Correspondence
"Right" ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy
To the Editor, We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancement may be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m2; indexed end-systolic volume, 25 mL/m2). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m2; indexed endsystolic volume, 19 mL/m2). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3]. Graziapia Casavecchia, MD Cardiologia Universitaria, Ospedali Riuniti, Foggia, Italy Matteo Gravina, MD Radiologia Universitaria, Ospedali Riuniti, Foggia, Italy Antonio Totaro, MD Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy Riccardo Ieva, MD Cardiologia Universitaria, Ospedali Riuniti, Foggia, Italy Roberta Vinci, MD Luca Macarini, MD Department of Medical and Surgical Sciences, University of Foggia, Italy
469
Matteo Di Biase, MD Natale Daniele Brunetti, MD, PhD⁎ Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ⁎Corresponding author. Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.065
References [1] Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306:277–86. [2] Ieva R, Correale M, Brunetti ND, Di Biase M. A "bad" case of Tako-Tsubo syndrome. J Thromb Thrombolysis 2009;28:248–51. [3] Santoro F, Ieva R, Di Martino LF, Musaico F, Scarcia M, Ferraretti A, et al. Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular TakoTsubo cardiomyopathy. Int J Cardiol 2014;177:e99-101. [4] Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27:2433–9. [5] Casavecchia G, Gravina M, Totaro A, Ieva R, Vinci R, Macarini L, Di Biase M, Brunetti ND. Role of cardiac magnetic resonance in the differential diagnosis of Tako- Tsubo cardiomyopathy. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.040. [6] Hanna M, Finkelhor RS, Shaw WF, Bahler RC. Extent of right and left ventricular focal wall-motion abnormalities in differentiating transient apical ballooning syndrome from apical dysfunction as a result of coronary artery disease. J Am Soc Echocardiogr 2007;20:144–50.
Evaluation of right ventricular function in Takotsubo cardiomyopathy☆
To the Editor, We read with great pleasure the work by Casavecchia et al [1]. Cardiac magnetic resonance imaging (CMR) may indeed play an important role in selected patients with suspected Takotsubo cardiomyopathy (TCM) especially when other associated or alternate diagnoses need to be entertained. Recently, associations of TCM with other cardiac conditions such as myopericarditis have been described [2]. In these selected clinical conditions, CMR may play a pivotal role for diagnostic confirmation because the clinical data supported by the standard diagnostic imaging modalities alone sometimes may not be adequate. Cardiac magnetic resonance imaging provides an excellent characterization of myocardial infarction with recanalization or typical ischemic transmural late gadolinium enhancement and also reliably differentiates TCM from acute myocarditis and other noncardiac causes [2,3]. Indeed, CMR is also considered the criterion standard diagnostic modality for evaluation of right ventricular (RV) function [4]. Data from the prospective studies have shown that TCM patients who develop concomitant RV dysfunction have increased incidence of heart failure, bilateral pleural effusions, and also significantly increased length of hospital stay compared with the patients with isolated left ventricular involvement [2,5]. In fact, biventricular apical ballooning pattern is seen in one third of patients with TCM. Thus, we would greatly appreciate if the authors could share the data on RV function in the patients involved in their study because the knowledge of RV involvement not only helps clinicians to tailor their treatment options but also carries a significant prognostic influence.
☆ Funding: None.
