Effect of Point-of-Care Echocardiography by Noncardiologists on Treatment Time and Diagnostic Accuracy in Acute Chest Pain

Effect of Point-of-Care Echocardiography by Noncardiologists on Treatment Time and Diagnostic Accuracy in Acute Chest Pain | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Effect of Point-of-Care Echocardiography by Noncardiologists on Treatment Time and Diagnostic Accuracy in Acute Chest Pain Petr Grenar, Martin Jakl, Karel Medilek, Jiri Novy, Jaromir Koci, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6735927/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 24 Nov, 2025 Read the published version in Internal and Emergency Medicine → Version 1 posted 4 You are reading this latest preprint version Abstract Background As point-of-care echocardiography (POCE) has expanded beyond cardiology into general emergency medical practice, there has been a lack of standardized, evidence-based imaging protocols and training, thus leading to challenges with respect to the quality of cardiac imaging for acute cardiovascular syndromes. The ENDEMIC study aims to assess the effectiveness of POCE based on structured training for noncardiologists on the management of patients with acute chest pain in emergency departments. Methods A total of 150 patients presenting with acute chest pain were enrolled in this prospective randomized clinical trial. Patients were assigned to either the POCE-assisted management group or the standard management group. Physicians performing POCE examinations received focused training based on the British Society of Echocardiography level 1 standard. The primary outcome was the length of stay in the emergency department (ED), and the secondary outcomes included the time to revascularization and diagnostic accuracy at the initial examination. Results The results revealed that the POCE group had a significantly shorter length of ED stay (209.0 vs. 271.0 min, p = 0.0003), time to decision (138.0 vs. 252.0 min, p < 0.0001) and time to coronary angiography (29.6 vs. 120.3 hours, p = 0.027) than the control group. Furthermore, the error of initial diagnoses was lower in the POCE group (6.3% vs. 30.4%, RR = 0.21 [0.047-0.90]). Conclusion The implementation of POCE by trained noncardiologists significantly reduced the duration of ED stay and enhanced the management of patients with acute chest pain in the ED. Systematic training enables physicians without prior echocardiography experience to perform POCE accurately and efficiently. Point-of-care echocardiography Acute chest pain Education Emergency medicine Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction In the past, echocardiography was performed exclusively by dedicated specialists. Today, physicians from a variety of specialties, including emergency medicine, intensive care, anaesthesiology and even primary care, perform bedside echocardiography. This shift has been driven by the advent of compact, easy-to-use ultrasound devices that have made it easier for non-specialists to perform cardiac imaging. Although point-of-care ultrasound has emerged over the past three decades, its growth may have accelerated since 2020, likely due to the COVID-19 pandemic [ 1 – 3 ]. Point-of-care echocardiography (POCE) is defined as the acquisition, interpretation and immediate clinical integration of echocardiographic images performed by clinicians at the patient's bedside, rather than by a radiologist or cardiologist [ 4 ]. The different levels of cardiac ultrasound can be categorised according to the extent of the examination [ 5 , 6 ] (Fig. 1). The current study corresponds to a detailed FOCUS examination according to the scheme. Figure1 One of the key uses of POCE is to diagnose patients with acute chest pain [ 7 , 8 ]. Acute chest pain is one of the most common yet challenging presentations in emergency clinical practice, requiring immediate and accurate diagnosis and management. In the context of emergency medicine, where time is of the essence, POCE has emerged as a pivotal diagnostic tool beyond the traditional confines of cardiology departments. The use of POCE by trained non-cardiologists has begun to revolutionise patient assessment, providing a real-time view of cardiac function at the bedside. However, there is little evidence on the optimal scope of the examination and the training of the examiner. A key question remains: Can structured training in POCE for non-cardiologists significantly improve the speed and quality of patient care? And at what cost? Aims of the study The study “Echocardiography by Non-cardiologist in Early Management of Patients With Chest Pain (ENDEMIC)” aims to assess the effect of controlled training of non-cardiologists on the use of POCE in the management of patients with acute chest pain. The primary objective was to assess the impact of POCE on the length of stay in the emergency department (ED). The primary safety endpoint was the occurrence of major adverse cardiovascular events (MACE) within 30 days of enrolment. Secondary objectives were to evaluate the impact of POCE on the time to revascularisation and to assess the quality of the examination performed. Methods We conducted a prospective, randomised cohort study at the Department of Emergency Medicine and First Department of Medicine - Cardioangiology, University Hospital Hradec Kralove, Czech Republic (ClinicalTrial.gov NCT05306730). The study protocol was approved by the Ethics Committee and was conducted in accordance with the Declaration of Helsinki. All patients provided informed written consent. Training on point-of-care echocardiography The training programme was described in detail previously [ 9 ]. The training program enrolled four physicians who had not undergone systematic training in echocardiography (including self-education) and had performed examinations up to the level of ultrasound-augmented physical examination. The British Society of Echocardiography (BSE) Level 1 protocol [ 10 ] was chosen as the basis for determining the scope of the training. The following modalities were added to this training: diameter of ascending aorta, colour flow mapping of aortic and mitral valve in short axis projection and measurement of tricuspid valve gradient. This additional training was added to the original protocol to cover common and serious conditions encountered in the emergency department (e.g. aortic dissection, severe valvular disease and significant pulmonary hypertension). The training programme consisted of several steps: an introductory course in focused echocardiography, a supervised examination of patients in whom at least 29 predefined findings had to be identified (Supplementum 1) and a final examination of real patient assessed by a specialist with European Association of Cardiovascular Imaging accreditation in transthoracic echocardiography. The total training period was approximately 6 months. Physicians began performing POCE on study participants immediately after successfully completing the course. To maintain the quality of the examinations, graduates were required to document at least fifty examinations per year. In addition, once a year, graduates spent four hours in the EchoLab under the supervision of a mentor to verify their continuing competence in performing POCE. Selection of participants Patients presenting to the ED with chest pain were eligible for the study. Inclusion criteria were as follows: 18 years of age or older; and pain that may have had a cardiovascular aetiology based on the patient's history, physical examination, and ECG findings. Exclusion criteria were as follows: ST-elevation myocardial infarction (STEMI), active pacemaker, pregnancy, performance status of 4 on the Zubrod scale, and refusal or inability to give informed consent. Patients were not excluded on the basis of poor ultrasound visualisation. All patients were followed up for a minimum of 3 months. Patients were randomized in an even-odd manner to a POCE-assisted management group or a standard management group (control group). Echocardiography examination POCE was performed following ECG and standard clinical examination, but no later than 90 minutes after arrival at the emergency department. It was performed by an operator who had completed the aforementioned training programme. The recommended scope of POCE was based on the BSE Level 1 protocol. However, the examining physician was authorised to extend the scope of the examination if necessary. All images of the examination were archived in the hospital information system and reviewed post hoc by an EACVI accredited echocardiographer and the approved supervisor of the British Society of Echocardiography to assess the accuracy of the examinations performed. In patients in control group, echocardiography was performed only if required by specific ESC guidelines (in case of 3-hour troponine protocol etc.). In that case, the examination was performed by a cardiology fellow. Outcomes The primary endpoint of the study was the length of ED stay. The start of the ED stay was defined as the time of the patient's first contact with the ED, regardless of whether the patient was referred by the emergency medical service or self-referred. The end of the ED stay was defined as the time when the patient physically left the ED. The time to decision was defined as the time at which the final decision regarding diagnosis or the initiation of a guideline-based therapeutic intervention was made in the ED, depending on which occurred later. Time to revascularisation and occurrence of MACE were obtained from the patients' medical records and confirmed by evidence from the Czech National Population Registry. MACE was defined as the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or unplanned hospitalisation due to cardiovascular disease within 30 days of the clinical examination. Because of the absence of non-fatal myocardial infarction and very low incidence of death in discharged patients, discrepancy between working and final diagnosis was added as a secondary safety endpoint. A working diagnosis was considered accurate if it