Agreement of point of care ultrasound and final clinical diagnosis in patients with acute decompensated heart failure, acute coronary syndrome, and shock: POCUS not missing the target

Agreement of point of care ultrasound and final clinical diagnosis in patients with acute decompensated heart failure, acute coronary syndrome, and shock: POCUS not missing the target | 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 Agreement of point of care ultrasound and final clinical diagnosis in patients with acute decompensated heart failure, acute coronary syndrome, and shock: POCUS not missing the target José Atilio Núñez Ramos, Dagoberto Duarte Misol, María Andrea Burgos Petro, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3793211/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 4 You are reading this latest preprint version Abstract Introduction : Point-of-Care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. Dyspnea, chest pain and shock are conditions valuable to evaluate with ultrasound considering diagnostic accuracy and clinical impact already proven. There is scarce evidence in diagnosis agreement using ultrasound as an extension of physical examination. We aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams and discuss details. Methods : A cross-sectional analytical study was conducted in adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, shock. All were evaluated with ultrasound at admission. Agreement between initial diagnosis using POCUS and final definite diagnosis was calculated. Failed diagnosis and inconclusive exams were analyzed. Results : A total of 209 patients were analyzed. Populations mostly males, mean age 64yo, hypertensive. Patients with dyspnea, agreement in heart failure diagnosis was 0.98; agreement in chest pain with non-ST acute coronary syndrome was 0.96; agreement in type of shock was 0.90. Twelve 12 (5%) patients had an inconclusive POCUS exam, and 16 (7%) patients had a failed diagnosis. Conclusion : The use POCUS in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute myocardial infarction, and shock. Prospective studies are needed to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors. Point-of-Care ultrasound diagnosis agreement heart failure shock acute coronary syndrome Figures Figure 1 Introduction Point-of-Care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. To this moment, ultrasound (US) has been used for more than twenty years in intensive care units (ICU) and emergency departments (ED) around the world. The impact on diagnosis and clinical outcomes is evident. Several accuracy studies have proved its diagnostic value over physical examination alone, and chest x-ray ( 1 ). Clinical impact has been evaluated through cohort studies and clinical trial, demonstrating better outcomes in patients who received POCUS evaluation ( 2 – 5 ). Ultrasound at the bedside has been used for several critical or emergent conditions. Regarding shock, POCUS has proved to be of great value. Recently Yoshida et al published an accuracy study reporting a sensitivity and specificity of 98% and 96% when POCUS is used alongside history and physical examination ( 6 ). Diagnosing dyspnea using lung ultrasound is better than using clinical examination and/or chest x-ray ( 1 ). Specifically, heart failure diagnosis based on lung POCUS is recommended in recent guidelines ( 7 ). Chest pain is a complex clinical presentation in the ED, and ultrasound has shown the ability to narrow the differential diagnosis in critical scenarios. Aortic dissection and acute coronary syndromes are two of the main diagnoses in which US is helpful ( 8 ). Since the introduction of point of care ultrasonography, many studies have evaluated the agreement between ultrasound findings and formal ultrasonography. B lines, pleural effusion, dilated heart cavities, valvulopathies, and many other specific alterations have been analyzed ( 9 – 12 ). Most studies show good agreement between novice operator-performed ultrasound and experienced operator-performed ultrasound. Reported evidence includes findings in echocardiography with good agreement ( 9 ) and others with a not so good agreement ( 10 , 11 ). Lung ultrasound is valuable and reproducible ( 8 ). In a population of patients with shock, studies have conflicting results ( 12 ) considering a heterogenous population and different levels of training. There is scarce evidence comparing initial clinical diagnosis using ultrasound as an extension of physical examination and final diagnosis in clinical practice. Baid et al published a paper using POCUS as an initial diagnostic tool in the ED with good concordance with final diagnosis ( 13 ). Buhumaid showed good differential narrowing using US but no concordance with final diagnosis ( 8 ). Knowing diagnostic agreement could lead to more confident diagnosis at emergency department and possibly to more rapid treatment initiation. We aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis at discharge in specific groups of patients. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams and discuss details. Methods This is an analytical cross-sectional study of emergency department patients consulting for dyspnea, chest pain and undifferentiated shock state. It was carried out in a University-based hospital in Colombia. The Ethics Committee and Institutional Research Board approved the protocol (Act 281, November 24th, 2022). Population The study was conducted between 2019 and 2022. Patients eligible were adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, shock. Inclusion criteria were a POCUS evaluation performed at admission, US findings reported in clinical records, reported initial diagnosis using POCUS alongside usual clinical evaluation, reported discharge (final) diagnosis considering evolution, laboratory parameters and images. Exclusion criteria were death during the first 24 hours of admission, not definitive diagnosis at discharge, in-hospital transfer to another healthcare facility and not clear diagnosis at entrance. Ultrasound and clinical evaluation Patients in the ED with any of the three main complaints were first evaluated by an emergency physician. Initial orders were given (oxygen, intravenous fluids, images, electrocardiogram, etc) and then, an internal medicine specialist was consulted. Clinical history was taken by the attending internal medicine physician, then a thorough physical examination was performed, including Point-of-Care Ultrasound as an extension of the physical exam and an aid to assure an initial diagnosis. Every patient had an initial diagnosis using clinical history, physical examination, and ultrasound evaluation. POCUS evaluation was performed using a multiprobe ultrasound machine (Sonoscape Corp. Model S2. Guangdong, China. 2016–3) by the attending internal medicine physician trained in POCUS. Assessment included BLUE protocol ( 14 ) using a linear transducer with a frequency of 5–10 MHz and a phased array with a frequency of 2–5 MHz in patients with dyspnea. B-lines, pleural effusion, and lung consolidation were specific findings at US evaluation. Findings were integrated with clinical symptoms to consider a specific initial diagnosis. A focused cardiac ultrasound evaluation, using a phased array probe with a frequency of 2–5 MHz, in chest pain included at least three of the four main cardiac views (parasternal long and short axis, apical and subxiphoid). Eyeball systolic ventricular function, pericardial effusion, and wall motion abnormalities were considered. RUSH protocol ( 15 ) was followed in shock patients to rule-in or rule-out specific etiologies such as obstructive causes, cardiogenic shock or hypovolemic shock. Patients were treated according to the initial diagnosis. Medications, images, and laboratory tests were ordered considering clinical context and to-date clinical guidelines. No further ultrasound evaluation was performed during hospitalization. The internal medicine specialist from the ED did not have any other interaction with the patient or clinical staff in the ICU and general ward. Specialists from these clinical areas were aware of the POCUS initial evaluation. Final Diagnosis The final diagnosis was given by the attending physician at discharge in the general ward. This internal medicine specialist was in charge of every patient included in the study from in-ward admission until discharge. This diagnosis considered