Revista Española de Cardiología (English Edition) Revista Española de Cardiología (English Edition)
Rev Esp Cardiol. 2018;71:935-40 - Vol. 71 Num.11 DOI: 10.1016/j.rec.2018.05.039

Consensus Document of the SEMI, semFYC, SEN, and SEC on Focused Cardiac Ultrasound in Spain

Leopoldo Pérez de Isla a,, Santiago Díaz Sánchez b, Jorge Pagola c, Gonzalo García de Casasola Sánchez d, Teresa López Fernández e, Ignacio Manuel Sánchez Barrancos f, Patricia Martínez-Sánchez g, Antonio Zapatero Gaviria h, Manuel Anguita i, Antonio Lorenzo Ruiz Serrano j, Juan Torres Macho d

a Servicio de Cardiología, Hospital Clínico San Carlos, Madrid, Spain
b Centro de Salud «Los Pintores», Parla, Madrid, Spain
c Servicio de Neurología, Hospital Vall d’Hebron, Barcelona, Spain
d Servicio de Medicina Interna-Urgencias, Hospital Universitario Infanta Cristina, Parla, Madrid, Spain
e Servicio de Cardiología, Hospital Universitario La Paz, Madrid, Spain
f Consultorio de Membrilla, Centro de Salud Manzanares II, Ciudad Real, Spain
g Servicio de Neurología, Hospital Torrecárdenas, Almería, Spain
h Servicio de Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
i Servicio de Cardiología, Hospital Reina Sofía, Córdoba, Spain
j Centro de Salud Ciudad Real III, Ciudad Real, Spain

Keywords

Focused cardiac ultrasound. Consensus.

Abstract

This document summarizes the concept of focused cardiac ultrasound, the basic technical aspects related to this technique, and its diagnostic objectives. It also defines training requisites in focused cardiac ultrasound. This consensus document has been endorsed by the Spanish Society of Internal Medicine (SEMI), the Spanish Society of Family and Community Medicine (semFYC), the Spanish Society of Neurology (SEN), and the Spanish Society of Cardiology (SEC).

Article

INTRODUCTION

With the advent of hand-carried devices, ultrasound has evolved from a bedside procedure into an essential mobile imaging test in several specialties.1 In recent years, the term “focused cardiac ultrasound” has been introduced to describe the use of ultrasound by the treating physician to complement the standard cardiac physical examination. This application of ultrasound is diagnostically valuable and has a relatively short theoretical and practical learning curve.2 The fundamental characteristics of focused cardiac ultrasound are as follows:

  • • The technique serves to guide the diagnosis of a specific and clinically important problem. It should be integrated into the decision tree and guide the physician in patient diagnosis and treatment.3

  • • It is indicated in specific clinical situations, mainly defined by patient symptoms (eg, dyspnea, chest pain) and the clinical setting (eg, critical patient, medical emergency, asymptomatic patient).

  • • It is a limited (nonexhaustive) technique, uses fewer slices than a complete study, and its main goal is to provide a high negative predictive value. Focused cardiac ultrasound generally does not require the technical specifications of more advanced equipment (pulsed, continuous, and tissue Doppler, etc.).

  • • It is fast and repeatable, and can thus be used to analyze the clinical course of defined parameters related to the patient's condition.

  • • Focused cardiac ultrasound can be used by any physician who has completed the necessary theoretical and practical training.4 To obtain the maximum benefit, it is essential to first review the patient's medical history and conduct a physical examination, in order to propose a reasonable differential diagnosis.

FOCUSED CARDIAC ULTRASOUND: BASIC PRINCIPLES

In Spain, cardiologists and other specialists have increasingly incorporated focused cardiac ultrasound into their daily clinical practice,4, 5, 6, 7, 8, 9, 10, 11 creating the need for a consensus on its use among the various scientific societies affected. To this end, the present document has been prepared by a joint committee of the Spanish Society of Internal Medicine (Sociedad Española de Medicina Interna, SEMI), the Spanish Society of Family and Community Medicine (Sociedad Española de Medicina Familiar y Comunitaria, semFYC), the Spanish Society of Neurology (Sociedad Española de Neurología, SEN), and the Spanish Society of Cardiology (Sociedad Española de Cardiología, SEC) (Table 1).

