Introduction
In the emergency setting, focused cardiac ultrasound has become a fundamental tool for diagnostic, initial emergency treatment and triage decisions. A new ultra-miniaturized pocket ultrasound device (PUD) may be suited to this specific setting. Therefore, we aimed to compare the diagnostic ability of an ultra-miniaturized ultrasound device (Vscan™, GE Healthcare, Wauwatosa, WI) and of a conventional high-quality echocardiography system (Vivid S5™, GE Healthcare) for a cardiac focused ultrasonography in patients admitted to the emergency department.

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Evaluation of a new pocket echoscopic device for focused cardiac ultrasonography in an emergency setting.

The Darlington Retrospective Outpatient Study (DROPSY) was carried out at the Darlington Memorial Hospital Darlington. From Jan 2002 to Dec 2007, 1041 patients were seen in the heart failure (HF) clinic. Of these 270 (26%) were diagnosed as having left ventricular systolic dysfunction (LVSD). Of the 771 patients who did not have systolic dysfunction, we identified 243 patients who fulfilled the study criteria for heart failure with preserved ejection fraction (HFpEF). The remaining 528 patients formed the non heart failure (Other) group.
Patients with HFpEF were older and more likely to have hypertension and diabetes than the other two groups. The LVSD group had more men plus ischemic heart disease patients while the third group of non HF also had more females and a high number with COPD. 
Over the mean follow up of 7 years, the number of admissions to hospital per patient was similar in both the LVSD and HFpEF groups, but HFpEF patients had a significantly longer length of stay. In the HFpEF group, the use of beta blockers, ACE inhibitors, and a lower median resting HR of < 78 / min predicted better survival. All cause mortality was high in both LVSD and HFpEF groups, with strikingly different cause of death. Patients with LVSD had more cardiovascular deaths whereas HFpEF patients were more likely to die of non cardiovascular causes. Patients in the third group diagnosed as not having HF (Other group) also had high five year mortality. 
Conclusion
Patients with LVSD and HFpEF have high mortality but different causes of death. The use of beta blockers, ACE inhibitors, and a lower resting heart rate in the HFpEF group was associated with better survival. Patients who were reassured as not having HF do badly as well.

Long term outcomes in patients with heart failure : the Darlington Retrospective Out-Patient Study (DROPSY)

Heart failure is a common chronic disorder with high associated morbidity, mortality and cost [1]. Although therapeutic intervention markedly improves prognosis [2], heart failure may be difficult to diagnose in primary care where facilities are limited due to the non-specificity of the clinical symptoms and the non-sensitivity of the clinical signs [3]. Echocardiography has been recognised as the best and most convenient non-invasive assessment of left ventricular function, also providing information on valvular structure and function, left ventricular hypertrophy and congenital heart defects. Accordingly, authors have proposed establishing direct access echo services where general practitioners can refer patients presenting with possible heart failure or other cardiac abnormalities for definitive echocardiographic diagnosis without cardiology referral [4, 5]. Although many such services are already well established in the United Kingdom, the study by Baur et al. presents the results of such a service in Holland over a 19 month period where general practitioners could refer patients for echocardiography if they had any of dyspnoea, a cardiac murmur or peripheral oedema of unknown origin [6]. Of the 77 patients referred with dyspnoea, 12% had significant left ventricular systolic dysfunction; 49% had evidence of left ventricular diastolic dysfunction and 14% had significant mitral valve disease. Similarly, of the 61 patients referred with cardiac murmur, 17% had significant aortic valve disease, 13% had important mitral valve disease and 3% had significant pulmonary valve disease. Similar results have been seen elsewhere. In one direct access echo study, Francis et al. found that among referred patients already on heart failure medications, only 36% of men and 18% of women had definite left ventricular systolic dysfunction, with the echo result leading to a change in treatment in 70% of those on diuretics [4]. A number of important caveats must be borne in mind when establishing direct access echocardiography, namely guidelines governing whom to refer; the interpretation of results to minimise incorrect conclusions by the general practitioners, and established mechanisms to guarantee maintenance of a high echocardiographic standard. Furthermore, echocardiography may sometimes be difficult to interpret without a fuller individual assessment. Certainly, one difficulty alluded to by Baur et al. is that many symptomatic patients will have no evidence of left ventricular systolic dysfunction but may have evidence of ‘diastolic dysfunction’. Unfortunately, diastolic dysfunction is currently difficult to diagnose, with no accepted diagnostic criteria and no simple diagnostic tests [7], and thus whether such apparent diastolic dysfunction on echocardiography is the cause of the patient’s symptoms or not may require a further cardiological opinion.

Gavin I. W. Galasko

Papers

Direct access echocardiography.