Tag Archives: echocardiogram

The Skeptical Cardiologist Answers Good Questions: Retesting For Symptomatic Benign PVCs?

One of the many things I enjoy about writing this blog is the interesting comments and questions that readers post. Many of them stimulate me to better answer and inform my patients.

Here’s one such question (about premature ventricular contractions):

Wondering your opinion on retesting. I’ve had PVCs since I was 15 (63 now) and they have come and gone over the years, attributed to hormones, low potassium, stress, and dehydration/bad diet. Recently they started again and are driving me insane and none of the usual fixes are working. Two ER visits with normal EKGs and my cardiologist all say no worries. I’m thinking maybe I should have another ultrasound, buy MD doesn’t think it’s necessary. I had a perfectly normal cath in 2015 but no tests since. Your thoughts? Thank you.

This was the response I typed off the top of my head:

Good question. I consider retesting for patients who have not had documentation of “structurally normal heart” for some time and who have a significant change in their symptoms. You would qualify since no testing in 3 years and worsened symptoms.
Typically I would order a stress echocardiogram which allows a reassessment of both LV structure and function and for any blockage in the coronary arteries and I would consider some kind of monitor-a 24 hour Holter would be fine if you are having daily symptoms.
You might also consider acquiring an AliveCor device to monitor your rhythm with symptoms. I’ve written a lot about this elsewhere on this site. Unfortunately AliveCor does not identify PVCs but if you connect via KardiaPro with your physician your recordings can be viewed and interpreted by him/her.

The answer reflects my clinical practice, which is based on 30 years of experience taking care of patients with PVCs, in conjunction with regularly reading papers, reviews and guidelines in this area.

Periodically, both for specific patient problems and for blog questions, I will search the medical/scientific literature and review guideline publications to see if there is any new information that I am unaware of to ensure that my recommendations are scientifically grounded.

In this case, a more prolonged search of the literature did not yield precise guidance on the frequency of retesting of patients with benign PVCs.

This 2014 guideline comments briefly on the evaluation and treatment of PVCs without structural heart disease (SHD):

In the absence of SHD, the most common indication for treating PVCs remains the presence of symptoms that are not improved by explanation of their benign nature and reassurance from the physician.

In addition, some patients may require treatment for frequent asymptomatic PVCs if longitudinal imaging surveillance reveals an interval decline in LV systolic function or an increase in chamber volume.

For patients with  >10,000 PVCs/24 h, follow-up with repeat echocardiography and Holter monitoring should be considered.

In patients with fewer PVCs, further investigation is only necessary should symptoms increase.

It should also be recognized that PVC burden often fluctuates over time.

This initial testing approach corresponds closely to what I wrote in my post on benign PVCs here.

Retesting with echocardiography and Holter monitoring is advised for those few patients who have lots of PVCs, but the frequency of this retesting is not specified and cardiologists have to use their best judgement, balancing the cost (to patient and to society) and patient safety.  Most cardiologists will err on the side of more frequent repeat testing for a variety of reasons.

Personally, I will advise an annual echocardiogram to such patients since they are at a higher risk of developing a cardiomyopathy.

In the absence of really frequent PVCs (>10,000 per 24 hours is a nice round number, but the precise cut-off is debatable), we should probably only repeat testing if the patient recognizes a significant change in their symptoms.

The reader clearly fits into that category, and retesting in her will provide reassurance that all is still good with her heart. This, in turn, should help with managing symptoms and preventing recurrent ER visits.

The final question (and the toughest) that we could pose related to retesting is “What is the time interval that one should wait before retesting in a patient with worsened symptoms?”

For example, if the reader had a normal echocardiogram 6 months ago should we repeat it when symptoms worsen? My reflex answer would be no, but at some time interval depending on the individual characteristics of the case-patient risks for heart disease, patient anxiety levels, patient symptom severity and frequency, the answer would become yes.

Cardiologists have to answer dozens of questions like this daily.  There is no science to inform a precise answer, consequently the answers will vary wildly from one cardiologist to another depending on a variety of factors specific to the cardiologist.

Those cardiologist-specific factors are complex and sometimes controversial. Part of this makes up the art of medicine and part reflects the business of medicine. They are definitely worthy of another post when time permits.

Questioningly Yours,

-ACP

N.B. The Eternal Fiancee’ (my layperson surrogate) expressed surprise that one could have 10 000 PVCs per day. I told her that if your heart beats roughly once per second (6o beats per minute) since there are  60 x 60 x 24 = 86400 seconds in a day, your heart beats almost 90 000 times in 24 hours.