shared both a pathophysiological mechanism and diagnostic criteria with the final diagnosis (e.g., a working diagnosis of acute coronary syndrome was considered accurate if the final diagnosis was myocardial infarction or unstable angina but not takotsubo cardiomyopathy). In case of discrepancy between the working and final diagnosis, the final diagnosis was determined by independent review. Ethics approval This study was approved by the local ethical committee (Ethics Committee of University Hospital in Hradec Kralove, accredited by the Office for Human Research Protections under the number IORG0008813). The study was conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent. Statistical analysis Categorical variables are expressed as group counts and relative frequencies (%), and continuous variables are expressed as group means, standard deviations and totals (N). Effect size is expressed as median of difference (ΔM) with 95% confidence interval (95% CI). As most of the continuous variables examined here did not follow a normal distribution (as indicated by exploratory analysis and the Shapiro-Wilk test), the non-parametric Wilcoxon rank-sum test was used to compare continuous outcomes between groups. Categorical variables were compared using Fisher's exact test. Statistical significance was set at alpha = 0.05 for all tests. In cases of multiple testing of similar hypothesis (e.g. various ways of reducing management time), the Bonferroni-Holm correction for the nominal level of statistical significance was applied to keep the familywise Type I error rate alpha at 0.05. Statistical analyses were performed using R software (R version 3.5.3; R Foundation for Statistical Computing, Vienna, Austria). In this study, we aimed to test the hypothesis that the implementation of POCE would lead to a reduction in the length of stay in the ED of at least 15% (≈ 30 minutes). We performed a power analysis to determine the appropriate sample size for our study. The desired power was set at β = 0.8. The effect size was estimated on the basis of preliminary data in which the length of stay in the ED was determined to be 176 ± 90 minutes. Taking these parameters into account, the sample size was determined to be 430 patients. An interim analysis was performed after every 50 patients. If both the primary and secondary endpoints reached statistical significance (including the Bonferroni-Holm correction), the Data Safety Monitoring Board was asked to assess the ethics of continuing the study. Given the continued superiority of POCE in both reducing the length of stay in the ED and improving diagnostic accuracy, the Board recommended early termination of the study after enrolment of 150 patients. Results Characteristics of study subjects Between September 2022 and October 2023, a total of 150 patients were enrolled in the study. The baseline demographic and clinical data of the patients are summarized in Table 1 . The descriptive characteristics were well balanced across the groups. In the POCE group, echocardiography was performed in all patients. All records were subsequently reviewed, and the real extent of the examination was recorded. Of the 16 projections based on the BSE Level 1 protocol, 12.5 ± 2.5 (78.4 ± 15.9%) were actually performed. An additional 5.4 ± 1.6 projections were performed on average. A total of 91.1% of the projections were fully conclusive, 7.6% were partly inconclusive, and 1.3% were completely inconclusive (Table 2). Regional wall motion abnormity (including septal D-shape) was present in 38.5% of patients; however, it was present in only 21.4% of patients with confirmed acute coronary syndrome. Table 1 Comparison of baseline characteristics between the POCE and control groups POCE group (n = 75) Control group (n = 75) p Age [years; mean ± SD] 61.1 ± 17.8 66.1 ± 15.6 0.072 Male sex [n (%)] 50 (66.7) 41 (54.7) 0.181 Caucasian ethnicity [n (%)] 75 (100) 75 (100) 1.0 Chronic coronary artery disease [n (%)] 19 (25.3) 20 (26.7) 1.0 Diabetes mellitus [n (%)] 19 (25.3) 12 (16.0) 0.226 Arterial hypertension [n (%)] 39 (52.0) 42 (56.0) 0.743 Severe valvular disease [n (%)] 4 (5.3) 4 (5.3) 1.0 Atrial fibrillation [n (%)] 7 (9.3) 10 (13.3) 0.608 Active smoker [n (%)] 14 (18.7) 14 (18.7) 1.0 Former smoker [n (%)] 15 (20.0) 17 (22.7) 0.690 Antiplatelet therapy [n (%)] 20 (26.6) 23 (30.7) 0.718 Anticoagulation therapy [n (%)] 8 (10.6) 13 (17.3) 0.239 GRACE score [points] 96.0 (69.0-125.5) 100.0 (64.5–134.0) 0.536 HEART score [points; median (IQR)] 5.0 (3.0–7.0) 5.0 (3.0–6.0) 0.648 Indication of further follow-up [n; %] 30 (40.0) 26 (24.7) 0.612 Patients requiring hospital admission [n; %] 25 (33.3) 14 (18.7) 0.062 POCE - point-of-care echocardiography GRACE - Global Registry of Acute Coronary Events [ 1 ] HEART - History, ECG, Age, Risk factors and Troponin (18665203)[ 2 ] ECG - electrocardiography Table 2 Extent of POCE examinations Projection Number patients with a projection performed [n (%)] • fully conclusive [n (%)] • partially inconclusive [n (%)] Parasternal ascending aorta** 69 (92.0) • 67 (89.3) • 1 (1.3) PLAX (2D)* 67 (89.3) • 61 (81.3) • 5 (6.7) PLAX (LVIDd)* 66 (88.0) • 46 (61.3) • 14 (18.7) PLAX with CFM aortic and mitral valve* 71 (94.7) • 58 (77.3) • 13 (17.3) PSAX outflow (2D)* 46 (61.3) • 42 (54.7) • 4 (5.3) PSAX outflow with CFM aortic valve** 54 (72.0) • 50 (66.7) • 3 (4.0) PSAX outflow with CFM mitral valve** 34 (45.3) • 30 (40.0) • 2 (2.7) PSAX base (2D)* 39 (52.0) • 38 (50.7) • 0 (0) PSAX mid (2D)* 61 (81.3) • 61 (81.3) • 0 (0) PSAX apex (2D)* 28 (37.3) • 28 (37.3) • 0 (0) A4C (2D)* 71 (94.7) • 61 (81.3) • 10 (13.3) A4C (M-Mode) TAPSE* 71 (94.7) • 71 (94.7) • 0 (0) A4C with CFM tricuspid valve* 34 (45.3) • 34 (45.3) • 0 (0) A4C Tricuspid gradient (CW)** 52 (69.3) • 52 (69.3) • 0 (0) A4C with CFM mitral valve* 60 (80.0) • 56 (74.7) • 3 (4.0) A5C (2D)* 18 (24.0) • 15 (20.0) • 3 (4.0) A5C with CFM aortic valve* 28 (37.3) • 27 (36.0) • 1 (1.3) A2C (2D) 68 (88.0) • 58 (77.3) • 8 (10.7) A2C with FCM mitral valve 44 (58.7) • 40 (53.3) • 4 (5.3) A3C 64 (85.3) • 58 (77.3) • 6 (8.0) A3C with CFM aortic valve 38 (50.7) • 34 (45.3) • 4 (5.3) Subcostal 4C (2D)* 63 (84.0) • 49 (65.3) • 12 (16.0) Subcostal IVC (2D)* 67 (88.0) • 64 (85.3) • 3 (4.0) Subcostal IVC (M-Mode)* 58 (74.7) • 56 (74.7) • 1 (1.3) Suprasternal long axis 3 (4.0) • 3 (4.0) • 0 (0) Left ventricular systolic function assessed by at least two independent projections 74 (98.6) Mitral valve assessed by at least one projection 62 (82.6) Aortic valve assessed by at least one projection 62 (82.6) IVC assessed by at least one projection 56 (74.6) * - projections required by the BSE Level 1 protocol ** - additional projections involved in pr-estudy education POCE - point-of-care echocardiography PLAX - parasternal long axis projection LVIDd - Left ventricular internal diameter in diastole PSAX - parasternal short axis projection CFM - colour flow mapping A4C - apical 4-chamber projection TAPSE - tricuspid annular plane systolic excursion A3C - apical 3-chamber projection A2C - apical 2-chamber projection IVC - inferior vena cava Table 1 Table 2 Main results The use of POCE resulted in a significant shortening of ED stay, time to decision and time to coronary angiography. The reduction in ED stay was most pronounced in patients with bundle branch block, ST elevations not meeting STEMI criteria, or those with severe non-coronary disease (Fig. 2 and Fig. 3; Supplementum 2 and 3). The incidence of adverse events was lower than expected; therefore, the study would be underpowered for a reliable analysis even if enrolment were not stopped (Table 3 ). We found no evidence to support the hypothesis that the use of POCE increases the risk of an incorrect working diagnosis (6.3% in the POCE group vs. 30.4% in the control group, p = 0.997 for inferiority). Although this was not a prespecified endpoint, the risk ratio suggests that the use of POCE resulted in superior diagnostic accuracy: RR = 0.21 (0.047–0.90). Table 3 Comparison of the POCE and control groups POCE group (n = 75) Control group (n = 75) p Time to decision in whole study group [min; mean (IQR)] 138.0 (68.5 − 230.5) 252.0 (165.5 − 304.0) < 0.0001 Duration of ED stay in whole study group [min; mean (IQR)] 209.0 (143.5 − 260.0) 271.0 (206.5 − 336.0) 0.0003 Time to decision among hospitalized patients [min; mean (IQR)] 112.0 (51.0 − 180.0) 183.5 122.75 − 252.0 0.024 Duration of ED stay among hospitalized patients [min; mean (IQR)] 178.0 (75.0 − 224.0) 219.5 (145.5 − 293.75) 0.058 Time to coronary angiography [hours] 29.6 (23.6–38.1) 120.3 (45.6-147.9) 0.027 MACE at day 30 [n; %] 0 (0) 0 (0) 1.0 All cause deaths at day 90 [n; %] 1 (1.33) 1 (1.33) 1.0 POCE - point-of-care echocardiography ED - emergency department IQR - interquartile range MACE – Mayor cardiovascular adverse events Table 3 Figure 2 Figure 3 Discussion The present study stands at the intersection of educational strategy and clinical effectiveness and provides insight into how systematic training in echocardiography can equip non-cardiologists with the skills needed to effectively manage patients with acute chest pain. We have shown that physicians with no previous experience can be effectively trained to perform POCE, and that their clinical performance resulted in shorter emergency department stays and more accurate diagnoses. Despite the widespread use of echocardiography in patients with acute cardiovascular disease, recommendations for POCE in the emergency setting remain vague, particularly regarding the optimal extent and timing of examinations[ 7 , 8 , 11 – 13 ]. This lack of clarity is a cause for concern and is in line with the recognition of POCE as a major health technology risk [ 13 ]. In addition, evidence on the extent of necessary education is limited and primarily based on national standards, despite calls for high-quality, competency-based cardiac imaging service delivery[ 14 ]. The efficacy and accuracy of POCE has been evaluated in several previous studies. Previous studies have shown acceptable agreement between POCE and comprehensive echocardiography, as