The Association Between Common Bile Duct Diameter and the

https://doi.org/10.1177/87564793231191506

Journal of Diagnostic Medical Sonography

2023, Vol. 39(6) 561 –567

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DOI: 10.1177/87564793231191506

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Original Research

Biliary disorders associated with a biliary system obstruc-

tion can affect a significant portion of the world’s popula-

tion. Most biliary diseases result in the dilation of

intrahepatic and extrahepatic bile ducts. The diameter of

the common bile duct (CBD) is an important factor used

to differentiate obstructive (dilated CBD) from non-

obstructive causes of jaundice.

Sonography is a well-

established method for evaluating the extrahepatic biliary

system and serves as a major diagnostic tool in suspected

bile duct obstruction. To better understand the signifi-

cance of a dilated CBD, it is essential to establish the nor-

mal diameter.

However, establishing an accurate

reference range for the diameter of the CBD remains a

topic of debate. A reference range is needed to determine

the significance of spontaneous abnormalities or atypical

dilation. CBD diameters exceeding the upper limit of this

range can be classified as abnormal.

Traditionally, using sonography, the CBD diameter’s

upper limit is determined as 6–7.0 mm, in those individu-

als without cholecystectomy and 10 mm in post-chole-

cystectomy patients.

However, contrast-enhanced

abdominal computed tomography (CT) has yielded a

more prominent upper limit for diameter of the CBD. In a

1191506JDM

XXX10.1177/87564793231191506Journal of Diagnostic Medical SonographyKheiridoost Langroudi et al

research-article2023

Department of Radiology, Modarres Hospital, Shahid Beheshti

University of Medical Sciences, Tehran, Iran

Department of Radiology, Hillcrest Hospital, University of California

San Diego, San Diego, CA, USA

Amirkabir University of Technology, Tehran, Iran

Received January 20, 2023, and accepted for publication July 13, 2023.

Corresponding Author:

Neda Akhoundi, MD, Department of Radiology, Hillcrest Hospital,

University of California San Diego, San Diego, CA 92093-0602, USA.

Email: [email protected]

The Association Between Common

Bile Duct Diameter and the Severity

of Coronary Artery Atherosclerosis,

Based on Calcium Score

Fatemeh Kheiridoost Langroudi, MD

Taraneh Faghihi Langroudi, MD

, Neda Akhoundi, MD

and Alireza Siami, MSc

Abstract

Objective: The aim was to assess the relationship between the coronary calcium score and the common bile duct

(CBD) diameter, to determine whether the increase in CBD diameter in patients without hepatobiliary disease could

represent cardiovascular disease, or the extent of atherosclerosis in coronary arteries.

Materials and Methods: The study cohort consisted of 103 patients referred for computed tomographic angiography

(CTA) for coronary artery assessment. None of the patients had a gallbladder, biliary, or pancreatic disease or surgery

history. The Agatston score determined the rates of arterial calcification. The diameter of the CBD was measured

for a sonogram.

Results: There was a statistically significant relatively strong correlation between calcium score and CBD diameter

(r = 0.44, P = .001), independent of baseline variables, such as demographics and cardiovascular risk profiles. In the

multivariable regression model, advanced age (beta = 0.825, P = .005), history of hypertension (beta = 0.591, P =

.034), and history of coronary stenting (beta = 1.339, P = .001) were shown to be the main determinants of CBD

dilatation.

Conclusion: A statistically significant correlation existed between the CBD diameter and calcium score, within the

coronary arteries and this could represent a shared pathophysiology between CBD dilatation and the severity of

coronary atherosclerosis.

Keywords

common bile duct diameter, extrahepatic bile duct, Agatston score, calcification

562 Journal of Diagnostic Medical Sonography 39(6)

sample of 604 asymptomatic subjects, the largest diame-

ter reported ranged from 1.8 to 11.8 mm.

The diameter of

the CBD can change in response to various factors,

including age, cholecystectomy, sphincterotomy, certain

drugs, such as methadone, measurement location, respi-

ration, and body mass index (BMI).

3–9

Among these fac-

tors, age has been a focus of many studies. Although the

results of these studies have been controversial, and a

strong correlation between age and CBD diameter has not

been established, some considerations have been sug-

gested for evaluating the normal CBD width with aging.

For example, adding 0.2–1.0 mm to the normal upper

limit of the CBD diameter, for each increased decade of

age, starting at age 40 or 60.

Since the increased diam-

eter of the CBD in the elderly is associated with reduced

blood flow to the CBD, it could be inferred that the CBD

diameter changes may indicate atherosclerosis in arteries.

In this regard, the relationship between the calcium aortic

score and CBD diameter was investigated, and a moder-

ate relationship between these two parameters was

reported.

This study was the first to determine the rela-

tionship between CBD diameter and coronary artery cal-

cium score using a 64-slice abdominal CT examination.

If a significant relationship is observed between these

two variables, it could be concluded that changes in CBD

diameter may not only represent cardiovascular disease

but also indicate the extent of atherosclerosis in the coro-

nary arteries. Furthermore, considering the non-invasive

nature of sonography, in measuring CBD diameter, this

could be used as a primary diagnostic test for estimating

the severity of coronary artery atherosclerosis, based on

patients’ calcium score without known biliary disease.

Materials and Methods

Study Setting and Participants

The current study was completed with a prospective cohort

and conducted at a teaching hospital in Tehran, Iran, between

May 2018 and September 2019. The study received approval

from the hospital’s local ethics committee (IRB# IR.SBMU.

