Hand-Carried Ultrasound Improves the

Bedside Cardiovascular Examination*

Sergio L. Kobal, MD; Shaul Atar, MD; and Robert J. Siegel, MD

Objectives: We assessed the clinical utility of hand-carried cardiac ultrasound (HCU) devices to
assist physicians in the diagnosis of cardiovascular disease.
Materials and methods: We reviewed 42 articles published from 1978 to 2004.
Results: The capability and simplicity of the HCU device assist physicians in the diagnosis of
cardiovascular disease at the initial patients contact. HCU is particularly useful in the setting of
emergency or critical care, community screening, or in remote areas with limited access to health
care.
Conclusion: The inherent limitations of the physical examination as well as the reduced focus and
training in physical diagnosis of current and recent medical school graduates has set the stage for
the HCU device to modify traditional medical practices by complementing the physical examination with real-time cardiovascular imaging.
(CHEST 2004; 126:693701)
Key words: cardiovascular disease; diagnostic techniques; echocardiography; hand-carried cardiac ultrasound
Abbreviations: 2D two-dimensional; HCU hand-carried cardiac ultrasound; LV left ventricle, ventricular;
StdEcho standard, cart-based echocardiography

accuracy of the physical examinaT hetiondiagnostic

is problematic, even when performed by
experts.13 New generations of doctors rely to a great
extent on laboratory data and imaging techniques for
making cardiovascular diagnoses. Echocardiography
offers precise anatomic and functional information
on the cardiovascular system, and is the most commonly used technique for diagnosing cardiovascular
diseases.4 However, their cost and size, and the need
for considerable expertise to acquire and interpret
the ultrasound studies limit the use of standard,
cart-based echocardiography (StdEcho) machines.
The hand-carried cardiac ultrasound (HCU) unit
is a portable echocardiography device that is batteryoperated, lightweight, and the size of a laptop computer. These relatively low-cost units can be used to
identify cardiovascular pathologies during routine
encounters at the bedside or in the outpatient clinic.5
Thus, this technology extends the physicians diagnostic capabilities beyond the limits of the physical

examination with the potential for more accurate

diagnoses and rapid treatment decisions.
HCU
In 1978, Ligtvoet et al6 described the technical
features of the first ultrasonic stethoscope, a battery-operated device housed in a 25-cm long, 1.5-kg
box. In the same journal, Roelandt et al7 published
their clinical experience with this device. The imaging capability of this miniaturized system was satisfactory. However, it would take another 20 years for
the medical industry to develop microprocessor
technology to integrate high-resolution, two-dimensional (2D), Doppler imaging into small hand-carried units.8 The principal differences between HCU
and StdEcho are summarized in Table 1.
Clinical Experience With HCU
HCU as an Extension of the Physical Examination

*From the Division of Cardiology, Cedars-Sinai Medical Center,

Los Angeles, CA.
Manuscript received September 12, 2003; revision accepted April
16, 2004.
Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (e-mail:
permissions@chestnet.org).
Correspondence to: Robert J. Siegel, MD, Cardiac Non-Invasive
Laboratory, Room 5335, Cedars-Sinai Medical Center, Los Angeles, CA 90048; e-mail: siegel@cshs.org
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The accuracy of physicians cardiovascular physical

examinations has been extensively reported in the
past. Mangione and Nieman9 found that only 56% of
cardiology fellows and 39% of medical residents
were proficient in the auscultation of 12 cardiac
findings. This inaccuracy extended to board-certified
cardiologists, who missed 59% of the cardiovascular
findings in their physical examinations.10 A number
CHEST / 126 / 3 / SEPTEMBER, 2004

693

Table 1Major Differences Between Ultrasound

Systems
Variables
Size
Personnel
Encounter
Setting

Duration
Device cost

Std Echo Unit

HCU Unit

Large (135 kg)

Sonographers
echocardiologists
Deferred study

Small, portable ( 3.5 kg)

Cardiologists, noncardiologists

Hospitals,
echocardiography
laboratories
Time consuming
Expensive
($80$150,000)

