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Handheld echocardiographic screening for rheumatic heart disease by non-experts
  1. Michelle Ploutz1,
  2. Jimmy C Lu1,
  3. Janet Scheel1,
  4. Catherine Webb2,
  5. Greg J Ensing2,
  6. Twalib Aliku1,
  7. Peter Lwabi3,
  8. Craig Sable1,
  9. Andrea Beaton1
  1. 1Department of Pediatric Cardiology, Children's National Health System, Washington DC, USA
  2. 2Department of Pediatric Cardiology, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Department of Pediatric Cardiology, Uganda Heart Institute, Kampala, Uganda
  1. Correspondence to Dr Michelle Ploutz, Department of Pediatric Cardiology, Children's National Health System, 111 Michigan Ave NW, Washington DC 20010, USA; mploutz{at}


Objectives Handheld echocardiography (HAND) has good sensitivity and specificity for rheumatic heart disease (RHD) when performed by cardiologists. However, physician shortages in RHD-endemic areas demand less-skilled users to make RHD screening practical. We examine nurse performance and interpretation of HAND using a simplified approach for RHD screening.

Methods Two nurses received training on HAND and a simplified screening approach. Consented students at two schools in Uganda were eligible for participation. A simplified approach (HAND performed and interpreted by a non-expert) was compared with the reference standard (standard portable echocardiography, performed and interpreted by experts according to the 2012 World Heart Federation guidelines). Reasons for false-positive and false-negative HAND studies were identified.

Results A total of 1002 children were consented, with 956 (11.1 years, 41.8% male) having complete data for review. Diagnoses included: 913 (95.5%) children were classified normal, 32 (3.3%) borderline RHD and 11 (1.2%) definite RHD. The simplified approach had a sensitivity of 74.4% (58.8% to 86.5%) and a specificity of 78.8% (76.0% to 81.4%) for any RHD (borderline and definite). Sensitivity improved to 90.9% (58.7% to 98.5%) for definite RHD. Identification and measurement of erroneous colour jets was the most common reason for false-positive studies (n=164/194), while missed mitral regurgitation and shorter regurgitant jet lengths with HAND were the most common reasons for false-negative studies (n=10/11).

Conclusions Non-expert-led HAND screening programmes offer a potential solution to financial and workforce barriers that limit widespread RHD screening. Nurses trained on HAND using a simplified approach had reasonable sensitivity and specificity for RHD screening. Information on reasons for false-negative and false-positive screening studies should be used to inform future training protocols, which could lead to improved screening performance.

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