REC.9716). The study’s objectives were explained to the

patients, and written informed consent was obtained from all

participants. The study recruitment included individuals

with coronary artery disease (CAD) and referred for coro-

nary artery computed tomographic angiography (CTA). The

exclusion criteria included a history of liver, gallbladder,

biliary, or pancreatic disease or surgery, such as patients with

cholelithiasis or any gallbladder or pancreatic abnormality.

Before the examination, serum bilirubin levels, alkaline

phosphatase, and liver transaminases were measured and

reported as within normal reference ranges for all patients.

Patients taking medications that caused smooth muscle

relaxation (e.g., calcium blockers and papaverine hydro-

chloride) and patients with a BMI of more than 25 kg/m

were also excluded from the study. In addition, patients with

a history of coronary artery stent implantation or coronary

artery bypass grafting (CABG) were evaluated separately

based on their history of atherosclerosis.

Coronary Artery CTA

CTA was performed with a 64-slice device (Siemens Co.,

Germany), at least 6 hours after the patient’s last meal, and

two board-certified radiologists examined the images

obtained in all patients. Each patients’ heart rates were

evaluated, and a rate of 65 beats per minute was consid-

ered appropriate for starting imaging. If necessary, Metoral

tablets were used to lower those patients with an elevated

heart rate. The patient’s coronary CTA images were

assessed to find any stenosis or plaques (See Figure 1).

The rates of calcification of plaques were given a number

called an Agatston score. Based on the total calcium score,

grading of coronary artery disease was done as below:

 No evidence of CAD: 0 calcium score

 Minimal: 1–10 calcium score

 Mild: 11–100 calcium score

 Moderate: 101–400 calcium score

 Severe: > 400 calcium score

Sonography of the CBD

Sonography was performed on patients after a fasting

period of 6–12 hours by a diagnostic radiologist with 15

years of experience, in conducting sonography. The radi-

ologist was blinded to each patient’s Agatston score. A

Samsung WS80A ultrasound equipment system (Samsung

Figure 1. An axial image from the cardiac computed

tomogram that shows calcified plaques in the left circumflex

and left anterior descending artery (indicated with white

arrows).

Kheiridoost Langroudi et al 563

Healthcare.com) equipped with a curvilinear transducer

(2.5–3.5 MHz) was used for the examination. Patients

were examined supine or in the left lateral oblique posi-

tion and during a deep inspiration, using a right subcostal

approach. The CBD was measured below the cystic duct

and closely associated with the right hepatic artery.

Electronic calipers were used to measure the CBD diam-

eter from the outer to inner edges of the duct (See Figure

2). Three measurements were taken, and the average was

considered the CBD’s final diameter. A cut-off value of

7.0 mm was considered for CBD dilatation in this study.

In addition to the CBD sonographic findings and the

calcium score of each patient, demographic characteris-

tics and clinical signs of patients were also recorded.

Statistical Analysis

Descriptive data were reported as a mean and ± standard

deviation (SD) for continuous variables. Numeric data

(percentage) were provided for categorical variables. The

Kolmogorov-Smirnov test was used to determine a nor-

mal distribution of continuous variables. The means of

continuous variables with normal distribution were com-

pared using an independent group t-test. Proportions for

categorical variables were compared using the chi-square

test. Pearson’s or Spearman’s correlation test, which

determines the association between quantitative vari-

ables. The multivariable linear regression model was

employed to determine the main factors correlating with

increased CBD diameter. All statistical analyses were

performed using SPSS version 22.0 software (IBM,

Armonk, New York), and a P-level of < .05 was deter-

mined a priori, as statistically significant.

Results

In this study, a total of 103 patients who were referred

for CTA and met inclusion criteria were enrolled, how-

ever, 21 patients had no evidence of CAD, 24 had mini-

mal CAD, and 22, and 23 had mild and moderate CAD

based on their Agatston score, respectively. Thirteen

patients had severe CAD (Agatston score > 400). The

mean age of participants was 53.79 ± 10.79 years and

ranged from 31 to 76 years. In this cohort, 28% were

male. Overall, 17.4% had diabetes, 40% were hyperten-

sive, 12% were current smokers, and 30% had hyperlip-

idemia (See Table 1).

The mean calcium score in men was 49.82 ± 11.74,

and in women was 47.32 ± 23.50, with no significant

difference (P = .920).

The mean CBD diameter according to the baseline

variables is summarized in Table 2. In this regard, the

mean CBD diameter was independent of gender, smok-

ing, or history of diabetes. In contrast, a higher mean

CBD diameter was found more in older patients than

younger patients, as well as those with hyperlipidemia

compared with cases without hyperlipidemia. Likewise,

a higher mean CBD diameter was found in patients with

hypertension compared with patients without, and in

patients with a history of coronary stenting than in those

without this intervention (See Figures 3–8). In the mul-

tivariable regression model, advanced age (beta =

0.825, P = .005), history of hypertension (beta = 0.591,

P = .034), and history of coronary stenting (beta =

1.339, P = .001) were shown to be the main determi-

nants of CBD dilatation (See Table 3). A statistically

significant relatively strong positive correlation was

observed between calcium score and CBD diameter (r

= 0.444, P = .001). In addition, a similar association

was found between age and the Agatston score (r =

0.543, P = .014) (See Table 4).

Discussion

The role of CT and sonography in assessing various dis-

eases is well known.

11–19

This cohort study investigated

the potential association between coronary artery athero-

sclerosis, based on CT, and the diameter of the CBD,

which was measured during sonography. Therefore, the

Agatston calcium score method was utilized to assess the

level of coronary artery atherosclerosis. The findings

obtained in this study revealed a positive correlation

between CBD diameter and coronary Agatston calcium

score.