Thus, roughly  1 in 9 beats is a PVC.

How Much Does or Should An Echocardiogram Cost?

One might assume the skeptical cardiologist has a quick and accurate answer to this question given that he has spent a very large amount of his career either researching, teaching or interpreting echocardiograms.

Surprisingly, however, it turns out to be extremely difficult to come up with a good response.

An echocardiogram is an ultrasound test that tells us very precisely what is going on with the heart muscle and valves. I’ve written previously here and here on how important they are in cardiology, and how they can be botched.

As in the  example of a severely leaking aortic valve  below, we get information on the structure of the heart (in grey scale) and   on  blood flow (color Doppler). This type of information is invaluable in assessing cardiac patients.

In the last week I’ve had 2 patients call the office indicating that even with insurance coverage, their out of pocket costs for an echocardiogram were unacceptably high – almost a thousand dollars.

Wide Variations In Equipment, Recording and Interpretation Expertise For Echocardiograms

A small, handheld ultrasound machine that performs the basics of echocardiography can now be purchased for 5 to 10K. More sophisticated systems with more elaborate capabilities cost up to 200K. In my echo lab the machines are typically replaced about every 5 years, but in smaller, more cost sensitive labs they can be used for decades.

An echo test typically takes up to an hour, and a sonographer performs up to 8-10 tests per day. At facilities trying to maximize profit, tests are shortened and sonographers might perform 20 per day.

In the U.S., echos are performed by sonographers who have trained for several years (specifically in the field of ultrasound evaluation of the heart) and earn on average around 30$ per hour, however, Medicare and third party payors usually don’t require any sonographer certification for echo reimbursement.

Physicians who read echocardiograms vary from having rudimentary training to having spent years of extra training in echocardiography, and gaining board certification documenting their expertise.

Interpretation of a normal echocardiogram takes less than 10 minutes, whereas a complicated valvular or congenital examination requiring comparison to previous studies, review of clinical records and other imaging modalities, could take more than an hour.

Given these wide parameters, estimating what one should charge for the technical or physician portions of the average echo is challenging.

Wildly Differing Charges For Echocardiograms

Elizabeth Rosental wrote an excellent piece for the NY Times in 2014 in which she described the striking discrepancy between 2 echos a man underwent at 2 different locations:

Len Charlap, a retired math professor, has had two outpatient echocardiograms in the past three years that scanned the valves of his heart. The first, performed by a technician at a community hospital near his home here in central New Jersey, lasted less than 30 minutes. The next, at a premier academic medical center in Boston, took three times as long and involved a cardiologist.

And yet, when he saw the charges, the numbers seemed backward: The community hospital had charged about $5,500, while the Harvard teaching hospital had billed $1,400 for the much more elaborate test. “Why would that be?” Mr. Charlap asked. “It really bothered me.”

Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups”

This graph shows the marked variation across the US in price of an echo.  In all the examples, however, what the hospitals were paid was around 400$ which is the amount that CMS pays for the complete echo CPT code 93306.

Costs Outside the US

At the Primus Super Specialty Hospital in New Delhi, India, apparently you can get an echocardiogram for $50.

This site looks at prices for private echos across the UK. The cheapest is in Bridgend in Wales (where suicide is rampant) at 175 pounds. You can get an echo for 300 pounds at the Orwell clinic (where their motto is “War is peace. Freedom is slavery. Ignorance is strength.”)

At one private  UK clinic, you can have your echo read by Dr. Antoinette Kenny, who appears extremely well qualified  for the task.

“In 1993, at the relatively young age of 33, she was appointed Consultant Cardiologist and Clinical Head of Echocardiography at The Regional Cardiothoracic Centre, Freeman Hospital, Newcastle upon Tyne.  At that time only 19 (<5%) of consultant cardiologists in the UK were female and an even smaller percentage of cardiologists had achieved consultant status by the age of 33, facts which serve to highlight Dr. Kenny’s postgraduate career achievements.”

Whereas I would not be interested in getting an echo done in India or Mexico, I would definitely have one done in Dr. Kenny’s center if I lived nearby.

Self Pay Cost

My hospital, like most, will write off the costs of an echo for indigent patients. I will read the tests on such patients pro bono (although doctors never use that term because we feel it makes us sound to lawyeresque).

