CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 5, November/December 2023 268 AFRICA Feasibility of focused cardiac ultrasound training for non-cardiologists in a resource-limited setting using a handheld ultrasound machine Benjamin Acheampong, Joseph R Starnes, Yaw A Awuku, David Parra, Muktar H Aliyu, Jonathan H Soslow Abstract Background: Heart disease remains a leading cause of morbidity and mortality, particularly in low- and middle-income countries. Access to diagnostic modalities is limited in these settings. Limited echocardiographic studies performed by non-cardiologists can increase access, improve diagnosis and allow for earlier medical therapy. Methods: Two internal medicine residents at a tertiary-level hospital in Ghana were trained to perform limited echocardiographic studies. Each trainee performed 50 echocardiograms and interpreted 20 studies across three predetermined timepoints. Interpretation was compared to expert interpretation. Results: Agreement improved over time. At the final evaluation, there was high agreement across all aspects: left ventricular structure (70%, kappa 0.52, p = 0.01), left ventricular function (80%, kappa 0.65, p = 0.004), right ventricular structure (90%, kappa 0.71, p = 0.002), right ventricular function (100%, kappa 1.00, p < 0.001), and presence of effusion (100%, kappa 1.00, p < 0.001). Conclusion: Non-cardiologists can be trained in focused echocardiography using handheld machines. Such training can increase access to diagnostic capabilities in resource-limited settings. Keywords: echocardiography, Ghana, training programmes, healthcare access Submitted 10/11/21, accepted 17/10/22 Published online 14/12/22 Cardiovasc J Afr 2023; 34: 268–272 www.cvja.co.za DOI: 10.5830/CVJA-2022-057 Both congenital and acquired heart disease remain important sources of childhood morbidity and mortality around the world. Congenital heart disease (CHD) accounted for more than 260 000 deaths in 2017, more than 180 000 of which were in infants less than one year of age.1 Although high-income countries have seen improvement in CHD-related mortality of more than 50% since 1990, countries in the lowest quantile have improved by just 6%.1 Similarly, an estimated 319 400 deaths occurred due to rheumatic heart disease (RHD) in 2015.2 While RHD has essentially been eliminated in many high-income countries, rates remain as high as 10 per 1 000 in sub-Saharan Africa.2 There is a significant difference in reported prevalence of CHD between high- and low-income countries (LIMCs), likely secondary to differences in access to healthcare and diagnostics.3 Although sub-Saharan Africa has the highest prevalence of RHD, prevalence is likely underestimated for the same reasons.4 Ischaemic heart disease and stroke are the leading causes of the cardiovascular disease burden, but RHD, cardiomyopathy and acute myocarditis remain important causes of morbidity and mortality.5 Rates of cardiac death are higher in LMICs, suggesting that later diagnosis and reduced access to care play a role in higher mortality rates.6,7 Furthermore, rates of cardiac disease in LMICs are difficult to quantify due to lack of data5 and are likely underestimated due to poor availability of diagnostic technologies.8 Cardiovascular imaging in the developing world is limited by cost and expertise. Recent improvements in handheld ultrasound technology have the potential to reduce barriers to access and lead to better identification of paediatric and adult cardiac disease. Portable ultrasound, including for echocardiography, has shown promise in the triage, diagnosis and treatment of patients in LMICs.9 This technology has been used successfully by experts in LMICs in a variety of settings for adults10-14 and for RHD screening in children.15-19 As this technology has become more available, various efforts have aimed to train non-experts to perform focused handheld echocardiography. A number of studies have demonstrated acceptable accuracy of focused studies by non-echocardiographers in high-resource settings.20-28 In the LMIC setting, studies have included cardiologists,11,14-17 cardiology trainees,10,13 sonographers,12 and, more recently, nurses and other non-experts.18,29-33 These studies were performed only in adults,11-14 were performed by expert cardiologists,15-17 or were limited to the evaluation of RHD.18,29-33 We hypothesised that non-experts, specifically internal medicine trainees, could use focused handheld echocardiography to successfully evaluate both children and adults. To our knowledge, this is the first study in an LMIC setting in which non-experts applied focused handheld echocardiography to such a broad patient group. Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA Benjamin Acheampong, MD, bacheampong@childrensomaha.org Joseph R Starnes, MD, joseph.starnes@vumc.org David Parra, MD Jonathan H Soslow, MD Department of Pediatrics, Division of Pediatric Cardiology, University of Nebraska Medical Center, Omaha, Nebraska, USA Benjamin Acheampong, MD Department of Medicine and Therapeutics, University of Cape Coast, Cape Coast, Ghana Yaw A Awuku, MD Vanderbilt Institute for Global Health, Vanderbilt University Medical Center, Nashville, Tennessee, USA Muktar H Aliyu, MD
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