As discussed earlier, several factors can influence

CBD diameter, and radiologists need to consider these

factors when determining whether an observed increase

in diameter is pathological. This cohort of patients

Figure 2. A sonogram of the liver, which demonstrates the

method of measuring the diameter of the common bile duct.

The electronic calipers are used to measure the diameter

of the common bile duct and placed on the outer and inner

edges of the duct.

564 Journal of Diagnostic Medical Sonography 39(6)

demonstrated that in addition to factors, such as old age,

history of cholecystectomy, drug use, and high BMI, ath-

erosclerosis was also a variable that affected the size of

their CBD. Previous research has shown that connective

tissue fibers replace normal smooth myocytes as individ-

uals’ age, and tissue metabolism undergoes changes,

likely associated with decreased blood supply.

These

findings and evidence of hypoxia and smooth muscle

relaxation

suggest the need for further studies to deter-

mine the extent to which chronic hypoxia can impact the

diameter of the CBD.

Several recent studies have highlighted the susceptibility

of pathological changes in biliary dilatation following athero-

sclerotic changes in the bile ducts, particularly the CBD.

Moharramzad et al, found a close correlation between the

atherosclerotic score, based on the Agatston score, and the

diameter of the CBD.

This may suggest that the occurrence

of atherosclerosis, especially with age, leads to changes in the

vascular supply to the biliary system, particularly the bile

ducts. This diminished vascular supply may cause significant

changes in the muscles of these ducts and ultimately result in

changes to CBD diameter. However, histological evaluations

and pathological studies are required to prove such hypothe-

ses, and further research in this area is recommended.

Moreover, studies have suggested an association between

acute cholecystitis and choledocholithiasis with ischemic

heart disease. Salameh et al reported that one-fifth of patients

with angina pectoris that needed coronary angioplasty and

stenting also required CBD exploration.

That study would

support the findings of the current study regarding the asso-

ciation between a history of coronary stenting and CBD

diameter. In addition, Zheng et al found that patients with a

history of gallbladder disease had a 1.15-fold increased risk

of coronary heart disease compared with individuals without

gallbladder disease.

They observed increased intima-media

Table 2. The Mean Diameter of the Common Bile Duct

Based on the Baseline Variables.

Parameter Mean CBD P-value

Gender .444

Male 4.28 ± 1.41

Female 4.07 ± 1.28

Age group .001

≤ 60 years 3.92 ± 1.24

> 60 years 4.87 ± 1.41

Diabetes mellitus .155

Positive 4.62 ± 1.03

Negative 4.11 ± 1.40

Hyperlipidemia .022

Positive 4.65 ± 1.07

Negative 3.99 ± 1.42

Hypertension .005

Positive 4.63 ± 1.36

Negative 3.88 ± 1.27

Smoking .326

Positive 4.54 ± 1.77

Negative 4.14 ± 1.28

Coronary stenting .016

Positive 5.07 ± 1.01

Negative 4.08 ± 1.35

Figure 3. A box plot that compares the mean diameter of

common bile duct in men and women.

Table 1. The Study Patient’s Clinical Characteristics Based on Their Calcium Score.

No evidence of CAD:

0 calcium score

N = 21

Minimal: 1–10

calcium score

N = 24

Mild: 11–100

calcium score

N = 22

Moderate: 101–400

calcium score

N = 23

Severe: > 400

calcium score

N = 13

Total

N = 103

Gender (male) 2 8 14 3 2 29 (28%)

Age > 60 years 6 2 5 10 6 29 (28%)

Diabetes mellitus 0 4 8 4 2 18 (17.4%)

Hyperlipidemia 1 4 6 11 9 31 (30%)

Hypertension 2 8 18 4 10 42 (40%)

Smoking 1 2 8 1 1 13 (12%)

Coronary stenting 0 0 0 2 11 13 (12%)

Kheiridoost Langroudi et al 565

thickness, plaque formation, and calcification in the aorta and

iliac arteries, suggesting a link between biliary disease and

atherosclerosis.

The current study has revealed significant

findings regarding the association between CBD diameter

and cardiovascular risk factors, such as old age, hyperten-

sion, and previous history of coronary intervention. The

observed relationship between increased CBD diameter and

aging is consistent with findings from other published stud-

ies,

4,24,25

indicating that aging may lead to decreased flexibil-

ity and inflammation in the bile ducts. Similarly, the

association between hypertension and CBD diameter may

be related to biliary dysfunction and underlying hyperten-

sion, although further evaluation is needed to understand the

pathophysiology of this relationship.

Limitations

These results are limited by the non-randomized research

design with threats to internal and external validity. In

addition, the study was conducted at a single center with

a convenient sample of patients. The limited the sample

size and inability to utilize the full capacity of all univer-

sity hospitals, in the area, is an additional limitation. In

addition, extensive exclusion criteria were implemented

to control various factors affecting atherosclerosis and

CBD diameter, which further reduced the sample size.

Including patients with clinical atherosclerosis, such as

those with myocardial infarction, stroke, or peripheral

Figure 4. A box plot that compares the mean diameter of

the common bile duct in patients younger than 60 and those

older than 60.

Figure 5. A box plot that compares the mean diameter of

the common bile duct in diabetic and non-diabetic patients.

Figure 6. A box plot that compares the mean diameter

of the common bile duct in patients with and without

hyperlipidemia.

Figure 7. A box plot that compares the mean diameter

of the common bile duct in patients with and without

hypertension.