Immediate (at patient

encounter)
Clinics, community,
remote areas
Brief
Relatively inexpensive
($15$35,000)

of published studies have demonstrated a remarkable increase in diagnostic accuracy by both cardiologists and noncardiologists when they added a brief
cardiac ultrasound study to their conventional physical examination. The addition of a short ultrasound
study with the HCU device to the physical examination by four board-certified cardiologists increased
their diagnostic accuracy by 39%.10 More recently,
Spencer et al11 proved that a routine ultrasound
study with an HCU unit could identify unsuspected
clinically significant pathology in 40% of patients in a
medical department. Rugolotto et al12 found that a
6-min examination with an HCU unit in 55 patients
in an ICU changed 40% of their initial diagnoses or
diagnostic likelihood and modified the management
of 24% of the patients. Severe left ventricular (LV)
dysfunction, severe aortic stenosis, and pericardial
effusion with tamponade were among the 22 unexpected pathologies found by the HCU operator.
Bruce et al13 demonstrated that a 5-min study with
an HCU unit expedited patient triage regardless of
the encounter location (inpatient triage, 25%; outpatient triage, 15%) or the experience of the operator,
and identified unexpected significant pathology in
19% of the population studied. Recently, Fedson et
al14 showed that 39% of the patients admitted to an
internal medicine department, who had no indication for an echocardiographic study based on history
and physical examination findings, had clinically
significant cardiac findings diagnosed by nonexpert
physicians operating an HCU device.
Echocardiographic Experience of the User
The diagnostic accuracy of an HCU depends on
the technical features of the ultrasound equipment,
and on the skills of the user in acquiring and
interpreting the images. Table 2 summarizes the
studies10,1224 that assessed the accuracy of the HCU
device in identifying a variety of parameters using
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2D imaging, and StdEcho was used for validation.

Compared to the StdEcho device, the HCU unit has
been found to be accurate for the detection of global
LV dysfunction and pericardial effusion, even in the
hands of relatively inexperienced personnel.16,19,20
For instance, agreement in the assessment of LV
systolic function graded on a scale of 1 (normal) to 4
(severely reduced) between the StdEcho and HCU
devices operated by expert cardiologists was found in
96% of the cases.12 Kimura et al25 showed that a
brief training session (1 h) in the use of the HCU
that was given to 13 medical residents improved
their detection of asymptomatic LV dysfunction by
40%. Internists who received 3 h of echocardiography training were able to correctly categorize the LV
ejection fraction as 55% or 55% in 83% of
cases.16 Cardiac fellows with 6 weeks of training in
portable echocardiographic studies correctly assessed normal/abnormal LV function in 100% of
patients studied, as confirmed with StdEcho.20 In
contrast, the diagnosis of segmental wall motion
abnormalities and right ventricular dysfunction requires a higher level of expertise. For instance, the rate
of agreement in diagnoses between those made with
the HCU device and those made with the StdEcho
device in the assessment of regional wall motion by
cardiologists with limited echocardiographic training
was 80% vs 96%, respectively, when assessments
were performed by experienced echocardiologists.13
Medical residents misdiagnosed 56% of the cases of
right ventricular dysfunction compared to 26% of
misdiagnoses by experienced cardiologists.19
When assessing valvular lesions, the level of expertise of the HCU unit operator is of major importance. We assessed the accuracy of an HCU device
(OptiGo; Philips Medical Systems; Andover, MA) in
the diagnosis of valvular regurgitation in 120 hospitalized patients.26 The HCU device operators had
level 2 echocardiographic training (defined as at least
150 studies performed and 300 studies interpreted
under supervision). Valvular regurgitation was
scored from 0 (none) to 3 (severe), and the StdEcho
device was used for validation. The StdEcho device
identified 312 regurgitant jets, and 53% were clinically significant (moderate regurgitation, 91 jets;
severe regurgitation, 75 jets). HCU device operators
identified a regurgitant lesion in 99% of those valves
with clinically significant lesions and correctly assessed the severity in 83% of the cases. Bruce et al13
compared the utility of the HCU unit when used by
cardiologists with and without significant echocardiographic experience. The agreement of the HCU
unit with the StdEcho device for the assessment of
valve function was 93% (64 of 69 valves). Of note, the
less experienced cardiologists performed assessClinical Investigations

32

33

34

35

36

pericardial effusion in patients in PEA and near-PEA states.

