The impact of early use of echocardiography performed by non-cardiologist in patients with chest pain - the ENDEMIC study

Abstract Background Echocardiography is well-established method in management of chest pain at Emergency department (ED). However, evidence on the optimal scope of the examination and the education of the examiner is scarce. Early point of care echocardiography (POCE) by ED physician can speed up the diagnostic process compared to echocardiography performed by dedicated specialist, at the cost of a higher risk of misdiagnosis. Purpose Primary objective was to assess the impact of POCE on length of stay on emergency department (ED). Secondary objectives were to evaluate the impact of POCE on time to revascularization and on the accuracy of the diagnosis at the initial examination. Methods ENDEMIC study is a prospective, randomised, open-label, single centre study. Prior to enrolment, physicians without any previous experiences with POCE were educated according to BSE standard level 1. Patients examined for chest pain of uncertain etiology were enrolled into the study and randomised in even-odd manner for POCE within 90 minutes or for usual management. In all patients the length of ED stay, time to coronary angiography and accuracy of working diagnosis. Length of ED stay was defined as time form first contact of the patient with ED to the moment when the patient physically leaved the ward. Time to revascularization was retrieved from patient´s medical records and confirmed by telephonic visit. A working diagnosis was considered accurate if it shared both pathophysiological mechanism and diagnostic criteria with the final diagnosis. All POCE examinations were recorded and revised by certified echocardiography specialist for errors. Results The study was early terminated after enrolment of 150 patients, because main objectives were met. The use of POCE resulted in a significant shortening of both time of decision (138.0 [68.5−230.5] min vs. 252.0 [165.5−304.0], p=0.000004) and length of ED stay (209.0 [143.5−260.0] min vs. 271.0 [206.5−336.0], p=0.0002. Moreover, in patients indicated for further follow-up, utilisation of POCE resulted in better concordance of working and final diagnosis: 91,6 % vs. 50 %; RR = 1.83 (1.104-2.565); p = 0.0063. Benefits of POCE were most pronounced in patients requiring hospitalization. Conclusion The study showed that echocardiography performed by sufficiently educated physician in patients with acute chest pain results in significant shortening of ED stay along with improved diagnostic accuracy.