566 Journal of Diagnostic Medical Sonography 39(6)

arterial disease, could have increased the number of study

patients. However, ethical considerations and radiation

risks associated with abdominal CT for these patients

prevented their inclusion in the study. It is recommended

that future studies focus on investigating the association

between CBD diameter and the use of the atherosclerotic

cardiovascular disease (ASCVD) score to further enhance

our understanding of this possible association.

Conclusion

The findings of this study revealed a statistically signifi-

cant relatively strong correlation between CBD diameter

and the calcium score, within coronary arteries, which

may suggest a potentially shared pathophysiology

between CBD dilatation and the severity of coronary ath-

erosclerosis. It is important to note that this study had

inherent limitations, therefore, the results must be inter-

preted with caution, regarding the broader population.

Further studies with larger and more diverse cohorts are

needed to confirm these findings and establish a specific

diagnostic cut-off point for CBD diameter. Such a diag-

nostic cut-off point would be valuable in clinical practice,

as measurements exceeding this threshold in patients

without the known biliary disease could indicate higher

calcium scores in the coronary arteries. This could poten-

tially warrant further evaluation of these at risk patients

using more invasive imaging techniques, such as coro-

nary CTA or routine diagnostic angiography.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with

respect to the research, authorship, and/or publication of this

article.

Funding

The authors received no financial support for the research,

authorship, and/or publication of this article.

Ethics Approval

The study received approval from the hospital’s local ethics

committee (IRB# IR.SBMU.REC.9716).

Informed Consent

Informed consent was not sought for the present study because

all case data was de-identified and/or aggregated and followed

ethics committee or IRB guidelines (also referred to as the

Honest Broker System).

Animal Welfare

Guidelines for humane animal treatment did not apply to the

present study because no animals were used for the purpose of

this study.

Trial Registration

Not applicable.

ORCID iD

Neda Akhoundi https://orcid.org/0000-0002-5886-5897

Figure 8. A box plot that compares the mean diameter of

the common bile duct in patients with and without coronary

stenting.

Table 3. The Study Parameters That Were Tested for

Association With Dilatation of the Common Bile Duct.

Study parameters Beta

Standard

error

P-value

(P ≤ .05)

Gender –0.219 0.274 .427

Age 0.825 0.290 .005

Diabetes mellitus –0.378 0.415 .364

Hyperlipidemia 0.452 0.301 .137

Hypertension 0.591 0.275 .034

Smoking 0.438 0.389 .263

Coronary stenting 1.339 0.389 .001

Table 4. The Strength of Association Between Age,

Common Bile Duct (CBD) Diameter, and Agatston Score, for

This Study Cohort.

Study parameters

coefficient

P-value

(P ≤ .05)

Age and CBD diameter

0.493 .001

CBD diameter and Agatston score

0.444 .002

Age and Agatston score

0.543 .014

Pearson’s correlation test.

Spearman’s rank correlation test.

Kheiridoost Langroudi et al 567

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SDMS CME Credit – The Association Between

Common Bile Duct Diameter and the Severity of

Coronary Artery Atherosclerosis, Based on Calcium

Score

SDMS members can earn SDMS CME credit by successfully completing the complimentary online

CME test in the SDMS Learning Center at learn.sdms.org. Non-members may access the online CME

test for a fee. Note: questions may appear in random order online.

1. Traditionally, the upper limits of normal for a common

bile duct diameter in a patient that is post cholecystec-

tomy is _______.

A. 6.0 mm

B. 11.8 mm

C. 10.0 mm

D. 1.8 mm

2. Which of the following is not a factor that can change

common bile duct diameter?

A. Sphincterotomy

B. Splenectomy

C. Body Mass Index

D. Respiration

3. According to this study, which individual factor has a

larger common bile duct diameter?

A. Prior coronary stenting

B. Age less than 60 years old

C. Woman

D. Hypotension

4. The findings of this study showed a relationship

between ____________.

A. Common bile duct dilatation and coronary athero-

sclerosis

B. Biliary atresia and common bile duct dilatation

C. Hypertension and coronary atherosclerosis

D. Common bile duct dilatation and hypotension

5. Which modality was used to measure total calcium

score?

A. US

B. CTA

C. MRA

D. NM

1201586JDM

XXX10.1177/87564793231201586Journal of Diagnostic Medical SonographyMeeting-Report

meeting-report2023

Authors: Fatemeh Kheiridoost Langroudi, MD, Taraneh Faghihi Langroudi, MD, Neda Akhoundi, MD, and Alireza Siami, MSc

Category: Abdomen [AB]

Credit: 0.75 SDMS CME Credit

Objectives: After studying the article, you should be able to:

 Discuss the difference in common bile duct diameter measurements.

 Explain the relationship between common bile duct diameter and coronary artery atherosclerosis.

 Describe the different modalities used to measure bile duct diameter and calcium scoring.

https://doi.org/10.1177/87564793231192831

Journal of Diagnostic Medical Sonography

2023, Vol. 39(6) 569 –574

Article reuse guidelines:

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DOI: 10.1177/87564793231192831

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Original Research

In this recent decade, the mortality rate caused by cardio-

vascular diseases has increased drastically in Middle

Eastern countries compared with other parts of the world.

Studies have also revealed that the mortality caused by

cardiovascular disorders in the Middle East increased by

171% from 1990 to 2020. The epidemiological studies in

Iran and the United Arab Emirates reflect an estimated

prevalence of 5.9% for cardiovascular diseases in the

future.

In response to this rise in cardiovascular disease,

goal-directed, emergency medicine departments (EDs)

have used a point-of-care ultrasound (POCUS) curricu-

lum to try to increase a physician trainee’s self-confi-

dence and performance.