Resuscitation 2003; 59:315318
Mandavia DP, Hoffner RJ, Mahaney K, et al. Bedside
echocardiography by emergency physicians. Ann Emerg Med
2001; 38:377382
Karavidas A, Matsakas E, Lazaros G, et al. Emergency
bedside echocardiography as a tool for early detection and
clinical decision making in cases of suspected pulmonary
embolism: a case report. Angiology 2000; 51:10211025
Croft LB, Stanizzi SH, Shilpa H, et al. Impact of front line,
limited, focused and expedited echocardiography in the adult
emergency department using a compact echo machine [abstract]. Circulation 2001; 104(suppl):II-334
Society of Echocardiography and the American College of
Cardiology. Echocardiography in emergency medicine: a
policy statement by the Society of Echocardiography and the
American College of Cardiology. J Am Coll Cardiol 1999;
33:10971099
Firstenberg MS, Cardon L, Jones P, et al. Initial clinical
experience with an ultra-portable echocardiograph for the
rapid diagnosis and evaluation of critically ill patients [ab-

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stract]. J Am Soc Echocardiogr 2000; 13:486

37 Osranek M, Bursi F, OLeary PW, et al. Hand-carried
ultrasound-guided pericardiocentesis and thoracentesis. J Am
Soc Echocardiogr 2003; 16:480 484
38 Keenan SP. Use of ultrasound to place central lines. J Crit
Care 2002; 17:126 137
39 Kimura BJ, Sklansky MS, Eaton CH, et al. Screening for
hypertrophic cardiomyopathy in the pre participation athletic
exam: feasibility and cost using a hand-held ultrasound device
[abstract]. J Am Coll Cardiol 2001; 37(suppl):496A
40 Kobal SL, Czer LCS, Czer PC, et al. Making an impossible
mission, possible. Chest 2004; 125:293296
41 Seward JB, Douglas PS, Erbel R, et al. Hand-carried cardiac
ultrasound (HCU) device: recommendations regarding new
technology; a report from the echocardiography task force on
new technology of the nomenclature and standards committee of the American Society of Echocardiography. J Am Soc
Echocardiogr 2002; 15:369 373
42 Spevack DM, Tunick PA, Kronzon I. Hand carried echocardiography in the critical care setting. Echocardiography 2003;
20:455 461

CHEST / 126 / 3 / SEPTEMBER, 2004

701

general ward as a complement to the physical examination. They had a high rate of false-positive results,
leading to a positive predictive value of 32%. The
HCU unit operator failed, principally, to assess
correctly the grade of valvular regurgitation in 20 of
28 patients, mainly by overestimating its severity.14
Technical Limitations
State-of-the-art echocardiography machines use
different image modalities, probe frequencies, and
vertical and horizontal gain controls to enhance
image acquisition and to overcome many technical
difficulties. Some of the HCU units (eg, the OptiGo)
have few settings to control the 2D general gain and
depth. Some units (eg, SonoHeart; Sonosite, Inc;
Bothell, WA; and Terason 2000; Teratech Corp;
Burlington, MA) have power color-flow Doppler
imaging, which is nonaliasing (ie, it measures the
mean amplitude but not the frequency shifts from
the motion signal of blood cells), so the diagnosis of
turbulent jets, which is frequently found in cases of
valvular lesions and intracardiac shunts, is more
difficult. Spectral Doppler, imaging, which is present
in some of the currently available HCU devices (ie,
SonoHeart and Terason 2000), but not all of them,
has limited capability.
Experienced sonographers operating an HCU device in an ICU failed to identify 17 of 99 significant

clinical findings, of which 11 were due to the poor

sensitivity of the color-flow Doppler mode of the
HCU device.27 Four patients (ie, pulmonary hypertension, three patients; LV outflow tract obstruction,
one patient) were missed because of the lack of
spectral Doppler. On the other hand, Vourvouri et
al28 demonstrated that cardiologists using an HCU
unit were able to answer a clinical question for which
patients were referred for cardiac consultation in
almost 79% of cases, reducing considerably the cost
and time of a medical diagnosis. The most frequent
reason that led to the subsequent referral for study
using StdEcho device was to evaluate the severity of
a valvular lesion and the diagnosis of pulmonary
hypertension (20 of 23 patients), which require the
use of spectral Doppler mode, which was not present
in the HCU device used in the study.
HCU Technical Features
Four HCU devices for cardiovascular diagnosis
are commercially available. OptiGo (Philips Medical
Systems) weighs 2.9 kg and has a screen display of
6.5 inches. Figure 1 was obtained from a patient with
a systolic murmur, documented by the OptiGo colorflow Doppler device as severe mitral regurgitation.
The image from the HCU device in Figure 2

