Archives of Academic Emergency Medicine. 2021; 9(1): e53 OR I G I N A L RE S E A RC H Comparison of Emergency Echocardiographic Results be- tween Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome Fatemeh Rasooli1, Farideh Bagheri 2, Azadeh Sadatnaseri 3, Haleh Ashraf3, Maryam Bahreini 1,4∗ 1. Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran. 2. Emergency Medicine Department, Tehran University of Medical Sciences, Tehran, Iran. 3. Cardiology Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. 4. Emergency Medicine Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran. Received: May 2021; Accepted: June 2021; Published online: 27 July 2021 Abstract: Introduction: Early detection of regional wall motion abnormality (RWMA) can be a reliable tool for rapid dis- position of patients with acute coronary syndrome (ACS) in the emergency department. In this study, the di- agnostic accuracy of point-of-care echocardiography performed by a trained emergency medicine resident was evaluated in comparison with board-certified cardiologists. Methods: A prospective, cross-sectional study was implemented on adult patients with ACS. A trained emergency medicine (EM) PGY-3 resident performed point- of-care echocardiography under the supervision of two cardiologists and the reports were compared with car- diologists as a reference test. Results: 100 patients with the mean age of 54.1 ± 11.5 years were recruited (65% male). Based on Thrombolysis in Myocardial Infarction (TIMI) and History, EKG, Age, Risk factors, and troponin (HEART) scores, 43.0% and 25.0% of patients were categorized as low-risk for ACS, respectively. The absolute measure of agreement between cardiologists to determine ejection fraction (EF) was 0.829 (95% CI: 0.74-0.89) based on intraclass correlation coefficient (ICC) estimation. The measurements of agreement between special- ists and the EM resident based on the analysis of Kappa coefficient were 0.677 and 0.884 for RWMA and peri- cardial effusion, respectively. Moreover, 25 patients were in the-low risk group according to the HEART score with an agreement rate of 92% for the lack of RWMA between the EM resident and cardiologists. Conclusion: This study found acceptable agreement between the EM resident and cardiologists in assessing RWMA in differ- ent ACS risk groups. In addition, there was acceptable agreement between the EM resident and cardiologists in determining left ventricular ejection fraction (LVEF) and pericardial effusion. Keywords: Emergency medicine; Cardiologists; Patient Discharge; Ultrasonography; Point-of-Care Systems Cite this article as: Rasooli F, Bagheri F, Sadatnaseri A, Ashraf H, Bahreini M. Comparison of Emergency Echocardiographic Results be- tween Cardiologists and an Emergency Medicine Resident in Acute Coronary Syndrome . Arch Acad Emerg Med. 2021; 9(1): e53. https://doi.org/10.22037/aaem.v9i1.1247. 1. Introduction It is crucial to manage the large number of patients who present to emergency departments (EDs) with acute chest pain with utmost accuracy. Traditionally, medical history, physical examination, elec- trocardiography, and chest radiography have been used in ∗Corresponding Author: Maryam Bahreini; Emergency Department, Sina Hospital, Imam-Khomeini Ave., Tehran, Iran. E-mail: bahreinima- ryam@gmail.com; m-bahreini@tums.ac.ir, Tel/Fax: +98-21-66348553, Postal Code: 1136746911, ORCID: https://orcid.org/0000-0002-7655-0987. the emergency ward for screening patients with cardiovascu- lar complaints (1). However, these diagnostic tools are not completely accurate for exact disposition of those with acute coronary syndrome (ACS), especially in the low-risk group. Focused cardiac ultrasound (FOCUS) has become a vital tool in the evaluation of ACS patients (2), as suggested by the American Society of Echocardiography (ASE) and the Amer- ican College of Emergency Physicians (ACEP) (3). It is a bedside, readily available, and noninvasive tool for real-time assessment of left ventricular ejection fraction (LVEF), in- travascular volume, pericardial effusion, and assessment of regional wall motion abnormality (RWMA), as well as car- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Rasooli et al. 2 diac activity in patients with pulseless electrical activity (4- 7). Echocardiography is considered a highly reliable modal- ity to identify RWMA (8). Abnormal left ventricular wall mo- tion can suggest a significant coronary artery obstruction. The sensitivity of transthoracic echocardiography alone for suspecting myocardial ischemia was found to be 91 percent for ACS disposition in low-risk