1192831JDM

XXX10.1177/87564793231192831Journal of Diagnostic Medical SonographyMohammadi et al

research-article2023

Emergency Medicine Management Research Center, Health

Management Research Institute, Iran University of Medical Sciences,

Tehran, Iran

Student Research Committee, School of Medicine, Iran University of

Medical Sciences, Tehran, Iran

Trauma and Injury Research Center, Iran University of Medical

Sciences, Tehran, Iran

Received February 11, 2023, and accepted for publication July 17, 2023.

Corresponding Author:

Samira Vaziri, Emergency Medicine Management Research Center,

Health Management Research Institute, Iran University of Medical

Sciences, Tehran 1449614535, Iran.

Email: [email protected]

Determining the Extent of Agreement

for Determining the Echographic

Ejection Fraction Determined by

Emergency Medicine Residents

Compared with a Cardiologist

Fatemeh Mohammadi, MD

, Seyedamir Tabibzadeh Dezfooli, MD

Babak Sadeghzadeh, PhD

, Mojtaba Chardoli, PhD

, Hamed Basir Ghafouri, PhD

Mahdi Rezai, PhD

, Reza Mosaddegh, PhD

, and Samira Vaziri, PhD

Abstract

Objective: The aim of this study was to determine the extent of agreement on the measured echographic ejection

fraction measured by emergency medicine (EM) residents compared with a cardiologist.

Materials and Methods: This study was conducted with cardiac patients admitted to a hospital emergency

department in Tehran, Iran. A total of 156 patient cases were reviewed. A group of trained EM residents evaluated

the ejection fraction (EF) of these patients utilizing three different methods: Simpson’s method (N = 50), E-Point

Septal Separation (EPSS, N = 56), and a visual technique (N = 50). A final assessment was made for all patients by a

cardiologist.

Results: In 69.3% of these patient cases, there was a significant correlation between the EM residents’ report and

the cardiologists, with Cohen’s Kappa coefficient of .746 (P < .001). The Kappa coefficient for the visual technique,

Simpson’s method, and EPSS was .697, .467, and .487, respectively. The sensitivity, specificity, positive and negative

predictive values of EF measurements, provided by the EM residents, were 0.89%, 64.2%, 81.6%, and 76.5% compared

with the cardiologist, respectively.

Conclusion: This description study was done to determine the agreement of echocardiographic measurement of

EF, assessed by trained EM residents, compared with a cardiologist’s review. In this case, the results demonstrated

moderate to good agreement.

Keywords

inter-rater reliability, ventricular ejection fraction reporting, echocardiography, emergency medicine cardiac evaluation

570 Journal of Diagnostic Medical Sonography 39(6)

As the most important indicator of cardiac function,

obtaining the cardiac ejection fraction (EF) is vital in

deciding on an at-risk patient’s clinical management,

daily clinical examinations, and ultimate prognosis.

The

cardiac EF serves as reliable evidence of total heart func-

tion, and changes in EF can indicate various congenital

and acquired heart disorders.

The advantages of obtain-

ing this measurement include easy implementation,

safety, the minimal need for preparing the patient, repeat-

ability, noninvasiveness, and cost-effectiveness. Hence,

physicians highly use echocardiography a noninvasive

diagnostic tool to measure EF.

A heart attack or other cardiac disease can negatively

influence the EF.

The accurate assessment of left ven-

tricular ejection fraction (LVEF) is essential for manag-

ing patients with acute diseases, such as those with chest

pain, cardiogenic shock, or severe respiratory distress.

Physicians who are not cardiologists can learn to conduct

a basic echocardiogram and assess cardiac EF.

An echo-

cardiogram allows emergency medicine (EM) physicians

to obtain diagnostic information on many acute cardio-

vascular diseases, such as tamponade, pulmonary embo-

lism (PE), cardiogenic shock, and cardiogenic pulmonary

edema.

Currently, the rapid ultrasound for shock and

hypotension (RUSH) examination can be conducted in

the ED, at the bedside of critically ill patients, to deter-

mine the cause of cardiogenic shock. This exam includes

an assessment of EF, while can assess cardiac function

and the probability of PE, tamponade, and pericardial

effusion.

8,10

However, only a few studies have been con-

ducted to validate the accuracy of EF calculations in the

ED. Therefore, this study was composed to determine the

reliability and potential accuracy of these measurements,

made in the ED. To this end, a reliability and accuracy

test was conducted, of the echographic EF measurements,

made by EM residents compared with a cardiologist.

Materials and Methods

Study Design

This study was designed to determine concordance

between diagnostic test results and a gold standard. The

study design was presented to the Ethics Committee of

Iran University of Medical Sciences and was approved

(ethics code: IR.IUMS.FMD.REC.1398.070). After pro-

viding a complete explanation of the study, informed

written consent was obtained from all patients. It was

important stress to the patients that participation in the

study was optional and medical services would still be

provided regardless of their willingness to participate in

the study. There were no additional expenses charged to

the patient for additional interpretations. The researchers

abided by the Helsinki Convention principles during this

study. Each patient provided verbal consent and was

assured of medical confidentiality.

Study Cohort and Sample Size

This study was conducted, in 2020, with qualified patients

between the ages of 18 and 80 years of age and presenting

with dyspnea, to the ED at Rasoul Akram Hospital.

Exclusion criteria included those patients who were intu-

bated, pregnant, elevated cardiac biomarkers, hemody-

namically unstable, and patients with atrial fibrillation.

These exclusions were made due to the possible influence

on echocardiographic EF measurements.

In this study, sample measurements were gathered

using a convenient sampling technique. A total of 156

participants were enrolled in the study.

Measurement Technique

In this study, five senior EM residents received theoretic

content (4 hours) and practical training (5 hours on 15

patients) from a skilled and experienced echocardiologist.

