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Sarosi E, Gatta LA, Berman DR, Kuller JA. A Rational and Standardized Prenatal Examination. Obstet Gynecol Surv 2023; 78:358-368. [PMID: 37322997 DOI: 10.1097/ogx.0000000000001154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Importance As prenatal care is in transition after the COVID-19 pandemic, reviewing fundamental physical examination approaches is necessary for providers examining obstetrical patients. Objective The objective of this review is 3-fold: (1) convey why the age of telemedicine necessitates reconsideration of the standardized physical examination in routine prenatal care; (2) identify the screening efficacy of examination maneuvers used within a standard prenatal examination of the neck, heart, lungs, abdomen, breasts, skin, lower extremities, pelvis, and fetal growth; and (3) propose an evidence-based prenatal physical examination. Evidence Acquisition A comprehensive literature review identified relevant research, review articles, textbook chapters, databases, and societal guidelines. Results We conclude that an evidence-based prenatal examination for asymptomatic patients includes the following maneuvers: inspection and palpation for thyromegaly and cervical lymphadenopathy, cardiac auscultation, fundal height measurement, and a pelvic examination for purposes including testing for gonorrhea and chlamydia, assessing pelvimetry, and assessing cervical dilation later in the pregnancy, intrapartum, or in the setting of ultrasonogram-detected prelabor preterm cervical shortening. Conclusions and Relevance Although not true of all physical examination maneuvers, this article demonstrates that there are maneuvers that continue to play important screening roles in asymptomatic patients. With the increase in virtual visits and fewer in-person prenatal appointments, the rational basis for maneuvers recommended in this review should inform decision making around the prenatal examination performed.
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Affiliation(s)
- Ellery Sarosi
- Medical Student, University of Michigan Medical School, Ann Arbor, MI
| | - Luke A Gatta
- Fellow, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
| | - Deborah R Berman
- Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI
| | - Jeffrey A Kuller
- Professor, Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC
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Davidsen AH, Andersen S, Halvorsen PA, Schirmer H, Reierth E, Melbye H. Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review. BMJ Open 2023; 13:e068121. [PMID: 36963797 PMCID: PMC10040065 DOI: 10.1136/bmjopen-2022-068121] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2023] Open
Abstract
OBJECTIVE The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. DESIGN/METHODS A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947-November 2021) and EMBASE (1947-November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. MAIN OUTCOME MEASURES Sensitivity, specificity and likelihood ratios (LRs). RESULTS We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. CONCLUSION Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD. PROSPERO REGISTRATION NUMBER CRD42018091675.
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Affiliation(s)
- Anne Herefoss Davidsen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Stian Andersen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Peder Andreas Halvorsen
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
| | - Henrik Schirmer
- Department of Clinical Medicine, University of Oslo Faculty of Medicine, Lørenskog, Norway
- Department of Cardiology, Akershus University Hospital, Lorenskog, Norway
| | - Eirik Reierth
- Science and Health Library, UiT The Arctic University, Tromso, Troms, Norway
| | - Hasse Melbye
- General Practice Research Unit, Department of Community Medicine, UiT The Arctic University, Tromso, Norway
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Lekic M, Lekic V, Riaz IB, Mackstaller L, Marcus FI. The Cardiovascular Physical Examination - Is It Still Relevant? Am J Cardiol 2021; 149:140-144. [PMID: 33753042 DOI: 10.1016/j.amjcard.2021.02.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/21/2021] [Accepted: 02/26/2021] [Indexed: 11/18/2022]
Abstract
Advances in technology have reshaped the practice of medicine. These changes have greatly benefited our patients. However, in the setting of these advances, the importance of basic clinical tools is more pertinent than ever. Despite the growing reliance on technology, the physical exam remains valuable and cost effective, often enabling the well-trained clinician to arrive at the diagnosis, rapidly and accurately. The physical exam must not become a relic of a distant past. We aim to investigate current competency and proficiency, proposals for change in teaching curriculums, and the relationship with technology such as hand-held echocardiography. A skillful exam provides both emotional and intellectual satisfaction. It may be a lost art but it is well worth the effort to restore.