patients. Also, early normal echocardiogram in suspected patients in the ED indicates a lower clinical risk (8). Cardiologists routinely perform full standard transthoracic echocardiography (TTE) to manage ACS patients; however, they do not usually work full-time and are not always avail- able in EDs. As a result of the delay in the disposition of ACS patients, emergency rooms become more crowded, which has financial consequences for both patients and hos- pitals. On the other hand, emergency medicine (EM) special- ists constantly reside in EDs and are familiar with applying point-of-care ultrasound in emergency situations. The aim of this study was to assess the diagnostic accuracy of point- of-care echocardiography performed by a trained emergency medicine resident in comparison with board-certified cardi- ologists. 2. Methods 2.1. Study design and setting This is a prospective, cross-sectional study on adult pa- tients (≤18 years-old) with acute coronary syndrome pre- senting to the EDs of two referral university hospitals with 50000-75000 annual visits from 2018 to 2019. The ethical as- pects of this study were approved by Tehran University of Medical Sciences Institutional Review Board (Ethics code: IR.TUMS.VCR.REC.1398.144). Informed consent was taken from all patients after complete explanation of the study. 2.2. Participants Patients with ST segment elevation myocardial infarction (MI) who needed primary coronary intervention (PCI) and participants with pacemaker implantation were excluded be- cause of their influence on estimating cardiac wall motion. 2.3. Data gathering and procedure Data were recruited by an emergency medicine resident of postgraduate residency year (PGY)-3 as well as the cardiol- ogists who were present in the hospitals to give cardiology consults in different days of the week in the morning and evening shifts. According to the routine protocol, patients are emergently visited by emergency medicine residents, stabilized, and then visited by internal medicine residents by request for car- diology visits. Except for very low-risk ACS patients who are discharged, others stay in the emergency ward to undergo further testing for final disposition. Data were collected via convenient sampling. The EM resident initially spent a 2- hour theoretical course emphasizing on quantitative ejec- tion fraction (EF) estimation, presence of pericardial effu- sion, and RWMA assessment, then passed a 20-hour hands- on training course under the supervision of the two cardiol- ogists according to the emergency ultrasound guidelines of ACEP (1). The echocardiographs were performed using the ultrasound machines GE Vivid E9 and Samsung UGEO HM70A using phased-array 2-4 MHz transducers. Visual estimation was performed for the assessment of left ventricular function (LVF) both qualitatively and quantitatively, and focused ul- trasound views were performed, including parasternal long axis, parasternal short axis, apical 4-chamber and subcostal views. The LVF according to the LVEF was categorized as normal (LVEF >55%), mild to moderate dysfunction (LVEF 35-55%), and severe dysfunction (LVEF<35%) (9). Patients were assessed to determine whether they had RWMA or not. RWMA was assessed in four views including long axis, short axis, apical 4-chamber and two chamber views. Akinesia, hy- pokinesia and dyskinesia of left ventricle were considered as RWMA that can be detected immediately after an ischemic event preceding ECG and biomarker alternations (8). Be- sides, increased echogenicity, decreased thickness, and evi- dence of remodeling such as dyskinesia, as chronic ischemic changes, were evaluated. The sub-xiphoid view was also used to assess pericardial effusion. The study was performed in two phases. Echocardiography was first implemented by the emergency medicine resident, then by either cardiologist, who was blind to the resident’s results, at most 1 hour apart. Echocardiogram findings were documented along with other information such as History, EKG, Age, Risk factors, and tro- ponin (HEART) and Thrombolysis in Myocardial Infarction (TIMI) scores in the questionnaire. The clinical decisions and interventions were performed ac- cording to the risk stratification of HEART score and based on the cardiologists’ decisions for moderate-risk patients. Pa- tients with regional wall motion abnormality on FOCUS were admitted for further assessment. Acute coronary syndrome was defined as acute chest pain, dyspnea, or weakness, and also syncope with a cardiac cause. 