Portable 'Echo' Devices Offer PPE Possibilities
Published on: Mar 4, 2016
Transcripts - Portable 'Echo' Devices Offer PPE Possibilities
Portable Echo Devices Offer PPEPossibilitiesIn past years, arguments against the use of echocardiography screening in the preparticipation physicalexam (PPE) setting revolved around cost and the number of false positives. However, the recent introductionof portable echocardiography devices has decreased the cost from about $400 to between $2 and $39 perathlete (1), renewing the debate about echocardiographys role in the cardiac exam.What Do the Guidelines Say?Noninvasive tests such as echocardiography and electrocardiography have been discussed as ways toenhance the detection of identifiable conditions that may cause sudden cardiac death, such as hypertrophiccardiomyopathy (HCM), in athletes. Overall, sudden cardiac death is estimated to occur in 1 in 200,000 to 1in 300,000 high school and college athletes per year (2). Though rare, HCM is the most common cause ofsudden cardiac death in young athletes in the United States.Several practical considerations have impeded regular screening with echocardiography. A 1996 AmericanHeart Association (AHA) statement on the cardiovascular PPE (3) listed the limitations of echocardiographyscreening, which included the potential for false-positive and false-negative results and the heavy emotional,financial, and medical burdens created by uncertainty and additional testing. The authors also noted thatevidence of HCM may not be evident in some athletes, particularly those younger than 15.AHA guidelines (4) published in 1997 list asymptomatic competitive athletes as a class 3 indication forechocardiography screening, meaning that that there is no evidence or agreement that the procedure isuseful.New Devices in the PPE SettingTwo portable echocardiography devices (also called point-of-care ultrasound devices) are marketed forcardiac screening in the PPE--the OptiGo (Philips Medical Systems, Andover, Massachusetts) (figure 1A: notshown) and the SonoHeart (SonoSite, Inc, Bothell, Washington) (figure 1B: not shown). The devices allowusers to perform an initial limited exam using the parasternal long-axis view. Operators can follow up on anabnormal initial reading with additional measures and views. The devices weigh about 5 lb and cost around$12,000.In a study (1) of portable echocardiography screening in high school students, researchers from theUniversity of California at San Diego reported that two cardiologists performed limited echocardiography withthe devices on 197 students in 125 minutes (average time, 1.3 min/exam). HCM was excluded with initialevaluation in 74% of the students. Frozen diastolic images were made on the remaining 26%; none of thestudents had a septal wall thickness of 15 mm or greater. In calculating the cost of portableechocardiography screening, researchers used a 5-year depreciation of a $15,000 portable device, a $400 to$800 charge for a full echocardiogram when referral was needed, and physician labor costs of $100 perhour. Average costs of the screening examination were calculated for various referral cutoffs (>12 mm, $21to $39/student; >13 mm, $8 to $14/student; >14 mm, $4 to $6/student; and >15 mm or if no referral wasrequired, $2/student).Bruce J. Kimura, MD, lead author of the study, says staffing questions still need to be resolved. Currently,screening is performed by cardiologists on site, but with the new technology it may be possible for them tointerpret the screening results off site. "Eventually, it may be possible that the appropriately trainednoncardiologist will be able to perform this in a primary care setting," says Kimura, who is director ofnoninvasive cardiology at Scripps Mercy Medical Center in San Diego.
He says physicians should not equate the results of screening with the new devices with those of traditionalechocardiography. "That is why I believe it should not be called an echo, " he says. "It can enhance thephysicians physical examination." He compares ultrasound screening for cardiac problems to finger stickglucose measurement for the detection of diabetes. "Its portable, at the point of care, fast, and reasonablyaccurate, but not definitive."Renewed DebatePaul D. Thompson, MD, director of preventive cardiology at Hartford Hospital in Hartford, Connecticut, andprofessor of medicine at the University of Connecticut School of Medicine in Farmington, Connecticut,cowrote the AHAs statement on cardiovascular preparticipation screening (3). He notes that despite theirconvenience and lower cost, there is no evidence that the devices actually save lives, and they mayunnecessarily exclude a number of athletes.Thompson, an editorial board member of The Physician and Sportsmedicine, pointed to an Italian study(5) that showed that the cardiac death rate was higher in Italian athletes who were cleared for competitionafter extensive screening than for American male athletes who underwent less screening (6). Only 4 of the365 Italian athletes who were excluded from competition died of a cardiac condition. "Consequently, insteadof supporting extensive screening, these results actually raise questions about its effectiveness," Thompsonsays. Another concern is that there are many unanswered questions about HCM. "Many people have mildforms that dont seem to do much damage," he says. "I fear we will wind up excluding lots of folksunnecessarily. Will the ultimate benefit be good or ill? I really dont know."Aaron Rubin, MD, director of the Kaiser Permanente Sports Medicine Fellowship in Fontana, California, saysdespite the lowered costs of portable echocardiography, he is still struck by the high cost-versus-benefitratio. "Instead of looking for the needle in the haystack with our hands, were using an expensive magnet,"says Rubin, who is an editorial board member of The Physician and Sportsmedicine. He also worries thataffluent school districts will be able to afford a higher standard of care than less affluent districts.Still, the isolated cases of sudden cardiac death in young athletes will continue to make news headlines,prompting physicians, parents, and athletic administrators to consider putting more resources intoexpanding cardiac screening efforts. In California, a nonprofit organization has formed to provide freeportable echocardiography screening to high school and college athletes. The organization, A Heart ForSports (http://www.aheartforsports.org), based in Yorba Linda, California, coordinates regional communityoutreach programs and staffs the screening sessions with its own sonographers who are supervised bycardiologists.Lisa SchnirringMinneapolisREFERENCES 1. Kimura BJ, Sklansky MS, Eaton CH, et al: Screening for hypertrophic cardiomyopathy in the preparticipation athletic exam: feasibility and cost using a hand-held ultrasound device, abstracted. J Am Coll Cardiol 2000 2. Maron BJ: Cardiovascular risks to young persons on the athletic field. Ann Intern Med 1998;129(5):379-386 3. Maron BJ, Thompson PD, Puffer JC, et al: Cardiovascular preparticipation screening of competitive athletes: a statement for health professionals from the sudden death committee (clinical cardiology) and congenital cardiac defects committee (cardiovascular disease in the young), American Heart Association. Circulation 1996;94(4):850-856 4. Cheitlin MD, Alpert JS, Armstrong WF, et al: ACC/AHA guidelines for the clinical application of echocardiography. Circulation 1997;95(6):1686-1744 5. Corrado D, Basso C, Schiavon M, et al: Screening for hypertrophic cardiomyopathy in young athletes. N Engl J Med 1998;339(6):364-369 6. Van Camp SP, Bloor CM, Mueller FO, et al: Nontraumatic sports death in high school and college athletes. Med Sci Sports Exerc 1995;27(5):641-647