Introduction: Demographic inequities in cardiovascular care have been well established, with evidence of effects from sex, age, and body mass index (BMI). For instance, women are less likely to receive guideline-based care for acute myocardial Infarction, bystander cardiopulmonary resuscitation, or recognition of cardiac arrest. We investigated the impact of patient sex, along with other patient demographics such as age and BMI, on the quality of focused cardiac ultrasounds (FOCUS). We hypothesized that females would have lower overall FOCUS quality and more frequently omitted apical four-chamber (A4C) views due to breast tissue. Secondary objectives included evaluating differences in image quality and omission rates by BMI, and by age and sonographer sex and training level.

Methods: In this multicenter, retrospective study we investigated 1,200 total adult patients (100 females and 100 males per site) at six participating sites. The FOCUS quality was determined by two blinded experts per site using a 1-5 ordinal scale per view (parasternal long, parasternal short, A4C, and subxiphoid). The primary outcome, overall quality, was the summed score of the four views, with a maximum score of 20. This scale was then collapsed into three categories for the individual FOCUS views: images inadequate to support diagnosis; images meeting the minimum to support diagnosis; and images supporting the diagnosis well. Secondary outcomes were A4C quality and omission rate. We evaluated associations between sex and FOCUS overall quality using unadjusted mixed-effects models followed by multivariable mixed-effects models adjusted for patient age, BMI, operator sex, and operator experience level.

Results: The A4C images of female patients were of significantly lower quality (P < .001) and had been omitted more frequently (P < .001); male patients had > 60% higher odds of a diagnostic A4C view (95% CI 1.3 - 2.0). Overall FOCUS quality decreased as BMI deviated from normal and as age increased. There was no significant difference in overall FOCUS quality between female and male patients.

Conclusion: We did not find sex-based differences in overall FOCUS quality; however, we did find that females received lower quality apical four-chamber views and had this view omitted more frequently. Additionally, overall quality declined as BMI deviated from normal, and as age advanced. Future research should elucidate the clinical implications of these differences in quality and the explanation behind not obtaining high-quality views in older patients, in individuals whose BMI deviated from normal toward either underweight or overweight, or in female patients.