well as increased diagnostic confidence among physicians, although without significant clinical benefit[ 15 – 17 ]. Recent research has demonstrated reductions in patient management time but not mortality endpoints, but there is no detailed information on examiner training and scope of examination[ 18 , 19 ]. However, we believe that it is not echocardiography itself that should be the focus of scientific interest, but rather the way in which it is taught, indicated and performed. In particular, it needs to be shown that POCE can be beneficial to ordinary emergency physicians, not just highly experienced specialists. This is where we see the greatest contribution of this study. The rationale for performing early echocardiography in patients with chest pain is traditionally based on the pathophysiology of the ischaemic cascade[ 20 ] (Fig. 4). Although our study was not designed to identify specific patient subgroups that would benefit most from early POCE, the greatest benefit was observed in patients with non-coronary causes of pain, such as pulmonary embolism, pericarditis, and aortic valve stenosis. In relation to ECG findings, patients with difficult-to-interpret findings (e.g. bundle branch block, ST elevations not meeting STEMI criteria) benefited most from POCE. Early recognition of less common causes of pain was also the main reason for the trend towards a higher number of hospital admissions in the POCE group. Interestingly, regional wall motion abnormalities were rare in patients with acute coronary syndrome. However, when such impairment was detected, the diagnostic process was significantly accelerated, thereby reducing the length of stay in the ED in rule-in patients. It must be emphasised that the standard troponin algorithm remains the main diagnostic method to rule out acute coronary syndrome in most patients with acute chest pain. Figure 4 Although the training in this study was based on the BSE Level 1 protocol, which is considered to be one of the most valuable focused protocols[ 21 ], physicians often expanded the scope of the examination to reliably detect regional wall motion abnormalities. This finding is consistent with previous findings that assessment of wall motion abnormalities is poorly predictive of acute coronary syndrome when insufficiently detailed POCE protocols are used[ 22 ]. Archiving and sharing POCE records has been shown to be very important in improving collaboration with consulting specialists. We therefore strongly agree with the need to archive POCE examinations as recommended by the European Association of Cardiovascular Imaging[ 23 ]. We recommend the development of evidence-based international recommendations for POCE training for basic clinical syndromes, which may broaden the impact of POCE and consolidate its role in emergency medicine[ 14 ]. In addition, we support the American Society of Echocardiography's recommendation that cardiologists should lead the training of non-cardiologists in echocardiography, with an emphasis on standardised, competency-based service delivery[ 6 , 24 – 26 ]. Study limitations The main limitation of this study is its monocentric design. We expect that the benefits of POCE may differ from those observed in tertiary cardiovascular centres. Acceleration of chest pain management may not be feasible in centres that are unable to respond immediately to the full range of POCE findings, either due to lack of resources or free capacity. The benefit may also be compromised by mistrust of other specialists in the reliability of POCE performed by emergency physicians. The study was not designed to prove improved diagnostic accuracy by POCE. This is because, at the time the study was designed, there was more concern about the high error rate of POCE carried out by non-cardiologists. For this reason, the error rate assessment was only included as a safety endpoint. The randomisation process cannot be blinded due to the nature of POCE, which requires direct interaction between the clinician and the process of performing the ultrasound examination. The chosen study design does not distinguish to what extent the disclosure of key findings or the increase in physician confidence in the diagnostic process is the cause of the acceleration of care. Patients for whom POCE could not be performed within 90 minutes of arriving at the ED were excluded from the study. The number of such patients in the study population was very low. In chronically congested EDs, this condition may significantly limit the generalisability of the results. The number of patients included does not allow reliable subanalysis for rare diseases and ECG findings. Given the monocentric nature of the study, the impact of POCE on the management of less common conditions may also be biased. Another limitation of the study is the small number of physicians performing POCE examinations. Without enthusiasm for the implementation of POCE in clinical practice and confidence in the method, the benefits may be reduced or absent. Conclusion The results of our study clearly demonstrate the significant benefits of POCE performed in the ED by non-cardiologists who have undergone structured training. In particular, the implementation of POCE led to a significant reduction in length of ED stay and decision-making times, which are critical measures of the efficiency of emergency care. The time to coronary angiography was also reduced. The accuracy of initial diagnosis improved significantly, highlighting the clinical value of POCE in the management of acute chest pain. An incidental finding of the study is that the BSE Level 1 protocol appears to be an insufficient training resource for the use of POCE in the management of acute chest pain. Declarations Competing interest None declared Funding The work was supported by the Ministry of Defence of the Czech Republic “Long Term Organization Development Plan 1011” – Clinical Disciplines II of the Military Faculty of Medicine Hradec Kralove, University of Defence, Czech Republic (Project No: DZRO-FVZ22-KLINIKA II) and the Research Project of Charles University Cooperatio, research area CARD. Author contributions: PG and MJ are lead authors and contributed equally to the paper. PG, MJ, KM and RP conceived the study and designed the trial. MJ, RP and JN supervised the conduct of the trial and data collection. PG, MC and JB undertook recruitment of patients. 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Eur Heart J 44(45):4771–4780 Croft PE, Strout TD, Kring RM, Director L, Vasaiwala SC, Mackenzie DC (2019) WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction. Am J Emerg Med 37(12):2224–2228 Blans MJ, Bousie E, van der Hoeven JG, Bosch FH (2021) A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy. Ultrasound J 13(1):29 Saglam C, Unluer EE, Yamanoglu NGC, Kara PH, Ediboglu E, Bektasli R et al (2021) Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST-Elevation Myocardial Infarction. J Ultrasound Med 40(7):1335–1342 Guner NG, Yurumez Y, Yucel M, Alacam M, Guner ST, Ercan B (2020) Effects of Point-of-care Ultrasonography on the Diagnostic Process of Patients Admitted to the Emergency Department with Chest Pain: A Randomised Controlled Trial. 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West J Emerg Med 25(1):9–16 Neskovic AN, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al (2013) Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging 14(1):1–11 Neskovic AN, Edvardsen T, Galderisi M, Garbi M, Gullace G, Jurcut R et al (2014) Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint. Eur Heart J Cardiovasc Imaging 15(9):956–960 Cardim N, Dalen H, Voigt JU, Ionescu A, Price S, Neskovic AN et al (2019) The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update). Eur Heart J Cardiovasc Imaging 20(3):245–252 Popescu BA, Stefanidis A, Fox KF, Cosyns B, Delgado V, Di Salvo GD et al (2020) Training, competence, and quality improvement in echocardiography: the European Association of Cardiovascular Imaging Recommendations: update 2020. Eur Heart J Cardiovasc Imaging 21(12):1305–1319 List of Supplemental Digital Content 1: Supplementary tables.docx Supplementary Files Supplementum1logbook.docx List of Supplemental Digital Content 1: Supplementary tables.docx Cite Share Download PDF Status: Published Journal Publication published 24 Nov, 2025 Read the published version in Internal and Emergency Medicine → Version 1 posted Reviewers agreed at journal 05 Jun, 2025 Reviewers invited by journal 04 Jun, 2025 Editor assigned by journal 28 May, 2025 First submitted to journal 27 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6735927","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":466631494,"identity":"e0d34aac-6e20-401b-b20d-d34e1e9249fd","order_by":0,"name":"Petr Grenar","email":"","orcid":"","institution":"University of Defense in Brno Faculty of Military Health Sciences: Univerzita obrany v Brne Fakulta vojenskeho zdravotnictvi","correspondingAuthor":false,"prefix":"","firstName":"Petr","middleName":"","lastName":"Grenar","suffix":""},{"id":466631495,"identity":"a6b8cf62-4e3c-4b30-8f0b-817713d7e55c","order_by":1,"name":"Martin 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version\u003c/p\u003e","description":"","filename":"Image3.png","url":"https://assets-eu.researchsquare.com/files/rs-6735927/v1/1282c04ab29443c3086a20ee.png"},{"id":84339943,"identity":"339b751f-3046-4cb3-a7f2-362e2e6cc9bf","added_by":"auto","created_at":"2025-06-10 18:21:06","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":359117,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version\u003c/p\u003e","description":"","filename":"Image4.png","url":"https://assets-eu.researchsquare.com/files/rs-6735927/v1/d12f9917d695681ae0b47ce1.png"},{"id":97178588,"identity":"07d60630-86ce-4219-adbb-18df71ed97ac","added_by":"auto","created_at":"2025-12-01 16:11:09","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1975464,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6735927/v1/baeb9f0b-96e7-40f3-ae63-bda971d67aa7.pdf"},{"id":84339172,"identity":"ce5ec5b6-1097-4844-be3b-1a57a612c491","added_by":"auto","created_at":"2025-06-10 