The hospital also has a price it charges for those patients who are not indigent, but who have excessively high deductibles or co-pays with their insurance. In some cases this “self-pay” charge is significantly less than what the patient would pay with their insurance.

Paying out of the pocket for the echocardiogram may also make sense if the patient and/or physician really thinks the test is warranted, but the patient’s insurance deems it unncessary.

If you find yourself in a situation where a needed echocardiogram performed at your ordering doctor’s preferred facility is prohibitively high, it makes sense to look around for a more affordable option.

However, I must advise readers to be very cautious. In the NY Times example, the hospital charges for Mr. Charlap seemed inversely proportional to the quality of the echo he received.

This is not necessarily the case for a self pay echo. It is more likely that a cheap upfront out-of-pocket cost quote in a doctor’s office or a screening company reflects cheap equipment with minimal commitment to quality and brevity of exam and interpretation time.

I have encountered numerous examples of this in my own practice.

One of my patients who has undergone surgical repair of her mitral valve decided to get an echocardiogram as part of a LifeLine screening (see here and here for all the downsides of such screenings).

The report failed to note that my patient had a bicuspid aortic valve and an enlarged thoracic aorta.  These are extremely significant findings with potentially life threatening implications if missed.

If a high quality echo recording and interpretation is indicated for you make sure that the equipment, technician and physician reader involved in your case are up to the task.

Ultrasonically Yours,

-ACP

Are SSM and HealthFair Cardiovascular Screenings Promoting Wellness or Unwellness?

IMG_5657My patients and I continue to receive mailings from SSM Health Care (here in St. Louis), informing us that they have “partnered with HealthFair to deliver ultrasound tests of the heart and arteries” in our neighborhood.

If you are considering getting these, I recommend reading my  previous post on them (Shoddy Cardiovascular Screenings are more likely to cause harm than good). Also, I recommend this summary (which points out in well-referenced detail that these are not recommended by major preventive organizations) from a blogger who writes eloquently on the lack of benefit of wellness programs.

HealthFair’s financial model involves partnering with hospitals like SSM to promote these unnecessary screenings performed in mobile vans that travel to settings like Walgreen’s out in the community. The hospital system pays HealthFair (typically an “undisclosed amount”) to put the SSM name on their promotional flyers.  SSM does not provide any review of the quality of the studies performed.

SSM benefits by having its “brand” spread around and when abnormalities are detected on the exams, these patients are then provided with the names of SSM physicians.

Both SSM and HealthFair benefit in this relationship by identifying as many abnormalities as possible. It doesn’t really matter to either if the abnormalities detected are real or important. The bottom line is getting more patients into the SSM system, getting down stream referrals and testing and adding to the SSM bottom line.

Steven Weinberger, MD executive vice president and chief executive of the American College of Physicians. and two co-authors wrote in the Annals of Internal Medicine journal,  calling hospital involvement without disclosing potential downsides “unethical.”

“Because of a lack of counseling by these companies about the potential risks of an “abnormal” test result, the consumer is initially unaware that this may open a Pandora’s box of referrals and additional testing to monitor or treat these abnormal findings. Our medical system and society bear the cost of poor coordination of care and additional testing and treatment to follow up on unnecessary “abnormal” screening test results (10). That most of these tests are not medically indicated in the first place is left undisclosed to the consumer, nor is there a discussion of potential adverse consequences or additional costs.”

The Particular Dangers of Screening Echocardiography

In my previous post I warned in particular of the dangers of getting a screening echocardiogram, a test which I have spent my professional lifetime studying, writing on, teaching and interpreting.

I’ve also discussed in detail how easy it is to botch an echocardiogram and what to look for to guarantee that you are getting an accurate study.

Let me provide another example of how a poorly performed and/or interpreted echocardiogram can lead to a lifetime of unnecessary anxiety and inappropriate testing.

I saw a patient in my office recently who was changing cardiologists because of dissatisfaction with communication. Reviewing records from the prior cardiologists, I saw that an echocardiogram was performed in 2012 and read as showing enlargement of the aortic root and pulmonary hypertension.

A greatly enlarged aorta or aortic aneurysm can rupture or tear resulting in sudden death. It’s a very serious condition, consequently once enlargement of the aorta is identified, we counsel patients on appropriate activities, screening of relatives, and follow them lifelong with tests to monitor the size of the aorta.

