Accuracy of Point-of-Care Ultrasound Versus Consultative Echocardiography to Identify Right Ventricular Dysfunction in Emergency Department Patients With Pulmonary Embolism.

Abstract

Assessment of right ventricular dysfunction facilitates risk stratification of emergency department (ED) patients with pulmonary embolism (PE). We evaluated the accuracy of emergency physician-interpreted point-of-care ultrasound (POCUS) compared with cardiologist-interpreted consultative echocardiography for right ventricular dysfunction in patients with PE. We developed a retrospective cohort using a regular expression algorithm to identify PE+ patients. Patients were included if they received both an ED POCUS and a cardiologist-interpreted consultative echocardiogram. Right ventricular dysfunction on POCUS was defined as RV size greater than left ventricular size, decreased RV systolic function by tricuspid annular plane systolic excursion, or both. Right ventricular dysfunction on consultative echocardiography was categorized as absent, mild, or moderate to severe using this verbiage to describe the presence of RV dilation, reduced RV function, or both. We report test characteristics (sensitivity and specificity), and agreement as inter-rater reliability coefficients (kappa) of POCUS stratified by right ventricular dysfunction severity and emergency residency training level. In a 194-patient cohort with 97 emergency physician ultrasound operators, POCUS was 76.8% sensitive and 85.9% specific for the identification of right ventricular dysfunction compared with consultative echocardiography. There was 81.4% agreement, overall (kappa=0.63, 95% CI, 0.51 to 0.75). POCUS accuracy improved when right ventricular dysfunction was interpreted as moderate to severe on consultative ultrasound. Inter-rater reliability declined through residency training. POCUS is 76.8% sensitive and 85.9% specific for right ventricular dysfunction in ED patients with PE compared with consultative echocardiography. There is moderate agreement between modalities. Accuracy and agreement improve when right ventricular dysfunction is moderate to severe.