18:13:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":28191,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eList of Supplemental Digital Content\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e1: Supplementary tables.docx\u003c/p\u003e","description":"","filename":"Supplementum1logbook.docx","url":"https://assets-eu.researchsquare.com/files/rs-6735927/v1/f6a9336ad571351124a2c934.docx"}],"financialInterests":"","formattedTitle":"Effect of Point-of-Care Echocardiography by Noncardiologists on Treatment Time and Diagnostic Accuracy in Acute Chest Pain","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn the past, echocardiography was performed exclusively by dedicated specialists. Today, physicians from a variety of specialties, including emergency medicine, intensive care, anaesthesiology and even primary care, perform bedside echocardiography. This shift has been driven by the advent of compact, easy-to-use ultrasound devices that have made it easier for non-specialists to perform cardiac imaging. Although point-of-care ultrasound has emerged over the past three decades, its growth may have accelerated since 2020, likely due to the COVID-19 pandemic [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003ePoint-of-care echocardiography (POCE) is defined as the acquisition, interpretation and immediate clinical integration of echocardiographic images performed by clinicians at the patient's bedside, rather than by a radiologist or cardiologist [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The different levels of cardiac ultrasound can be categorised according to the extent of the examination [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] (Fig.\u0026nbsp;1). The current study corresponds to a detailed FOCUS examination according to the scheme.\u003c/p\u003e \u003cp\u003eFigure1\u003c/p\u003e \u003cp\u003eOne of the key uses of POCE is to diagnose patients with acute chest pain [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Acute chest pain is one of the most common yet challenging presentations in emergency clinical practice, requiring immediate and accurate diagnosis and management. In the context of emergency medicine, where time is of the essence, POCE has emerged as a pivotal diagnostic tool beyond the traditional confines of cardiology departments. The use of POCE by trained non-cardiologists has begun to revolutionise patient assessment, providing a real-time view of cardiac function at the bedside. However, there is little evidence on the optimal scope of the examination and the training of the examiner. A key question remains: Can structured training in POCE for non-cardiologists significantly improve the speed and quality of patient care? And at what cost?\u003c/p\u003e\n\u003ch3\u003eAims of the study\u003c/h3\u003e\n\u003cp\u003eThe study “Echocardiography by Non-cardiologist in Early Management of Patients With Chest Pain (ENDEMIC)” aims to assess the effect of controlled training of non-cardiologists on the use of POCE in the management of patients with acute chest pain. The primary objective was to assess the impact of POCE on the length of stay in the emergency department (ED). The primary safety endpoint was the occurrence of major adverse cardiovascular events (MACE) within 30 days of enrolment. Secondary objectives were to evaluate the impact of POCE on the time to revascularisation and to assess the quality of the examination performed.\u003c/p\u003e \n "},{"header":"Methods","content":"\u003cp\u003eWe conducted a prospective, randomised cohort study at the Department of Emergency Medicine and First Department of Medicine - Cardioangiology, University Hospital Hradec Kralove, Czech Republic (ClinicalTrial.gov NCT05306730). The study protocol was approved by the Ethics Committee and was conducted in accordance with the Declaration of Helsinki. All patients provided informed written consent.\u003c/p\u003e\u003ch3\u003eTraining on point-of-care echocardiography\u003c/h3\u003e\u003cp\u003eThe training programme was described in detail previously [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The training program enrolled four physicians who had not undergone systematic training in echocardiography (including self-education) and had performed examinations up to the level of ultrasound-augmented physical examination. The British Society of Echocardiography (BSE) Level 1 protocol [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] was chosen as the basis for determining the scope of the training. The following modalities were added to this training: diameter of ascending aorta, colour flow mapping of aortic and mitral valve in short axis projection and measurement of tricuspid valve gradient. This additional training was added to the original protocol to cover common and serious conditions encountered in the emergency department (e.g. aortic dissection, severe valvular disease and significant pulmonary hypertension).\u003c/p\u003e\u003cp\u003eThe training programme consisted of several steps: an introductory course in focused echocardiography, a supervised examination of patients in whom at least 29 predefined findings had to be identified (Supplementum 1) and a final examination of real patient assessed by a specialist with European Association of Cardiovascular Imaging accreditation in transthoracic echocardiography. The total training period was approximately 6 months.\u003c/p\u003e\u003cp\u003ePhysicians began performing POCE on study participants immediately after successfully completing the course. To maintain the quality of the examinations, graduates were required to document at least fifty examinations per year. In addition, once a year, graduates spent four hours in the EchoLab under the supervision of a mentor to verify their continuing competence in performing POCE.\u003c/p\u003e\u003ch3\u003eSelection of participants\u003c/h3\u003e\u003cp\u003ePatients presenting to the ED with chest pain were eligible for the study. Inclusion criteria were as follows: 18 years of age or older; and pain that may have had a cardiovascular aetiology based on the patient's history, physical examination, and ECG findings. Exclusion criteria were as follows: ST-elevation myocardial infarction (STEMI), active pacemaker, pregnancy, performance status of 4 on the Zubrod scale, and refusal or inability to give informed consent. Patients were not excluded on the basis of poor ultrasound visualisation. All patients were followed up for a minimum of 3 months. Patients were randomized in an even-odd manner to a POCE-assisted management group or a standard management group (control group).\u003c/p\u003e\u003ch3\u003eEchocardiography examination\u003c/h3\u003e\u003cp\u003ePOCE was performed following ECG and standard clinical examination, but no later than 90 minutes after arrival at the emergency department. It was performed by an operator who had completed the aforementioned training programme. The recommended scope of POCE was based on the BSE Level 1 protocol. However, the examining physician was authorised to extend the scope of the examination if necessary.\u003c/p\u003e\u003cp\u003eAll images of the examination were archived in the hospital information system and reviewed post hoc by an EACVI accredited echocardiographer and the approved supervisor of the British Society of Echocardiography to assess the accuracy of the examinations performed.\u003c/p\u003e\u003cp\u003e In patients in control group, echocardiography was performed only if required by specific ESC guidelines (in case of 3-hour troponine protocol etc.). In that case, the examination was performed by a cardiology fellow.\u003c/p\u003e\u003ch3\u003eOutcomes\u003c/h3\u003e\u003cp\u003eThe primary endpoint of the study was the length of ED stay. The start of the ED stay was defined as the time of the patient's first contact with the ED, regardless of whether the patient was referred by the emergency medical service or self-referred. The end of the ED stay was defined as the time when the patient physically left the ED. The time to decision was defined as the time at which the final decision regarding diagnosis or the initiation of a guideline-based therapeutic intervention was made in the ED, depending on which occurred later.\u003c/p\u003e\u003cp\u003eTime to revascularisation and occurrence of MACE were obtained from the patients' medical records and confirmed by evidence from the Czech National Population Registry.\u003c/p\u003e\u003cp\u003eMACE was defined as the composite endpoint of cardiovascular death, non-fatal myocardial infarction, or unplanned hospitalisation due to cardiovascular disease within 30 days of the clinical examination. Because of the absence of non-fatal myocardial infarction and very low incidence of death in discharged patients, discrepancy between working and final diagnosis was added as a secondary safety endpoint.\u003c/p\u003e\u003cp\u003eA working diagnosis was considered accurate if it shared both a pathophysiological mechanism and diagnostic criteria with the final diagnosis (e.g., a working diagnosis of acute coronary syndrome was considered accurate if the final diagnosis was myocardial infarction or unstable angina but not takotsubo cardiomyopathy). In case of discrepancy between the working and final diagnosis, the final diagnosis was determined by independent review.\u003c/p\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003e This study was approved by the local ethical committee (Ethics Committee of University Hospital in Hradec Kralove, accredited by the Office for Human Research Protections under the number IORG0008813). The study was conducted in accordance with the Declaration of Helsinki. All patients provided written informed consent.\u003c/p\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCategorical variables are expressed as group counts and relative frequencies (%), and continuous variables are expressed as group means, standard deviations and totals (N). Effect size is expressed as median of difference (ΔM) with 95% confidence interval (95% CI).