Highlight
This study demonstrates that point-of-care ultrasound (POCUS) interpreted by emergency physicians has moderate sensitivity (76.8%) and specificity (85.9%) in detecting right ventricular dysfunction (RVD) among pulmonary embolism (PE) patients compared to consultative echocardiography interpreted by cardiologists. Accuracy and inter-rater agreement improve when detecting moderate to severe RVD. Interestingly, diagnostic accuracy declined as emergency physicians progressed through residency training.
Study Background
Pulmonary embolism remains a significant cause of morbidity and mortality in emergency departments worldwide. Risk stratification in PE is critical to guide management and prognosis. Right ventricular dysfunction is a key prognostic marker, associated with increased mortality risk, necessitating timely and accurate diagnosis. While consultative echocardiography interpreted by cardiologists is the gold standard for assessing RVD, access delays and resource constraints may limit its timely use in the ED. Point-of-care ultrasound (POCUS), performed and interpreted by emergency physicians at bedside, offers a potentially rapid diagnostic alternative. However, the accuracy of POCUS compared to consultative echocardiography for RVD detection in PE patients remains inadequately characterized, with implications for risk stratification and clinical decision-making.
Study Design
This retrospective cohort study identified patients with pulmonary embolism using a regular expression algorithm applied to hospital records. Eligible patients were those who underwent both emergency department POCUS and cardiologist-interpreted consultative echocardiography. The cohort comprised 194 patients evaluated by 97 different emergency physician ultrasound operators.
Right ventricular dysfunction by POCUS was defined by emergency physicians as either an enlarged right ventricle compared to the left ventricle (RV size > LV size), decreased right ventricular systolic function assessed by tricuspid annular plane systolic excursion (TAPSE), or both. Consultative echocardiography reports classified RVD into absent, mild, or moderate-to-severe categories based on RV dilation, reduced function, or both.
The primary endpoints evaluated included the sensitivity, specificity, and inter-rater reliability (measured by Cohen’s kappa) of POCUS for detecting RVD relative to the cardiologist-interpreted echocardiograms. Analyses were stratified by the severity of right ventricular dysfunction and the emergency physician residency training level.
Key Findings
Overall, POCUS demonstrated a sensitivity of 76.8% and specificity of 85.9% in detecting any right ventricular dysfunction compared to consultative echocardiography. The overall agreement rate was 81.4%, with a kappa coefficient of 0.63 (95% CI, 0.51 to 0.75), indicating moderate agreement between modalities.
Importantly, accuracy and agreement improved when moderate to severe RVD on consultative echocardiography was the benchmark. This suggests that POCUS is more reliable in identifying clinically significant right ventricular impairment, which bears greater prognostic importance in PE management.
Interestingly, the study observed a decline in inter-rater reliability of POCUS as emergency physicians advanced through residency training. This finding raises questions regarding consistency in image interpretation relative to training level, potentially reflecting variations in experience or overconfidence.
Expert Commentary
The results reinforce the potential utility of POCUS as a rapid, bedside tool for initial assessment of right ventricular dysfunction in PE patients. Moderate sensitivity and specificity support its role in early risk stratification, especially in resource-limited or time-sensitive settings where consultative echocardiography may be delayed.
Nevertheless, POCUS should not supplant formal echocardiography but rather serve as an adjunct to guide urgent management decisions. The diminished diagnostic accuracy with milder RV dysfunction emphasizes the need for confirmatory cardiology assessment.
Training programs may consider targeted interventions to improve POCUS interpretive consistency, particularly monitoring skill progression across residency years. Furthermore, adoption of standardized imaging protocols and quality assurance measures can enhance reliability.
Limitations include the retrospective design and potential selection bias inherent in requiring both imaging modalities. The generalizability may be limited to centers with similar ultrasound expertise and patient populations.
Conclusion
Point-of-care ultrasound interpreted by emergency physicians offers a moderately accurate and specific diagnostic modality for identifying right ventricular dysfunction in patients with pulmonary embolism, particularly when dysfunction is moderate to severe. While it improves timeliness of risk stratification, it should be integrated with consultative echocardiography and clinical findings to guide management. Focused training and quality control are essential to optimize POCUS utility and consistency among emergency clinicians.
Future prospective studies may clarify the impact of POCUS-driven RVD assessment on clinical outcomes and resource utilization in emergency medicine settings.
Funding and Clinical Trials
The original study did not disclose specific funding sources or clinical trial registration. Further research recommendations include multi-center, prospective validations with standardized POCUS training protocols.
References
- Thomas AL, Rupp JD, Suszanski J, et al. Accuracy of Point-of-Care Ultrasound Versus Consultative Echocardiography to Identify Right Ventricular Dysfunction in Emergency Department Patients With Pulmonary Embolism. Ann Emerg Med. 2026 Jun 18. PMID: 42313044.
- Kabrhel C, van Diepen S, Rosovsky RP, et al. Risk Stratification of Pulmonary Embolism Patients in the Emergency Department. Crit Care Med. 2020;48(6):865-875.
- McConnell MV, Solomon SD, Rayan ME, et al. Regional right ventricular dysfunction detected by echocardiography in acute pulmonary embolism. Am J Cardiol. 1996;78(4):469-473.
