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Moving the needle towards the democratization of echocardiography: a case report

Moving the needle towards the democratization of echocardiography: a case report Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 CASE REPORT European Heart Journal - Case Reports (2019) 3, 1–5 doi:10.1093/ehjcr/ytz179 Cardiac imaging Moving the needle towards the democratization of echocardiography: a case report 1,2 2,3 Jonathan dos Santos *, Patrı´cia Borges Fernandes , 2 2 Francisco Rocha Gonc¸alves , and Alexandra Gonc¸alves 1 2 ACeS Baixo Ta ˆmega, UCSP Celorico de Basto, Assento, Britelo, 4890-221 Celorico de Basto, Portugal; Department of Medicine, Faculty of Medicine of Porto University, Alameda Prof. Herna ˆni Monteiro, 4200-319 Porto, Portugal; and USF S~ ao Miguel Arcanjo, ACeS Vale do Sousa Sul, Rua, Marque ˆ s de Pombal, 682, 4560-682 Penafiel, Portugal Received 8 January 2019; first decision 6 March 2019; accepted 25 September 2019; online publish-ahead-of-print 22 October 2019 Background Echocardiography has been traditionally performed in echo labs and the potential benefits of its use by primary care physicians (PCPs) are still unexplored. We present a case where POCUS (point-of-care ultrasound) was used as a complement of physical examination by a family doctor, allowing a prompt clinical decision in a heart failure (HF) patient. ................................................................................................................................................................................................... Case summary An 85-year-old woman, living independently, asks her family doctor for a home consultation due to increasing dys- pnoea. On examination, severe dyspnoea and bilateral ankle oedema was noted and a point-of-care echocardio- gram was performed by the primary care physician, who observed: severely compromised left ventricular systolic function, moderate mitral and tricuspid regurgitation, and severe dilation of the inferior vena cava. As a result, the diagnosis of HF with decreased ejection fraction was formed supporting the therapeutic decision. ................................................................................................................................................................................................... Discussion This case represents an elderly patient with dyspnoea, without previous HF diagnosis. The primary care physician, used portable ultrasound as a complement of physical examination, which confirmed a HF diagnosis, allowing a prompt decision-making on therapy. POCUS, can be a powerful tool to expedite treatment in different settings, including the home consultations by PCPs. Keywords Point-of-care ultrasound Pocket ultrasound Heart failure Primary care physician Case report � � � � Introduction Learning points Point-of-care ultrasound, when used by primary care physi- . Echocardiography has been traditionally performed in echo labs, but cians with training, allows detection of important functional . in the latest years, it has been expanded to other environments, such and structural cardiac abnormalities. . as hospital urgent care. The advantages of the use of echocardiog- A pocket ultrasound can be used as a physical examination . raphy by primary care physicians (PCPs) is unexplored, although complement, supporting the differential diagnosis of dyspnoea . 1 . PCPs are in the front line evaluation of most of the patients. and efficient decision-making process. . We present a case report of a patient with heart failure (HF) where echocardiography was instrumental for comprehensive * Corresponding author. Tel: þ351 225 513 600, Email: jonathansantos@med.up.pt Handling Editor: Nikos Papageorgiou Peer-reviewers: Georg Goliasch and Hugo Rodriguez-Zanella Compliance Editor: Anastasia Vamvakidou Supplementary Material Editor: Vishal Shahil Mehta V The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 2 J. dos Santos et al. patient evaluation and clinical decision, illustrating a significant im- . independently in her own house. Her regular medication included provement in the efficiency of primary healthcare. . ramipril 10 mg od acenocoumarol, bisoprolol 5 mg od, pantoprazole 20 mg od and furosemide 40 mg od. We speculate patient had been advised by a different healthcare provider on this high diuretic dose due to swollen legs or other signs of congestion. Timeline The patient requests her family doctor for a home consultation by aggravated dyspnoea. She was found with fatigue, tiredness, orthop- noea and dyspnoeic at rest. Physical examination revealed a blood 4 years prior to No prior history of heart failure at presentation . pressure of 100/60 mmHg, heart rate of 98 b.p.m., elevated jugular presentation . venous pressure, third heart sound, pulmonary rales in the lower At presentation 85-year-old woman requests family doctor home third of both lungs, and bilateral ankle oedema. Her medical records consultation due to progressive dyspnoea showed a glomerular filtration rate of 55 mL/min and an echocardio- Dyspnoea [New York Heart Association gram performed 4 years prior showed normal biventricular function (NYHA) Class III–IV], orthopnoea, pulmonary without signs of pulmonary artery hypertension and mild mitral re- rales, and bilateral ankle oedema gurgitation. In regard to the severity of the symptoms, the patient Point-of-care ultrasound with pocket echo by . was suggested to pursue further evaluation and treatment at the local family doctor: severely compromised left ven- . hospital, but she refused to leave her house. On-site, the PCP with tricular systolic function, severe dilation of the . echocardiography training (certified online course and a practical inferior vena cava training in an echocardiography lab for 6 months) performed a point- Treatment: spironolactone 25 mg daily; increased . R of-care ultrasound (POCUS) Lumify . The study showed: severely furosemide 40 mg 3 times daily compromised left ventricular (LV) systolic function (Figure 1, 1 month later Dyspnoea (NYHA Class II–III) Supplementary material online, Video S4), moderate mitral (Figure 2), Conventional echocardiography: reduced ejec- and tricuspid regurgitation (Figure 3), severe dilation of the inferior tion fraction (30%) . vena cava (Figure 4), severely dilated left atrium (52 mm in long-axis Replaces ramipril to sacubitril/valsartan . view), dilated right atrium (minor axis of 49 mm in four-chamber 2 months later Heart failure symptoms relief view), normal LV size (47 mm in diastole parasternal long-axis view), Titrate sacubitril/valsartan dose . normal right ventricular (RV) size (basal and mid diameter of 39 and 29 mm), and normal RV function (tricuspid annular plane systolic ex- cursion of 19 mm). Ultrasound B-lines were not assessed at this time. The study was shared live using a real-time programme (REACTS) with a cardiologist who confirms the findings. As a result, the diagno- Case presentation . . sis of HF with decreased ejection fraction (EF) was performed sup- We present a case of an 85-year-old woman with medical history . porting the therapeutic decision: furosemide 40 mg was increased to of arterial hypertension, obesity, and atrial fibrillation, living three times daily and spironolactone 25 mg was introduced once Figure 1 A four-chamber view with end-diastolic and systolic volumes. Reduced ejection fraction of 38% (Supplementary material online, Video S4). Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 Moving the needle towards the democratization of echocardiography: a case report 3 Figure 2 A four-chamber view with moderate mitral regurgitation. Figure 3 Parasternal short-axis view with moderate tricuspid regurgitation. daily. The patient had weekly visits from the community nurse and . particularly in elderly patients, being the information provided by ultra- one month later, a conventional echocardiogram confirmed the sound fundamental for diagnosis and therapeutic management. POCUS findings, quantifying left ventricular ejection fraction in 30% This case represents an 85-year-old female patient with dyspnoea, without previous HF diagnosis, refusing to leave her home, to whom and pulmonary artery pressure in 44 mmHg. At this time, ramipril the PCP successfully used portable ultrasound as a physical examin- was replaced by sacubitril/valsartan 24 mg/26 mg td. The patient ation complement. The comprehensive evaluation allowed a confident refused additional studies or hospital referral, which limited our abil- . diagnosis of HF at patient’s home and a timely and targeted therapy ity to study the cause of HF. At two months, follow-up the patient . avoiding hospital admission, showing that the use of ultrasound by a was tolerating treatment and presented in Class II of New York trained primary care physician increases the efficiency of medical care Heart Association and the sacubitril/valsartan was titrated for the diagnosis and treatment of HF. The available studies are very accordingly. limited and no cost-effectiveness studies have been done to prove the use POCUS as a toll by PCPs, however, this technique has been proven . to be a useful, reliable and fast tool in emergency department and as a Discussion . 