Table 1. Author Membership of the Endorsing Scientific Societies

 

Society Authors
Spanish Society of Internal Medicine (SEMI) Gonzalo García de Casasola Sánchez
Antonio Zapatero Gaviria
Juan Torres Macho
Spanish Society of Family and Community Medicine (semFYC) Santiago Díaz Sánchez
Ignacio Manuel Sánchez Barrancos
Antonio Lorenzo Ruiz Serrano
Spanish Society of Neurology (SEN) Jorge Pagola
Patricia Martínez-Sánchez
Spanish Society of Cardiology (SEC) Leopoldo Pérez de Isla
Teresa López Fernández
Manuel Anguita

Focused cardiac ultrasound is the limited and targeted use of echocardiography as an extension of the physical examination by cardiologists or noncardiologist physicians. As such, its goal is to improve the diagnostic, prognostic, and therapeutic evaluation obtained during the standard physical examination.12 As with other imaging techniques, it is essential to establish an agreed training and accreditation program that equips operators with the skills they need to carry out the procedure.

When using focused cardiac ultrasound, it is important to keep in mind the following guiding principles7:

  • 1. Focused cardiac ultrasound is not a substitute for a complete echocardiographic examination.

  • 2. Patients should be informed about the limitations of the technique and the possible need to extend the study to a complete echocardiographic examination.

  • 3. The procedure is indicated for the detection of defined cardiac abnormalities specified in the scientific literature and in the training and accreditation program, with the aim of helping the physician to make an accurate diagnosis.

  • 4. As with the physical examination, focused cardiac ultrasound studies should be assessed within the context of the patient's medical history. This assessment can never take the place of a full echocardiographic evaluation, and should be restricted to the parameters outlined in this document.

  • 5. As with any other imaging technique, it is essential for operators to undergo specific, accredited training in order to ensure the quality and reliability of the results.

  • 6. When focused cardiac ultrasound detects abnormalities suggesting heart disease or produces inconclusive results, the patient should undergo a complete echocardiographic examination.

  • 7. To ensure quality control focused cardiac ultrasound operators should be supervised by an accredited echocardiography laboratory linked to their institution.

TECHNICAL ASPECTS

Information related to the diagnostic goals of focused cardiac ultrasound can be obtained with a low number of views (Table 2). Nonetheless, to ensure correct patient evaluation, good image quality should generally be obtained in at least 2 views.4, 13, 14, 15, 16, 17, 18, 19, 20, 21 The most useful are the parasternal longitudinal view and 4-chamber apical views because they allow the evaluation of multiple cardiac structures and the diagnosis of disease.

Table 2. Training Objectives in Focused Cardiac Ultrasound and Common Clinical Settings in Which They Can Be Achieved

 

Training objective Clinical setting Skills and applications
Acquisition of essential ultrasound views and measurement of heart chambers Evaluation of patients with X-ray-detected cardiomegaly
Evaluation of left ventricular dilatation in patients with idiopathic stroke
All patients with an indication for focused cardiac ultrasound
Basic ultrasound views: parasternal long and short axis; 4-,3-and 2-chamber apical; and subcostal
It is useful to measure the size of the ventricles, atria (area and volume), interventricular septum, ascending aorta, and vena cava
LVEF estimation Evaluation of patients with dyspnea
Evaluation of hemodynamically unstable patients
Evaluation of patients with abnormalities on the ECG or chest X-ray
Evaluation of patients with cardioembolic stroke
Comprehensive evaluation of patients at high cardiovascular risk
To strengthen diagnosis of ventricular systolic dysfunction, an indirect parameter can be included, such as LV telediastolic diameter or MAPSE
Detection of the absence of mechanical activity during cardiopulmonary resuscitation
Evaluation of RV function and estimation of RV pressure or volume overload Evaluation of patients with dyspnea
Evaluation of patients with suspected pulmonary embolism
Evaluation of patients with hypotension or shock
Screening for pulmonary hypertension
Estimation of right chamber dimensions, vena cava size, RD:LV ratio in 4-chamber apical view, and RV thickness in subcostal view
Operators can include visual evaluation of RV systolic function and TAPSE as a quantitative measure of general RV function
Detection of significant valve disease Initial evaluation of patients with dyspnea
Initial evaluation of patients with suspected heart failure
Evaluation of patients with hypotension or shock
Evaluation of patients with significant heart murmur in the physical examination
Evaluation of patients with cardioembolic stroke
The goal is to identify when a valve lesion could be related to the patient's clinical status
If focused cardiac ultrasound indicates suspected valve disease or related uncertainty, the patient should undergo a complete echocardiographic study
Detection of pericardiac effusion and identification of patients with cardiac tamponade Evaluation of patients with dyspnea
Evaluation of patients with hypertension or shock
Evaluation of patients with X-ray-detected cardiomegaly
Patients with acute pericarditis
Operators will be able to identify the presence of pericardiac effusison and discern whether this has repercussions on the heart chambers (chamber collapse, swinging heart syndrome)
Practioners must recognize that the indication for emergency pericardiocentesis is the patient's clinical and hemodynamic status and not the focused cardiac ultrsound findings
Estimation of LVH and suspected diastolic dysfunction Evaluation of patients with dyspnea
Suspicion of hypertensive heart disease
Comprehensive evaluation of patients at high cardiovascular risk
For patients with dyspnea on exertion in whom focused cardiac ultrasound shows marked ventricular wall thickening and left ventricular dilatation
Evaluation of blood volume Hypotension or shock Evaluation of the presence or absence of chamber dilatation and inferior vena cava diameter and collapsibility
Detection of aortic plaques and cardiac masses Evaluation of patients with embolic stroke Aortic or valve plaques and cardiac masses that require confirmation in a complete echocardiographic study