\u003c/p\u003e\u003cp\u003eAs most of the continuous variables examined here did not follow a normal distribution (as indicated by exploratory analysis and the Shapiro-Wilk test), the non-parametric Wilcoxon rank-sum test was used to compare continuous outcomes between groups. Categorical variables were compared using Fisher's exact test. Statistical significance was set at alpha = 0.05 for all tests. In cases of multiple testing of similar hypothesis (e.g. various ways of reducing management time), the Bonferroni-Holm correction for the nominal level of statistical significance was applied to keep the familywise Type I error rate alpha at 0.05. Statistical analyses were performed using R software (R version 3.5.3; R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e\u003cp\u003eIn this study, we aimed to test the hypothesis that the implementation of POCE would lead to a reduction in the length of stay in the ED of at least 15% (≈ 30 minutes). We performed a power analysis to determine the appropriate sample size for our study. The desired power was set at β = 0.8. The effect size was estimated on the basis of preliminary data in which the length of stay in the ED was determined to be 176 ± 90 minutes. Taking these parameters into account, the sample size was determined to be 430 patients.\u003c/p\u003e\u003cp\u003eAn interim analysis was performed after every 50 patients. If both the primary and secondary endpoints reached statistical significance (including the Bonferroni-Holm correction), the Data Safety Monitoring Board was asked to assess the ethics of continuing the study. Given the continued superiority of POCE in both reducing the length of stay in the ED and improving diagnostic accuracy, the Board recommended early termination of the study after enrolment of 150 patients.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n \u003ch2\u003eCharacteristics of study subjects\u003c/h2\u003e\n \u003cp\u003eBetween September 2022 and October 2023, a total of 150 patients were enrolled in the study. The baseline demographic and clinical data of the patients are summarized in Table \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The descriptive characteristics were well balanced across the groups.\u003c/p\u003e\n \u003cp\u003eIn the POCE group, echocardiography was performed in all patients. All records were subsequently reviewed, and the real extent of the examination was recorded. Of the 16 projections based on the BSE Level 1 protocol, 12.5 \u0026plusmn; 2.5 (78.4 \u0026plusmn; 15.9%) were actually performed. An additional 5.4 \u0026plusmn; 1.6 projections were performed on average. A total of 91.1% of the projections were fully conclusive, 7.6% were partly inconclusive, and 1.3% were completely inconclusive (Table 2). Regional wall motion abnormity (including septal D-shape) was present in 38.5% of patients; however, it was present in only 21.4% of patients with confirmed acute coronary syndrome.\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of baseline characteristics between the POCE and control groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePOCE group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAge [years; mean \u0026plusmn; SD]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61.1 \u0026plusmn; 17.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66.1 \u0026plusmn; 15.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMale sex [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e50 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e41 (54.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.181\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eCaucasian ethnicity [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e75 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eChronic coronary artery disease [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (26.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDiabetes mellitus [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e19 (25.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e12 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.226\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eArterial hypertension [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (52.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e42 (56.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.743\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSevere valvular disease [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAtrial fibrillation [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e7 (9.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e10 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.608\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eActive smoker [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eFormer smoker [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e15 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e17 (22.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.690\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAntiplatelet therapy [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e20 (26.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e23 (30.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.718\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAnticoagulation therapy [n (%)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e8 (10.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e13 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.239\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eGRACE score [points]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e96.0\u003c/p\u003e\n \u003cp\u003e(69.0-125.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e100.0\u003c/p\u003e\n \u003cp\u003e(64.5\u0026ndash;134.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.536\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eHEART score [points; median (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0 (3.0\u0026ndash;7.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e5.0 (3.0\u0026ndash;6.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.648\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIndication of further follow-up [n; %]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e30 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e26 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.612\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePatients requiring hospital admission [n; %]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e25 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e14 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.062\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ePOCE - point-of-care echocardiography\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eGRACE - Global Registry of Acute Coronary Events [\u003cspan class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eHEART - History, ECG, Age, Risk factors and Troponin (18665203)[\u003cspan class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eECG - electrocardiography\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\u0026nbsp;\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eExtent of POCE examinations\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"2\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eProjection\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eNumber patients with a projection performed [n (%)]\u003c/p\u003e\n \u003cp\u003e\u0026bull; fully conclusive [n (%)]\u003c/p\u003e\n \u003cp\u003e\u0026bull; partially inconclusive [n (%)]\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eParasternal ascending aorta**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e69 (92.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 67 (89.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePLAX (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (89.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 61 (81.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 5 (6.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePLAX (LVIDd)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e66 (88.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 46 (61.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 14 (18.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePLAX with CFM aortic and mitral valve*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (94.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 58 (77.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 13 (17.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX outflow (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e46 (61.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 42 (54.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX outflow with CFM aortic valve**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e54 (72.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 50 (66.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX outflow with CFM mitral valve**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (45.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 30 (40.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 2 (2.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX base (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e39 (52.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 38 (50.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX mid (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e61 (81.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 61 (81.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003ePSAX apex (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (37.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 28 (37.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA4C (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (94.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 61 (81.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 10 (13.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA4C (M-Mode) TAPSE*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e71 (94.