Following the referral of patients, eligible individuals

underwent an echocardiogram that was conducted on a

Samsung HM70A ultrasound equipment system

(Samsung Healthcare.com). Each EM resident measured

the LVEF using one of the following three diagnostic

methods: Simpson’s method, E-Point Septal Separation

(EPSS), and a visual assessment. Simpson’s method

requires tracking the endocardium in apical four-chamber

and two-chamber views, during end-systole and end-

diastole. The left ventricle’s end-diastolic volume (EDV)

and the end-systolic volume (ESV) were calculated.

Afterward, the left ventricular EF is calculated via the

following formula

VolVol

Vol

ed es

−

×100

Normal function is defined as an EF of more than

55%. Mild dysfunction is an EF between 45% and 54%.

Moderate and severe dysfunctions are considered 30%–

44% and less than 30%, respectively.

The EPSS is an M-mode method measured in the para-

sternal long-axis (PLAX) view. The shortest distance

between the apex of the anterior leaflet of the mitral valve

and the ventricular septum is measured in millimeters,

called EPSS. A distance less than 8.0 mm is defined as a

normal function (EF >55%), between 8 and 14 is mild

dysfunction (EF = 45%–54%), between 14 and 17 is

moderate dysfunction (EF = 30%–44%), and more than

17 is considered as severe dysfunction (EF <30%).

Using a visual method (sometimes referred to as “eye-

balling”), the EF was estimated based on personally

detecting LV contraction in the PLAX view.

Mohammadi et al 571

Each resident looked for an inward movement of the

endocardium, thickening of the myocardium, the motion

of the anterior mitral valve leaflet, and geometry of the

left ventricle (e.g., size and aneurysms). This method

classified dysfunction in comparison with Simpson’s and

EPSS method of measurement.

Finally, a cardiologist assessed all the patients using the

same offline approach and device to assess the LVEF. The

cardiologist’s report was considered the diagnostic gold

standard for interpretation. It is also worth noting that the

cardiologist was unaware of the results reported by the EM

residents. Also, one cardiologist conducted all the echocar-

diographic readings. There was a maximum interval of 1

hour between two echocardiography examinations con-

ducted by the EM resident and the cardiologist. As men-

tioned, all patients were in stable condition, and two

echocardiograms did not hinder or postpone the diagnostic

or therapeutic measures. All the cardiac function informa-

tion was recorded as well as their age, gender, blood pres-

sure, heart rate, respiratory rate, and body mass index (BMI).

These data were all collected on a predesigned checklist.

Finally, all data points were analyzed statistically.

Data Analysis

The analysis was conducted using SPSS statistical soft-

ware (IBM Corp., Armonk, NY, USA). The quantitative

data were descriptively defined by the mean and standard

deviations. The qualitative data were described using per-

centages and frequency. Cohen’s Kappa coefficient,

Mann-Whitney U test, and Spearman’s correlation tests

were performed on this data set. The diagnostic sensitiv-

ity, specificity, positive and negative predictive values of

the resident’s measured EF were preformed (See Table

1). As previously mentioned, the reported measurements

made by the cardiologist were considered the diagnostic

gold standard. The statistical significance was set a priori

at P < .05.

Results

The aim of this study was to determine the extent of

agreement on the measured echographic EF measured by

EM residents compared with a cardiologist. The study

participants included 156 patients. According to the car-

diologist’s report, 57 patients had normal cardiac func-

tion based on their EF measurement. Demographic

characteristics are provided in Table 2. The mean blood

pressure, respiratory rate, and heart rate values are also

provided (See Table 3).

As shown in Table 4, the comparison between the EF

measurements made by the EM residents and the cardi-

ologist was analyzed qualitatively and quantitatively.

In the qualitative section, the agreement between the

EM resident and the cardiologist reports was at 69.3% for

all the cases. A moderately strong Cohen’s Kappa coeffi-

cient of .746 (P < .001) was statistically significant. The

results of the quantitative analysis were also compared

with moderately strong comparison between the EM resi-

dents’ reports and the cardiologist’s reports (P < .001).

The Kappa contingency coefficient and Spearman’s

coefficient for each diagnostic method are shown

Table 1. Evaluation of Sensitivity, Specificity, Positive Predictive Value, and Negative Predictive Value of the Measured Ejection

Fraction by Emergency Medicine Residents.

Groups Sensitivity Specificity Positive Predictive Value Negative Predictive Value

Visual technique 94.8% 72.7% 92.5% 80.0%

E-Point Septal Separation 85.1% 65.5% 69.6% 82.6%

Simpson’s method 85.2% 56.2% 80.5% 64.2%

Total 89.0% 64.2% 81.6% 76.5%

Table 2. The Study Cohort’s Demographic Characteristics.

% of the

Total Sample

Sample size 156 100

Male 69 44.2

Female 87 55.8

Minimum Maximum M SD

Age 18 80 65.14 14.70

Body mass

index

17 31 24.74 6.96

Abbreviations: M, mean; SD: standard deviation.

Table 3. The Mean Blood Pressure, Heart Rate, and

Respiratory Rate for the Study Cohort.

Variables M ± SD Minimum Maximum

Systolic blood

pressure in mmHg

128.49 ± 23.49 80 190

Diastolic blood

pressure in mmHg

75.51 ± 9.10 60 110

Heart rate 80.50 ± 12.83 45 110

Respiratory rate 17.39 ± 1.78 12 25

Abbreviations: M, mean; SD: standard deviation.