470
Correspondence
Vinod K. Chaubey, MD Department of Medicine, St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA Corresponding author. 123 Summer Street, Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798 E-mail address: [email protected] Lovely Chhabra, MD Department of Cardiovascular Medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT Nirmal J. Kaur, MD Department of Medicine, St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA
from the Medicare reimbursements. Still, the reimbursements for POC echocardiograms may be considered reasonable for physicians because they involve much lesser time and upfront infrastructure cost. This may be extremely useful in the upcoming model of care of Accountable Care Organization [5]. However, the big question still remains: “Can handheld ultrasound devices be considered the standard of care across the country’s EDs?” Certainly, the answer is affirmative when the goal is cost-effective health care. This would indeed require a dedicated training of the ED staff and commitment of the ED physicians across the country for its adoption as a new standard of care not only for quick screening but which also meets the more comprehensive diagnostic standards. Lovely Chhabra, MD Department of Cardiovascular Medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT
http://dx.doi.org/10.1016/j.ajem.2014.12.064 References [1] Casavecchia Graziapia, Gravina Matteo, Totaro Antonio, Leva Riccardo, Vinci Roberta, Macarini Luca, et al. Role of cardiac magnetic resonance in the differential diagnosis of Tako-Tsubo cardiomyopathy. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.040. [2] Chhabra L, Khalid N, Kluger J, Spodick DH. Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy. Proc (Bayl Univ Med Cent) 2014;27:327–30. [3] Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306:277–86. [4] Simon MA. Assessment and treatment of right ventricular failure. Nat Rev Cardiol 2013;10:204–18. [5] Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27(20):2433–9.
Implication of bedside cardiopulmonary ultrasound on health care cost: an additional advantage☆
To the Editor, We read with great interest the work by Gallard et al [1]. Authors’ work is commendable in triaging and diagnosing patients with acute dyspnea with the use of bedside cardiopulmonary ultrasound. Indeed, the point-of-care (POC) cardiopulmonary ultrasound is not only an important diagnostic modality but also serves as an immensely useful guide during emergent cardiac procedures (such as pericardiocentesis) and resuscitation of critically ill patients [2]. This is especially true with the newest high-quality and easy-to-use handheld cardiac ultrasound devices. The current study especially sparks our interest from a financial perspective. A recently published New York Times article sheds light on the wide variations of medical billing and reimbursements for echocardiograms based on the various institutions, practice settings, and medical insurance carriers involved [3]. In our personal opinion, a POC ultrasound (if appropriately used) may offer a significant impact on reducing the health care costs and improving patient satisfaction. For instance, a point of contact ultrasound may prevent an inpatient admission for a patient presenting to the emergency department (ED) with acute dyspnea demonstrating symptomatic resolution with the initial ED therapy who would otherwise be just admitted for a comprehensive inpatient workup with the limiting time factor being an echocardiogram for many practical purposes [4]. Furthermore, office-based or ED-based POC echocardiograms billing cost is much lower as opposed to echocardiograms performed in hospital-based outpatient or inpatient setting as per the data
☆ Funding: None.
Vinod K. Chaubey, MD Department of Medicine, Saint Vincent Hospital University of Massachusetts Medical School, Worcester, MA Corresponding author. 123 Summer St., Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.041 References [1] Gallard Emeric, Redonnet Jean-Philippe, Bourcier JeanEudes, Deshaies Dominique, Largeteau Nicolas, Amalric Jeanne-Marie, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.12.003 [pii: S0735-6757(14)00896-1, Epub ahead of print]. [2] Herbst MK, Camargo Jr CA, Perez A, Moore CL. Use of Point-of-Care Ultrasound in Connecticut Emergency Departments. J Emerg Med 2015;48(2) 191–196.e2. [3] http://www.nytimes.com/2014/12/16/health/the-odd-math-of-medical-tests-oneechocardiogram-two-prices-both-high.html?_r=1. [4] Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, et al. Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination. J Am Soc Echocardiogr 2011;24:117–24. [5] Berwick DM. Making good on ACOs' promise–the final rule for the Medicare shared savings program. N Engl J Med 2011;365:1753–6.
Implication of bedside cardiopulmonary ultrasound on health care cost – An additional advantage: Author reply☆
To the Editor, We thank you for your interest in our study and agree with you on the importance of thinking about the costs resulting from patient care in the emergency department (ED). Although our study did not focus on this issue, we have demonstrated that, in comparison with the usual procedure, cardiopulmonary ultrasound in the hands of the ED physician succeeds in giving an exact diagnosis for more patients. This allows us nowadays to avoid realizing costly examinations such as N-terminal pro-brain natriuretic peptide or chest x-ray. Nevertheless, this does not represent the main cost reduction. Ultrasound in the ED allows us to direct elderly patients into units better suited to their pathology. Being better treated and oriented, these patients have a shorter stay, thus reducing the costs, although this still has to
☆ Conflict of interest: The authors have no conflict of interest to disclose.
