1. Int J Cardiol. 2017 Oct 1. pii: S0167-5273(17)32599-8. doi:
10.1016/j.ijcard.2017.09.172. [Epub ahead of print]

Quality control of regional wall motion analysis in stress Echo 2020.

Ciampi Q(1), Picano E(2), Paterni M(3), Daros CB(4), Simova I(5), de Castro E
Silva Pretto JL(6), Scali MC(7), Gaibazzi N(8), Severino S(9), Djordjevic-Dikic
A(10), Kasprzak JD(11), Zagatina A(12), Varga A(13), Lowenstein J(14), Merlo
PM(14), Amor M(15), Celutkiene J(16), Perez JE(17), Di Salvo G(18), Galderisi
M(19), Mori F(20), Costantino MF(21), Massa L(22), Dekleva M(23), Chaves DQ(24), 
Trambaiolo P(25), Citro R(26), Colonna P(27), Rigo F(28), Torres MAR(29), Monte
I(30), Stankovic I(31), Neskovic A(31), Cortigiani L(32), Re F(33), Dodi C(34),
D'Andrea A(35), Villari B(36), Arystan A(3), De Nes M(3), Carpeggiani C(3);
Stress Echo 2020 study group of the Italian Society of Cardiovascular Echography.

Author information: 
(1)CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy;
Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy.
(2)CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy.
Electronic address: picano@ifc.cnr.it.
(3)CNR, Institute of Clinical Physiology, Biomedicine Department, Pisa, Italy.
(4)Cardiology Division, Hospital San José, Criciuma, Brazil.
(5)Acibadem City Clinic Cardiovascular Center, University Hospital, Sofia,
Bulgaria.
(6)Hospital Sao Vicente de Paulo e Hospital de Cidade, Passo Fundo, Brazil.
(7)Cardiology Department, Nottola Hospital, Siena, and Cardiothoracic Department,
University of Pisa, Italy.
(8)Cardiology Department, Parma University Hospital, Italy.
(9)Cardiology Department, Monaldi Hospital, Naples, Italy.
(10)Cardiology Clinic, Clinical Center of Serbia, Medical School, University of
Belgrade, Serbia.
(11)Chair of Cardiology, Bieganski Hospital, Medical University, Lodz, Poland.
(12)Cardiology Department, Medika Cardiocenter, Saint Petersburg, Russian
Federation.
(13)Institute of Family Medicine, University of Szeged, Hungary.
(14)Cardiodiagnosticos, Investigaciones Medicas, Buenos Aires, Argentina.
(15)Cardiology Department, Ramos Mejia Hospital, Buenos Aires, Argentina.
(16)Centre of Cardiology and Angiology, Vilnius University Hospital Santariškių
Klinicos, Lithuania.
(17)Washington University School of Medicine, Barnes-Jewish Hospital, St. Louis, 
MO, USA.
(18)Pediatric Cardiology Department, Brompton Hospital, London, UK.
(19)Department of Advanced Biomedical Sciences, Federico II University Hospital, 
Naples, Italy.
(20)Cardiology Department, Careggi Hospital, Florence, Italy.
(21)Cardiology Department, San Carlo Hospital, Potenza, Italy.
(22)Cardiology Department, University Hospital "Ospedale Riuniti", Trieste,
Italy.
(23)Clinical Hospital Zvezdara Belgrade, Serbia.
(24)Hospital San Vicente de Paul, Heredia, Costa Rica.
(25)Department of Cardiology, Sandro Pertini Hospital, Rome, Italy.
(26)Cardiology Department and Echocardiography Lab, University Hospital "San
Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy.
(27)Cardiology Hospital, Policlinico of Bari, Italy.
(28)Cardiology Department, Ospedale dell'Angelo Mestre-, Venice, Italy.
(29)Hospital de Clinicas de Porto Alegre - Universidade Federal do Rio Grande do 
Sul, Porto Alegre, Brazil.
(30)Cardio-Thorax-Vascular Department, Echocardiography Lab, "Policlinico
Vittorio Emanuele", Catania University, Italy.
(31)Department of Cardiology, Clinical Hospital Center Zemun, Faculty of
Medicine, University of Belgrade, Serbia.
(32)Cardiology Department, San Luca Hospital, Lucca, Italy.
(33)Cardiology Department, San Camillo-Forlanini Hospital, Roma, Italy.
(34)Casa di Cura Figlie di San Camillo, Cremona, Italy.
(35)Cardiology Department, Echocardiography Lab, Monaldi Hospital, Second
University of Naples, Italy.
(36)Cardiology Division, Fatebenefratelli Hospital, Benevento, Italy.

BACKGROUND: The trial "Stress Echo (SE) 2020" evaluates novel applications of SE 
beyond coronary artery disease. The aim of the study was control quality and
harmonize reading criteria.
METHODS: One reader from 78 centers of the SE 2020 network asked for credentials 
to read a set of 20 SE video-clips selected by the core lab. All aspiring centers
met the pre-requisite of high-volume and the years of experience in SE ranged
from 5 to 31years (mean value 18years). The diagnostic gold standard was a
reading by the core lab. The a priori determined pass threshold was 18/20 (≥90%).
RESULTS: Of the initial 78 who started, 57 completed the first attempt:
individual readers' score on first attempt ranged from 07/20 to 20/20 (accuracy
from 35% to 100%, mean 78.7±13%) and 44 readers passed it. There was a very poor 
correlation between years of experience and the reader's score on first attempt
(r=-0.161, p=0.231). Of the 13 readers who failed the first attempt, 12 took it
again after the web-based session and their accuracy improved (74% vs. 96%,
p<0.001). The kappa inter-observer agreement before and after web-based training 
was 0.59 on first attempt and rose to 0.91 on the last attempt.
CONCLUSIONS: In SE reading, the volume of activity or years of experience is not 
synonymous with diagnostic quality. Qualitative analysis and operator-dependence 
can become a limiting weakness in clinical practice, in the absence of strict
pathways of learning, credentialing and audit.

Copyright © 2017 Elsevier Ireland Ltd. All rights reserved.

DOI: 10.1016/j.ijcard.2017.09.172 
PMID: 28986062