initial evaluation, all laboratory diagnostic work-up, images, and clinical evolution to declare a final and definite diagnosis. Data and statistical analysis All the information was taken from clinical records. An Excel de-identified database was built for analysis purposes. Every variable was drawn from initial clinical history, ultrasound evaluation at admission and final diagnosis on discharge day. According to published methods for sample size estimation ( 16 ), considering a disagreement probability of 20%, a Cohen’s Kappa of 0.85 and an alfa value of 0.05, the population should be of 192 patients. Qualitative variables are expressed in absolute and relative frequencies. Quantitative variables are expressed in mean and standard deviation, median and interquartile ranges. The initial diagnosis was compared for agreement with the final diagnosis using Cohen's kappa statistic in patients with heart failure, chest pain and shock. A two-sided p value < 0.05 was considered to indicate statistical significance. All statistical analyses were conducted using SPSS version 25. Results There were 9051 patients presenting to the ED with dyspnea, shock, or chest pain in the specified period. Out of the total population, 318 (3,5%) patients received a POCUS evaluation at admission. Patients not fulfilling inclusion criteria were 63 (0,7%) and 255 (2,8%) were included. There were 46 (0,5%) patients excluded. Finally, 209 patients were analyzed (Fig. 1 ). Population was predominantly male (56,5%), mean age of 64 years old, with a background of hypertension (60,3%) and type 2 diabetes (23,4%). The main reason to visit the ED was dyspnea (56,9%), chest pain (32,5%) and shock (8,6%). The most frequent diagnosis at the entrance was acute decompensated heart failure (36,8%) followed by acute coronary syndrome (28,2%). See Table 1 . Table 1 Population baseline characteristics Variables All n = 209 Demographic and clinical Age years (Mean, SD) 64 (17) Male Sex n, (%) 118 (56) Hypertension n, (%) 126 (60) Type 2 diabetes n, (%) 49 (23) Heart failure n, (%) 41 (20) Coronary heart disease n, (%) 51 (24) POCUS indication Dyspnea n, (%) 119 (57) Chest pain n, (%) 61 (29) Shock n, (%) 29 (14) Radiologic studies Chest X-ray n, (%) 174 (83,2) Echocardiogram n, (%) 153 (73,2) CT scan n, (%) 78 (37,3) POCUS findings B-lines n, (%) 75,4 Pleural efussion n, (%) 34,5 Lung consolidation/Atelectasis n, (%) 40,1 Left ventricle dysfunction n, (%) 52,3 Wall motion abnormalities n, (%) 46,3 Pericarial effusion n, (%) 11,5 Non-conclusive n, (%) 12 (5,7) A total of 153 patients (73,2%) received a comprehensive echocardiogram. Regarding radiologic studies 174 (83,2%) patients had a chest x-ray at the ED entrance and 78 (37,3%) had a CT scan. See Table 1 . All patients were evaluated with POCUS at ED entrance (see Table 1 ). Cardiac findings include ventricular systolic dysfunction in 52,3% of the patients, 46,3% of evaluations had wall motion abnormalities, 16,3% of cardiac evaluations revealed dilated right ventricle and only 11,5% of patients had pericardial effusion. Regarding lung ultrasound 75,4% of exams had B-lines, 34.5% reported pleural effusion, 25,3% encountered lung consolidation and 14,8% an atelectasis. Out of the 209 POCUS evaluations, 12 patients (5,7%) had a non-conclusive exam. The number of missed diagnosis or non-concordant diagnosis was 16 (13%). See Table 1 . Heart Failure Analyzing this group of patients, we found a total of 77 patients with a final diagnosis consistent with acute decompensated heart failure. POCUS identified all these patients. Two patients were inadequately classified as having acute decompensated heart failure (ADHF). The first patient was a 53-year-old female patient consulting with dyspnea, bilateral basal B lines were identified and a unilateral small pleural effusion. POCUS reported systolic dysfunction. Formal echocardiography revealed normal LVEF over 40%. Chest CT scan showed a lung consolidation. The final diagnosis was pneumonia, and the patient was treated accordingly and recovered with no complications. The second patient was a 70-year-old female with dyspnea as chief complaint with bilateral basal B lines. Chest images were reported normal. The echocardiogram showed no structural or functional abnormality. The final diagnosis was a urinary tract infection and heart failure was ruled-out. The patient recovered well and was discharged with no complications. POCUS correctly diagnosed all patients (no false negatives) and had two false positive results. Overall concordance between initial diagnosis and final diagnosis in patients consulting with dyspnea for ADHF diagnosis resulted in a Cohen's Kappa of 0.98. See Table 2 . Table 2 Agreement in specific groups Heart failure Clinical exam + POCUS diagnosis 80 Final diagnosis 78 Clinical exam + POCUS discards 129 Final diagnosis discards 131 Agreement (Cohen's Kappa) 0,98 Acute coronary syndrome Clinical exam + POCUS diagnosis 64 Final diagnosis 61 Clinical exam + POCUS discards 145 Final diagnosis discards 148 Agreement (Cohen's Kappa) 0,96 Shock Clinical exam + POCUS diagnosis 22 Final diagnosis 26 Clinical exam + POCUS discards 187 Final diagnosis discards 183 Agreement (Cohen's Kappa) 0,9 Acute Coronary Syndrome This group of patients represented non-ST segment elevation acute coronary syndrome (ACS) considering that ST segment elevation is a medical emergency that does not need any ultrasound evaluation to decide urgent management. A total of 61 patients were finally classified as ACS. All were correctly diagnosed using clinical history, physical exam, and ultrasound. There were three patients initially classified as having ACS who finally were diagnosed with hypertensive angina (two of them) and one with osteochondritis. Out of the 61 patients with ACS, only 28 patients had regional wall motion abnormalities (RWMA) in formal echocardiography and 23 of those patients were correctly identified by POCUS. There were 5 false negatives and 5 false positives. Cohen´s Kappa in this subgroup of patients was 0.40. Seven patients were correctly identified as having normal contractility. Overall concordance between initial diagnosis and final diagnosis in patients consulting with chest pain for non-ST ACS diagnosis resulted in a Cohen´s Kappa of 0.96. See Table 2 . Shock In this group we found 26 patients with a final diagnosis of shock. Regarding type of shock, 17 patients had septic shock, 5 were diagnosed with cardiogenic shock, 3 with shock and dilated right ventricle (supposedly obstructive) and 1 with hypovolemic shock. Ultrasound and clinical evaluation correctly identified the type of shock in 22 patients. Four patients were initially misclassified. Two patients had an initial non-conclusive ultrasound exam. No specific findings were seen and alongside history were classified as non-conclusive. Finally, these two patients were diagnosed with septic shock. One patient had a dilated right ventricle and was classified as obstructive shock, but at discharge was given a diagnosis of septic shock. The fourth patient was identified as having COPD exacerbation at ED admission, but at the end of hospitalization was classified as septic shock. There were no false positives in the initial classification and there were 4 false negatives. Overall concordance between initial diagnosis of the type of shock resulted in a Cohen’s Kappa of 0.90. See Table 2 . Non-Conclusive POCUS exams Out of 209 ultrasound evaluations 12 were reported as non-conclusive. This report was given considering a normal ultrasound evaluation during which no lung abnormality was found, cardiac ultrasound was normal with a good quality image of normal systolic function. This report was applied when there was not a specific finding that could explain the patient's symptoms or any abnormality that may serve as a diagnosis support. There were 6 patients with pneumonia not identified at initial POCUS evaluation, 2 patients with septic shock and one patient with each of these diagnoses: non-cardiac chest pain, hypertensive angina, obstructive sleep apnea, and soft-tissue infection. See Table 2 . Discussion In this real-life study, an almost perfect concordance was observed between the point-of-care ultrasound POCUS-guided diagnosis conducted in the emergency department and the final diagnosis given at discharge for patients presenting with shock, acute coronary syndrome, or acute decompensated