"Right" ventricular assessment by cardiac magnetic resonance in Takotsubo cardiomyopathy
To the Editor, We would thank the colleagues for their kind interest in our work. We actually do agree that cardiac magnetic resonance (CMR) can be a useful tool for the assessment of the right ventricular (RV) function, in particular, of regional wall motion abnormalities and ejection fraction (EF), where echocardiography often fails. Different patterns of contraction may be found during the acute phase of Takotsubo cardiomyopathy (TTC), including apical, midventricular, basal, and biventricular ballooning. Eitel et al. [1] observed in their study that RV involvement may be present in one third of patients with TTC and reported an association with longer hospitalization, increased levels of heart failure markers, and older age. Consequently, biventricular ballooning may portend a more severe prognosis [2], when compared with isolated left ventricular (LV) involvement. Such findings have been confirmed also in other studies [3,4]. Cardiac magnetic resonance may improve our ability in assessing RV function and identifying the pattern of biventricular ballooning. The case 1 described in our paper [5] is a complex clinical case, where CMR shows its potential in the diagnostic workup of acute cardiac syndromes. The pattern of edema distribution and late gadolinium enhancement may be useful in the differential diagnosis in acute cardiac setting. In this case, we found RV involvement, with anteroapical segment akinesis. The RVEF was normal (58%) with normal indexed volumes (indexed end-diastolic volume, 61 mL/m2; indexed end-systolic volume, 25 mL/m2). Our hypothesis is that the LV apical akinesis with hypokinesis of the remaining segments was because of myocardial stunning, probably secondary to microvascular dysfunction in the left anterior descending (LAD) coronary territory. In this case, the LAD was long, extending over the apex and supplying the apical region (so-called wrap around LAD), probably also the anteroapical RV segment. This may explain the regional and localized akinesis of the RV with normal EF. In case 2, instead, the clinical and instrumental data were suggestive for a TTC, further confirmed at CMR on the basis of typical localized edema to midapical LV segments, in the absence of late enhancement. The RV function was normal, without regional wall motion abnormalities (EF, 60%; indexed end-diastolic volume, 47 mL/m2; indexed endsystolic volume, 19 mL/m2). The assessment of RV abnormalities, when present, could therefore allow an early diagnosis of TTC [6]. We thus believe that a systematic evaluation of RV function by echocardiogram is recommended for an optimal management of patients with TTC [3]. Graziapia Casavecchia, MD Cardiologia Universitaria, Ospedali Riuniti, Foggia, Italy Matteo Gravina, MD Radiologia Universitaria, Ospedali Riuniti, Foggia, Italy Antonio Totaro, MD Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy Riccardo Ieva, MD Cardiologia Universitaria, Ospedali Riuniti, Foggia, Italy Roberta Vinci, MD Luca Macarini, MD Department of Medical and Surgical Sciences, University of Foggia, Italy
469
Matteo Di Biase, MD Natale Daniele Brunetti, MD, PhD⁎ Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy ⁎Corresponding author. Viale Pinto 1, 71100 Foggia, Italy. Tel.: +39 3389112358; fax: +39 0881745424 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.12.065
References [1] Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306:277–86. [2] Ieva R, Correale M, Brunetti ND, Di Biase M. A "bad" case of Tako-Tsubo syndrome. J Thromb Thrombolysis 2009;28:248–51. [3] Santoro F, Ieva R, Di Martino LF, Musaico F, Scarcia M, Ferraretti A, et al. Incomplete leaflet coaptation and tricuspid regurgitation mechanism in right ventricular TakoTsubo cardiomyopathy. Int J Cardiol 2014;177:e99-101. [4] Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27:2433–9. [5] Casavecchia G, Gravina M, Totaro A, Ieva R, Vinci R, Macarini L, Di Biase M, Brunetti ND. Role of cardiac magnetic resonance in the differential diagnosis of Tako- Tsubo cardiomyopathy. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.040. [6] Hanna M, Finkelhor RS, Shaw WF, Bahler RC. Extent of right and left ventricular focal wall-motion abnormalities in differentiating transient apical ballooning syndrome from apical dysfunction as a result of coronary artery disease. J Am Soc Echocardiogr 2007;20:144–50.