ECG, electrocardiogram; LV, left ventricle; LVEF, left ventricular ejection fraction; LVH, left ventricular hypertrophy; MAPSE, mitral annular plane systolic excursion; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion.

As with other imaging techniques, it is advisable to systematize the sequence for acquiring views and the essential information sought in each one.22 Videos and images should be stored so that the findings can be reviewed and confirmed, increasing the degree of competence in complex cases with a study review by expert echocardiographers.4

DIAGNOSTIC GOALS

The diagnostic goals of focused cardiac ultrasound are closely aligned with those of complete echocardiographic studies and are influenced by the technique's relatively short learning curve and its usefulness in clinical practice. The goals outlined here are based on key studies conducted with diverse methodologies and varying levels of evidence, as well as the consensus documents of several scientific societies (Table 2).

Left Ventricular Systolic Function

Focused cardiac ultrasound provides a visual estimate of left ventricular size and overall systolic function at an acceptable level of agreement with quantitative methods. Moreover, from a clinical standpoint, it is sufficient to distinguish between normal function and dysfunction.4, 6, 13, 18, 19, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33

Quantification of ejection fraction falls outside the scope of focused cardiac ultrasound. Nonetheless, left ventricular systolic function can be assessed visually, especially from the 4-chamber view, which can be used to obtain a semiquantitative estimate by applying the following classification system: normal, probably reduced, and severely reduced. Another semiquantitative parameter that can provide an index of systolic function is mitral annular plane systolic excursion (MAPSE).34, 35, 36, 37, 38, 39 However, the use of annular plane systolic excursion is limited; in particular, it cannot be used in patients with mitral valve calcification.

Detection of Pericardial Effusion Suspected Tamponade

Ultrasound is the method of choice for the diagnosis of pericardial effusion. Numerous studies have demonstrated the ability of “noncardiologists” to detect pericardial effusion in different clinical settings (eg, shock, electromechanical dissociation, X-ray detected cardiomegaly, patients on hospital wards). It is important to emphasize that tamponade is diagnosed clinically from a constellation of symptoms including hypertension, tachycardia, and elevated venous pressure; ultrasound findings such as significant pericardial effusion, right heart collapse, and swinging heart syndrome serve to confirm the clinical diagnosis.40, 41, 42, 43, 44, 45

Estimation of Heart-chamber Dimensions

Focused cardiac ultrasound is a relatively straightforward way to screen for structural cardiac alterations such as left ventricular dilatation,2, 44 moderate-to-severe left ventricular hypertrophy,43, 46 or dilatation of the left atrium29, 44, 45, 47, 48; the information obtained can make a major contribution to the comprehensive evaluation of patients with cardiovascular disease.21, 49, 50, 51, 52 Focused cardiac ultrasound can also be used to evaluate other structures, such as the ascending aorta.53

