POCUS into clinical practice would require cardiologists to become more hands-on with scanning and reduce reliance on sonographers and other support staff.

Despite the exciting opportunities that cardiac POCUS provides as a diagnostic tool, a number of challenges exist regarding this technology. One concern is that image misinterpretation may lead to omission of definitive testing or necessary procedures. The converse is also possible wherein misinterpretation of findings leads to unnecessary procedures, exposing patients to excessive risk and increasing healthcare costs. In addition, while we believe that the responsible use of cardiac POCUS can be beneficial in cardiology practice, more research is necessary to study the impact on safety, quality of clinical care, and clinical outcomes. Another issue is that the healthcare economics associated with widespread adoption of cardiac POCUS remains unclear. However, it is encouraging that recent evidence from emergency medicine suggests that cardiac POCUS has the potential to provide substantial cost savings.⁶ Finally, the utilization of cardiac POCUS by various medical subspecialties has the potential to generate conflicts related to ownership, certification, and credentialing. These issues may prove incredibly challenging as providers and medical centers move toward reimbursement for performing cardiac POCUS in various settings.

Although we acknowledge that philosophical differences within cardiology has limited the widespread adoption of cardiac POCUS by cardiologists, it appears clear that the increasing clinical application of POCUS in medicine is reshaping the practice of cardiac imaging. We believe it is time for cardiologists play a more active role in leading cardiac POCUS education, certification, research, and clinical implementation, as well as in collaborating with other medical subspecialties in a concerted effort to improve quality of care.

Disclosures

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.