Evaluation of right ventricular function in Takotsubo cardiomyopathy☆
To the Editor, We read with great pleasure the work by Casavecchia et al [1]. Cardiac magnetic resonance imaging (CMR) may indeed play an important role in selected patients with suspected Takotsubo cardiomyopathy (TCM) especially when other associated or alternate diagnoses need to be entertained. Recently, associations of TCM with other cardiac conditions such as myopericarditis have been described [2]. In these selected clinical conditions, CMR may play a pivotal role for diagnostic confirmation because the clinical data supported by the standard diagnostic imaging modalities alone sometimes may not be adequate. Cardiac magnetic resonance imaging provides an excellent characterization of myocardial infarction with recanalization or typical ischemic transmural late gadolinium enhancement and also reliably differentiates TCM from acute myocarditis and other noncardiac causes [2,3]. Indeed, CMR is also considered the criterion standard diagnostic modality for evaluation of right ventricular (RV) function [4]. Data from the prospective studies have shown that TCM patients who develop concomitant RV dysfunction have increased incidence of heart failure, bilateral pleural effusions, and also significantly increased length of hospital stay compared with the patients with isolated left ventricular involvement [2,5]. In fact, biventricular apical ballooning pattern is seen in one third of patients with TCM. Thus, we would greatly appreciate if the authors could share the data on RV function in the patients involved in their study because the knowledge of RV involvement not only helps clinicians to tailor their treatment options but also carries a significant prognostic influence.
☆ Funding: None.
470
Correspondence
Vinod K. Chaubey, MD Department of Medicine, St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA Corresponding author. 123 Summer Street, Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798 E-mail address: [email protected] Lovely Chhabra, MD Department of Cardiovascular Medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT Nirmal J. Kaur, MD Department of Medicine, St. Vincent Hospital, University of Massachusetts Medical School, Worcester, MA
from the Medicare reimbursements. Still, the reimbursements for POC echocardiograms may be considered reasonable for physicians because they involve much lesser time and upfront infrastructure cost. This may be extremely useful in the upcoming model of care of Accountable Care Organization [5]. However, the big question still remains: “Can handheld ultrasound devices be considered the standard of care across the country’s EDs?” Certainly, the answer is affirmative when the goal is cost-effective health care. This would indeed require a dedicated training of the ED staff and commitment of the ED physicians across the country for its adoption as a new standard of care not only for quick screening but which also meets the more comprehensive diagnostic standards. Lovely Chhabra, MD Department of Cardiovascular Medicine, Hartford Hospital University of Connecticut School of Medicine, Hartford, CT
http://dx.doi.org/10.1016/j.ajem.2014.12.064 References [1] Casavecchia Graziapia, Gravina Matteo, Totaro Antonio, Leva Riccardo, Vinci Roberta, Macarini Luca, et al. Role of cardiac magnetic resonance in the differential diagnosis of Tako-Tsubo cardiomyopathy. Am J Emerg Med 2014. http://dx.doi.org/10.1016/j.ajem.2014.11.040. [2] Chhabra L, Khalid N, Kluger J, Spodick DH. Lupus myopericarditis as a preceding stressor for takotsubo cardiomyopathy. Proc (Bayl Univ Med Cent) 2014;27:327–30. [3] Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA 2011;306:277–86. [4] Simon MA. Assessment and treatment of right ventricular failure. Nat Rev Cardiol 2013;10:204–18. [5] Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, et al. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J 2006;27(20):2433–9.