Evaluation of Right Ventricular Size and Function

Despite the complexity of right ventricular abnormalities, focused cardiac ultrasound can be used for the subjective detection of right ventricular dysfunction and a dilated right ventricle, principally based on the finding of a right-to-left ratio of the ventricular telediastolic diameters > 1 in the apical 4-chamber view.19, 23 The measurement of tricuspid annular plane systolic excursion (TAPSE) is a relatively simple and reproducible method that provides prognostic information in clinical settings such as heart failure and acute pulmonary embolism.54

Evaluation of the right ventricle is probably of most value in patients in shock or with pulseless electrical activity and suspected massive pulmonary thromboembolism. In noncritical patients, right ventricle parameters are of less significance.55, 56

Estimation of Inferior Vena Cava Diameter and Collapsibility

In spontaneously ventilated patients, noncardiologists have a proven ability to determine blood volume and, indirectly, central venous pressure from ultrasound estimates of the diameter and collapsibility of the inferior vena cava. It is nonetheless important to be aware of the many factors that can influence these estimates.57 This application of focused cardiac ultrasound can be used to identify patients who require “volume repositioning” when the vena cava diameter is decreasing and the collapsibility index is > 50%.57, 58, 59 In patients on invasive or noninvasive mechanical ventilation, the parameters for evaluating the inferior vena cava should be interpreted with caution.16, 60, 61, 62, 63, 64, 65

Detection of Significant Heart-valve Abnormalities

The detection of heart-valve abnormalities is a frequent and feasible application of focused cardiac ultrasound that can be used as a screening method.43, 51, 66, 67, 68, 69, 70 The early detection of severe valve lesions in shock or heart-failure patients can speed up diagnosis and therapy, with positive repercussions on morbidity and mortality.71, 72, 73 The use of quantitative methods such as blood flow velocity analysis to estimate the severity of valve lesions falls outside the scope of focused cardiac ultrasound.4 Nonetheless, operators should be able to visually identify decreases in valve aperture and the presence of regurgitation from color Doppler ultrasound. Although focused cardiac ultrasound cannot quantify the severity of valve disease, it can be used to classify valve lesions into levels: absence, trivial or minimal, and severe. When this approach detects valve lesions that appear to be more than mild, the patient should undergo a conventional echocardiographic examination.

Other Diagnostic Possibilities

Focused cardiac ultrasound can detect segmentary contraction abnormalities in the left ventricle, cardiac masses, thrombi, vegetations, or signs of aortic dissection, such as the presence of a dilated ascending aorta or significant pericardial effusion in a patient with chest pain, stroke, or syncope. These applications require a sufficient level of experience. Obviously, these findings should be confirmed by a complete echocardiographic study unless this is not available and a therapeutic decision needs to be taken immediately. The failure to detect these abnormalities by focused cardiac ultrasound does not exclude their diagnosis.5, 53

The parameters that can be evaluated by focused cardiac ultrasound are applicable to many clinical settings, some of them common and others characteristic of a specific specialty. These clinical settings are listed in Table 2.

TRAINING AND SKILL ACQUISITION IN FOCUSED CARDIAC ULTRASOUND

Regulated training and accreditation exists to ensure that physicians acquire the skills needed to complete the procedures they are tasked with performing. Accreditation in any activity, and specifically in imaging techniques, is of the utmost importance in ensuring that the professional using the technique is equipped with the knowledge and skills needed to carry out the study, in terms of both image acquisition and interpretation. These concerns are reflected in the central recommendation of this consensus document endorsed by the SEC, SEMI, SEN, and semFYC: focused cardiac ultrasound studies must be performed in accordance with qualtity-control and accreditation criteria in order to guarantee the best care and maximum benefit for the patient.

Numerous studies published in recent years have proposed different training routes in focused cardiac ultrasound and the number of training hours needed to achieve specific objectives.18, 29, 31, 42, 43, 44, 49, 51, 69, 70, 74, 75, 76, 77 After an initial basic training in theory and practice, skills can be acquired progressively through experience at the patient bedside.42, 49, 78

There is no agreed consensus on the training needed to attain a basic level of competence in focused cardiac ultrasound; however, several studies concur in recommending at least 50 hours of supervised real-world training with patients in a variety of clinical situations.4, 5, 23, 49, 76 To achieve this, it is essential to organize training in coordination with the cardiology service.5 After completing their training, noncardiologists should incorporate focused cardiac ultrasound into their daily clinical practice; within a few months they will have acquired experience in evaluating patients with very diverse cardiac lesions.76 This approach will give operators the optimal competence level suited to the specific requirements of their specialty (emergency medicine, internal medicine, vascular neurology, primary care, telemedicine, etc.).5, 13, 79, 80

