Handheld echocardiography for rural cardiac triage in primary care: A feasibility and diagnostic agreement study of a task-shifting model with remote cardiologist validation.

Abstract

Introduction: Access to formal echocardiography is often delayed in geographically remote settings. This study evaluated the feasibility, image quality and diagnostic agreement of focused handheld echocardiography performed by a trained Family Medicine Specialist (FMS) in a rural Malaysian clinic with asynchronous cardiologist validation.

Materials and methods: We conducted a retrospective observational study of 41 adult patients who underwent focused handheld echocardiography for dyspnoea or suspected cardiac symptoms at a rural primary care clinic in Sarawak, Malaysia, between 24 August 2025 and 5 February 2026. A trained FMS performed focused examinations during routine care. Stored images were reviewed asynchronously by a consultant cardiologist blinded to the FMS interpretation. We evaluated workflow feasibility, cardiologist-rated image quality and agreement for classification of left ventricular (LV) systolic function as normal or reduced.

Results: Forty-one patients were included (mean age 60.4±17.5 years; 51% male). Median scan duration was 8 minutes (range 3-14), and technical difficulties were reported in 19 examinations (46.3%). Nevertheless, all 41 stored studies contained sufficient images for cardiologist classification of LV systolic function. Endocardial border definition was rated good or fair in 87.8% of studies, whereas colour Doppler was frequently non-diagnostic. The FMS identified reduced LV systolic function in 13 patients (32%), compared with 10 patients (24%) by cardiologist review. Overall agreement was 82.9%, with Cohen's kappa 0.58. Sensitivity was 80.0%, specificity 83.9%, positive predictive value 61.5%, negative predictive value 92.9% and overall accuracy 82.9%.

Conclusion: In this rural primary care setting, focused handheld echocardiography performed by a trained FMS was feasible and showed moderate agreement with remote cardiologist interpretation for identifying reduced left ventricular systolic function. These findings support a hypothesis-generating service-delivery model in which handheld ultrasound may assist rural cardiac triage and referral prioritization, but larger multi-site studies are needed before practice-changing implementation can be recommended.