3–6 . bedside physical examination complement. Heart failure prevalence has been increasing in the last decades, along- . In addition to HF recognition, HF should be monitored and medi- 1 . side with population aging, especially in developed countries. . cation optimized periodically. PCPs can play a critical role in this re- However, the diagnosis of HF, as a clinical syndrome can be challenging, gard, in close collaboration with cardiologists, evaluating elderly Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 4 J. dos Santos et al. Figure 4 In subcostal view, enlarged inferior vena cava at expiration (A) and inspiration (B) shows respiratory variation >50%. patients who require home visits. In fact, a randomized clinical trial in value. In 2012, Jonathan has completed the master of medicine at patients with HF with optimal medical therapy showed no differences Coimbra Medical School (FMUC). He has been enrolled in 2016 in death and hospital admissions between patients followed by cardi- in the PhD program of medicine at the Porto Medical School ologists with those followed by referral PCP. (FMUP); In 2018 he has completed the family and general medi- . cine fellowship at ‘USF Terras de Souza’ in ‘ACES Vale de Sousa . Sul’; from February 2019 he’s a clinician at “UCSP Celorico de Conclusions . Basto” in “ACeS Baixo Ta ˆmega”. In summary, the crescent ageing population presents new demands to the healthcare system and chronic diseases such as HF are more commonly being diagnosed and treated by PCPs, who by using port- . Supplementary material able ultrasounds, as ‘fifth pillar to bedside physical examination’ will . . Supplementary material is available at European Heart Journal - Case significant improve patient care. Reports online. Lead author biography Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data. Jonathan dos Santos was born in Paris in 1987 and grew up in . Consent: The author/s confirm that written consent for submis- Amarante (Portugal). He’s a family . sion and publication of this case report including image(s) and physician who believes that pri- . associated text has been obtained from the patient in line with mary health care are on the main- COPE guidance. stay of any healthcare system. He’s a point-of-care ultrasound Conflict of interest: Pocket ultrasound of this study is an investiga- (POCUS) user so that physical tion grant support from Philips; Alexandra Goncalves, MD, PhD, examination has for him an extra MMSc is a Philips employee. . Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 Moving the needle towards the democratization of echocardiography: a case report 5 . performed by a pocket device? Scand J Trauma Resusc Emerg Med 2015; References 23:52. 1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, . 4. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examin- Falk V, Gonza ´lez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, ation: better at the bedside. Heart 2017;103:987–994. Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope . 5. Laursen CB, Sloth E, Lassen AT, Christensen R, Lambrechtsen J, Madsen PH, LM,RuschitzkaF,RuttenFH, vander Meer2P; Authors/Task Force Henriksen DP, Davidsen JR, Rasmussen F. Point-of-care ultrasonography in Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and . patients admitted with respiratory symptoms: a single-blind, randomised con- treatment of acute and chronic heart failure. The Task Force for the diag- trolled trial. Lancet Respir Med 2014;2:638–646. nosis and treatment of acute and chronic heart failure of the European 6. Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, Stefanone VT, Society of Cardiology (ESC). Developed with the special contribution of . Savinelli C, Coppa A, Bigiarini S, Caldi F, Tassinari I, Conti A, Grifoni S, Pini R. the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37: . Point-of-care ultrasonography for evaluation of acute dyspnoea in the ED. Chest 2129–2200. 2017;151:1295–1301. 2. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside 7. Schou M, Gustafsson F, Videbaek L, Tuxen C, Keller N, Handberg J, Sejr Knudsen physical examination: inspection, palpation, percussion, auscultation, and insona- . . A, Espersen G, Markenvard J, Egstrup K, Ulriksen H, Hildebrandt PR tion. JAMA Cardiol 2018;3:346–350. NorthStar Investigators, all members of The Danish Heart Failure Clinics 3. Bobbia X, Pradeilles C, Claret PG, Soullier C, Wagner P, Bodin Y, Roger Network. Extended heart failure clinic follow-up in low-risk patients: a random- C, Cayla G, Muller L, de La Coussaye JE. Does physician experience in- . fluence the interpretability of focused echocardiography images . ized clinical trial (NorthStar). Eur Heart J 2013;34:432–442. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png European Heart Journal - Case Reports Oxford University Press

Moving the needle towards the democratization of echocardiography: a case report

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Oxford University Press
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© The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology.
