Article Text

other Versions

Download PDFPDF
Original research article
Integration of echocardiographic screening by non-physicians with remote reading in primary care
  1. Bruno R Nascimento1,2,
  2. Andrea Z Beaton3,
  3. Maria Carmo Pereira Nunes1,2,
  4. Allison R Tompsett3,
  5. Kaciane K B Oliveira1,
  6. Adriana C Diamantino1,
  7. Márcia M Barbosa1,
  8. Tainá V Lourenço2,
  9. Isabella M Teixeira2,
  10. Gabriela Z L Ruiz2,
  11. João Pedro P Rios2,
  12. Antonio Luiz P Ribeiro1,2,
  13. Craig Sable3
  14. On behalf of the PROVAR+ (Programa de RastreamentO da VAlvopatia Reumática and Other Cardiovascular Diseases) investigators
    1. 1Serviço de Cardiologia e Cirurgia Cardiovascular e Centro de Telessaúde, Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
    2. 2Departamento de Clínica Médica, Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
    3. 3Department of Cardiology, Children’s National Health System, Washington, District of Columbia, USA
    1. Correspondence to Dr Bruno R Nascimento, Hospital das Clínicas da Universidade Federal de Minas Gerais, Avenida Professor Alfredo Balena 110, 1st floor, Belo Horizonte, MG 30130-100, MG, 30130-100, Brazil; ramosnas{at}


    Introduction Heart disease (HD) accounts for high morbidity and mortality in Brazil. Underserved populations often suffer long delays in diagnosis. We aimed to evaluate the feasibility of integrating screening echocardiography (echo) with remote interpretation in the established primary care system (PC) in Brazil and to assess HD prevalence.

    Methods Over 11 months, 20 healthcare workers (four physicians, four nurses, and 12 technicians) at 16 PC centres were trained on simplified handheld echo protocols. Three screening (SC) groups, including all consented patients aged 17–20, 35–40 and 60–65 years, and patients referred (RF) for clinical indications underwent focused echo. Studies were remotely interpreted through telemedicine. Significant HD was defined as moderate/severe valve disease, ventricular dysfunction/hypertrophy, pericardial effusion, wall-motion abnormalities and congenital heart disease.

    Results Total 1004 patients underwent echo; 299 (29.8%) in the SC group. Median age was 51±18 years, 63.9% females; 42.7% had cardiovascular symptoms. Significant HD was found in 354 (35.3%) patients (23.4% in SC vs 40.3% in RF group, p<0.001). Prevalence was higher in patients in the SC group aged >60 years (29.2%), compared with 35–40 (14.9%) and under 20 (16.5%), p=0.012. Comparing SC to RF groups, moderate/severe left ventricular dysfunction was observed in 4.1% vs 8.1%, p=0.03, mitral regurgitation in 8.9% vs 20.3%, p<0.001 and aortic stenosis in 5.4% vs 4.3%, p=0.51.

    Conclusions Integration focused echo into PC is feasible in Brazil as a strategy to deliver cardiovascular care to low-resourced areas through task shifting. The burden of HD observed suggests this tool may improve early diagnosis and referral.

    • heart disease
    • echocardiography
    • ehealth/telemedicine/mobile health
    • cardiac imaging and diagnostics
    View Full Text

    Statistics from


    • Contributors BRN, AZB, MCPN and CS contributed to the conception and design of the research. KKBO, ACD, MMB, TVL, IMT, GZLR and JPPR contributed to the acquisition of data. BRN, AZB, MCPN, ART and CS contributed to the analysis and interpretation of data. BRN, ALPR and CS contributed to the statistical analysis. BRN, AZB and CS obtained the financing. BRN, ALRP and CS contributed to the writing of the manuscript. BRN, AZB, ALRP and CS were responsible for the overall content as guarantors. All authors contributed to the critical revision of the manuscript for intellectual content.

    • Funding The Telehealth Network of Minas Gerais was funded by the State Government of Minas Gerais, by its Health Department (Secretaria de Estado da Saúde de Minas Gerais) and Fundação de Amparo à Pesquisa de Minas Gerais (FAPEMIG) and by the Brazilian Government, including the Health Ministry and the Science and Technology Ministry and its research and innovation agencies, Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) and Financiadora de Estudos e Projetos (FINEP). Dr Ribeiro was supported in part by CNPq (Bolsa de produtividade em pesquisa, 310679/2016-8) and by FAPEMIG (Programa Pesquisador Mineiro, PPM-00428-17). Medical students received scholarships from the National Institute of Science and Technology for Health Technology Assessment (IATS, project: 465518/2014-1).

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval Comitê de Ética em Pesquisa da Universidade Federal de Minas Gerais (COEP/UFMG).

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement The data analytic methods and study unpublished materials will be made available to other researchers for purposes of reproducing the results or replicating the procedure, from the corresponding author by e-mail contact, upon reasonable request.

    • Collaborators Adriana C Diamantino, MD, MSc, Allison Tompsett, MD, Amanda O Lauar, MD, Ana Luísa M Costa, MD, Andrea Z Beaton, MD, Antonio Luiz P Ribeiro, MD, PhD, Breno De Filippo Rezende, MD, Bruno R Nascimento, MD, MSc, PhD, Camila G Ferreira, BSN, Cassio M Oliveira, PhD, Catherine L Webb, MD, Craig A Sable, MD, Eduardo LV Lopes, MD, Gabriela ZL Ruiz, MD, Gabriel AL Carmo, MD, PhD, Graziela Chequer, MD, MSc, PhD, Hedda Richards, RDCS, Iara M Castro, MD, Isabella M Teixeira, MD, João Pedro P Rios, MD, Júlia PA Santos, MD, Lara Castro, BSN, Lindsay Perlman, MPh, Luciana CX Lafeta, BSN, Luise Cristina TR Barros, MD, Kaciane KB Oliveira, BSN, MSc, Letícia Maria M Rabelo, MD, Maria do Carmo P Nunes, MD, PhD, Michelle C Galbas, MD, Sandra Regina T Castilho, MD, Tainá V Lourenço, MD, Vitória MLR de Rezende, MD, Zilda Maria A Meira, MD, PhD.

    • Presented at The abstract of this work was presented at the American College of Cardiology 67th Annual Scientific Session, 10–12 March 2018, in Orlando, Florida, USA (J Am Coll Cardiol 2018;71(11):1462).

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Linked Articles