heart failure. This finding highlights the utility of POCUS as an effective tool for evaluating patients in these clinical scenarios and the high confidence that should be placed on a multiorgan ultrasound evaluation alongside clinical exam. In every case, the categorization of individuals with acute heart failure was accurate. Gallard et al. ( 17 ) conducted a study involving a cohort of 130 patients to assess the diagnostic accuracy of heart failure. Their findings indicated a diagnostic accuracy of 90% which aligns with our research. Baid et al. ( 13 ) found a sensitivity of 77% in diagnosing left ventricular systolic dysfunction. Previous research has indicated that emergency physicians have achieved a detection rate of 82%. The agreement observed in our study, using multimodal Point-of-care ultrasound was found to be 0.98. This result contrasts with the findings reported by Baid et al., who reported agreement values of 0.59 for systolic dysfunction and 0.83 for pulmonary edema. These findings may be due to differences in observations made by various observers and the population being studied. Similarly, the assessment methods for evaluating left ventricular systolic function may vary in the POCUS approach. Previous studies have evaluated a specific finding in an ultrasound exam. Our study aimed to analyze a global clinical-ultrasound approach that combines clinical reasoning using POCUS. In a systematic review conducted by Albaroudi et al ( 18 ) eyeballing was associated with a Kappa of 0.46–0.79, suggesting substantial variations but with at least moderate diagnostic accuracy. The high concordance found in our research may be influenced by a global clinical evaluation. Conducting a complete clinical history, identifying clinical signs of congestion, and confirming these findings with a well-executed ultrasound evaluation form the basis of a well-founded diagnosis. In the ACS group adequate classification was performed on 61 patients diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), yielding a Kappa agreement value of 0.98. Prior studies have shown variability in the accuracy of POCUS diagnosing acute coronary syndrome. Zanobetti et al. established a concordance of 0.70 between the initial diagnosis of acute coronary syndrome and the final diagnosis in emergency department patients presenting with dyspnea ( 19 ). This study evaluated POCUS diagnoses versus ED diagnoses, but our study evaluated a different diagnosis stage: initial using POCUS versus final diagnosis. Our work showed better performance of a clinical approximation to patients including cardiac ultrasound and integrating findings to clinical diagnosis. We are aware that focused cardiac ultrasound neither confirms nor discards a patient having ACS. Identifying patients with left ventricle dysfunction, regional wall abnormalities and/or ruling out other critical conditions such as acute aortic dissection (no patients were found in this study), pulmonary embolism, pneumothorax and pericardial effusion could be very valuable to make a decision in an emergency care situation. Regional wall motion abnormalities (RWMA) are considered an advanced ability in focused cardiac ultrasound. Farsi et al. ( 20 ) previously reported a correlation Kappa of 0.83 between trained residents and the formal echocardiogram conducted by a cardiologist. In our investigation, we identified segmental contractility disorders in 82.1% of cases, with 5 false positives and 5 false negatives, yielding a Kappa of 0.40 in this ACS group of patients. This underscores the importance of accurate diagnosis and the potential consequences of inappropriate interventions based on inaccurate observations from ultrasound. Croft et al evaluated the diagnostic potential of RWMA in individuals with ST elevation myocardial infarction in the WAMAMI study ( 21 ) reporting a Kappa 0.79 after specific training of emergency medicine residents. Again, not a clinical diagnosis but a specific ultrasound finding. Another study conducted by Saglam ( 22 ) in patients with suspected non-ST myocardial infarction reported a good agreement of 0.84 after a 3-hour training. The variability observed in these studies may be attributed to the varying levels of training of point-of-care ultrasound (POCUS) operators and different studied populations. Our data shows a low agreement, thus, reflecting the high variability of this specific ultrasound finding and the need to not rely only on RWMA to diagnose or treat a patient with chest pain. The acquisition of RWMA viewing skill needs thorough training, and the existence of abnormalities does not invariably indicate the presence of acute coronary syndrome, nor is it exclusive to this pathology. The American Society of Echocardiography (ASE) has issued a recommendation concerning POCUS and the interpretation of these conditions as an advanced skill. Its implementation may limit the widespread utilization of the tool ( 23 ). Analyzing the shock population we found good agreement between initial POCUS-guided diagnosis and final diagnosis. A recent systematic review conducted by Yoshida et al ( 6 ) highlights the diagnostic efficacy of point-of-care ultrasound (POCUS) in this set of patients, showing over 95% of diagnostic accuracy. We correctly identified the type of shock in 84.6% of our patients. It is important to say that our patients had similar basal characteristics compared to those included in the systematic review previously mentioned. If we separate cardiogenic shock in this study, all patients were classified correctly. No false positives or false negatives. In septic shock group, we had two patients with inconclusive findings at admission. Septic shock is an entity with no specific ultrasound finding. Clinical history and reasoning are crucial to correct diagnosis. According to our results, a clinician should always be aware of septic shock and interpret the whole clinical picture, including POCUS, to give a shock type diagnosis. Previously, Javali et al ( 24 ) demonstrated that in cases of undifferentiated shock in the emergency department, the diagnostic accuracy for identifying the type of shock increased from 45–89% with the addition of point-of-care ultrasound. A kappa value of 0.89 was reported and is consistent with similar findings by Vaidya et al ( 25 ) and our data. The findings of these studies depict a scenario akin to the one outlined in our study, where clinical data was integrated with POCUS information. Kanji et al. ( 2 ) previously presented evidence of a potential effect on mortality in patients with hypotension when treatment was oriented by ultrasound findings. Current initiatives are underway to standardize assessment protocols ( 26 ). An examination of the MIMIC III database indicates a significant effect on mortality (odds ratio = 0.78, 95% CI 0.68–0.90, p < 0.001) among patients with septic shock in the intensive care unit who underwent echocardiography for diagnostic and therapeutic guidance ( 27 ). The strong diagnostic capability of point-of-care ultrasound (POCUS) described in our study underscores the importance of its integration into routine clinical practice. We had 12 patients with a non-conclusive POCUS at admission, explaining most patients with wrong diagnosis. Analyzing these patients, we found 6 with pneumonia not diagnosed adequately. We explain these findings considering the limited sensitivity of lung ultrasound in certain scenarios. It is required that lung consolidation involves pleura and to be in an area susceptible to visualization (BLUE points), this could be a limitation for a given diagnosis. This highlights the need of an extensive lung ultrasound evaluation if BLUE points are non-conclusive, and the clinical picture is consistent with a lower respiratory tract infection. The other 6 non-conclusive were a hypertensive angina, 2 septic shock, 1 non-cardiovascular chest pain, 1 obstructive sleep apnea and 1 soft tissue infection. Patients with a wrong diagnosis were followed during hospitalization, all of them had an expected clinical evolution with no mortality. There should be more research on missed diagnoses with POCUS and clinical impact on prognosis and mortality to comprehensively evaluate ultrasound errors. Limitations and advantages This study was conducted at a single center within a university hospital, involving a specific population, which may limit the generalizability of the