Implication of bedside cardiopulmonary ultrasound on health care cost: an additional advantage☆
To the Editor, We read with great interest the work by Gallard et al [1]. Authors’ work is commendable in triaging and diagnosing patients with acute dyspnea with the use of bedside cardiopulmonary ultrasound. Indeed, the point-of-care (POC) cardiopulmonary ultrasound is not only an important diagnostic modality but also serves as an immensely useful guide during emergent cardiac procedures (such as pericardiocentesis) and resuscitation of critically ill patients [2]. This is especially true with the newest high-quality and easy-to-use handheld cardiac ultrasound devices. The current study especially sparks our interest from a financial perspective. A recently published New York Times article sheds light on the wide variations of medical billing and reimbursements for echocardiograms based on the various institutions, practice settings, and medical insurance carriers involved [3]. In our personal opinion, a POC ultrasound (if appropriately used) may offer a significant impact on reducing the health care costs and improving patient satisfaction. For instance, a point of contact ultrasound may prevent an inpatient admission for a patient presenting to the emergency department (ED) with acute dyspnea demonstrating symptomatic resolution with the initial ED therapy who would otherwise be just admitted for a comprehensive inpatient workup with the limiting time factor being an echocardiogram for many practical purposes [4]. Furthermore, office-based or ED-based POC echocardiograms billing cost is much lower as opposed to echocardiograms performed in hospital-based outpatient or inpatient setting as per the data
☆ Funding: None.
Vinod K. Chaubey, MD Department of Medicine, Saint Vincent Hospital University of Massachusetts Medical School, Worcester, MA Corresponding author. 123 Summer St., Worcester, MA 01604 Tel.: +1 508 363 5000; fax: +1 508 363 9798 E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2015.01.041 References [1] Gallard Emeric, Redonnet Jean-Philippe, Bourcier JeanEudes, Deshaies Dominique, Largeteau Nicolas, Amalric Jeanne-Marie, et al. Diagnostic performance of cardiopulmonary ultrasound performed by the emergency physician in the management of acute dyspnea. Am J Emerg Med 2014. http://dx.doi.org/ 10.1016/j.ajem.2014.12.003 [pii: S0735-6757(14)00896-1, Epub ahead of print]. [2] Herbst MK, Camargo Jr CA, Perez A, Moore CL. Use of Point-of-Care Ultrasound in Connecticut Emergency Departments. J Emerg Med 2015;48(2) 191–196.e2. [3] http://www.nytimes.com/2014/12/16/health/the-odd-math-of-medical-tests-oneechocardiogram-two-prices-both-high.html?_r=1. [4] Cardim N, Fernandez Golfin C, Ferreira D, Aubele A, et al. Usefulness of a new miniaturized echocardiographic system in outpatient cardiology consultations as an extension of physical examination. J Am Soc Echocardiogr 2011;24:117–24. [5] Berwick DM. Making good on ACOs' promise–the final rule for the Medicare shared savings program. N Engl J Med 2011;365:1753–6.
Implication of bedside cardiopulmonary ultrasound on health care cost – An additional advantage: Author reply☆
To the Editor, We thank you for your interest in our study and agree with you on the importance of thinking about the costs resulting from patient care in the emergency department (ED). Although our study did not focus on this issue, we have demonstrated that, in comparison with the usual procedure, cardiopulmonary ultrasound in the hands of the ED physician succeeds in giving an exact diagnosis for more patients. This allows us nowadays to avoid realizing costly examinations such as N-terminal pro-brain natriuretic peptide or chest x-ray. Nevertheless, this does not represent the main cost reduction. Ultrasound in the ED allows us to direct elderly patients into units better suited to their pathology. Being better treated and oriented, these patients have a shorter stay, thus reducing the costs, although this still has to
☆ Conflict of interest: The authors have no conflict of interest to disclose.