2.4. Outcomes First, the agreement between the EM resident and cardiolo- gists was analyzed in assessment of cardiac function (RWMA, LVEF, and pericardial effusion) using point-of-care ultra- sound in ACS. The examination results of the board-certified cardiologists were considered as gold standard. The results were also sub-analyzed based on the risk stratification of pa- tients. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2021; 9(1): e53 Figure 1: The Bland-Altman plot of ejection fraction (EF) which shows the agreement between the EM resident and cardiologists. 2.5. Statistical Analysis Based on a previous study, the kappa coefficient of agree- ment between EM specialists and cardiologists in evaluation of cardiac function was considered 0.71; with a confidence interval of 95% and a margin of error of 5%, a sample size of 88 patients was required (nQuery Advisor). Adding 10% to adjust for potential missing data, the final total sample size was about 100. The mean differences of EF between the emergency medicine resident and the cardiologists were assessed us- ing independent T-test. Furthermore, the Bland-Altman plot was used to measure the agreement between the two spe- cialists. To construct a Bland-Altman plot, the difference be- tween EF measured by specialists was plotted on the y-axis against the average of the total amount on the x-axis. More- over, the intra-class correlation coefficient (ICC) was ana- lyzed to assess the agreement on EF estimation. The spe- cialists’ agreement on RWMA and pericardial effusion was as- sessed by measuring Kappa coefficient. In addition, the per- formance accuracy of the EM resident in determining RWMA was assessed in comparison with board-certified cardiolo- gists as the gold-standard. Thus, we used Receiver Operat- ing Characteristic (ROC) curve analysis and calculated sensi- tivity, specificity, and negative and positive predictive values with 95% confidence interval. The statistical uncertainty of calculated statistics was shown by 95% confidence interval. The level of significance was 0.05. Data were analyzed using Stata and Medcalc softwares. 3. Results 3.1. Baseline characteristics of studied cases In this study, 100 patients with the mean age of 54.1 ± 11.5 (24-84) years were recruited (65.0% male). Of whom, 26.0% Table 1: Baseline characteristics of studied cases Variable Value Age (year) 54.1 ± 11.5 Gender Male 65 (65.0) Female 35 (35.0) Vital signs Systolic blood pressure (mmHg) 136.2 ± 16.4 Diastolic blood pressure (mmHg) 81.6 ± 9.0 Pulse Rate (bpm) 75.3 ± 10.6 Respiratory Rate (bpm) 13.1 ± 1.6 Saturation O2 93.7 ± 2.5 Medical History Angiography 26 (26.0) CABG 9 (9.0) ASA Use 50 (50.0) Hypertension 49 (49.0) Diabetes mellitus 19 (19.0) Hyperlipidemia 33 (33.0) Cigarette smoking 40 (40.0) Troponin I Abnormal 22 (22.0) ECG changes Not Visible 8 (8.0) Not Noticeable 59 (59.0) Clinically significant 33 (33.0) TIMI score Low risk 43 (43.0) Moderate risk 47 (47.0) High risk 10 (10.0) HEART score Low risk 25 (25.0) Moderate risk 54 (54.0) High risk 21 (21.0) Data are presented as mean ± standard deviation or number (%). SD: Standard deviation; CABG: Coronary Artery Bypass Graft; ASA: Acetylsalicylic Acid; ECG: Electrocardiogram; CABG: Coronary Artery Bypass Graft; ASA: Acetylsalicylic Acid; ECG: Electrocardiogram. and 9.0% had a positive history of coronary angiography (CAG) and coronary artery bypass graft (CABG), respectively. Based-on the TIMI and HEART scores, 43.0% and 25.0% of patients were categorized as low-risk, respectively. Table 1 depicts the distribution of demographics, clinical presenta- tions, vital signs, past history, and risk factors of patients at the time of admission. 3.2. Echocardiographic findings EF The mean ejection fraction determined by cardiologists and the emergency medicine resident was 50.7 ± 4.8 vs. 49.8 ± 5.2 percent, respectively (P=0.001). Figure 1 presents the Bland- Altman plot of ejection fraction (EF) between the EM resident and cardiologists. The absolute measure of agreement be- tween specialists for EF estimation was 0.829 (95% CI: 0.74- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Rasooli et al. 4 Table 2: Agreement and accuracy indices of regional wall motion abnormality (RWMA) and pricardial effusion between cardiologist (gold- standard) and emergency medicine (EM) resident Cardiologists Kappa Accuracy Sesitivity Spesificity AUC PPV NPV P N RWMA in Total EM P 29 9 0.677 85.0% 82.9 (66.4,93.4) 86.2 (75.3,93.5) 0.85 (0.76,0.91) 76.3 (59.8,88.6) 90.3 (80.1,96.4) resident N 6 56 Pricardial Effusion EM P 4 0 0.884 99.0% 80.0 (28.4,99.5) 100 (96.2, 100) 0.90 (0.82,0.95) 100 (39.8, 100) 99.0 (94.3, 100) resident N 1 95 RWMA without patients with prior angiography or CABG EM P 15 7 0.682 85.0% 88.2 (63.6,98.5) 86.8 (74.7,94.5) 0.88 (0.77,0.94) 68.2 (45.1,86.1) 95.8 (85.7, 9.5) resident N 2 46 Data are presented with 95% confidence interval. P: Positive; N: Negative in retest; CI: Confidence interval; AUC: Area Under the Curve; PPV: Positive predictive values; NPV: Negative predictive values; CABG: Coronary artery bypass graft. 