findings. Although a varied population, representative of a given usual ED population, caution should be taken when applying the results. Similarly, using images captured by a single provider may limit the application of our study, it reduces the potential for differences in interpretation among observers. The study's strengths lie in its real-life depiction of typical conditions in the emergency department, where point-of-care ultrasound (POCUS) information is integrated into the diagnostic process. This integration enables real-time decision-making for patients with potentially life-threatening pathologies. We had a comorbid population, consulting to the ED with the most common symptoms in clinical practice, evaluated with ultrasound and diagnosed with clear parameters at discharge. All patients had POCUS and gold standard clinical diagnosis. Statistical analyses were performed following adequate procedures and sample size was achieved giving enough power to our study. Finally, we think POCUS should be at the center of clinical evaluation in every emergency department considering our results. Nonetheless, we find a caution message in our findings that lead us to always integrate ultrasound with clinical evaluation. The results of this study demonstrate a strong correlation with definitive diagnosis, emphasizing the significance of integrating these findings into the assessment of patients with potentially life-threatening conditions. It is essential to consider using POCUS to shorten the time for diagnosis and subsequent treatment, thereby possibly impacting mortality. This should be evaluated in well-design prospective studies. Conclusion The use of point-of-care ultrasound in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute myocardial infarction, and shock. This reinforces the need for regular implementation of POCUS in clinical practice with a caution message to always integrate ultrasound to clinical reasoning in a specific clinical scenario. Prospective studies are essential to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors. Declarations Competing Interests: Authors have no conflict of interest or financial funding to disclose. 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Indian J Crit care Med peer-reviewed. Off Publ Indian Soc Crit Care Med 24(5):313–320 Vaidya T, D’costa P, Pande S (2018) Role of Ultrasound in Evaluation of Undifferentiated Shock in ICU Settings. J Assoc Physicians India 66(8):13–17 Ramadan A, Abdallah T, Abdelsalam H, Mokhtar A, Razek AA (2023) Evaluation of parameters used in echocardiography and ultrasound protocol for the diagnosis of shock etiology in emergency setting. BMC Emerg Med 23(1):132 Feng M, McSparron JI, Kien DT, Stone DJ, Roberts DH, Schwartzstein RM et al (2018) Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database. Intensive Care Med 44(6):884–892 Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 29 Dec, 2023 Reviewers invited by journal 26 Dec, 2023 Editor assigned by journal 22 Dec, 2023 First submitted to journal 21 Dec, 2023 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. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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-3793211","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":263481421,"identity":"48479145-b552-4304-bf35-a668ad09f0db","order_by":0,"name":"José Atilio Núñez Ramos","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYPACNjkGBsYGGM+AKC3GUC0GRGthSGxAsgC/Fv7ZPWYPPvzhS99wu7ntwcc9f+QY2Ju3STDU2ODUInHnjLnhDB623A13DrYbznhmYMzAc6xMguFYGm5rbuSYSfNIALXcSGyT5jlgkNggkWMmwdhwGKcOeZCWPwZs6QZQLfUN8m/wazEAaWFIYEuAaUlgkODBr8XwRlqZZM8BNsOZQC2SMw4YG7bxpBVbJODxi9yN5G0SP/4ck+e7kf5M4sMBOXl+9sMbb3zAE2JQcAzBZAMRCYQ0MDDUEFYyCkbBKBgFIxcAAIWwTuA2GmglAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-8554-4925","institution":"Universidad del Norte Division Ciencias de la Salud","correspondingAuthor":true,"prefix":"","firstName":"José","middleName":"Atilio Núñez","lastName":"Ramos","suffix":""},{"id":263481422,"identity":"da654d9b-9ce0-48dc-bcac-7db4fb1297eb","order_by":1,"name":"Dagoberto Duarte Misol","email":"","orcid":"","institution":"Hospital Universidad del Norte. Emergency Deparment.","correspondingAuthor":false,"prefix":"","firstName":"Dagoberto","middleName":"Duarte","lastName":"Misol","suffix":""},{"id":263481423,"identity":"9a680ef5-7c94-43d2-a6b8-7c22aaf158dd","order_by":2,"name":"María Andrea Burgos Petro","email":"","orcid":"","institution":"Hospital Universidad del Norte","correspondingAuthor":false,"prefix":"","firstName":"María","middleName":"Andrea Burgos","lastName":"Petro","suffix":""},{"id":263481424,"identity":"b1815e10-08a3-4795-8019-ba6a893114a7","order_by":3,"name":"Keren Jemima Sarmiento Pérez","email":"","orcid":"","institution":"Hospital Universidad del Norte","correspondingAuthor":false,"prefix":"","firstName":"Keren","middleName":"Jemima Sarmiento","lastName":"Pérez","suffix":""},{"id":263481425,"identity":"953e4f4f-ad4c-4c54-b8e9-30881a4f373b","order_by":4,"name":"Vanesa Paola Gutiérrez Echeverry","email":"","orcid":"","institution":"Hospital Universidad del Norte","correspondingAuthor":false,"prefix":"","firstName":"Vanesa","middleName":"Paola Gutiérrez","lastName":"Echeverry","suffix":""},{"id":263481426,"identity":"012c45f0-e8de-4d77-ba41-6ce2191f1436","order_by":5,"name":"Sergio Velasco-Malagón","email":"","orcid":"","institution":"Universidad Nacional de Colombia","correspondingAuthor":false,"prefix":"","firstName":"Sergio","middleName":"","lastName":"Velasco-Malagón","suffix":""}],"badges":[],"createdAt":"2023-12-22 17:21:39","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3793211/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3793211/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49088087,"identity":"24f2f1d3-51f5-495d-9915-9d18e4407552","added_by":"auto","created_at":"2024-01-03 01:18:15","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":35566,"visible":true,"origin":"","legend":"\u003cp\u003eLegend not included with this version.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-3793211/v1/1394b099414201b9f1b5261c.png"},{"id":49088669,"identity":"65530ee4-68b4-4e3e-ae37-792f646ea2d7","added_by":"auto","created_at":"2024-01-03 01:26:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":359655,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3793211/v1/c1d20c56-19a8-49d4-8778-c8c4242f1cdb.pdf"}],"financialInterests":"","formattedTitle":"Agreement of point of care ultrasound and final clinical diagnosis in patients with acute decompensated heart failure, acute coronary syndrome, and shock: POCUS not missing the target","fulltext":[{"header":"Introduction","content":"\u003cp\u003ePoint-of-Care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. To this moment, ultrasound (US) has been used for more than twenty years in intensive care units (ICU) and emergency departments (ED) around the world. The impact on diagnosis and clinical outcomes is evident. Several accuracy studies have proved its diagnostic value over physical examination alone, and chest x-ray (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Clinical impact has been evaluated through cohort studies and clinical trial, demonstrating better outcomes in patients who received POCUS evaluation (\u003cspan additionalcitationids=\"CR3 CR4\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eUltrasound at the bedside has been used for several critical or emergent conditions. Regarding shock, POCUS has proved to be of great value. Recently Yoshida et al published an accuracy study reporting a sensitivity and specificity of 98% and 96% when POCUS is used alongside history and physical examination (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Diagnosing dyspnea using lung ultrasound is better than using clinical examination and/or chest x-ray (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Specifically, heart failure diagnosis based on lung POCUS is recommended in recent guidelines (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Chest pain is a complex clinical presentation in the ED, and ultrasound has shown the ability to narrow the differential diagnosis in critical scenarios. Aortic dissection and acute coronary syndromes are two of the main diagnoses in which US is helpful (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSince the introduction of point of care ultrasonography, many studies have evaluated the agreement between ultrasound findings and formal ultrasonography. B lines, pleural effusion, dilated heart cavities, valvulopathies, and many other specific alterations have been analyzed (\u003cspan additionalcitationids=\"CR10 CR11\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Most studies show good agreement between novice operator-performed ultrasound and experienced operator-performed ultrasound. Reported evidence includes findings in echocardiography with good agreement (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) and others with a not so good agreement (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Lung ultrasound is valuable and reproducible (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In a population of patients with shock, studies have conflicting results (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e) considering a heterogenous population and different levels of training.