Jeffrey A. Marbach, MBBS, MS; Aws Almufleh, MBBS, MPH; Pietro Di Santo, MD; Richard Jung, BSc; Trevor Simard, MD; Matthew McInnes, MD, PhD; Jean-Paul Salameh, BSc; Trevor A. McGrath, MD; Scott J. Millington, MD; Gretchen Diemer, MD; Frances Mae West, MD; Marie-Cecile Domecq, MLIS; Benjamin Hibbert, MD, PhD
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M19-1337.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: The protocol is registered in PROSPERO (CRD42019124318). Statistical code and data set: See appendix figures and tables; additional data are available from Dr. Hibbert (e-mail, BHibbert@ottawaheart.ca).
Corresponding Author: Benjamin Hibbert, MD, PhD, Interventional Cardiologist, Clinician Scientist, and Assistant Professor, CAPITAL Research Group, Vascular Biology and Experimental Medicine Laboratory, University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada; e-mail, BHibbert@ottawaheart.ca.
Current Author Addresses: Drs. Marbach, Almufleh, Di Santo, Simard, and Hibbert and Mr. Jung: University of Ottawa Heart Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada.
Drs. McInnes and McGrath and Mr. Salameh: The Ottawa Hospital Civic Campus, Room C159, 1053 Carling Road, Ottawa, Ontario K1Y 4E9, Canada.
Dr. Millington: The Ottawa Hospital, 501 Smyth Road, Box 207, Ottawa, Ontario K1H 8L6, Canada.
Dr. Diemer: Thomas Jefferson University, 833 Chestnut Street, Suite 701, Philadelphia, PA 19107.
Dr. West: Thomas Jefferson University, 834 Walnut Street, Suite 650, Philadelphia, PA 19107.
Ms. Domecq: Health Sciences Library, University of Ottawa, 451 Smyth Road, Room 1020, Ottawa, Ontario K1H 8M5, Canada.
Author Contributions: Conception and design: J.A. Marbach, A. Almufleh, P. Di Santo, M. McInnes, G. Diemer, B. Hibbert.
Analysis and interpretation of the data: J.A. Marbach, A. Almufleh, P. Di Santo, R. Jung, T. Simard, M. McInnes, J.P. Salameh, T.A. McGrath, B. Hibbert.
Drafting of the article: J.A. Marbach, P. Di Santo, T. Simard, M. McInnes, J.P. Salameh, F.M. West, B. Hibbert.
Critical revision of the article for important intellectual content: J.A. Marbach, A. Almufleh, P. Di Santo, R. Jung, T. Simard, M. McInnes, J.P. Salameh, T.A. McGrath, S.J. Millington, G. Diemer, B. Hibbert.
Final approval of the article: J.A. Marbach, A. Almufleh, P. Di Santo, R. Jung, T. Simard, M. McInnes, J.P. Salameh, T.A. McGrath, S.J. Millington, G. Diemer, F.M. West, M.C. Domecq, B. Hibbert.
Provision of study materials or patients: B. Hibbert.
Statistical expertise: P. Di Santo, R. Jung, M. McInnes, J.P. Salameh, T.A. McGrath, B. Hibbert.
Obtaining of funding: B. Hibbert.
Administrative, technical, or logistic support: J.A. Marbach, T. Simard, M. McInnes, J.P. Salameh, M.C. Domecq, B. Hibbert.
Collection and assembly of data: J.A. Marbach, A. Almufleh, P. Di Santo, R. Jung, T. Simard, J.P. Salameh, B. Hibbert.
Incorporating focused cardiac ultrasonography (FoCUS) into clinical examination could improve the diagnostic yield of bedside patient evaluation.
To compare the accuracy of FoCUS-assisted clinical assessment versus clinical assessment alone for diagnosing left ventricular dysfunction or valvular disease in adults having cardiovascular evaluation.
English-language searches of MEDLINE, Embase, and Web of Science from 1 January 1990 to 23 May 2019 and review of reference citations.
Eligible studies were done in patients having cardiovascular evaluation; compared FoCUS-assisted clinical assessment versus clinical assessment alone for the diagnosis of left ventricular systolic dysfunction, aortic or mitral valve disease, or pericardial effusion; and used transthoracic echocardiography as the reference standard.
Three study investigators independently abstracted data and assessed study quality.
Nine studies were included in the meta-analysis. The sensitivity of clinical assessment for diagnosing left ventricular dysfunction (left ventricular ejection fraction <50%) was 43% (95% CI, 33% to 54%), whereas that of FoCUS-assisted examination was 84% (CI, 74% to 91%). The specificity of clinical assessment was 81% (CI, 65% to 90%), and that of FoCUS-assisted examination was 89% (CI, 85% to 91%). The sensitivities of clinical assessment and FoCUS-assisted examination for diagnosing aortic or mitral valve disease (of at least moderate severity) were 46% (CI, 35% to 58%) and 71% (CI, 63% to 79%), respectively. Both the clinical assessment and the FoCUS-assisted examination had a specificity of 94% (CI, 91% to 96%).
Evidence was scant, persons doing ultrasonography had variable skill levels, and most studies had unclear or high risk of bias.
Clinical examination assisted by FoCUS has greater sensitivity, but not greater specificity, than clinical assessment alone for identifying left ventricular dysfunction and aortic or mitral valve disease; FoCUS-assisted examination may help rule out cardiovascular pathology in some patients, but it may not be sufficient for definitive confirmation of cardiovascular disease suspected on physical examination.
None. (PROSPERO: CRD42019124318)
Marbach JA, Almufleh A, Di Santo P, et al. Comparative Accuracy of Focused Cardiac Ultrasonography and Clinical Examination for Left Ventricular Dysfunction and Valvular Heart Disease: A Systematic Review and Meta-analysis. Ann Intern Med. 2019;171:264–272. [Epub ahead of print 6 August 2019]. doi: https://doi.org/10.7326/M19-1337
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Published: Ann Intern Med. 2019;171(4):264-272.
Published at www.annals.org on 6 August 2019
Cardiac Diagnosis and Imaging, Cardiology, Hospital Medicine.
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