0.89) based-on intraclass correlation coefficient (ICC). We also analysed data after removing patients with a history of CAG or CABG. The mean EF determined by cardiologists in comparison with emergency medicine specialists was 51.9 ± 4.6 vs. 50.6 ± 5.2 percent, respectively (P=0.001). The abso- lute agreement of specialists for determining EF was 0.897 (95% CI: 0.80-0.94) based on intraclass correlation coefficient (ICC). 3.3. RWMA and pericardial effusion The agreement rates between specialists and the EM resident based on analysing Kappa coefficient were 0.677 and 0.884 for RWMA and pericardial effusion, respectively. Further- more, the performance of EM resident had the sensitivity and specificity of 82.9% and 86.2% for RWMA estimation and 80.0 and 100% for detecting pericardial effusion, respectively. From all low-risk patients according to the TIMI score (43 pa- tients), 35 and 40 individuals were reported to have no RWMA by the EM resident and cardiologists on echocardiography, respectively. Thus, the agreement between them was 81.3%. Moreover, 25 patients were in the low-risk group according to the HEART score; of whom, 23 and 25 patients had nor- mal wall motion according to the report of the EM resident and cardiologists, respectively. Therefore, the agreement be- tween them was 92%. 3.4. Screening performance characteristics of echocardiography by EM resident Table 2, presents acuracy indices and predictive values in es- timation of RWMA and pricardial effusion by the EM resi- dent. 4. Discussion In our study, there was a moderate agreement between the EM resident and cardiologists with an acceptable accuracy. The specificity and negative predictive value of the echocar- diograms of the EM resident improved when eliminating pa- tients with a history of CAG or CABG. We found that the agreement on RWMA estimation was higher in low-risk pa- tients according to the HEART score risk stratification in comparison with the TIMI score. Furthermore, the absolute agreement on EF estimation was acceptable. Emergency medicine specialists make critical decisions in a short time period, mandating goal-directed and focused point-of-care ultrasound in many circumstances. Regarding benefits and harms, the determination of EF and RWMA us- ing FOCUS are important in low-risk patients with ACS to make more accurate dispositions and to reduce the possibil- ity of unpredictable major cardiac events (1) in conjunction with risk stratification tools such as HEART/TIMI score. Con- sidering the harmlessness of bedside ultrasound and the ap- plicability of this module, it can be performed frequently in EDs. Previous studies have administered several training modules, which varied in duration and major outcomes. In Monsom- boon’s study, EM residents passed a 3-hour echocardiogra- phy training course focusing on LVEF visual estimation (10) and other researchers mentioned 4 to 6 hours of video pro- grams (11-13). Furthermore, some aimed at training resi- dents of EM or intensive care to get familiar with standard cardiac views within 3 to 12 hours (14, 15). In a study by Kerwin et al. trainees were capable of interpreting echocar- diographic abnormalities with significant improvement af- ter a 30-minute training period (16). Overall, these studies confirmed the trainees’ capabilities to perform echocardiog- raphy in comparison with cardiologists after the mentioned training time. 4.1. Assessment of RWMA The detection of RWMA by EM residents is very helpful in patients’ disposition. A small number of studies have eval- uated the reliability of EM residents’ scans and few have as- This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2021; 9(1): e53 sessed their agreement with cardiologists. The probability of coronary artery disease (CAD) increases with new RWMAs in patients with acute chest pain (17). On the other hand, the absence of RWMA in patients with ACS can lead to a safer discharge in conjunction with being categorized as low-risk based on a risk stratification tool. As mentioned in Arntfield’s study, 98% of suspected CAD patients with no RWMA had a negative work-up for CAD (6). In our study, there was moderate agreement (0.677) between the EM