The SEC, SEMI, SEN, and semFYC have designed a training program in focused cardiac ultrasound that includes online theoretical instruction and a practical training course in which the trainee must carry out a minimum of 50 supervised real-world patient studies. Accreditation is conditional on successful completion of an objective practical evaluation. After completing their training, newly accredited focused cardiac ultrasound practitioners are strongly advised to maintain contact with echocardiography laboratories in the cardiac imaging units. This will facilitate consultations about ultrasound images and patient diagnosis and will also aid decision-making about which patients require a complete echocardiography study.

CONCLUSIONS

Focused cardiac ultrasound is an invaluable diagnostic tool that complements physical examination in patients with cardiovascular disease. This technique can also be used for prognostic stratification and follow-up.

The uptake and expansion of focused cardiac ultrasound is to be encouraged due to its benefits for patients; however, its widespread use requires proper training and accreditation for operators.

CONFLICTS OF INTEREST

None declared.

Corresponding author: Unidad de Imagen Cardiovascular, Hospital Clínico San Carlos, Prof. Martín Lagos s/n, 28040 Madrid, Spain. leopisla@hotmail.com

Bibliography

1. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med. 2011;364:749-57.
2. Martin LD, Howell EE, Ziegelstein RC, et al. Hand-carried ultrasound performed by hospitalists: does it improve the cardiac physical examination?. Am J Med. 2009;122:35-41.
3. Croft LB, Duvall WL, Goldman ME. A pilot study of the clinical impact of hand-carried cardiac ultrasound in the medical clinic. Echocardiography. 2006;23:439-46.
4. Via G, Hussain A, Wells M, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014;27:683. e1-683.e33
5. Labovitz AJ, Noble VE, Bierig M, et al. Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians. J Am Soc Echocardiogr. 2010;23:1225-30.
6. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013;26:567-81.
7. Barba Cosials J, Pérez de Isla L. Echocardiography Outside the Cardiology Setting. Position Paper and Recommendations of the Spanish Society of Cardiology. Rev Esp Cardiol. 2016;69:644-6.
8. Torres Macho J, García de Casasola G, Conthe Gutiérrez P. Ecocardiografía clínica básica en Medicina Interna. Rev Clin Esp. 2012;212:141-6.
9. Evangelista A, Galuppo V, Méndez J, et al. Hand-held cardiac ultrasound screening performed by family doctors with remote expert support interpretation. Heart. 2016;102:376-682.
10. Evangelista L, Juncadella E, Copetti S, Pareja A, Torrabadella J, Evangelista A. Utilidad diagnóstica de la ecografía de bolsillo practicada por un médico de familia en una población hipertensa. Med Clin (Barc). 2013;141:1-7.
11. López-Palmero S, Bolivar-Herrera N, López-Lloret G, et al. Utilidad diagnóstica de la ecografía de bolsillo como extensión de la exploración física en pacientes con insuficiencia cardiaca. Rev Clin Esp. 2015;215:204-10.
12. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart. 2017;103:987-94.
13. Beaulieu Y. Specific skill set and goals of focused echocardiography for critical care clinicians. Crit Care Med. 2007;35:S144-9.
14. Breitkreutz R, Price S, Steiger HV, et al. Focused echocardiographic evaluation in life support and peri-resuscitation of emergency patients: a prospective trial. Resuscitation. 2010;81:1527-33.
15. Ferrada P, Anand RJ, Whelan J, et al. Limited transthoracic echocardiogram: so easy any trauma attending can do it. J Trauma. 2011;71:1327-31. discussion 1331-1332
16. Gunst M, Ghaemmaghami V, Sperry J, et al. Accuracy of cardiac function and volume status estimates using the bedside echocardiographic assessment in trauma/critical care. J Trauma. 2008;65:509-16.
17. Kimura BJ, Yogo N, O’Connell CW, Phan JN, Showalter BK, Wolfson T. Cardiopulmonary limited ultrasound examination for “quick-look”bedside application. Am J Cardiol. 2011;108:586-90.