572 Journal of Diagnostic Medical Sonography 39(6)

separately in Table 5. In this cohort of patients, there were

significant Cohen’s Kappa coefficient and high correla-

tion between the EM residents and the cardiologist based

on all the diagnostic techniques to measure EF.

Based on these reported findings, the highest agree-

ment and correlation between the EM residents and the

cardiologist’s measurements, as well as the highest speci-

ficity, sensitivity, and positive and negative predictive

values, were reported when using the person visualiza-

tion technique. In addition, investigating the agreements

between EM residents and cardiologists indicated that for

all five trained EM residents, the agreements were sig-

nificant and very similar (81.3%, 80.6%, 83.8%, 77.4%,

and 77.4%, respectively).

Discussion

Based on the findings of this study, the overall agreement

between the EM residents and the cardiologists was

69.3%, which was significant. Besides, the sensitivity,

specificity, and positive and negative predictive values of

the EF measurements by the EM resident were 89.0%,

64.2%, 81.6%, and 76.5%, respectively, compared with

the cardiologist’s report, which was considered the gold

standard.

In an investigation, Unlüer et al. studied the visual

(eyeballing) technique for assessing echocardiographic

EF. In that study, the sensitivity, specificity, and positive

and negative predictive values of the patient’s bedside EF

measurements, made by an EM specialist compared with

a cardiologist, were 98.7%, 86.2%, 90.4%, and 90.4%,

respectively. In the Unlüer et al., study, the reported val-

ues were also higher than the total values in this study.

However, Unlüer et al.

only used the visual technique

for assessment and used EM physicians to provide the

reporting. The sensitivity, specificity, and positive and

negative predictive values resulting from the visual tech-

nique in this study were 94.8%, 72.7%, 92.5%, and

80.0%, respectively. These values are almost similar to

the values reported by Unlüer et al.

Similar to the study

by Unlüer et al., the lowest value reported in this study

was the specificity of the bedside EF calculation. In both

studies, the highest level of disagreement was in patients

with a normal left ventricular EF diagnosed with dys-

function or low EF by the EM residents/specialists.

In a study by Randazzo et al., the sensitivity of the left

ventricular EF in the EPSS method was 100%. However,

its specificity was below 51.6%.

Unlike this study,

Randazzo et al. observed the highest level of agreement

between the EM specialists and echocardiography spe-

cialists in the normal function category. This difference

between these studies could be attributed to the difference

between their inclusion and exclusion criteria and their

patient selection methods. In the study by Randazzo

et al.,

most participants were patients suffering from

low blood pressure, and only 5.7% of the 115 participants

had dyspnea. In contrast, one of the inclusion criteria in

this study was the presence of dyspnea.

A meta-analysis conducted by Albaroudi et al. assessed

the visual estimation technique by EM physicians, using

point-of-care echocardiography, compared with expert

Table 4. The Correlation Coefficient Between the Ejection Fraction Measured by Cardiologists and Emergency Medicine Residents.

N = 156

Cardiologists’ Report

Frequency (%)

Normal

Function

Mild

Dysfunction

Moderate

Dysfunction

Severe

Dysfunction

Qualitative Emergency medicine

residents’ report

Frequency (%)

Normal function 36 (23.1) 11 (7.0) 0 (0.0) 0 (0.0)

Mild dysfunction 19 (12.2) 42 (26.9) 5 (3.2) 1 (0.6)

Moderate dysfunction 1 (0.6) 5 (3.2) 16 (10.3) 5 (3.2)

Severe dysfunction 0 (0.0) 0 (0.0) 1 (0.6) 14 (9.0)

Result of statistical test Kappa contingency coefficient = .746

P = .000

Quantitative Result of statistical test Spearman correlation coefficient = .841

P = .000

Table 5. The Kappa Contingency Coefficient and Spearman

Correlation Coefficient for Each of the Diagnostic Methods

to Assess Cardiac Ejection Fraction.

Kappa

Contingency

Coefficient

Spearman

Correlation

Coefficient

Visual technique .697 .859

E-Point Septal Separation .487 .782

Simpson’s method .467 .847

Generally, a Kappa of less than .4 is considered poor (a Kappa of

0 means there is no difference between the observers and chance

alone). Kappa values of .4–.75 are considered moderate to good,

and a Kappa of >.75 represents excellent agreement. A Spearman’s

correlation is based on a perfect correlation approaching 1.0.

Mohammadi et al 573

sonographers. The sensitivity, specificity, and positive

and negative likelihood ratios of 89%, 85%, 5.98, and

0.13, respectively, were between clinician sonographers

and expert sonographers for normal and abnormal left

ventricular systolic function.

These findings compare

very nicely with the results of this study.

In comparison with this study, the work published by

Weekes et al.,

van Royen et al.,

and Amico et al.

demonstrated that the visual technique was superior to

the other relevant diagnostic methods in estimating the

EF. Jensen-Urstad et al.

and van’t Hof et al.

indicated

that the visual technique offered a high level of accuracy

in the estimation of EF. Gudmundsson et al. indicated that

the visual technique was like all the other EF calculation

methods, including Simpson’s method. None of these

evaluative methods for detecting EF is considerably

superior to the others.

In addition, a systematic review

by McGowan et al.

indicated that Simpson’s method,

EPSS, and the visual technique have similar advantages

and disadvantages.

In the study by McKaigney et al., they reported that

the visual technique has a weak correlation with the

actual output of the left ventricle. In contrast, the EPSS

method strongly correlates with the actual LVEF. Unlike

this study, in that report, the EPSS method was consider-

ably superior to the visual technique. They also referred

to its advantages, including faster deployment, less need

for the patient’s cooperation, and fewer views.