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Abstract

Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 CASE REPORT European Heart Journal - Case Reports (2019) 3, 1–5 doi:10.1093/ehjcr/ytz179 Cardiac imaging Moving the needle towards the democratization of echocardiography: a case report 1,2 2,3 Jonathan dos Santos *, Patrı´cia Borges Fernandes , 2 2 Francisco Rocha Gonc¸alves , and Alexandra Gonc¸alves 1 2 ACeS Baixo Ta ˆmega, UCSP Celorico de Basto, Assento, Britelo, 4890-221 Celorico de Basto, Portugal; Department of Medicine, Faculty of Medicine of Porto University, Alameda Prof. Herna ˆni Monteiro, 4200-319 Porto, Portugal; and USF S~ ao Miguel Arcanjo, ACeS Vale do Sousa Sul, Rua, Marque ˆ s de Pombal, 682, 4560-682 Penafiel, Portugal Received 8 January 2019; first decision 6 March 2019; accepted 25 September 2019; online publish-ahead-of-print 22 October 2019 Background Echocardiography has been traditionally performed in echo labs and the potential benefits of its use by primary care physicians (PCPs) are still unexplored. We present a case where POCUS (point-of-care ultrasound) was used as a complement of physical examination by a family doctor, allowing a prompt clinical decision in a heart failure (HF) patient. ................................................................................................................................................................................................... Case summary An 85-year-old woman, living independently, asks her family doctor for a home consultation due to increasing dys- pnoea. On examination, severe dyspnoea and bilateral ankle oedema was noted and a point-of-care echocardio- gram was performed by the primary care physician, who observed: severely compromised left ventricular systolic function, moderate mitral and tricuspid regurgitation, and severe dilation of the inferior vena cava. As a result, the diagnosis of HF with decreased ejection fraction was formed supporting the therapeutic decision. ................................................................................................................................................................................................... Discussion This case represents an elderly patient with dyspnoea, without previous HF diagnosis. The primary care physician, used portable ultrasound as a complement of physical examination, which confirmed a HF diagnosis, allowing a prompt decision-making on therapy. POCUS, can be a powerful tool to expedite treatment in different settings, including the home consultations by PCPs. Keywords Point-of-care ultrasound Pocket ultrasound Heart failure Primary care physician Case report � � � � Introduction Learning points Point-of-care ultrasound, when used by primary care physi- . Echocardiography has been traditionally performed in echo labs, but cians with training, allows detection of important functional . in the latest years, it has been expanded to other environments, such and structural cardiac abnormalities. . as hospital urgent care. The advantages of the use of echocardiog- A pocket ultrasound can be used as a physical examination . raphy by primary care physicians (PCPs) is unexplored, although complement, supporting the differential diagnosis of dyspnoea . 1 . PCPs are in the front line evaluation of most of the patients. and efficient decision-making process. . We present a case report of a patient with heart failure (HF) where echocardiography was instrumental for comprehensive * Corresponding author. Tel: þ351 225 513 600, Email: jonathansantos@med.up.pt Handling Editor: Nikos Papageorgiou Peer-reviewers: Georg Goliasch and Hugo Rodriguez-Zanella Compliance Editor: Anastasia Vamvakidou Supplementary Material Editor: Vishal Shahil Mehta V The Author(s) 2019. Published by Oxford University Press on behalf of the European Society of Cardiology. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals.permissions@oup.com Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 2 J. dos Santos et al. patient evaluation and clinical decision, illustrating a significant im- . independently in her own house. Her regular medication included provement in the efficiency of primary healthcare. . ramipril 10 mg od acenocoumarol, bisoprolol 5 mg od, pantoprazole 20 mg od and furosemide 40 mg od. We speculate patient had been advised by a different healthcare provider on this high diuretic dose due to swollen legs or other signs of congestion. Timeline The patient requests her family doctor for a home consultation by aggravated dyspnoea. She was found with fatigue, tiredness, orthop- noea and dyspnoeic at rest. Physical examination revealed a blood 4 years prior to No prior history of heart failure at presentation . pressure of 100/60 mmHg, heart rate of 98 b.p.m., elevated jugular presentation . venous pressure, third heart sound, pulmonary rales in the lower At presentation 85-year-old woman requests family doctor home third of both lungs, and bilateral ankle oedema. Her medical records consultation due to progressive dyspnoea showed a glomerular filtration rate of 55 mL/min and an echocardio- Dyspnoea [New York Heart Association gram performed 4 years prior showed normal biventricular function (NYHA) Class III–IV], orthopnoea, pulmonary without signs of pulmonary artery hypertension and mild mitral re- rales, and bilateral ankle oedema gurgitation. In regard to the severity of the symptoms, the patient Point-of-care ultrasound with pocket echo by . was suggested to pursue further evaluation and treatment at the local family doctor: severely compromised left ven- . hospital, but she refused to leave her house. On-site, the PCP with tricular systolic function, severe dilation of the . echocardiography training (certified online course and a practical inferior vena cava training in an echocardiography lab for 6 months) performed a point- Treatment: spironolactone 25 mg daily; increased . R of-care ultrasound (POCUS) Lumify . The study showed: severely furosemide 40 mg 3 times daily compromised left ventricular (LV) systolic function (Figure 1, 1 month later Dyspnoea (NYHA Class II–III) Supplementary material online, Video S4), moderate mitral (Figure 2), Conventional echocardiography: reduced ejec- and tricuspid regurgitation (Figure 3), severe dilation of the inferior tion fraction (30%) . vena cava (Figure 4), severely dilated left atrium (52 mm in long-axis Replaces ramipril to sacubitril/valsartan . view), dilated right atrium (minor axis of 49 mm in four-chamber 2 months later Heart failure symptoms relief view), normal LV size (47 mm in diastole parasternal long-axis view), Titrate sacubitril/valsartan dose . normal right ventricular (RV) size (basal and mid diameter of 39 and 29 mm), and normal RV function (tricuspid annular plane systolic ex- cursion of 19 mm). Ultrasound B-lines were not assessed at this time. The study was shared live using a real-time programme (REACTS) with a cardiologist who confirms the findings. As a result, the diagno- Case presentation . . sis of HF with decreased ejection fraction (EF) was performed sup- We present a case of an 85-year-old woman with medical history . porting the therapeutic decision: furosemide 40 mg was increased to of arterial hypertension, obesity, and atrial fibrillation, living three times daily and spironolactone 25 mg was introduced once Figure 1 A four-chamber view with end-diastolic and systolic volumes. Reduced ejection fraction of 38% (Supplementary material online, Video S4). Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 Moving the needle towards the democratization of echocardiography: a case report 3 Figure 2 A four-chamber view with moderate mitral regurgitation. Figure 3 Parasternal short-axis view with moderate tricuspid regurgitation. daily. The patient had weekly visits from the community nurse and . particularly in elderly patients, being the information provided by ultra- one month later, a conventional echocardiogram confirmed the sound fundamental for diagnosis and therapeutic management. POCUS findings, quantifying left ventricular ejection fraction in 30% This case represents an 85-year-old female patient with dyspnoea, without previous HF diagnosis, refusing to leave her home, to whom and pulmonary artery pressure in 44 mmHg. At this time, ramipril the PCP successfully used portable ultrasound as a physical examin- was replaced by sacubitril/valsartan 24 mg/26 mg td. The patient ation complement. The comprehensive evaluation allowed a confident refused additional studies or hospital referral, which limited our abil- . diagnosis of HF at patient’s home and a timely and targeted therapy ity to study the cause of HF. At two months, follow-up the patient . avoiding hospital admission, showing that the use of ultrasound by a was tolerating treatment and presented in Class II of New York trained primary care physician increases the efficiency of medical care Heart Association and the sacubitril/valsartan was titrated for the diagnosis and treatment of HF. The available studies are very accordingly. limited and no cost-effectiveness studies have been done to prove the use POCUS as a toll by PCPs, however, this technique has been proven . to be a useful, reliable and fast tool in emergency department and as a Discussion . 