18. Manasia AR, Nagaraj HM, Kodali RB, et al. Feasibility and potential clinical utility of goal-directed transthoracic echocardiography performed by noncardiologist intensivists using a small hand-carried device (SonoHeart) in critically ill patients. J Cardiothorac Vasc Anesth. 2005;19:155-9.
19. Mayo PH, Beaulieu Y, Doelken P, et al. American College of Chest Physicians/La Societe de Reanimation de Langue Francaise statement on competence in critical care ultrasonography. Chest. 2009;135:1050-60.
20. Schmidt GA, Koenig S, Mayo PH. Shock: ultrasound to guide diagnosis and therapy. Chest. 2012;142:1042-8.
21. Vignon P, Dugard A, Abraham J, et al. Focused training for goal-oriented hand-held echocardiography performed by noncardiologist residents in the intensive care unit. Intensive Care Med. 2007;33:1795-9.
22. Steeds RP, Garbi M, Cardim N, et al. EACVI appropriateness criteria for the use of transthoracic echocardiography in adults: a report of literature and current practice review. Eur Heart J Cardiovasc Imaging. 2017;18:1191-204.
23. Neskovic AN, Hagendorff A, Lancellotti P, et al. Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging. 2013;14:1-11.
24. Holm JH, Frederiksen CA, Juhl-Olsen P, Sloth E. Perioperative use of focus assessed transthoracic echocardiography (FATE). Anesth Analg. 2012;115:1029-32.
25. Moore CL, Rose GA, Tayal VS, Sullivan DM, Arrowood JA, Kline JA. Determination of left ventricular function by emergency physician echocardiography of hypotensive patients. Acad Emerg Med. 2002;9:186-93.
26. Royse CF, Haji DL, Faris JG, Veltman MG, Kumar A, Royse AG. Evaluation of the interpretative skills of participants of a limited transthoracic echocardiography training course (H.A.R.T.scan course). Anaesth Intensive Care. 2012;40:498-504.
27. Melamed R, Sprenkle MD, Ulstad VK, Herzog CA, Leatherman JW. Assessment of left ventricular function by intensivists using hand-held echocardiography. Chest. 2009;135:1416-20.
28. Randazzo MR, Snoey ER, Levitt MA, Binder K. Accuracy of emergency physician assessment of left ventricular ejection fraction and central venous pressure using echocardiography. Acad Emerg Med. 2003;10:973-7.
29. DeCara JM, Lang RM, Koch R, Bala R, Penzotti J, Spencer KT. The use of small personal ultrasound devices by internists without formal training in echocardiography. Eur J Echocardiogr. 2003;4:141-7.
30. Mark DG, Hayden GE, Ky B, et al. Hand-carried echocardiography for assessment of left ventricular filling and ejection fraction in the surgical intensive care unit. J Crit Care. 2009;24:470. e1-e7
31. Vignon P, Mucke F, Bellec F, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med. 2011;39:636-42.
32. Razi R, Estrada JR, Doll J, Spencer KT. Bedside hand-carried ultrasound by internal medicine residents versus traditional clinical assessment for the identification of systolic dysfunction in patients admitted with decompensated heart failure. J Am Soc Echocardiogr. 2011;24:1319-24.
33. Hope MD, de la Pena E, Yang PC, Liang DH, McConnell MV, Rosenthal DN. A visual approach for the accurate determination of echocardiographic left ventricular ejection fraction by medical students. J Am Soc Echocardiogr. 2003;16:824-31.
34. Bergenzaun L, Ohlin H, Gudmundsson P, Willenheimer R, Chew MS. Mitral annular plane systolic excursion (MAPSE) in shock: a valuable echocardiographic parameter in intensive care patients. Cardiovasc Ultrasound. 2013;11:16.
35. Elnoamany MF, Abdelhameed AK. Mitral annular motion as a surrogate for left ventricular function: correlation with brain natriuretic peptide levels. Eur J Echocardiogr. 2006;7:187-98.
36. Hu K, Liu D, Herrmann S, et al. Clinical implication of mitral annular plane systolic excursion for patients with cardiovascular disease. Eur Heart J Cardiovasc Imaging. 2013;14:205-12.