I reviewed the echocardiogram which was performed in the cardiologists’ office and it was clear that an older echocardiographic technique called M-mode had been utilized, and that the measurement was invalid. When I repeated the echocardiogram in my hospital’s echocardiography laboratory, it was normal (we have a very rigorous quality assurance program and review on a regular basis with the sonographers and physicians best practice for recording and measuring the aorta by two-dimensional recordings).

Pulmonary hypertension (elevation of the pressures on the right side of the heart) can also be a sign of very severe and life threatening cardiac or pulmonary problems. If diagnosed, it typically requires extensive testing with associated risks. Like aortic root enlargement, it must be followed carefully, lifelong.

Pulmonary hypertension can be measured reasonably accurately by a well done echocardiogram utilizing a combination of Doppler flow measurements and imaging of the inferior vena cava.  Because of the critical importance of getting these measurements right, I have devoted numerous educational conferences to reviewing them with our sonographers and reading physicians.

In the case of my patient (and I presume, numerous patients undergoing less rigorously performed screening echocardiograms) the initial echocardiogram did not truly show pulmonary hypertension and the echocardiogram I did confirmed this.

The Profit Factor

Ultimately, these types of screenings done in the name of promoting wellness, are being done for money.

HealthFair is strictly in it for profit; they want to get as many patients as possible paying for these screenings. Their bottom line is not enhanced by spending time and money on guaranteeing that good equipment, trained sonographers and experienced physician readers are involved.

SSM is only interested in getting more patients funneled into their system. They are paying HealthFair to identify abnormalities and therefore, abnormalities will be found. SSM in this relationship is going against good medical practice and recommendations of national medical organizations in order to make money.

A program that on the surface is promoting wellness, therefore, in the final analysis may be promoting unwellness.

If you have had one of these echocardiographic screenings and had an abnormality detected, I would be happy to review the initial recordings and provide my opinion on their accuracy.  I would do this gratis as the skeptical cardiologist in the interest of research and knowledge, not to accumulate patients or revenue.

-ACP

 

Shoddy Cardiovascular Screenings Are More Likely to Cause Harm Than Good

I was recently made aware, by one of my patients, of a brochure from one of the large hospital chains in the St. Louis area  that advertised “healthy heart screenings.” The website for this enterprise says the following:

Healthy Heart Screenings

In partnership with Health Fair, SSM Health Care will utilize a mobile clinic that will travel around the St. Louis area approximately 16 times per month. Screenings range from basic biometrics to cardiovascular.

Basic test package ($179) includes:
Echocardiogram Ultrasound
Stroke / Carotid Artery Ultrasound
Abdominal Aortic Aneurysm Ultrasound
Electrocardiogram (EKG)
Peripheral Arterial Disease (PAD) Test
Hardening of the Arteries Test (ASI)

Steven Nissen has discussed the dangers of these types of screenings in an article for Cardiosource.org (the online voice of the American College of Cardiology)  entitled “Screenings and Executive Physicals: Hazardous to Your Health.”

Being proactive about cardiovascular health is generally considered to be a good thing, however, these types of screenings have the potential for doing more harm than good.

First off, individuals should recognize that this service is being offered by hospital systems solely for the purpose of getting more patients into their system for further testing and procedures.

Secondly, the service is being performed by a “mobile clinic.” These types of mobile clinics typically exist to make as much money as they can. Quality control is not one of their goals. They seek high volume , rapid throughput and minimal expenses. The mobile clinic is most likely utilizing the cheapest equipment, technicians  and interpreters of these studies that they can get.

Cheap equipment and inexperienced or poorly trained technicians are more likely to yield studies which are difficult to interpret or introduce errors and artifacts. Artifacts in an imaging study are images which appear to be abnormalities but are not. The more artifacts in a study, the more inappropriate subsequent testing will most likely be performed.

One of the tests offered in this package is an ultrasound of the heart or echocardiogram. The echocardiogram is a brilliant technological development that allows us to image the structure and function of the heart. Abnormalities ranging from weakness in the pump function of the heart to leakage from the valves can very accurately be diagnosed with echocardiography when it is done right.  I have devoted a large part of my career to studying, writing about and insuring quality control in echocardiography and I have seen first hand many misdiagnoses made in the hands of the inexperienced, shoddy, greedy or unscrupulous.

Let’s consider the many ways a poorly done or interpreted echocardiogram can lead to more harm than good.

