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Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study

Disagreement between screening and standard echo

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Abstract

We aimed to evaluate the reasons for disagreement between screening echocardiography (echo), acquired by nonexperts, and standard echo in the Brazilian primary care (PC). Over 20 months, 22 PC workers were trained on simplified handheld (GE VSCAN) echo protocols. Screening groups, consisting of patients aged 17-20, 35-40 and 60-65 years, and patients referred for clinical indications underwent focused echo. Studies were remotelyinterpreted in US and Brazil, and those diagnosed with major or severe HD were referred for standard echoperformed by an expert. Major HD was defined as moderate to severe valve disease, ventriculardysfunction/hypertrophy, pericardial effusion or wall-motion abnormalities. A random sample of exams wasselected for evaluation of variables accounting for disagreement. A sample of 768 patients was analyzed, 651(85%) in the referred group. Quality issues were reported in 5.8%, and the random Kappa for major HD between screening and standard echo was 0.51. The most frequent reasons for disagreement were: overestimation of mitral regurgitation (MR) (17.9%, N=138), left ventricular (LV) dysfunction (15.7%, N=121), aortic regurgitation (AR) (15.2%, N=117), LV hypertrophy (13.5%, N=104) and tricuspid regurgitation (12.7%, N=98). Misdiagnosis of mitral and aortic morphological abnormalities was observed in 12.4% and 3.0%, and underestimation of AR and MR occurred in 4.6% and 11.1%. Among 257 patients with suspected mild/moderate MR, 129 were reclassified to normal. In conclusion, although screening echo with task-shifting in PC is a promising tool in low-income areas, estimation of valve regurgitation and LV function and size account for considerable disagreement with standard exams.

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Data analytic methods and study materials will be made available to other researchers for purposes of reproducing the results or replicating the procedure, from the corresponding author upon reasonable request.

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Funding

The PROVAR + investigators would like to thank Edwards Lifesciences Foundation® for supporting and funding the primary care screening program (PROVAR+) in Brazil, General Electric Healthcare® for providing echocardiography equipment and WiRed Health Resources for providing online curriculum on heart disease and echocardiography. The Telehealth Network of Minas Gerais was funded by the State Government of Minas Gerais, by its Health Department (Secretaria de Estado da Saúde de Minas Gerais) and FAPEMIG (Fundação de Amparo à Pesquisa de Minas Gerais), and by the Brazilian Government, including the Health Ministry and the Science and Technology Ministry and its research and innovation agencies, CNPq (Conselho Nacional de Desenvolvimento Científico e Tecnológico) and FINEP (Financiadora de Estudos e Projetos). Dr Ribeiro is supported in part by CNPq (310790/2021-2 and 465518/2014-1) and by FAPEMIG (PPM-00428-17 and RED-00081-16. Dr Nascimento is partially financed CNPq (Bolsa de produtividade em pesquisa, 312382/2019-7), by the Edwards Lifesciences Foundation (Improving the Prevention and Detection of Heart Valve Disease Across the Lifespan, 2022) and by FAPEMIG (grant APQ-000627-20). Medical students received scholarships from the National Institute of Science and Technology for Health Technology Assessment (IATS, project: 465518/2014-1). This study was funded by Edwards Lifesciences Foundation, USA, and FAPEMIG, Brazil. The funder did not have any relationship with the conduct of the study, data collection, analysis, and interpretation, and the preparation, review, or approval of this manuscript.

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Authors and Affiliations

  1. Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil

    Bruno F. Galdino, Marcelo Augusto A. de Nogueira, Rodrigo T. L. Rocha, Maria Carmo P. Nunes, Victor R. H. Silva, Antonio Luiz P. Ribeiro & Bruno R. Nascimento

  2. Faculdade de Medicina da Universidade Federal de Ouro Preto, Ouro Preto, MG, Brazil

    Arthur M. Amaral

  3. Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil

    Luiza P. A. Santos

  4. Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde do Hospital das Clínicas da UFMG, Belo Horizonte, MG, Brazil

    Maria Carmo P. Nunes, Kaciane K. B. Oliveira, Juliane Franco, Márcia M. Barbosa, Antonio Luiz P. Ribeiro & Bruno R. Nascimento

  5. The Heart Institute, Cincinnati Children’s Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, OH, USA

    Andrea Z. Beaton

  6. Cardiology, Children’s National Health System, Washington, DC, USA

    Alison T. Reese & Craig A. Sable

  7. Serviço de Cardiologia e Cirurgia Cardiovascular, Hospital das Clínicas, Universidade Federal de Minas Gerais, Minas Gerais, Rua Muzambinho, 710, apt. 802, CEP 30.210-530, Serra, Belo Horizonte, Brasil

    Bruno R. Nascimento

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  1. Bruno F. Galdino
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Consortia

On behalf of the PROVAR+ (Programa de RastreamentO da VAlvopatia Reumática e outras Doenças Cardiovasculares) investigators

Contributions

Conception and design of the research: Galdino BF, Nascimento BR, Nunes, MCP; Acquisition of data: Oliveira KKB, Franco J, Galdino, BF, Barbosa MM, Nunes, MCP, Amaral, AM, Santos, LPA, Nogueira, MAA, Rocha, RTL, Silva, VRH; Analysis and interpretation of data: Nascimento BR, Nunes MCP, Beaton AZ, Reese AT, Sable C; Statistical analysis: Nascimento BR; Funding acquisition: Sable C, Beaton AZ, Nascimento BR; Writing of the manuscript: Nascimento, BR, Galdino, BF, Amaral, AM, Santos, LPA, Nogueira, MAA, Rocha, RTL, Silva, VRH; Critical revision of the manuscript for intellectual content: Nascimento BR, Ribeiro, ALP, Sable C, Beaton AZ; Authors responsible for the overall content as guarantors: Nascimento, BR, Nunes, MCP.

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Correspondence to Bruno R. Nascimento.

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The authors have no conflicts of interest to declare regarding this manuscript.

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was obtained from the Universidade Federal de Minas Gerais Institutional Review Board and the Belo Horizonte City Board of Health, and all patients included in this analysis signed an informed consent form prior to enrollment.

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The abstract with partial results of this work was presented at the American Heart Association Scientific Sessions, November 16 to 18, 2019, in Philadelphia, PA, USA.

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Galdino, B.F., Amaral, A.M., Santos, L.P.A. et al. Reasons for disagreement between screening and standard echocardiography in primary care: data from the PROVAR + study. Int J Cardiovasc Imaging 39, 929–937 (2023). https://doi.org/10.1007/s10554-023-02800-6

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