37. Koestenberger M, Nagel B, Ravekes W, et al. Left ventricular long-axis function: reference values of the mitral annular plane systolic excursion in 558 healthy children and calculation of z-score values. Am Heart J. 2012;164:125-31.
38. Matos J, Kronzon I, Panagopoulos G, Perk G. Mitral annular plane systolic excursion as a surrogate for left ventricular ejection fraction. J Am Soc Echocardiogr. 2012;25:969-74.
39. Wenzelburger FW, Tan YT, Choudhary FJ, Lee ES, Leyva F, Sanderson JE. Mitral annular plane systolic excursion on exercise: a simple diagnostic tool for heart failure with preserved ejection fraction. Eur J Heart Fail. 2011;13:953-60.
40. Tayal VS, Graf CD, Gibbs MA. Prospective study of accuracy and outcome of emergency ultrasound for abdominal aortic aneurysm over two years. Acad Emerg Med. 2003;10:867-71.
41. Mjolstad OC, Dalen H, Graven T, Kleinau JO, Salvesen O, Haugen BO. Routinely adding ultrasound examinations by pocket-sized ultrasound devices improves inpatient diagnostics in a medical department. Eur J Intern Med. 2012;23:185-91.
42. Mjolstad OC, Andersen GN, Dalen H, et al. Feasibility and reliability of point-of-care pocket-size echocardiography performed by medical residents. Eur Heart J Cardiovasc Imaging. 2013;14:1195-202.
43. Panoulas VF, Daigeler AL, Malaweera AS, et al. 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. 2013;14:323-30.
44. Martin LD, Howell EE, Ziegelstein RC, Martire C, Shapiro EP, Hellmann DB. Hospitalist performance of cardiac hand-carried ultrasound after focused training. Am J Med. 2007;120:1000-4.
45. Lucas BP, Candotti C, Margeta B, et al. Hand-carried echocardiography by hospitalists: a randomized trial. Am J Med. 2011;124:766-74.
46. Perez-Avraham G, Kobal SL, Etzion O, et al. Left ventricular geometric abnormality screening in hypertensive patients using a hand-carried ultrasound device. J Clin Hypertens. 2010;12:181-6.
47. Liu SC, Chang WT, Huang CH, Weng TI, Ma Matthew HM, Chen WJ. The value of portable ultrasound for evaluation of cardiomegaly patients presenting at the emergency department. Resuscitation. 2005;64:327-31.
48. Kimura BJ, Fowler SJ, Fergus TS, et al. Detection of left atrial enlargement using hand-carried ultrasound devices to screen for cardiac abnormalities. Am J Med. 2005;118:912-6.
49. Hellmann DB, Whiting-O’Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC. The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med. 2005;118:1010-8.
50. Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012;7:537-42.
51. Jones AE, Tayal VS, Kline JA. Focused training of emergency medicine residents in goal-directed echocardiography: a prospective study. Acad Emerg Med. 2003;10:1054-8.
52. Botker MT, Vang ML, Grofte T, Sloth E, Frederiksen CA. Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures. Acta Anaesthesiol Scand. 2014;58:807-14.
53. Taylor RA, Oliva I, Van Tonder R, Elefteriades J, Dziura J, Moore CL. Point-of-care focused cardiac ultrasound for the assessment of thoracic aortic dimensions, dilation, and aneurysmal disease. Acad Emerg Med. 2012;19:244-7.
54. Daley J, Grotberg J, Pare J, et al. Emergency physician performed tricuspid annular plane systolic excursion in the evaluation of suspected pulmonary embolism. Am J Emerg Med. 2017;35:106-11.
55. Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63:16-24.
56. Taylor RA, Davis J, Liu R, Gupta V, Dziura J, Moore CL. Point-of-care focused cardiac ultrasound for prediction of pulmonary embolism adverse outcomes. J Emerg Med. 2013;45:392-9.
57. Via G, Tavazzi G, Price S. Ten situations where inferior vena cava ultrasound may fail to accurately predict fluid responsiveness: a physiologically based point of view. Intensive Care Med. 2016;42:1164-7.
58. Schmidt GA. POINT: Should acute fluid resuscitation be guided primarily by inferior vena cava ultrasound for patients in shock? Yes. Chest. 2017;151:531-2.
59. Corl KA, George NR, Romanoff J, et al. Inferior vena cava collapsibility detects fluid responsiveness among spontaneously breathing critically-ill patients. J Crit Care. 2017;41:130-7.