Figure 1. A regurgitant jet into the left atrium (LA) during systole due to severe mitral regurgitation
is identified by color Doppler imaging with a four-chamber view. RA right atrium; RV right
ventricle.
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Clinical Investigations

Figure 2. An apical four-chamber view demonstrates a small-to-moderate pericardial effusion.

* pericardial effusion.

demonstrates a mild-to-moderate pericardial effusion (the *) in a postoperative patient with pleuritic

chest pain. The SonoHeart (Sonosite) is another
HCU device that weighs 2.6 kg including battery and
has a screen display of 5 inches. A smaller device
manufactured by Sonosite (iLook) weighs 1.6 kg and
provides only 2D images. The Terason 2000 device
(Teratech Corp) is conceptually different from the
other HCU devices because the ultrasound system is
housed in the probe (weight, 1.3 kg), which connects
to any laptop personal computer, which may be used
as an image monitor. All of these systems are batteryoperated, and offer 2D and color-flow Doppler
imaging. Images can be frozen, and electronic calipers allow simple measurements. Images can be
stored, printed, or transferred to a personal computer. The second generation of these portable
devices (ie, the SonoHeart Elite and the Terason
2000) incorporate tissue harmonic imaging, spectral
and pulse Doppler, M-mode and ECG settings, and
the possibility of videotape recording using a video
cassette recorder and loop recording. The technical
features of the HCU devices are listed in Table 3.
Clinical Application of the HCU Unit
An examination with an HCU device is particularly
suitable in three specific environments (Table 4).
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Emergency and Critical Care Medicine

Noncardiologists were the first to use point-ofcare bedside echocardiography. This limited, focused ultrasound examination was initially performed by the medical personnel directly involved in
patient care to answer a specific clinical question.
Emergency and critical care physicians, after brief
training in ultrasonography, have used compact ultrasound units as a complement to their physical
examination to triage patients with chest trauma,29 to

Table 3Principal Features of the Available HCU

Devices
Features
Transducer

OptiGo

SonoHeart Elite

Terason 2000

2.5 MHz

24 MHz;
24 MHz
footprint is larger
2D
Yes
Tissue harmonic
Tissue harmonic
M-mode
No
Optional
Yes
Color Doppler Conventional Power Doppler
Directional power
CFD
Doppler
Spectral
No
Optional
Yes
Doppler
ECG setting No
Yes
Yes
Measurements Distance
Distance, area,
Distance, area,
flow velocity
flow velocity
Image storage Still frames VCR connection
Film storage
(optional)
Telemedicine Possible
Possible
Ready

CHEST / 126 / 3 / SEPTEMBER, 2004

697

Table 4 HCU Device Setting

Application
Triage

Screening

Population

Target

Chest pain
Shock
Electrical-mechanical
dissociation
Post-torso trauma
Community
Hypertensive/older

Acute coronary event

Cardiac vs noncardiac
Tamponade/pneumothorax/
hypovolemia
Cardiac injury/tamponade
LV systolic dysfunction
LVH/aortic abdominal
aneurysm
Hypertrophic
cardiomyopathy
Carotid artery stenosis