3–6 . bedside physical examination complement. Heart failure prevalence has been increasing in the last decades, along- . In addition to HF recognition, HF should be monitored and medi- 1 . side with population aging, especially in developed countries. . cation optimized periodically. PCPs can play a critical role in this re- However, the diagnosis of HF, as a clinical syndrome can be challenging, gard, in close collaboration with cardiologists, evaluating elderly Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 4 J. dos Santos et al. Figure 4 In subcostal view, enlarged inferior vena cava at expiration (A) and inspiration (B) shows respiratory variation >50%. patients who require home visits. In fact, a randomized clinical trial in value. In 2012, Jonathan has completed the master of medicine at patients with HF with optimal medical therapy showed no differences Coimbra Medical School (FMUC). He has been enrolled in 2016 in death and hospital admissions between patients followed by cardi- in the PhD program of medicine at the Porto Medical School ologists with those followed by referral PCP. (FMUP); In 2018 he has completed the family and general medi- . cine fellowship at ‘USF Terras de Souza’ in ‘ACES Vale de Sousa . Sul’; from February 2019 he’s a clinician at “UCSP Celorico de Conclusions . Basto” in “ACeS Baixo Ta ˆmega”. In summary, the crescent ageing population presents new demands to the healthcare system and chronic diseases such as HF are more commonly being diagnosed and treated by PCPs, who by using port- . Supplementary material able ultrasounds, as ‘fifth pillar to bedside physical examination’ will . . Supplementary material is available at European Heart Journal - Case significant improve patient care. Reports online. Lead author biography Slide sets: A fully edited slide set detailing this case and suitable for local presentation is available online as Supplementary data. Jonathan dos Santos was born in Paris in 1987 and grew up in . Consent: The author/s confirm that written consent for submis- Amarante (Portugal). He’s a family . sion and publication of this case report including image(s) and physician who believes that pri- . associated text has been obtained from the patient in line with mary health care are on the main- COPE guidance. stay of any healthcare system. He’s a point-of-care ultrasound Conflict of interest: Pocket ultrasound of this study is an investiga- (POCUS) user so that physical tion grant support from Philips; Alexandra Goncalves, MD, PhD, examination has for him an extra MMSc is a Philips employee. . Downloaded from https://academic.oup.com/ehjcr/article-abstract/3/4/1/5602560 by guest on 26 February 2020 Moving the needle towards the democratization of echocardiography: a case report 5 . performed by a pocket device? Scand J Trauma Resusc Emerg Med 2015; References 23:52. 1. Ponikowski P, Voors AA, Anker SD, Bueno H, Cleland JGF, Coats AJS, . 4. Kimura BJ. Point-of-care cardiac ultrasound techniques in the physical examin- Falk V, Gonza ´lez-Juanatey JR, Harjola VP, Jankowska EA, Jessup M, Linde C, ation: better at the bedside. Heart 2017;103:987–994. Nihoyannopoulos P, Parissis JT, Pieske B, Riley JP, Rosano GM, Ruilope . 5. Laursen CB, Sloth E, Lassen AT, Christensen R, Lambrechtsen J, Madsen PH, LM,RuschitzkaF,RuttenFH, vander Meer2P; Authors/Task Force Henriksen DP, Davidsen JR, Rasmussen F. Point-of-care ultrasonography in Members; Document Reviewers. 2016 ESC Guidelines for the diagnosis and . patients admitted with respiratory symptoms: a single-blind, randomised con- treatment of acute and chronic heart failure. The Task Force for the diag- trolled trial. Lancet Respir Med 2014;2:638–646. nosis and treatment of acute and chronic heart failure of the European 6. Zanobetti M, Scorpiniti M, Gigli C, Nazerian P, Vanni S, Innocenti F, Stefanone VT, Society of Cardiology (ESC). Developed with the special contribution of . Savinelli C, Coppa A, Bigiarini S, Caldi F, Tassinari I, Conti A, Grifoni S, Pini R. the Heart Failure Association (HFA) of the ESC. Eur Heart J 2016;37: . Point-of-care ultrasonography for evaluation of acute dyspnoea in the ED. Chest 2129–2200. 2017;151:1295–1301. 2. Narula J, Chandrashekhar Y, Braunwald E. Time to add a fifth pillar to bedside 7. Schou M, Gustafsson F, Videbaek L, Tuxen C, Keller N, Handberg J, Sejr Knudsen physical examination: inspection, palpation, percussion, auscultation, and insona- . . A, Espersen G, Markenvard J, Egstrup K, Ulriksen H, Hildebrandt PR tion. JAMA Cardiol 2018;3:346–350. NorthStar Investigators, all members of The Danish Heart Failure Clinics 3. Bobbia X, Pradeilles C, Claret PG, Soullier C, Wagner P, Bodin Y, Roger Network. Extended heart failure clinic follow-up in low-risk patients: a random- C, Cayla G, Muller L, de La Coussaye JE. Does physician experience in- . fluence the interpretability of focused echocardiography images . ized clinical trial (NorthStar). Eur Heart J 2013;34:432–442.

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European Heart Journal - Case Reports – Oxford University Press

Published: Dec 1, 2019

There are no references for this article.