\u003c/p\u003e \u003cp\u003eThere is scarce evidence comparing initial clinical diagnosis using ultrasound as an extension of physical examination and final diagnosis in clinical practice. Baid et al published a paper using POCUS as an initial diagnostic tool in the ED with good concordance with final diagnosis (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Buhumaid showed good differential narrowing using US but no concordance with final diagnosis (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Knowing diagnostic agreement could lead to more confident diagnosis at emergency department and possibly to more rapid treatment initiation.\u003c/p\u003e \u003cp\u003eWe aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis at discharge in specific groups of patients. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams and discuss details.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is an analytical cross-sectional study of emergency department patients consulting for dyspnea, chest pain and undifferentiated shock state. It was carried out in a University-based hospital in Colombia. The Ethics Committee and Institutional Research Board approved the protocol (Act 281, November 24th, 2022).\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePopulation\u003c/h2\u003e \u003cp\u003eThe study was conducted between 2019 and 2022. Patients eligible were adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, shock. Inclusion criteria were a POCUS evaluation performed at admission, US findings reported in clinical records, reported initial diagnosis using POCUS alongside usual clinical evaluation, reported discharge (final) diagnosis considering evolution, laboratory parameters and images. Exclusion criteria were death during the first 24 hours of admission, not definitive diagnosis at discharge, in-hospital transfer to another healthcare facility and not clear diagnosis at entrance.\u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eUltrasound and clinical evaluation\u003c/h2\u003e \u003cp\u003ePatients in the ED with any of the three main complaints were first evaluated by an emergency physician. Initial orders were given (oxygen, intravenous fluids, images, electrocardiogram, etc) and then, an internal medicine specialist was consulted.\u003c/p\u003e \u003cp\u003eClinical history was taken by the attending internal medicine physician, then a thorough physical examination was performed, including Point-of-Care Ultrasound as an extension of the physical exam and an aid to assure an initial diagnosis. Every patient had an initial diagnosis using clinical history, physical examination, and ultrasound evaluation.\u003c/p\u003e \u003cp\u003ePOCUS evaluation was performed using a multiprobe ultrasound machine (Sonoscape Corp. Model S2. Guangdong, China. 2016\u0026ndash;3) by the attending internal medicine physician trained in POCUS. Assessment included BLUE protocol (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e) using a linear transducer with a frequency of 5\u0026ndash;10 MHz and a phased array with a frequency of 2\u0026ndash;5 MHz in patients with dyspnea. B-lines, pleural effusion, and lung consolidation were specific findings at US evaluation. Findings were integrated with clinical symptoms to consider a specific initial diagnosis.\u003c/p\u003e \u003cp\u003eA focused cardiac ultrasound evaluation, using a phased array probe with a frequency of 2\u0026ndash;5 MHz, in chest pain included at least three of the four main cardiac views (parasternal long and short axis, apical and subxiphoid). Eyeball systolic ventricular function, pericardial effusion, and wall motion abnormalities were considered. RUSH protocol (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e) was followed in shock patients to rule-in or rule-out specific etiologies such as obstructive causes, cardiogenic shock or hypovolemic shock.\u003c/p\u003e \u003cp\u003ePatients were treated according to the initial diagnosis. Medications, images, and laboratory tests were ordered considering clinical context and to-date clinical guidelines. No further ultrasound evaluation was performed during hospitalization.\u003c/p\u003e \u003cp\u003eThe internal medicine specialist from the ED did not have any other interaction with the patient or clinical staff in the ICU and general ward. Specialists from these clinical areas were aware of the POCUS initial evaluation.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eFinal Diagnosis\u003c/h2\u003e \u003cp\u003eThe final diagnosis was given by the attending physician at discharge in the general ward. This internal medicine specialist was in charge of every patient included in the study from in-ward admission until discharge. This diagnosis considered initial evaluation, all laboratory diagnostic work-up, images, and clinical evolution to declare a final and definite diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData and statistical analysis\u003c/h2\u003e \u003cp\u003eAll the information was taken from clinical records. An Excel de-identified database was built for analysis purposes. Every variable was drawn from initial clinical history, ultrasound evaluation at admission and final diagnosis on discharge day.\u003c/p\u003e \u003cp\u003eAccording to published methods for sample size estimation (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), considering a disagreement probability of 20%, a Cohen\u0026rsquo;s Kappa of 0.85 and an alfa value of 0.05, the population should be of 192 patients.\u003c/p\u003e \u003cp\u003eQualitative variables are expressed in absolute and relative frequencies. Quantitative variables are expressed in mean and standard deviation, median and interquartile ranges. The initial diagnosis was compared for agreement with the final diagnosis using Cohen's kappa statistic in patients with heart failure, chest pain and shock. A two-sided p value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered to indicate statistical significance. All statistical analyses were conducted using SPSS version 25.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThere were 9051 patients presenting to the ED with dyspnea, shock, or chest pain in the specified period. Out of the total population, 318 (3,5%) patients received a POCUS evaluation at admission. Patients not fulfilling inclusion criteria were 63 (0,7%) and 255 (2,8%) were included. There were 46 (0,5%) patients excluded. Finally, 209 patients were analyzed (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePopulation was predominantly male (56,5%), mean age of 64 years old, with a background of hypertension (60,3%) and type 2 diabetes (23,4%). The main reason to visit the ED was dyspnea (56,9%), chest pain (32,5%) and shock (8,6%). The most frequent diagnosis at the entrance was acute decompensated heart failure (36,8%) followed by acute coronary syndrome (28,2%). See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePopulation baseline characteristics\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAll n\u0026thinsp;=\u0026thinsp;209\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic and clinical\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge years (Mean, SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale Sex n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHypertension n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2 diabetes n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e49 (23)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (20)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoronary heart disease n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (24)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOCUS indication\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyspnea n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e119 (57)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest pain n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRadiologic studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChest X-ray n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (83,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEchocardiogram n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (73,2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCT scan n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e78 (37,3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePOCUS findings\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eB-lines n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e75,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePleural efussion n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLung consolidation/Atelectasis n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40,1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLeft ventricle dysfunction n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e52,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWall motion abnormalities n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46,3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePericarial effusion n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11,5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-conclusive n, (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (5,7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eA total of 153 patients (73,2%) received a comprehensive echocardiogram. Regarding radiologic studies 174 (83,2%) patients had a chest x-ray at the ED entrance and 78 (37,3%) had a CT scan. See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003eAll patients were evaluated with POCUS at ED entrance (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Cardiac findings include ventricular systolic dysfunction in 52,3% of the patients, 46,3% of evaluations had wall motion abnormalities, 16,3% of cardiac evaluations revealed dilated right ventricle and only 11,5% of patients had pericardial effusion. Regarding lung ultrasound 75,4% of exams had B-lines, 34.5% reported pleural effusion, 25,3% encountered lung consolidation and 14,8% an atelectasis. Out of the 209 POCUS evaluations, 12 patients (5,7%) had a non-conclusive exam. The number of missed diagnosis or non-concordant diagnosis was 16 (13%). See Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eHeart Failure\u003c/h2\u003e \u003cp\u003eAnalyzing this group of patients, we found a total of 77 patients with a final diagnosis consistent with acute decompensated heart failure. POCUS identified all these patients. Two patients were inadequately classified as having acute decompensated heart failure (ADHF). The first patient was a 53-year-old female patient consulting with dyspnea, bilateral basal B lines were identified and a unilateral small pleural effusion. POCUS reported systolic dysfunction. Formal echocardiography revealed normal LVEF over 40%. Chest CT scan showed a lung consolidation. The final diagnosis was pneumonia, and the patient was treated accordingly and recovered with no complications. The second patient was a 70-year-old female with dyspnea as chief complaint with bilateral basal B lines. Chest images were reported normal. The echocardiogram showed no structural or functional abnormality. The final diagnosis was a urinary tract infection and heart failure was ruled-out. The patient recovered well and was discharged with no complications.\u003c/p\u003e \u003cp\u003ePOCUS correctly diagnosed all patients (no false negatives) and had two false positive results. Overall concordance between initial diagnosis and final diagnosis in patients consulting with dyspnea for ADHF diagnosis resulted in a Cohen's Kappa of 0.98. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e\u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement in specific groups\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement (Cohen's Kappa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,98\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAcute coronary syndrome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e145\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement (Cohen's Kappa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShock\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical exam\u0026thinsp;+\u0026thinsp;POCUS discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e187\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFinal diagnosis discards\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e183\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgreement (Cohen's Kappa)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0,9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eAcute Coronary Syndrome\u003c/h2\u003e \u003cp\u003eThis group of patients represented non-ST segment elevation acute coronary syndrome (ACS) considering that ST segment elevation is a medical emergency that does not need any ultrasound evaluation to decide urgent management.\u003c/p\u003e \u003cp\u003eA total of 61 patients were finally classified as ACS. All were correctly diagnosed using clinical history, physical exam, and ultrasound. There were three patients initially classified as having ACS who finally were diagnosed with hypertensive angina (two of them) and one with osteochondritis.\u003c/p\u003e \u003cp\u003eOut of the 61 patients with ACS, only 28 patients had regional wall motion abnormalities (RWMA) in formal echocardiography and 23 of those patients were correctly identified by POCUS. There were 5 false negatives and 5 false positives. Cohen\u0026acute;s Kappa in this subgroup of patients was 0.40.\u003c/p\u003e \u003cp\u003eSeven patients were correctly identified as having normal contractility. Overall concordance between initial diagnosis and final diagnosis in patients consulting with chest pain for non-ST ACS diagnosis resulted in a Cohen\u0026acute;s Kappa of 0.96. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section3\"\u003e \u003ch2\u003eShock\u003c/h2\u003e \u003cp\u003eIn this group we found 26 patients with a final diagnosis of shock. Regarding type of shock, 17 patients had septic shock, 5 were diagnosed with cardiogenic shock, 3 with shock and dilated right ventricle (supposedly obstructive) and 1 with hypovolemic shock.\u003c/p\u003e \u003cp\u003eUltrasound and clinical evaluation correctly identified the type of shock in 22 patients. Four patients were initially misclassified. Two patients had an initial non-conclusive ultrasound exam. No specific findings were seen and alongside history were classified as non-conclusive. Finally, these two patients were diagnosed with septic shock. One patient had a dilated right ventricle and was classified as obstructive shock, but at discharge was given a diagnosis of septic shock. The fourth patient was identified as having COPD exacerbation at ED admission, but at the end of hospitalization was classified as septic shock.\u003c/p\u003e \u003cp\u003eThere were no false positives in the initial classification and there were 4 false negatives. Overall concordance between initial diagnosis of the type of shock resulted in a Cohen\u0026rsquo;s Kappa of 0.90. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eNon-Conclusive POCUS exams\u003c/h2\u003e \u003cp\u003eOut of 209 ultrasound evaluations 12 were reported as non-conclusive. This report was given considering a normal ultrasound evaluation during which no lung abnormality was found, cardiac ultrasound was normal with a good quality image of normal systolic function. This report was applied when there was not a specific finding that could explain the patient's symptoms or any abnormality that may serve as a diagnosis support.