Athlete

Cardiac
diagnosis

High-risk stroke
patient
General population

Developing nations,
remote areas

identify treatable causes of pulseless cardiac activity,30,31 and to diagnose pericardial effusion and
pulmonary embolism.32,33 Croft et al34 showed that
after a focused ultrasound examination, emergency
physicians changed their first diagnosis in 26% of the
patients studied, and their management in 18%.
Most emergency medicine residencies in the United
States now offer formal instruction in bedside ultrasound examination, and medical organizations have
developed policies for the training and adequate
application of emergency bedside ultrasound examinations.35
The HCU device is well-suited for use in small,
crowded places like the emergency department and
ICU. However, lung disease, mechanical ventilation,
chest and abdominal tubes, and noncooperative patients are all factors that can affect the quality of the
ultrasound imaging. It is precisely in the difficult
environment of the ICUs that the accuracy of HCU
results is of paramount importance when decisions
on management and treatment are made regarding
the care of critically ill patients. Goodkin et al27
demonstrated that a first-generation HCU device in
the setting of an ICU, even when the studies were
performed by experienced sonographers and interpreted by echocardiographers, missed 31% of the
findings. On the other hand, Firstenberg et al36
demonstrated that in critically ill patients the HCU
device identified 27 of 30 pathologic findings, and
the image was satisfactory in all patients. It is
reasonable to conclude that experience in echocardiography is desirable in order to overcome the
adverse conditions of scanning the heart and interpreting the results in critically ill patients.
The diagnostic utility of using the HCU device in
critically ill patients can extend beyond the cardiovascular system. The HCU device can assist physicians in the diagnosis of pulmonary pathologies such
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as pneumothorax or hydropneumothorax, and can

help to determine bladder urine volume in anuric
patients. The HCU device is also useful in guiding
and monitoring invasive therapeutic procedures such
as the drainage of pleural and pericardial effusions,37
and the insertion of central lines and intracardiac
electrodes and catheters.38
Community Screening
The cost/benefit ratio of screening programs depends on the incidence of the disease under investigation, whether its detection and treatment change
patient outcome, and the existence of reliable and
inexpensive diagnostic methods. Asymptomatic patients with LV dysfunction or those with aortic
abdominal aneurysms can benefit from early detection and treatment. The diagnosis of LV hypertrophy
in hypertensive patients and of hypertrophic cardiomyopathy in athletes can be used to identify a
population that is at high-risk for cardiac mortality.
The HCU device has been proven to be a reliable
tool in assessing the prevalence of LV dysfunction in
the community,21 in assessing LV hypertrophy and
aortic abdominal aneurysm in hypertensive and older
patients,23,24 and in assessing hypertrophic cardiomyopathy in athletes.39 In these studies,21,23,24 the
degree of concordance between results obtained
with the HCU and StdEcho devices was 93 to 98%.
Therefore, these data suggest that the HCU device is
an ideal noninvasive screening tool because it offers
high sensitivity and specificity. However, more studies are required to validate the impact of screening
on the clinical outcomes of the different at-risk
populations in order to assess the cost/benefit ratio of
such a diagnostic method.
Remote Areas
Due to its size and use of battery power, the HCU
device can be used in remote places with difficult
access, as is the case in many rural areas in developing countries. In Gambia, we used a portable ultrasound (ie, SonoHeart) to examine 1997 people. Of
those people, 17% had hypertension, LV hypertrophy was found in 65%.40 The HCU device allowed
the identification of a high-risk hypertensive population by diagnosing LV hypertrophy. It is precisely
this population that can derive maximal benefit from
antihypertensive treatment. We evaluated the diagnostic utility of an HCU device on patients who were
referred for cardiac consultation to an outpatient
clinic in a rural area of Mexico. The HCU device
identified 69 major cardiac findings, including nine
cases of congenital heart disease in 88 patients, and
helped to elucidate a clinical problem in 89% of
them (78 of 88 patients), obviating the need for
Clinical Investigations

further comprehensive echocardiographic evaluation

(unpublished data). In developing countries, medical
care personnel may have infrequent opportunities to
diagnose cardiovascular disease. By adding a brief
ultrasound study with a portable device to the initial
encounter, disease may be recognized and treated
more efficiently, and in a timely manner. In areas
with reduced medical personnel, ultrasound studies
using an HCU device could be obtained by nurses or
other community health workers, with remote interpretation obtained when needed.