60. Blair JE, Brennan JM, Goonewardena SN, Shah D, Vasaiwala S, Spencer KT. Usefulness of hand-carried ultrasound to predict elevated left ventricular filling pressure. Am J Cardiol. 2009;103:246-7.
61. Stawicki SP, Braslow BM, Panebianco NL, et al. Intensivist use of hand-carried ultrasonography to measure IVC collapsibility in estimating intravascular volume status: correlations with CVP. J Am Coll Surg. 2009;209:55-61.
62. Goonewardena SN, Gemignani A, Ronan A, et al. Comparison of hand-carried ultrasound assessment of the inferior vena cava and N-terminal pro-brain natriuretic peptide for predicting readmission after hospitalization for acute decompensated heart failure. JACC Cardiovasc Imaging. 2008;1:595-601.
63. Goonewardena SN, Blair JE, Manuchehry A, et al. Use of hand carried ultrasound, B-type natriuretic peptide, and clinical assessment in identifying abnormal left ventricular filling pressures in patients referred for right heart catheterization. J Card Fail. 2010;16:69-75.
64. Pellicori P, Carubelli V, Zhang J, et al. IVC diameter in patients with chronic heart failure: relationships and prognostic significance. JACC Cardiovasc Imaging. 2013;6:16-28.
65. Cubo-Romano P, Torres-Macho J, Soni NJ, et al. Admission inferior vena cava measurements are associated with mortality after hospitalization for acute decompensated heart failure. J Hosp Med. 2016;11:778-84.
66. Lip GY, Gibbs CR, Beevers DG. ABC of heart failure: aetiology. BMJ. 2000;320:104-7.
67. Manno E, Navarra M, Faccio L, et al. Deep impact of ultrasound in the intensive care unit: the “ICU-sound”protocol. Anesthesiology. 2012;117:801-9.
68. Shmueli H, Burstein Y, Sagy I, et al. Briefly trained medical students can effectively identify rheumatic mitral valve injury using a hand-carried ultrasound. Echocardiography. 2013;30:621-6.
69. Kobal SL, Trento L, Baharami S, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005;96:1002-6.
70. Alexander JH, Peterson ED, Chen AY, Harding TM, Adams DB, Kisslo JAJ. Feasibility of point-of-care echocardiography by internal medicine house staff. Am Heart J. 2004;147:476-81.
71. Vahanian A, Ducrocq G. Emergencies in valve disease. Curr Opin Crit Care. 2008;14:555-60.
72. Torres Macho J, García De la Torre P, de Castro-García M, García de Casasola Sanchez G. Ecocardiografía clínica básica en urgencias: ¿podemos mejorar el pronóstico en algunos pacientes?. Emergencias. 2015;27:209-10.
73. Saura D, Rodríguez Palomares JF, López Fernández T, De la Morena G, Pérez de Isla L, Barba Cosials J. Selection of the Best of 2016 in Echocardiography in Heart Valve Disease. Rev Esp Cardiol. 2017;70:212-3.
74. Chisholm CB, Dodge WR, Balise RR, Williams SR, Gharahbaghian L, Beraud AS. Focused cardiac ultrasound training: how much is enough?. J Emerg Med. 2013;44:818-22.
75. Frederiksen CA, Juhl-Olsen P, Nielsen DG, Eika B, Sloth E. Limited intervention improves technical skill in focus assessed transthoracic echocardiography among novice examiners. BMC Med Educ. 2012;12:65.
76. Lucas BP, Candotti C, Margeta B, et al. Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program. J Hosp Med. 2009;4:340-9.
77. Galderisi M, Santoro A, Versiero M, et al. Improved cardiovascular diagnostic accuracy by pocket size imaging device in non-cardiologic outpatients: the NaUSiCa (Naples Ultrasound Stethoscope in Cardiology) study. Cardiovasc Ultrasound. 2010;8:51.
78. Khasawneh FA, Smalligan RD. Focused transthoracic echocardiography. Postgrad Med. 2010;122:. 230-207
79. Price S, Via G, Sloth E, et al. Echocardiography practice, training and accreditation in the intensive care: document for the World Interactive Network Focused on Critical Ultrasound (WINFOCUS). Cardiovasc Ultrasound. 2008;6:49.
80. Mayo PH. Training in critical care echocardiography. Ann Intensive Care. 2011;1:36.

1885-5857/© 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved

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