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 71 (94.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA4C with CFM tricuspid valve*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e34 (45.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 34 (45.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA4C Tricuspid gradient (CW)**\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e52 (69.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 52 (69.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA4C with CFM mitral valve*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e60 (80.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 56 (74.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA5C (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e18 (24.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 15 (20.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA5C with CFM aortic valve*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e28 (37.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 27 (36.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA2C (2D)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e68 (88.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 58 (77.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 8 (10.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA2C with FCM mitral valve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e44 (58.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 40 (53.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA3C\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e64 (85.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 58 (77.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 6 (8.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eA3C with CFM aortic valve\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e38 (50.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 34 (45.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 4 (5.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubcostal 4C (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e63 (84.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 49 (65.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 12 (16.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubcostal IVC (2D)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e67 (88.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 64 (85.3)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 (4.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSubcostal IVC (M-Mode)*\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e58 (74.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 56 (74.7)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eSuprasternal long axis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e3 (4.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 3 (4.0)\u003c/p\u003e\n \u003cp\u003e\u0026bull; 0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eLeft ventricular systolic function assessed by at least two independent projections\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e74 (98.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMitral valve assessed by at least one projection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAortic valve assessed by at least one projection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e62 (82.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eIVC assessed by at least one projection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e56 (74.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e* - projections required by the BSE Level 1 protocol\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e** - additional projections involved in pr-estudy education\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003ePOCE - point-of-care echocardiography\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003ePLAX - parasternal long axis projection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eLVIDd - Left ventricular internal diameter in diastole\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003ePSAX - parasternal short axis projection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eCFM - colour flow mapping\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eA4C - apical 4-chamber projection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eTAPSE - tricuspid annular plane systolic excursion\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eA3C - apical 3-chamber projection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eA2C - apical 2-chamber projection\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003eIVC - inferior vena cava\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n \u003ch2\u003eMain results\u003c/h2\u003e\n \u003cp\u003eThe use of POCE resulted in a significant shortening of ED stay, time to decision and time to coronary angiography. The reduction in ED stay was most pronounced in patients with bundle branch block, ST elevations not meeting STEMI criteria, or those with severe non-coronary disease (Fig. 2 and Fig. 3; Supplementum 2 and 3). The incidence of adverse events was lower than expected; therefore, the study would be underpowered for a reliable analysis even if enrolment were not stopped (Table \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). We found no evidence to support the hypothesis that the use of POCE increases the risk of an incorrect working diagnosis (6.3% in the POCE group vs. 30.4% in the control group, p\u0026thinsp;=\u0026thinsp;0.997 for inferiority). Although this was not a prespecified endpoint, the risk ratio suggests that the use of POCE resulted in superior diagnostic accuracy: RR\u0026thinsp;=\u0026thinsp;0.21 (0.047\u0026ndash;0.90).\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\u0026nbsp;\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cp\u003eComparison of the POCE and control groups\u003c/p\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003ccolgroup cols=\"4\"\u003e\u003c/colgroup\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ePOCE group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003eControl group\u003c/p\u003e\n \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;75)\u003c/p\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cp\u003ep\u003c/p\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to decision in whole study group [min; mean (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e138.0\u003c/p\u003e\n \u003cp\u003e(68.5\u0026thinsp;\u0026minus;\u0026thinsp;230.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e252.0 (165.5\u0026thinsp;\u0026minus;\u0026thinsp;304.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration of ED stay in whole study group [min; mean (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e209.0 (143.5\u0026thinsp;\u0026minus;\u0026thinsp;260.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e271.0\u003c/p\u003e\n \u003cp\u003e(206.5\u0026thinsp;\u0026minus;\u0026thinsp;336.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.0003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to decision among hospitalized patients [min; mean (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e112.0\u003c/p\u003e\n \u003cp\u003e(51.0 \u0026minus;\u0026thinsp;180.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e183.5\u003c/p\u003e\n \u003cp\u003e122.75\u0026thinsp;\u0026minus;\u0026thinsp;252.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eDuration of ED stay among hospitalized patients [min; mean (IQR)]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e178.0 (75.0\u0026thinsp;\u0026minus;\u0026thinsp;224.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e219.5\u003c/p\u003e\n \u003cp\u003e(145.5 \u0026minus;\u0026thinsp;293.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.058\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eTime to coronary angiography [hours]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e29.6 (23.6\u0026ndash;38.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e120.3 (45.6-147.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e0.027\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eMACE at day 30 [n; %]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e0 (0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003eAll cause deaths at day 90 [n; %]\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cp\u003e1 (1.33)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003ctfoot\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003ePOCE - point-of-care echocardiography\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eED - emergency department\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eIQR - interquartile range\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"4\"\u003eMACE \u0026ndash; Mayor cardiovascular adverse events\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tfoot\u003e\n \u003c/table\u003e\n \u003c/div\u003e\n \u003cp\u003eTable \u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e\u003c/p\u003e\n \u003cp\u003eFigure 2\u003c/p\u003e\n \u003cp\u003eFigure 3\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe present study stands at the intersection of educational strategy and clinical effectiveness and provides insight into how systematic training in echocardiography can equip non-cardiologists with the skills needed to effectively manage patients with acute chest pain. We have shown that physicians with no previous experience can be effectively trained to perform POCE, and that their clinical performance resulted in shorter emergency department stays and more accurate diagnoses.