Overcalling valve problems

In addition to imaging the structure or anatomy of the heart, during an echocardiogram a technique called Doppler allows us to measure the direction, velocity and location of blood flow within the heart. Doppler, developed in the 1980s, allows us, among other things, to see if the heart valves are doing their job of allowing blood to move forward while preventing back flow. In many normal individuals, a small or trivial  amount of back flow (called regurgitation or insufficiency) can be noted. The honest, experienced cardiologist will recognize this as normal. However, if the study is performed ineptly and misread, a normal individual could be mislabeled as having a significant heart valve problem leading to unnecessary stress and anxiety and the potential for additional inappropriate and potentially dangerous testing.

This might seem like just a theoretical concern, but in the 2000s as part of a settlement with the drug company Wyeth, the maker of Fen-Phen, hundreds of thousands of patients who had taken Fen-Phen for weight loss were screened by echocardiography to look for valve problems.  Thousands of individuals with normal hearts were diagnosed with significant valvular problems after undergoing echocardiography examinations set up by the lawyers engaged in the suit. These exams were often done in hotel suites and some cardiologists made millions reading thousands of these in a short period of time. Forbes has a good summary of the scandal entitled the $22 Billion Gold Rush  here. To quote:

“Material misrepresentations” amounting to “pervasive fraud” drove 70% of the serious claims that were found payable by the Wyeth trust fund, says Joseph Kisslo, a court-appointed cardiologist who reviewed a sample of 1,000 echocardiograms in late 2004. “Thousands of people have been defrauded into believing that they have valvular heart disease when in fact they do not,” Kisslo said in a report he wrote for the trust.

I saw a number of patients who had been identified by these shoddy echocardiograms as having significant valve problems and were convinced they had serious heart problems. After I obtained and reviewed the echocardiograms I was able to reassure the patients that their hearts were normal.

Misdiagnosing the function of the heart

The echocardiogram is our premier tool for looking at how the main pumping chamber or left ventricle (LV) is working. A left ventricle that is not functioning properly leads to heart failure. The LV fills with oxygen-rich blood from the lungs when it is relaxed (diastole) and then contracts (systole) and pumps the blood out into the aorta and to the rest of the body. Precise and well-made recordings and measurements of the blood flow during diastole allow the knowledgeable cardiologist to interpret how well the heart is functioning during diastole. Similarly, recordings of the LV allow interpretation of function during systole.

Misinterpretation of both the systolic and diastolic function of the heart are common in echocardiograms that are done by inexperienced sonographers and/or cardiologists.

Misinterpretation of artifacts

Due to various technical factors (outlined in detail here), a normal heart imaged by echocardiography may appear to have an abnormality. These artifacts are more likely due to poor quality equipment and inexperienced or incompetent sonographers. The more experienced the cardiologist reading the study, the less likely that these will be interpreted as pathology.

I have encountered numerous examples of what are normal variations of the heart anatomy or artifacts read on echocardiograms as possible tumors or clots or masses within the heart. Patients invariably end up getting unnecessary testing or surgery when such misdiagnoses are made; they also experience unnecessary stress and worry.

Making Sure You Get a Good Echocardiogram

If you are undergoing an echocardiogram, whether it be for screening which I (and the American Heart Association and the American College of Cardiology) do not recommend or for an appropriate indication (see here for appropriate indications), then it is in your best interest for you to make sure that the test is done and interpreted optimally.

Ideally, your test is being done by a sonographer who has undergone a recognized training program and is credentialed as a Registered Diagnostic Cardiac Sonographer (RDCS by the American Registry of Diagnostic Sonographers) or a Registered Cardiac Sonographer (RCS by the Cardiovascular Credentialing International).

Your echocardiogram should be done in a facility which has been certified by the Intersociety Accreditation Committee for Echocardiography (ICAEL). This will insure that the equipment, personnel , reports and interpretations are meeting minimal standards and that there is in place an ongoing program of quality assessment.

Your echocardiogram should be interpreted by a cardiologist who has undergone appropriate training in echocardiography and is staying up to date with the latest technology and information in the area. ICAEL certification of the lab will verify this to some extent. Even better, is a cardiologist who is Board Certified in Echocardiography.

In summary, don’t pay for an echocardiogram done by a mobile lab as part of a cardiovascular screening program no matter where it is performed or who is promoting it.  Although you may think you are being proactive about your health, chances are you will be more harmed than helped by the outcome.