\u003c/p\u003e \u003cp\u003eThere were 6 patients with pneumonia not identified at initial POCUS evaluation, 2 patients with septic shock and one patient with each of these diagnoses: non-cardiac chest pain, hypertensive angina, obstructive sleep apnea, and soft-tissue infection. See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this real-life study, an almost perfect concordance was observed between the point-of-care ultrasound POCUS-guided diagnosis conducted in the emergency department and the final diagnosis given at discharge for patients presenting with shock, acute coronary syndrome, or acute decompensated heart failure. This finding highlights the utility of POCUS as an effective tool for evaluating patients in these clinical scenarios and the high confidence that should be placed on a multiorgan ultrasound evaluation alongside clinical exam.\u003c/p\u003e \u003cp\u003eIn every case, the categorization of individuals with acute heart failure was accurate. Gallard et al. (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e) conducted a study involving a cohort of 130 patients to assess the diagnostic accuracy of heart failure. Their findings indicated a diagnostic accuracy of 90% which aligns with our research. Baid et al. (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e) found a sensitivity of 77% in diagnosing left ventricular systolic dysfunction. Previous research has indicated that emergency physicians have achieved a detection rate of 82%. The agreement observed in our study, using multimodal Point-of-care ultrasound was found to be 0.98. This result contrasts with the findings reported by Baid et al., who reported agreement values of 0.59 for systolic dysfunction and 0.83 for pulmonary edema.\u003c/p\u003e \u003cp\u003eThese findings may be due to differences in observations made by various observers and the population being studied. Similarly, the assessment methods for evaluating left ventricular systolic function may vary in the POCUS approach. Previous studies have evaluated a specific finding in an ultrasound exam. Our study aimed to analyze a global clinical-ultrasound approach that combines clinical reasoning using POCUS. In a systematic review conducted by Albaroudi et al (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e) eyeballing was associated with a Kappa of 0.46\u0026ndash;0.79, suggesting substantial variations but with at least moderate diagnostic accuracy. The high concordance found in our research may be influenced by a global clinical evaluation. Conducting a complete clinical history, identifying clinical signs of congestion, and confirming these findings with a well-executed ultrasound evaluation form the basis of a well-founded diagnosis.\u003c/p\u003e \u003cp\u003eIn the ACS group adequate classification was performed on 61 patients diagnosed with non-ST segment elevation myocardial infarction (NSTEMI), yielding a Kappa agreement value of 0.98. Prior studies have shown variability in the accuracy of POCUS diagnosing acute coronary syndrome. Zanobetti et al. established a concordance of 0.70 between the initial diagnosis of acute coronary syndrome and the final diagnosis in emergency department patients presenting with dyspnea (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). This study evaluated POCUS diagnoses versus ED diagnoses, but our study evaluated a different diagnosis stage: initial using POCUS versus final diagnosis. Our work showed better performance of a clinical approximation to patients including cardiac ultrasound and integrating findings to clinical diagnosis. We are aware that focused cardiac ultrasound neither confirms nor discards a patient having ACS. Identifying patients with left ventricle dysfunction, regional wall abnormalities and/or ruling out other critical conditions such as acute aortic dissection (no patients were found in this study), pulmonary embolism, pneumothorax and pericardial effusion could be very valuable to make a decision in an emergency care situation.\u003c/p\u003e \u003cp\u003eRegional wall motion abnormalities (RWMA) are considered an advanced ability in focused cardiac ultrasound. Farsi et al. (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) previously reported a correlation Kappa of 0.83 between trained residents and the formal echocardiogram conducted by a cardiologist. In our investigation, we identified segmental contractility disorders in 82.1% of cases, with 5 false positives and 5 false negatives, yielding a Kappa of 0.40 in this ACS group of patients. This underscores the importance of accurate diagnosis and the potential consequences of inappropriate interventions based on inaccurate observations from ultrasound. Croft et al evaluated the diagnostic potential of RWMA in individuals with ST elevation myocardial infarction in the WAMAMI study (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) reporting a Kappa 0.79 after specific training of emergency medicine residents. Again, not a clinical diagnosis but a specific ultrasound finding. Another study conducted by Saglam (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) in patients with suspected non-ST myocardial infarction reported a good agreement of 0.84 after a 3-hour training. The variability observed in these studies may be attributed to the varying levels of training of point-of-care ultrasound (POCUS) operators and different studied populations. Our data shows a low agreement, thus, reflecting the high variability of this specific ultrasound finding and the need to not rely only on RWMA to diagnose or treat a patient with chest pain.\u003c/p\u003e \u003cp\u003eThe acquisition of RWMA viewing skill needs thorough training, and the existence of abnormalities does not invariably indicate the presence of acute coronary syndrome, nor is it exclusive to this pathology. The American Society of Echocardiography (ASE) has issued a recommendation concerning POCUS and the interpretation of these conditions as an advanced skill. Its implementation may limit the widespread utilization of the tool (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAnalyzing the shock population we found good agreement between initial POCUS-guided diagnosis and final diagnosis. A recent systematic review conducted by Yoshida et al (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) highlights the diagnostic efficacy of point-of-care ultrasound (POCUS) in this set of patients, showing over 95% of diagnostic accuracy. We correctly identified the type of shock in 84.6% of our patients. It is important to say that our patients had similar basal characteristics compared to those included in the systematic review previously mentioned. If we separate cardiogenic shock in this study, all patients were classified correctly. No false positives or false negatives. In septic shock group, we had two patients with inconclusive findings at admission. Septic shock is an entity with no specific ultrasound finding. Clinical history and reasoning are crucial to correct diagnosis. According to our results, a clinician should always be aware of septic shock and interpret the whole clinical picture, including POCUS, to give a shock type diagnosis.\u003c/p\u003e \u003cp\u003ePreviously, Javali et al (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e) demonstrated that in cases of undifferentiated shock in the emergency department, the diagnostic accuracy for identifying the type of shock increased from 45\u0026ndash;89% with the addition of point-of-care ultrasound. A kappa value of 0.89 was reported and is consistent with similar findings by Vaidya et al (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e) and our data. The findings of these studies depict a scenario akin to the one outlined in our study, where clinical data was integrated with POCUS information. Kanji et al. (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) previously presented evidence of a potential effect on mortality in patients with hypotension when treatment was oriented by ultrasound findings. Current initiatives are underway to standardize assessment protocols (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAn examination of the MIMIC III database indicates a significant effect on mortality (odds ratio\u0026thinsp;=\u0026thinsp;0.78, 95% CI 0.68\u0026ndash;0.90, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) among patients with septic shock in the intensive care unit who underwent echocardiography for diagnostic and therapeutic guidance (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). The strong diagnostic capability of point-of-care ultrasound (POCUS) described in our study underscores the importance of its integration into routine clinical practice.