\u003c/p\u003e \u003cp\u003eDespite the widespread use of echocardiography in patients with acute cardiovascular disease, recommendations for POCE in the emergency setting remain vague, particularly regarding the optimal extent and timing of examinations[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This lack of clarity is a cause for concern and is in line with the recognition of POCE as a major health technology risk [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, evidence on the extent of necessary education is limited and primarily based on national standards, despite calls for high-quality, competency-based cardiac imaging service delivery[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe efficacy and accuracy of POCE has been evaluated in several previous studies. Previous studies have shown acceptable agreement between POCE and comprehensive echocardiography, as well as increased diagnostic confidence among physicians, although without significant clinical benefit[\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Recent research has demonstrated reductions in patient management time but not mortality endpoints, but there is no detailed information on examiner training and scope of examination[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, we believe that it is not echocardiography itself that should be the focus of scientific interest, but rather the way in which it is taught, indicated and performed. In particular, it needs to be shown that POCE can be beneficial to ordinary emergency physicians, not just highly experienced specialists. This is where we see the greatest contribution of this study.\u003c/p\u003e \u003cp\u003eThe rationale for performing early echocardiography in patients with chest pain is traditionally based on the pathophysiology of the ischaemic cascade[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] (Fig.\u0026nbsp;4). Although our study was not designed to identify specific patient subgroups that would benefit most from early POCE, the greatest benefit was observed in patients with non-coronary causes of pain, such as pulmonary embolism, pericarditis, and aortic valve stenosis. In relation to ECG findings, patients with difficult-to-interpret findings (e.g. bundle branch block, ST elevations not meeting STEMI criteria) benefited most from POCE. Early recognition of less common causes of pain was also the main reason for the trend towards a higher number of hospital admissions in the POCE group. Interestingly, regional wall motion abnormalities were rare in patients with acute coronary syndrome. However, when such impairment was detected, the diagnostic process was significantly accelerated, thereby reducing the length of stay in the ED in rule-in patients. It must be emphasised that the standard troponin algorithm remains the main diagnostic method to rule out acute coronary syndrome in most patients with acute chest pain.\u003c/p\u003e \u003cp\u003eFigure 4\u003c/p\u003e \u003cp\u003eAlthough the training in this study was based on the BSE Level 1 protocol, which is considered to be one of the most valuable focused protocols[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], physicians often expanded the scope of the examination to reliably detect regional wall motion abnormalities. This finding is consistent with previous findings that assessment of wall motion abnormalities is poorly predictive of acute coronary syndrome when insufficiently detailed POCE protocols are used[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Archiving and sharing POCE records has been shown to be very important in improving collaboration with consulting specialists. We therefore strongly agree with the need to archive POCE examinations as recommended by the European Association of Cardiovascular Imaging[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe recommend the development of evidence-based international recommendations for POCE training for basic clinical syndromes, which may broaden the impact of POCE and consolidate its role in emergency medicine[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, we support the American Society of Echocardiography's recommendation that cardiologists should lead the training of non-cardiologists in echocardiography, with an emphasis on standardised, competency-based service delivery[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStudy limitations\u003c/h2\u003e \u003cp\u003eThe main limitation of this study is its monocentric design. We expect that the benefits of POCE may differ from those observed in tertiary cardiovascular centres. Acceleration of chest pain management may not be feasible in centres that are unable to respond immediately to the full range of POCE findings, either due to lack of resources or free capacity. The benefit may also be compromised by mistrust of other specialists in the reliability of POCE performed by emergency physicians.\u003c/p\u003e \u003cp\u003eThe study was not designed to prove improved diagnostic accuracy by POCE. This is because, at the time the study was designed, there was more concern about the high error rate of POCE carried out by non-cardiologists. For this reason, the error rate assessment was only included as a safety endpoint.\u003c/p\u003e \u003cp\u003eThe randomisation process cannot be blinded due to the nature of POCE, which requires direct interaction between the clinician and the process of performing the ultrasound examination. The chosen study design does not distinguish to what extent the disclosure of key findings or the increase in physician confidence in the diagnostic process is the cause of the acceleration of care.\u003c/p\u003e \u003cp\u003ePatients for whom POCE could not be performed within 90 minutes of arriving at the ED were excluded from the study. The number of such patients in the study population was very low. In chronically congested EDs, this condition may significantly limit the generalisability of the results. The number of patients included does not allow reliable subanalysis for rare diseases and ECG findings. Given the monocentric nature of the study, the impact of POCE on the management of less common conditions may also be biased.\u003c/p\u003e \u003cp\u003eAnother limitation of the study is the small number of physicians performing POCE examinations. Without enthusiasm for the implementation of POCE in clinical practice and confidence in the method, the benefits may be reduced or absent.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe results of our study clearly demonstrate the significant benefits of POCE performed in the ED by non-cardiologists who have undergone structured training. In particular, the implementation of POCE led to a significant reduction in length of ED stay and decision-making times, which are critical measures of the efficiency of emergency care. The time to coronary angiography was also reduced. The accuracy of initial diagnosis improved significantly, highlighting the clinical value of POCE in the management of acute chest pain. An incidental finding of the study is that the BSE Level 1 protocol appears to be an insufficient training resource for the use of POCE in the management of acute chest pain.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eCompeting interest\u003c/strong\u003e \u003cp\u003eNone declared\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe work was supported by the Ministry of Defence of the Czech Republic \u0026ldquo;Long Term Organization Development Plan 1011\u0026rdquo; \u0026ndash; Clinical Disciplines II of the Military Faculty of Medicine Hradec Kralove, University of Defence, Czech Republic (Project No: DZRO-FVZ22-KLINIKA II) and the Research Project of Charles University Cooperatio, research area CARD.\u003c/p\u003e\u003ch2\u003eAuthor contributions:\u003c/h2\u003e \u003cp\u003ePG and MJ are lead authors and contributed equally to the paper. PG, MJ, KM and RP conceived the study and designed the trial. MJ, RP and JN supervised the conduct of the trial and data collection. PG, MC and JB undertook recruitment of patients. PG and MJ managed the data, including quality control. JK administrated the project. JV provided statistical advice on study design and analysed the data. JMH was responsible for funding the study. PG and MJ wrote the manuscript. MJ drafted the manuscript, and all authors contributed substantially to its revision. MJ takes responsibility for the paper as a whole.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eThe authors thank Richard Fisher, MD for his valuable comments during the preparation of this paper and Teresa Sokol for reliable extraction of patient data from the medical records.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eZhang L, Wang B, Zhou J, Kirkpatrick J, Xie M, Johri AM (2020) Bedside Focused Cardiac Ultrasound in COVID-19 from the Wuhan Epicenter: The Role of Cardiac Point-of-Care Ultrasound, Limited Transthoracic Echocardiography, and Critical Care Echocardiography. J Am Soc Echocardiogr 33(6):676\u0026ndash;682\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang G, Vengerovsky A, Morris A, Town J, Carlbom D, Kwon Y (2020) Development of a COVID-19 Point-of-Care Ultrasound Protocol. J Am Soc Echocardiogr 33(7):903\u0026ndash;905\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIyengar-Kapuganti RL, Patel N, Anastasius M, She T, Nelson BP, Lukas M et al (2020) Point-of-Care Ultrasound Findings and Clinical Outcomes in Patients with COVID-19. J Am Soc Echocardiogr 33(11):1416\u0026ndash;1417\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiaz-Gomez JL, Mayo PH, Koenig SJ (2021) Point-of-Care Ultrasonography. N Engl J Med 385(17):1593\u0026ndash;1602\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKimura BJ (2017) Point-of-care cardiac ultrasound techniques in the physical examination: better at the bedside. Heart 103(13):987\u0026ndash;994\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKirkpatrick JN, Grimm R, Johri AM, Kimura BJ, Kort S, Labovitz AJ et al (2020) Recommendations for Echocardiography Laboratories Participating in Cardiac Point of Care Cardiac Ultrasound (POCUS) and Critical Care Echocardiography Training: Report from the American Society of Echocardiography. J Am Soc Echocardiogr 33(4):409\u0026ndash;422 e4\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eByrne RA, Rossello X, Coughlan JJ, Barbato E, Berry C, Chieffo A et al (2023) 2023 ESC Guidelines for the management of acute coronary syndromes. Eur Heart J 44(38):3720\u0026ndash;3826\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, AHA/ACC/ASE/CHEST et al (2021) /SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. \u003cem\u003eCirculation.