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Affiliation(s)
- Mateja Lekic
- Department of Primary Care, Phoenix VA Health Care System, Phoenix, Arizona; University of Arizona College of Medicine, Phoenix, Arizona.
| | - Viktor Lekic
- University of Arizona College of Medicine, Tucson, Arizona
| | - Irbaz Bin Riaz
- Department of Oncology, Dana Farber Cancer Institute, Boston, Massachusetts
| | - Lorraine Mackstaller
- Department of Internal Medicine, University of Arizona College of Medicine, Tucson, Arizona
| | - Frank I Marcus
- Department of Cardiology, University of Arizona College of Medicine, Tucson, Arizona
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Austin AV, Owens DS, Prutkin JM, Salerno JC, Ko B, Pelto HF, Rao AL, Siebert DM, Carrol JS, Harmon KG, Drezner JA. Do 'pathologic' cardiac murmurs in adolescents identify structural heart disease? An evaluation of 15 141 active adolescents for conditions that put them at risk of sudden cardiac death. Br J Sports Med 2021; 56:88-94. [PMID: 33451997 DOI: 10.1136/bjsports-2019-101718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2020] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We assessed whether the presence and character of a cardiac murmur in adolescents were associated with structural heart disease that confers risk of sudden cardiac death (SCD). METHODS We performed a retrospective analysis of 15 141 adolescents age 12-19 who underwent a heart screen with history, physical examination and ECG. Participants with any screening abnormality underwent an echocardiogram for the assessment of structural heart disease. Murmurs were classified as physiological or pathological according to standard clinical criteria, and participants with murmurs were compared with a comparison group without murmurs. The primary outcome was echocardiogram-detected structural heart disease associated with SCD. RESULTS 905 participants with a cardiac murmur (mean age 15.8; 58% male) and 4333 participants without a murmur (comparison group; mean age 15.8; 55% male) had an echocardiogram to detect structural heart disease. 743 (82%) murmurs were described as physiological and 162 (18%) as pathological. Twenty-five (2.8%) participants with murmurs and 61 (1.4%) participants without murmurs had structural heart disease. Three (0.3%) participants in the murmur group were diagnosed with hypertrophic cardiomyopathy (HCM) which was the only identified condition associated with SCD. Two participants with HCM had physiological murmurs, one had a pathological murmur, and all three had an abnormal ECG. The most common minor structural heart disease was bicuspid aortic valve in both the murmur (7; 0.8%) and comparison (20; 0.5%) groups. The positive predictive value of physiological versus pathological murmurs for identifying any structural heart disease was 2.4% versus 4.3% (p=0.21), respectively. The positive predictive value of having any murmur versus no murmur for identifying structural heart disease was 2.8% versus 1.4% (p=0.003), respectively. CONCLUSIONS In adolescents, the traditional classification of cardiac murmurs as 'physiologic' or 'pathologic' does not differentiate for structural heart disease that puts individuals at risk for SCD. We recommend ECG evaluation in all patients with a cardiac murmur found during preparticipation screening to increase detection of HCM.
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Affiliation(s)
- Ashley V Austin
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - David S Owens
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jordan M Prutkin
- Department of Internal Medicine, Division of Cardiology, University of Washington, Seattle, Washington, USA
| | - Jack C Salerno
- Division of Cardiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Brian Ko
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Hank F Pelto
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - Ashwin L Rao
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - David M Siebert
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - Jennifer S Carrol
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - Kimberly G Harmon
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
| | - Jonathan A Drezner
- Department of Family Medicine, Sports Medicine Section, University of Washington, Seattle, Washington, USA
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5
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Maxwell AG, Jardine DL. Introduction of portable bedside echocardiography to acute general medicine. Intern Med J 2019; 49:1025-1028. [DOI: 10.1111/imj.14383] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 03/31/2019] [Accepted: 04/08/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Allan Gordon Maxwell
- Department of General MedicineChristchurch Hospital, Canterbury District Health Board Christchurch New Zealand
| | - David L. Jardine
- Department of General MedicineChristchurch Hospital, Canterbury District Health Board Christchurch New Zealand
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Gardezi SKM, Myerson SG, Chambers J, Coffey S, d’Arcy J, Hobbs FDR, Holt J, Kennedy A, Loudon M, Prendergast A, Prothero A, Wilson J, Prendergast BD. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart 2018; 104:1832-1835. [DOI: 10.1136/heartjnl-2018-313082] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 04/30/2018] [Accepted: 05/02/2018] [Indexed: 12/13/2022] Open
Abstract
ObjectiveCardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care.MethodsCardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve).ResultsNewly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index <25 kg/m2).ConclusionCardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.