\u003c/p\u003e \u003cp\u003eWe had 12 patients with a non-conclusive POCUS at admission, explaining most patients with wrong diagnosis. Analyzing these patients, we found 6 with pneumonia not diagnosed adequately. We explain these findings considering the limited sensitivity of lung ultrasound in certain scenarios. It is required that lung consolidation involves pleura and to be in an area susceptible to visualization (BLUE points), this could be a limitation for a given diagnosis. This highlights the need of an extensive lung ultrasound evaluation if BLUE points are non-conclusive, and the clinical picture is consistent with a lower respiratory tract infection. The other 6 non-conclusive were a hypertensive angina, 2 septic shock, 1 non-cardiovascular chest pain, 1 obstructive sleep apnea and 1 soft tissue infection. Patients with a wrong diagnosis were followed during hospitalization, all of them had an expected clinical evolution with no mortality. There should be more research on missed diagnoses with POCUS and clinical impact on prognosis and mortality to comprehensively evaluate ultrasound errors.\u003c/p\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and advantages\u003c/h2\u003e \u003cp\u003eThis study was conducted at a single center within a university hospital, involving a specific population, which may limit the generalizability of the findings. Although a varied population, representative of a given usual ED population, caution should be taken when applying the results. Similarly, using images captured by a single provider may limit the application of our study, it reduces the potential for differences in interpretation among observers.\u003c/p\u003e \u003cp\u003eThe study's strengths lie in its real-life depiction of typical conditions in the emergency department, where point-of-care ultrasound (POCUS) information is integrated into the diagnostic process. This integration enables real-time decision-making for patients with potentially life-threatening pathologies. We had a comorbid population, consulting to the ED with the most common symptoms in clinical practice, evaluated with ultrasound and diagnosed with clear parameters at discharge. All patients had POCUS and gold standard clinical diagnosis. Statistical analyses were performed following adequate procedures and sample size was achieved giving enough power to our study.\u003c/p\u003e \u003cp\u003eFinally, we think POCUS should be at the center of clinical evaluation in every emergency department considering our results. Nonetheless, we find a caution message in our findings that lead us to always integrate ultrasound with clinical evaluation. The results of this study demonstrate a strong correlation with definitive diagnosis, emphasizing the significance of integrating these findings into the assessment of patients with potentially life-threatening conditions. It is essential to consider using POCUS to shorten the time for diagnosis and subsequent treatment, thereby possibly impacting mortality. This should be evaluated in well-design prospective studies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe use of point-of-care ultrasound in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute myocardial infarction, and shock. This reinforces the need for regular implementation of POCUS in clinical practice with a caution message to always integrate ultrasound to clinical reasoning in a specific clinical scenario. Prospective studies are essential to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eCompeting Interests:\u003c/h2\u003e \u003cp\u003eAuthors have no conflict of interest or financial funding to disclose.\u003c/p\u003e \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eStaub LJ, Mazzali Biscaro RR, Kaszubowski E, Maurici R (2019) Lung Ultrasound for the Emergency Diagnosis of Pneumonia, Acute Heart Failure, and Exacerbations of Chronic Obstructive Pulmonary Disease/Asthma in Adults: A Systematic Review and Meta-analysis. J Emerg Med 56(1):53\u0026ndash;69\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKanji HD, McCallum J, Sirounis D, MacRedmond R, Moss R, Boyd JH (2014) Limited echocardiography-guided therapy in subacute shock is associated with change in management and improved outcomes. 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Off Publ Indian Soc Crit Care Med 24(5):313\u0026ndash;320\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVaidya T, D\u0026rsquo;costa P, Pande S (2018) Role of Ultrasound in Evaluation of Undifferentiated Shock in ICU Settings. J Assoc Physicians India 66(8):13\u0026ndash;17\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamadan A, Abdallah T, Abdelsalam H, Mokhtar A, Razek AA (2023) Evaluation of parameters used in echocardiography and ultrasound protocol for the diagnosis of shock etiology in emergency setting. BMC Emerg Med 23(1):132\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFeng M, McSparron JI, Kien DT, Stone DJ, Roberts DH, Schwartzstein RM et al (2018) Transthoracic echocardiography and mortality in sepsis: analysis of the MIMIC-III database. Intensive Care Med 44(6):884\u0026ndash;892\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 ultrasound, diagnosis, agreement, heart failure, shock, acute coronary syndrome","lastPublishedDoi":"10.21203/rs.3.rs-3793211/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3793211/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e: Point-of-Care ultrasound (POCUS) is an important tool for clinical diagnosis and decision-making in critical and non-critical scenarios. Dyspnea, chest pain and shock are conditions valuable to evaluate with ultrasound considering diagnostic accuracy and clinical impact already proven. There is scarce evidence in diagnosis agreement using ultrasound as an extension of physical examination. We aimed to evaluate ED patients in whom POCUS was performed, to analyze agreement between clinical initial diagnosis using ultrasound images and final diagnosis. Furthermore, we analyze failed diagnosis, inconclusive POCUS exams and discuss details.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: A cross-sectional analytical study was conducted in adults who visited the emergency department with any of these three chief complaints: dyspnea, chest pain, shock. All were evaluated with ultrasound at admission. Agreement between initial diagnosis using POCUS and final definite diagnosis was calculated. Failed diagnosis and inconclusive exams were analyzed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: A total of 209 patients were analyzed. Populations mostly males, mean age 64yo, hypertensive. Patients with dyspnea, agreement in heart failure diagnosis was 0.98; agreement in chest pain with non-ST acute coronary syndrome was 0.96; agreement in type of shock was 0.90. Twelve 12 (5%) patients had an inconclusive POCUS exam, and 16 (7%) patients had a failed diagnosis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: The use POCUS in the emergency department shows almost perfect agreement when compared with the final diagnosis in individuals experiencing acutely decompensated heart failure, acute myocardial infarction, and shock. Prospective studies are needed to evaluate the impact of this tool on mortality and prognosis when there are diagnostic errors.\u003c/p\u003e","manuscriptTitle":"Agreement of point of care ultrasound and final clinical diagnosis in patients with acute decompensated heart failure, acute coronary syndrome, and shock: POCUS not missing the target","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-03 01:18:11","doi":"10.21203/rs.3.rs-3793211/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2023-12-29T09:20:08+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-12-26T16:54:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-12-23T00:52:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Internal and Emergency Medicine","date":"2023-12-21T09:27:54+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":"031fb064-543d-4634-b170-1080dc5370a8","owner":[],"postedDate":"January 3rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-05-08T15:31:02+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-03 01:18:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3793211","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3793211","identity":"rs-3793211","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}