\u003c/em\u003e 2021;144(22):e368-e454\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGrenar P, Novy J, Medilek K, Jakl M (2024) Point-of-Care Cardiac Ultrasound Training Programme: Experience from the University Hospital Hradec Kralove. Emerg Med Int 2024:9974284\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHindocha R, Garry D, Short N, Ingram TE, Steeds RP, Colebourn CL et al (2020) A minimum dataset for a Level 1 echocardiogram: a guideline protocol from the British Society of Echocardiography. Echo Res Pract 7(2):G51\u0026ndash;G8\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdvardsen T, Asch FM, Davidson B, Delgado V, DeMaria A, Dilsizian V et al (2022) Non-invasive imaging in coronary syndromes: recommendations of the European Association of Cardiovascular Imaging and the American Society of Echocardiography, in collaboration with the American Society of Nuclear Cardiology, Society of Cardiovascular Computed Tomography, and Society for Cardiovascular Magnetic Resonance. Eur Heart J Cardiovasc Imaging 23(2):e6\u0026ndash;e33\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKonstantinides SV, Meyer G, Becattini C, Bueno H, Geersing GJ, Harjola VP et al (2020) 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J 41(4):543\u0026ndash;603\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInstitute E Top 10 Health Technology Hazards for 2020 2020 [cited 2024 May 22th]; Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ecri.org/landing-2020-top-ten-health-technology-hazards\u003c/span\u003e\u003cspan address=\"https://www.ecri.org/landing-2020-top-ten-health-technology-hazards\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWestwood M, Almeida AG, Barbato E, Delgado V, Dellegrottaglie S, Fox KF et al (2023) Competency-based cardiac imaging for patient-centred care. A statement of the European Society of Cardiology (ESC). With the contribution of the European Association of Cardiovascular Imaging (EACVI), and the support of the Association of Cardiovascular Nursing \u0026amp; Allied Professions (ACNAP), the Association for Acute CardioVascular Care (ACVC), the European Association of Preventive Cardiology (EAPC), the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Heart Rhythm Association (EHRA), and the Heart Failure Association (HFA) of the ESC. Eur Heart J 44(45):4771\u0026ndash;4780\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCroft PE, Strout TD, Kring RM, Director L, Vasaiwala SC, Mackenzie DC (2019) WAMAMI: emergency physicians can accurately identify wall motion abnormalities in acute myocardial infarction. Am J Emerg Med 37(12):2224\u0026ndash;2228\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBlans MJ, Bousie E, van der Hoeven JG, Bosch FH (2021) A point-of-care thoracic ultrasound protocol for hospital medical emergency teams (METUS) improves diagnostic accuracy. Ultrasound J 13(1):29\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSaglam C, Unluer EE, Yamanoglu NGC, Kara PH, Ediboglu E, Bektasli R et al (2021) Accuracy of Emergency Physicians for Detection of Regional Wall Motion Abnormalities in Patients With Chest Pain Without ST-Elevation Myocardial Infarction. J Ultrasound Med 40(7):1335\u0026ndash;1342\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuner NG, Yurumez Y, Yucel M, Alacam M, Guner ST, Ercan B (2020) Effects of Point-of-care Ultrasonography on the Diagnostic Process of Patients Admitted to the Emergency Department with Chest Pain: A Randomised Controlled Trial. J Coll Physicians Surg Pak 30(12):1262\u0026ndash;1268\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHuang CT, Chang CH, Chen JY, Ling DA, Lee AF, Wang PH et al (2023) The effect of point-of-care ultrasound on length of stay and mortality in patients with chest pain/dyspnea. Ultraschall Med 44(4):389\u0026ndash;394\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNesto RW, Kowalchuk GJ (1987) The ischemic cascade: temporal sequence of hemodynamic, electrocardiographic and symptomatic expressions of ischemia. Am J Cardiol 59(7):23C\u0026ndash;30C\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDowling K, Colling A, Walters H, Chandrasekaran B, Rimington H (2021) Piloting structured focused TTE in outpatients during the COVID-19 pandemic: 'old habits die hard'. Br J Cardiol 28(4):50\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXu Tan T, Wright D, Baloescu C, Lee S, Moore CL (2024) Emergency Physician-performed Echocardiogram in Non-ST Elevation Acute Coronary Syndrome Patients Requiring Coronary Intervention. West J Emerg Med 25(1):9\u0026ndash;16\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeskovic AN, Hagendorff A, Lancellotti P, Guarracino F, Varga A, Cosyns B et al (2013) Emergency echocardiography: the European Association of Cardiovascular Imaging recommendations. Eur Heart J Cardiovasc Imaging 14(1):1\u0026ndash;11\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNeskovic AN, Edvardsen T, Galderisi M, Garbi M, Gullace G, Jurcut R et al (2014) Focus cardiac ultrasound: the European Association of Cardiovascular Imaging viewpoint. Eur Heart J Cardiovasc Imaging 15(9):956\u0026ndash;960\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eCardim N, Dalen H, Voigt JU, Ionescu A, Price S, Neskovic AN et al (2019) The use of handheld ultrasound devices: a position statement of the European Association of Cardiovascular Imaging (2018 update). Eur Heart J Cardiovasc Imaging 20(3):245\u0026ndash;252\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePopescu BA, Stefanidis A, Fox KF, Cosyns B, Delgado V, Di Salvo GD et al (2020) Training, competence, and quality improvement in echocardiography: the European Association of Cardiovascular Imaging Recommendations: update 2020. Eur Heart J Cardiovasc Imaging 21(12):1305\u0026ndash;1319 List of Supplemental Digital Content 1: Supplementary tables.docx\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Point-of-care echocardiography, Acute chest pain, Education, Emergency medicine","lastPublishedDoi":"10.21203/rs.3.rs-6735927/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6735927/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAs point-of-care echocardiography (POCE) has expanded beyond cardiology into general emergency medical practice, there has been a lack of standardized, evidence-based imaging protocols and training, thus leading to challenges with respect to the quality of cardiac imaging for acute cardiovascular syndromes. The ENDEMIC study aims to assess the effectiveness of POCE based on structured training for noncardiologists on the management of patients with acute chest pain in emergency departments.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA total of 150 patients presenting with acute chest pain were enrolled in this prospective randomized clinical trial. Patients were assigned to either the POCE-assisted management group or the standard management group. Physicians performing POCE examinations received focused training based on the British Society of Echocardiography level 1 standard. The primary outcome was the length of stay in the emergency department (ED), and the secondary outcomes included the time to revascularization and diagnostic accuracy at the initial examination.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe results revealed that the POCE group had a significantly shorter length of ED stay (209.0 vs. 271.0 min, p\u0026thinsp;=\u0026thinsp;0.0003), time to decision (138.0 vs. 252.0 min, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001) and time to coronary angiography (29.6 vs. 120.3 hours, p\u0026thinsp;=\u0026thinsp;0.027) than the control group. Furthermore, the error of initial diagnoses was lower in the POCE group (6.3% vs. 30.4%, RR\u0026thinsp;=\u0026thinsp;0.21 [0.047-0.90]).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe implementation of POCE by trained noncardiologists significantly reduced the duration of ED stay and enhanced the management of patients with acute chest pain in the ED. Systematic training enables physicians without prior echocardiography experience to perform POCE accurately and efficiently.\u003c/p\u003e","manuscriptTitle":"Effect of Point-of-Care Echocardiography by Noncardiologists on Treatment Time and Diagnostic Accuracy in Acute Chest Pain","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-10 18:13:02","doi":"10.21203/rs.3.rs-6735927/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-06-05T05:02:12+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-04T20:07:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-29T02:47:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"Internal and Emergency Medicine","date":"2025-05-27T07:00:09+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"internal-and-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iaem","sideBox":"Learn more about [Internal and Emergency Medicine](http://link.springer.com/journal/11739)","snPcode":"11739","submissionUrl":"https://www.editorialmanager.com/iaem/default.aspx","title":"Internal and Emergency Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"54b88516-19e5-4147-acd4-bcedf2163641","owner":[],"postedDate":"June 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:04:09+00:00","versionOfRecord":{"articleIdentity":"rs-6735927","link":"https://doi.org/10.1007/s11739-025-04198-6","journal":{"identity":"internal-and-emergency-medicine","isVorOnly":false,"title":"Internal and Emergency Medicine"},"publishedOn":"2025-11-24 15:57:21","publishedOnDateReadable":"November 24th, 2025"},"versionCreatedAt":"2025-06-10 18:13:02","video":"","vorDoi":"10.1007/s11739-025-04198-6","vorDoiUrl":"https://doi.org/10.1007/s11739-025-04198-6","workflowStages":[]},"version":"v1","identity":"rs-6735927","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6735927","identity":"rs-6735927","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}