The cardiologist's view

Dr. Sloth raises several important issues worthy of consideration. Hand-carried ultrasound (HCU) devices provide an opportunity for widespread application of echocardiography (and ultrasound imaging in general) at the point-of-care permitting earlier diagnosis, triage and therapy. 1 Moreover, the introduction of this technology comes at a time when the focus of medicine is shifting from cure to prevention necessitating earlier diagnosis often long before disease is clinically manifest. Examples include detection of asymptomatic left ventricular dysfunction and abdominal aortic aneurysms. 2,3 These important clinical conditions can easily be missed on physical examination. Even left atrial enlargement, a parameter that cannot be determined by physical examination has been shown to be an important prognostic risk factor for cardiovascular disease. 4 Regarding the use of echocardiography, we agree completely with Dr. Sloth's recommendations that echocardiography should only be performed when clinically indicated. However, as a portable screening tool in a new era of preclinical diagnosis, it may be indicated as part of the general physical examination to screen for asymptomatic, clinically occult disease. Dr. Sloth's perception that the “advertised expansion was not founded on new and scientifically-based data” is interesting. There are several studies evaluating the use of these devices performed by qualified echocardiographers 1,3,5–9 and fewer by less well-trained health care providers. 10,11 Point-of-care ultrasound at the patient's bedside in the intensive care unit can potentially provide an immediate window to the heart assisting in timely diagnosis and facilitating management. Studies comparing HCU with standard echocardiography in this setting, however, have reported that HCU is limited by decreased image quality and that it may miss important diagnoses even when used in experienced hands. 9 Regarding assessment of effusions, we have found that HCU can play an important role not only in assessment but also guidance of treatment of both pleural and pericardial effusions. 7 We also agree that there are expanded roles for ultrasound imaging in the outpatient and inpatient settings and intensive care unit. 1 Moreover, the use of point-of-care ultrasound extends beyond the field of cardiology and, with the right training, may be used for other applications such as breast, thyroid and abdominal imaging.