In another study, Rasooli et al. compared the echocar-

diography results between an EM resident and cardiolo-

gists. The study showed an acceptable agreement between

the results of the EM resident and cardiologists’ echocar-

diography in assessing regional wall motion abnormali-

ties in acute coronary syndrome.

One of the distinguishing features of this study was the

assessment of the EF by five different EM residents,

which indicated that well-trained EM residents could pro-

vide acceptable measurements of EF, within a short time

in the ED. As for all five trained residents, the agreements

between the residents and the cardiologists were signifi-

cant and almost similar.

Limitations

The major limitation to this study was the research design

and as such the pre-experimental nature and nonrandom-

ization of the patient’s evaluated hamper the results due

to threats to internal and external validity. These reliabil-

ity results are unique to these EM residents and the

patients that they examined. Another concern was that

this was a single-center trial that used convenience sam-

pling for patient selection. Future work in this area should

be conducted across multiple health care centers with a

variety of EM residents.

In addition, further limitations exist due to the difference

in the time of assessment by EM residents and cardiologists.

Although it is very unlikely, the patient’s systolic function

may change through long intervals in some cases and due to

changes in the patient’s condition, such as the development

of acidosis, electrolyte derangements, or the intake of vaso-

pressors. Therefore, future reliability studies should account

for the time interval between the bedside EF assessment and

the measurement by a cardiologist as a determining variable.

In addition, EPSS is an M-mode method that is no longer a

reliable measure to assess the EF. Although, in this study,

“eyeballing” provided the highest correlation between phy-

sicians, it is not considered a scientific method. Moreover,

the inclusion criteria of this study did not include a wide

range of patients with different conditions.

Conclusion

The results of this reliability study showed acceptable

agreement between the diagnostic measurement of EF by

trained EM residents and a cardiologist. Furthermore, this

study also revealed that that the visual technique had

more consistency between EM residents and a cardiolo-

gist. Thus, an effort should be considered to educate EM

residents on conducting cardiac sonogram and how to

make reliable measurements of EF in patients presenting

to the ED. Care should be taken in educating residents on

using the visual technique for assessing EF, as published

study results may not be generalizable or applicable in

certain patient populations. Although, in general, the goal

would be to promote Simpson’s method because of its

accuracy. Therefore, there may be value in instructing

and using different diagnostic methods for the measure-

ment of EF among EM residents and ED physicians.

Further research with more rigorous methodologies is

needed to confirm the results of this study.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect

to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research,

authorship, and/or publication of this article.

Ethics Approval

The study design was presented to the Ethics Committee of Iran

University of Medical Sciences and was approved (ethics code:

IR.IUMS.FMD.REC.1398.070).

Informed Consent

Informed consent was not sought for the present study because

all case data were de-identified and/or aggregated and followed

574 Journal of Diagnostic Medical Sonography 39(6)

ethics committee or IRB guidelines (also referred to as the

Honest Broker System).

Animal Welfare

Guidelines for humane animal treatment did not apply to the

present study because no animals were used during the study.

Trial Registration

Not applicable.

ORCID iDs

Seyedamir Tabibzadeh Dezfooli https://orcid.org/0000-0002-

4962-4223

Samira Vaziri

https://orcid.org/0000-0002-7556-6813

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SDMS CME Credit – Determining the Extent of

Agreement for Determining the Echographic Ejection

Fraction Determined by Emergency Medicine

Residents Compared with a Cardiologist

SDMS members can earn SDMS CME credit by successfully completing the complimentary online

CME test in the SDMS Learning Center at learn.sdms.org. Non-members may access the online CME

test for a fee. Note: questions may appear in random order online.

1. Normal function is defined as an ejection fraction (EF)

of more than:

A. 55%

B. 50%

C. 75%

D. 45%

2. Jensen-Urstad et al. and van’t Hof et al. indicated that

the visual technique _______.

A. Was completely unreliable

B. Resulted in a low level of accuracy in the estima-

tion of EF

C. Was inconclusive

D. Offered a high level of accuracy in the estimation

of EF

3. The aim of this study was to ____________.

A. Determine the accuracy of EPSS measurement

B. Determine the extent of agreement on the mea-

sured echocardiographic EF measured by EM

residents compared to a cardiologist

C. Evaluate echocardiogram read times for critical

patients

D. Prove that visual assessment of EF is more accu-

rate than Simpson’s method

4. This study compared echocardiogram interpretations

from cardiologists and ________.

A. Emergency medicine residents

B. Cardiology fellows

C. General surgeons

D. Nurse practitioners

5. Based on the findings of this study, the overall agree-

ment percentage between the EM residents and cardi-

ologists was:

A. 90.3%

B. 70.5%

C. 69.3%

D. 89.0%

1201587JDM

XXX10.1177/87564793231201587Journal of Diagnostic Medical SonographyMeeting-Report

meeting-report2023

Authors: Fatemeh Mohammadi, MD, Seyedamir Tabibzadeh Dezfooli, MD, Babak Sadeghzadeh, PhD, Mojtaba Chardoli, PhD,

Hamed Basir Ghafouri, PhD, Mahdi Rezai, PhD, Reza Mosaddegh, PhD, and Samira Vaziri, PhD

Category: Cardiac (Adult) [AE]

Credit: 0.75 SDMS CME Credit

Objectives: After studying the article, you should be able to:

 Define the method of measurement used: EPSS, Simpson’s method, or visual assessment.

 Discuss the extent of agreement on the measured echocardiographic ejection fraction (EF) measured by emergency medicine

(EM) residents compared with a cardiologist.

 Explain the value of educating EM residents to interpret echocardiographic ejection fraction.