Accuracy of POCUS Versus Consultative Echocardiography for Identifying Right Ventricular Dysfunction in ED Patients With Pulmonary Embolism

Accuracy of POCUS Versus Consultative Echocardiography for Identifying Right Ventricular Dysfunction in ED Patients With Pulmonary Embolism

Authors: Thomas AL, Rupp JD, Suszanski J, Storrow AB, Kline JA, Birrenkott DA, Kabrhel C, Wrenn JO, Stubblefield WB
Journal: Annals of Emergency Medicine, June 2026

Conclusions:

  • Emergency physician-performed POCUS demonstrated moderate agreement with cardiologist-interpreted echocardiography for detecting right ventricular dysfunction in patients with pulmonary embolism.

  • POCUS was more specific than sensitive, meaning a clearly abnormal right ventricle can support PE risk stratification, but a normal POCUS examination does not reliably exclude RV dysfunction.

  • Accuracy improved when RV dysfunction was moderate to severe, suggesting POCUS performs best at recognizing clinically substantial right-heart strain rather than subtle abnormalities.

  • Practical takeaway: POCUS is a useful rapid adjunct for identifying significant RV dysfunction in PE, particularly in unstable or deteriorating patients, but should not be treated as interchangeable with comprehensive echocardiography.

Practice Takeaways:

  • A POCUS examination showing a dilated or hypokinetic RV can rapidly identify a PE patient who may warrant closer monitoring, biomarker assessment, multidisciplinary PE response, or consideration of advanced therapy.

  • Because sensitivity was only 76.8%, a normal bedside examination should not be used to downgrade an otherwise concerning patient or exclude intermediate-risk PE.

  • POCUS appears most dependable for obvious RV strain; subtle dysfunction may require formal echocardiography.

  • Interpret RV findings in combination with hemodynamics, troponin, BNP, CT evidence of RV enlargement, oxygen requirement, lactate, and the overall clinical trajectory.

  • The decline in reliability with advancing residency level is interesting but unexplained; it may reflect differences in case selection, scan frequency, operator confidence, or documentation rather than a true loss of skill.

  • The study included only patients who underwent both examinations, creating potential selection bias toward patients in whom clinicians already suspected RV dysfunction or greater PE severity.

Results:

  • Cohort: 194 ED patients with confirmed PE who received both:

    • Emergency physician-interpreted POCUS.

    • Cardiologist-interpreted consultative echocardiography.

  • Operators: 97 emergency physicians.

  • POCUS performance for identifying RV dysfunction:

    • Sensitivity: 76.8%.

    • Specificity: 85.9%.

    • Overall agreement: 81.4%.

    • Kappa: 0.63 (95% CI 0.51–0.75), indicating moderate intermodality agreement.

  • Accuracy and agreement improved when consultative echocardiography demonstrated moderate-to-severe RV dysfunction.

  • Inter-rater reliability unexpectedly declined with advancing residency training level.

Methods:

  • Retrospective cohort study of patients with confirmed pulmonary embolism.

  • A regular-expression algorithm was used to identify PE-positive patients.

  • Included only patients who underwent both ED POCUS and formal cardiology-interpreted echocardiography.

  • RV dysfunction on POCUS was defined by:

    • RV size greater than LV size.

    • Decreased RV systolic function based on tricuspid annular plane systolic excursion.

    • Or both findings.

  • Consultative echocardiography classified RV dysfunction as:

    • Absent.

    • Mild.

    • Moderate to severe.

  • Investigators calculated sensitivity, specificity, overall agreement, and kappa coefficients, with analyses stratified by RV dysfunction severity and emergency medicine training level.

Thomas, A.L., Rupp, J.D., Suszanski, J., Storrow, A.B., Kline, J.A., Birrenkott, D.A., Kabrhel, C., Wrenn, J.O. and Stubblefield, W.B., 2026. Accuracy of Point-of-Care Ultrasound Versus Consultative Echocardiography to Identify Right Ventricular Dysfunction in Emergency Department Patients With Pulmonary Embolism. Annals of Emergency Medicine, [online] Available at: <https://doi.org/10.1016/j.annemergmed.2026.05.003&gt; [Accessed 27 June 2026].

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