Echocardiogram reading by cardiologists needs to improve

by Crystal Phend

Insufficient training among cardiologists in reading echocardiography results is wasting healthcare dollars and subjecting patients to unnecessary procedures, researchers said.

A review by sonographers of cardiologist-interpreted echocardiography findings at a Milwaukee medical center during a period of just over a year indicated major discrepancies in 29% of cases, leading to unnecessary further diagnostic testing or treatments for the wrong indication, according to a study presented here at the American Society of Echocardiography meeting.

Of the 235 imaging studies reviewed at the single center, five patients went to the operating room with a wrong diagnosis, reported Elizabeth Thompson, RDCS, of the Aurora St. Luke’s Medical Center in Milwaukee, and colleagues.

The most common misreads were overdiagnosis of atrial septal defect and patent foramen ovale leading to transesophageal echocardiogram followed by misdiagnosis with aortic valve disease leading to cardiac catheterization.

Session moderator R. Parker Ward, MD, of the University of Chicago Medical Center in Chicago, described these as “very real world” results in an understudied but important area.

Physician training appeared to be playing an important role, since both the number of each type of echocardiogram read over a year’s time and the number of continuing medical education credit hours per year were linked to interpretation.

Rather than not allowing less experienced cardiologists to interpret the imaging studies, “we’re recommending that they have increased CME hours,” Thompson explained to MedPage Today. “Right now the ASE requires five CME hours per year but we really feel that it needs to be bumped up to 15.”

The field is changing quickly with new speckle tracking, strain, and other echocardiography techniques introduced over the past few years, she noted. “They need to stay current with trends.”

Thompson’s group prospectively and randomly selected 235 echocardiogram studies among more than 15,000 performed at the center between August 2007 and October 2008.

All physicians who interpret heart ultrasounds are required to have a minimum of six months of training during their fellowship; the highest level of training, Level 3, requires a minimum of 12 months of cardiac ultrasound training in an accredited fellowship.

Of the 35 physicians who performed clinical readings of the echocardiograms reviewed in the study, only three were Level 3 specialists within cardiology.

“Physicians are doing the final interpretation, but they are not physicians that have expertise in echocardiography,” Thomson said in an interview. “They do cardiac cath, they have a private practice, they do angiographies, CT.”

These nonspecialist cardiologists may be less likely to stay abreast of new, high-level modalities like 3D echocardiography, she noted. “They may be using it but not know how to correctly interpret it, and that’s what we found.”

Of the 10 stress echocardiograms included in the study, five had a major discrepancy between sonographer and physician interpretation. All five had been read as positive but came back normal on coronary angiography.

Five of the 15 transesophageal echocardiograms also had a discrepancy in interpretation that led to further testing or therapeutic intervention that would not have been necessary if correctly interpreted from the outset.

These cases included false positive diagnoses of:

* Aortic dissection leading to surgery
* Prosthetic valve regurgitation diagnosis with surgery cancelled in the operating room
* Idiopathic hypertrophic subaortic stenosis misinterpreted as mitral and aortic regurgitation with surgery cancelled in the operating room
* Arteriovenous fistula misinterpreted at mitral regurgitation

Given these findings, it’s not surprising second opinions are becoming more popular, Thompson said.

“I think we’re on the brink of changes that way,” she said. “You’ll find this in all modalities of healthcare. Patients are looking for a second opinion.”

Crystal Phend is a MedPage Today Senior Staff Writer.

Originally published in MedPage Today. Visit for more cardiology news.