Handheld Ultrasound A Heartbeat Away from Ousting the Stethoscope?

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 - VScan
The Vscan is a portable and pocket-size ultrasound device that allows cardiologists to do imaging at the point of care.
Source: Scripps Health

The stethoscope appears to have a name branding issue. The word “scope” derives from the Greek word for “to look,” yet stethoscopes only let physicians listen to a patient. Handheld ultrasound technology has gained traction as a tool to improve cost-efficient care and serve as an extension to traditional physical examination. Are we entering the era of handheld ultrasound as the new stethoscope?

Ultrasound devices are now at a point where they can be kept in a physician’s pocket, yet the tiny tools still pack enough technological capability to generate high-quality images of cardiac structure and function from the patient’s bedside. There’s nothing you can learn with a stethoscope during a physical exam that you can’t with a handheld ultrasound, according to Jagat Narula, MD, PhD, director of the cardiovascular imaging program at the Icahn School of Medicine at Mount Sinai in New York City.

Narula is a passionate evangelist of the power of handheld ultrasound, and considers the technology as perhaps the most important addition to the doctor’s handbag in all of medical history. A strong endorsement, but considering it may be on the cusp of replacing the traditional stethoscope—a tool used for nearly 200 years—the declaration may not be hyperbole.

“We can use [handheld ultrasound] as a physical exam device and it will improve sensitivity,” says Narula. “It will allow us to reduce referrals to imaging.”

What the research says

While the number of studies on the effectiveness of handheld ultrasound as a tool for spotting cardiac abnormalities is limited, the results so far have been promising. A decade ago, an early study of handheld ultrasound found that first-year medical students with just 18 hours of ultrasound training could outperform the physical exam findings of board-certified cardiologists. The ultrasound-equipped students were able to identify 75 percent of the cardiac abnormalities present in the study population, compared with 49 percent identified by cardiologists (Am J Cardiol 2005;96:1002-1006).

More recent studies have shown similarly promising results for the technology. Last year, a study from Sanjiv Kaul, MD, head of the Division of Cardiovascular Medicine at Oregon Health & Science University in Portland, and colleagues sought to test both the accuracy of handheld ultrasound vs. traditional physical examination and also the impact of the devices on downstream testing and costs (J Am Coll Cardiol Img 2014;7:983–990).

A total of 250 patients were included in the study, and all had been referred for a standard echocardiogram for common indications such as murmur, stroke, cardiac function or arrhythmia. Patients underwent examination using a handheld ultrasound and also a physical exam from separate cardiologists.

“These were all trained cardiologists, academic cardiologists, who did the physical exam on patients. That’s as good as it can get,” says Kaul. “They were no match for the handheld ultrasound.”

Of the 142 abnormal findings identified on the standard echocardiogram, handheld ultrasound was able to correctly flag 82 percent, while physical exam identified only 47 percent. Handheld ultrasound was superior to physical exam for both normal and abnormal cardiac function, and it was better able to identify substantial valve disease (71 percent vs. 31 percent) and miscellaneous findings (47 percent vs. 3 percent) than physical exam.

Kaul notes that handheld ultrasound’s impact on costs as assessed by the study could be as significant as the findings on accuracy. Of the 108 patients without any abnormalities on standard echocardiography, 82 percent were referred to further testing on the basis of physical exam, while only 56 percent were referred for additional tests after undergoing examination with handheld ultrasound.

Kaul and colleagues took these referral rates and used cost modeling to show that handheld ultrasound had an average overall cost of $644.43, once additional testing was factored in, compared with $707.44 for physical exam, yielding a savings of $63.01 per patient when handheld ultrasound was used.

“In this era of Obamacare and [a focus on healthcare costs], if we can be more efficient in our patient management starting from examining them to deciding whether they need any further tests, that would be a big boost. It could save millions of dollars,” says Kaul.

Back to school

While also being bullish on the prospects of handheld ultrasound, Scott D. Solomon, MD, director of noninvasive