resident and cardiologists with an accuracy of 85%. The specificity and negative predictive values of the echocar- diograms by the EM resident were 86.2% and 90.3%, which improved by eliminating patients with history of CAG or CABG. Farsi et al. showed 92% agreement on RWMA between cardiologists and EM residents. Interestingly, the specificity and negative predictive value of echocardiograms performed by the EM resident were 87% and 98%, which are very close to our findings (13). We found that the agreement on RWMA estimation was higher in patients who were low-risk according to the HEART score in comparison with the TIMI score. Thus, we propose using the combination of the HEART score with RWM sta- tus to speed up disposition of ACS patients from the emer- gency ward. In this regard, emergency specialists can more safely discharge low-risk patients with normal regional wall motion. 4.2. EF Assessment In this study, the mean EF measured by cardiologists was sig- nificantly higher than the EM resident (P=0.001), yet this dif- ference was not considered clinically significant. The abso- lute agreement on EF estimation was 0.829 based on the in- terclass correlation coefficient (ICC), which presents an ac- ceptable reliability. Eliminating patients with a history of CAG or CABG, the agreement reached 0.897, which may re- flect better evaluation of LVEF by the EM resident in less complicated patients. In this regard, the agreement between the EM resident and the cardiologist on estimating ventric- ular function was 79.4% in Monsomboon’s study (10). Also Moore and et al. showed weighted agreement of 84% be- tween emergency physicians (EPs) and cardiologists with a weighted kappa of 0.61 (p < 0.001) in quantitative visual es- timation of LVEF (12). In other studies, the agreement be- tween trainees and cardiologists were considered acceptable with fair accuracy for LVEF estimation after minimal training (12, 14, 18-20). In a study by Bustam et al., the agreement between trainees and the cardiologist was 93% for visual es- timation and 92.9 % for quantitative evaluation of LVEF and the Bland– Altman limits of agreement for LVEF assessment were similar to our study (11). This agreement was 91% in Farsi’s investigation (13). 4.3. Assessment of Pericardial Effusion In this study, there was a desirable agreement between the EM resident and cardiologists in determining pericardial ef- fusion, which is similar to Bustam’s study with a sensitivity, specificity, PPV and NPV of 60, 100, 100 and 97.9 %, respec- tively (11). The accuracy of finding pericardial effusion by EM residents was 99% in Mandavia and Monsomboon’s studies (10, 21). 5. Limitations and Suggestions It is worth assessing the inter-rater reliability of cardiologists, which can be further studied although we had similar insti- tutional protocols to carry out measurements. On the other hand, increasing the number of operators mandates coordi- nation and this issue can be addressed in further studies to improve generalizability. Potential bias was reduced through cardiologists teaching echocardiographic measures. Differ- entiating between new and old RMWA is considered chal- lenging even for skilled EM sonographers; thus, the EM resi- dent in this study detected every abnormality without spend- ing time on differentiation between the old and new lesions. Wall thickness measurements can differentiate old ischemia from a new one, which was not assessed in this study. On the other hand, the differential diagnoses of RWMA could con- fuse the operator, which are worth addressing. Applying a specific cardiac scoring system such as HEART score in conjunction with point-of-care echocardiography can lead to a faster and safer disposition focusing on RWMA in ACS patients. Patients who had a low risk of ACS according to HEART score with normal wall motion in echocardiogra- phy can have ambulatory follow-up for major cardiac events. 6. Conclusion This study found acceptable agreement between the EM res- ident and cardiologists in assessing RWMA, which was also seen in low-risk patients. Besides, there was acceptable agreement between the EM resident and cardiologists in de- termining LVEF and pericardial effusion. 7. Declarations 7.1. Acknowledgments We kindly thank Dr. Mehdi Mehrani, MD for his valuable co- operation in carrying out this study. 7.2. Funding None. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem F. Rasooli et al. 6 7.3. 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Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitations and Suggestions Conclusion Declarations References