Present and Future

The HCU device has a high level of diagnostic
accuracy in the identification of global LV systolic
dysfunction,12,13,18 21 LV hypertrophy,12,17,23 and
pericardial effusion,1214,16 18 but it is less precise in
assessing regional wall motion abnormalities,13,19
right ventricular dysfunction,13,19 and valvular lesions.13,14,16,26 The limited diagnostic capability of
the HCU device compared to the StdEcho device is
due not only to the technical limitations of the
portable device but also to the different levels of
expertise of those acquiring and interpreting the
images from the StdEcho device and other portable
systems. Thus, studies obtained with portable devices cannot replace comprehensive echocardiographic studies.
The impact of this new technology on patient care
must be assessed by comparing bedside diagnostic
accuracy based on the traditional physical examination to that of the physical examination complemented with a short ultrasound study performed
with the HCU device. By adding a brief ultrasound
study to the physical examination in one study,10
cardiologists increased their diagnostic accuracy by
almost 40%.The additional value of the HCU device
is considerable for those conditions with imperceptible or barely detectable clinical manifestations such
as ventricular dysfunction or pericardial effusion.
However, any hemodynamic compromise occurring
as a result of a pericardial effusion requires the
assessment of pulsus paradoxus and jugular venous
pressure. The diagnosis of pericarditis relies on the
auscultation of a pericardial friction rub regardless of
the presence of effusion. Auscultation of pulmonary
rales and a third heart sound in patients with congestive heart failure has therapeutic implications,
regardless of the severity of the ventricular dysfunction. The functional capacity of cardiac patients,
which is of paramount importance in deciding on
treatment and management, is obtained from the
patients history. Thus, the maximal benefit of the
use of the HCU device on patient care will be
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achieved by complementing the information obtained from the history and physical examination.
It is likely that smaller and less expensive HCU
units, and the capacity for long distance consultation
through high-resolution network transmission will
become available in the near future. Improvements
in image storage will allow the comparison of studies
at different points in time and may be used to guide
therapy, as in heart failure patients.
Appropriate Use
Due to the diversity of settings where an HCU
device can be used, and to the different levels of
difficulty present in the use of each one, there is
concern about the minimal level of training required
to get maximal benefit from the utilization of this
technology. The expertise of the HCU user will
affect the rate of false-positive results obtained when
HCU studies are performed in populations with a
low prevalence of cardiovascular disease,14 and it will
affect the number of false-negative cases when studies are performed in the ICU setting.27
The American Society of Echocardiography and
the American College of Cardiology/American Heart
Association41 recommend a minimum of level 2
training in echocardiography (defined as at least 150
studies performed and 300 studies interpreted under
supervision) for the use of an HCU device as an
extension of the physical examination (ie, a focused
or limited study). As these devices become equipped
with more diagnostic elements, the degree to which
they add information to the clinical evaluation will
depend mainly on the users level of expertise more
than on device-related limitations.
Unresolved Issues Regarding the Future Use of the
HCU Device
The HCU device has the potential to modify
traditional medical practices by complementing the
physical examination with real-time cardiovascular
imaging. However, financial, organizational, and liability issues are still to be resolved. Spevack et al42
considered that the training alone of 32,000 American emergency department physicians and 10,000
pulmonary and critical care specialists would cost
approximately $2.1 billion. Another $50 million
would be required to provide the 5,000 ICUs in the
United States with one portable unit. The current
price of the device is an obstacle to physicians
purchasing them for their personal use. On the other
hand, Vourvouri et al28 have demonstrated that,
based on the HCU device results, the cardiac consultant reduced by one third the cost of the medical
diagnosis and shortened significantly the time to
diagnosis.
CHEST / 126 / 3 / SEPTEMBER, 2004

699

As the use of HCU devices becomes more popular

and routine, the following several organizational and
liability issues will need to be addressed: (1) who will
be responsible for the training and continuing education of users?; (2) should HCU training be extended to paramedic personnel, emergency medicine technicians, and nurses?; and (3) will the
certification of users be needed or desirable?

Conclusions
Portable cardiac ultrasound technology is able to
assist physicians in the assessment of the cardiovascular system at the initial patient examination. When
operated by experienced personnel, the HCU device
renders its maximum benefit.
Use of the HCU device can lead to considerable
savings of cost and time, as physicians will be able to
more selectively order tests based on what is found
during the physical examination and after completing a brief ultrasound study. Thus, the HCU device
has the potential to help promote better and more
efficient health-care delivery.

13

14

15
16

17

18
19

20

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