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7
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Kattoor AJ, Shanbhag A, Abraham A, Vallurupalli S. Clinical Context and Detection of the Murmur of Advanced Aortic Stenosis. South Med J 2018; 111:230-234. [DOI: 10.14423/smj.0000000000000791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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9
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Coffey S, Harper AR, Cairns BJ, Roberts IS, Prendergast BD. Clinical information has low sensitivity for postmortem diagnosis of heart valve disease. Heart 2017; 103:1031-1035. [PMID: 28183793 DOI: 10.1136/heartjnl-2016-310718] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 12/26/2016] [Accepted: 12/27/2016] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Accuracy of routinely collected information concerning cause of death is essential for public health and health systems planning. Since clinical examination has relatively low sensitivity for detection of valvular heart disease (VHD), mortality data based on clinical information alone might routinely underestimate the number of deaths due to VHD. METHODS We compared autopsy findings against premortem clinical information for 8198 consecutive adult postmortems (mean age 69.1 years, 61.3% men), performed in a single UK tertiary referral centre with on-site cardiac surgical facilities over a 10-year period (2004-2013) during which 21% of the adult population underwent postmortem examination. RESULTS Following postmortem, VHD was the principal cause of death in 165 individuals (2.0%), a principal or contributory cause ('any cause') of death in 326 (4.0%) and an incidental (ie, non-causal) finding in a further 346 (4.2%). Clinical documentation of VHD before death was highly specific but relatively insensitive for postmortem identification of VHD as the principal (specificity 96.8%; 95% CI 96.4% to 97.2%; sensitivity 69.7%, 95% CI 62.1% to 76.6%) or any (specificity 98.1%; 95% CI 97.8% to 98.4%; sensitivity 68.4%, 95% CI 63.1% to 73.4%) cause of death. VHD (principally aortic stenosis, endocarditis and rheumatic heart disease) was newly noted at postmortem and listed as a cause of death in 142 individuals (1.7%). CONCLUSIONS Clinical information recorded premortem is highly specific but relatively insensitive for the cause of death established at autopsy. Population-based mortality statistics that depend on premortem clinical information are likely to routinely underestimate the mortality burden of VHD.
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Affiliation(s)
- Sean Coffey
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, UK
- Kolling Institute of Medical Research, University of Sydney, Royal North Shore Hospital, St Leonards, Australia
| | - Andrew R Harper
- National Institute for Health Research (NIHR) Oxford Biomedical Research Centre, Oxford University Hospitals NHS Trust, Oxford, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, UK
| | - Benjamin J Cairns
- Cancer Epidemiology Unit, University of Oxford, Oxford, UK
- British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Ian Sd Roberts
- Department of Cellular Pathology, Oxford University Hospitals NHS Trust, Oxford, UK
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10
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Abstract
Valvular heart disease is a common condition in today's patient population. Accurate characterization of vital cardiac structures has become crucial to early diagnosis and varied treatment options. The advent of ultrasound technology has had a large impact in cardiovascular medicine, particularly in the assessment of valvular heart disease. Today its versatility and availability have allowed it to become one of the most frequently ordered imaging tests for cardiovascular indications. Despite the tremendous evidence that suggests that clinical examinations are still standard of care, a large volume of referrals for echocardiograms suggests differently.
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Affiliation(s)
- Padmanabhan Premkumar
- Department of Medicine, Hartford Hospital, 85 Seymour Street, Hartford, CT 06102, USA.
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11
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Patel A, Tomar NS, Bharani A. Utility of physical examination and comparison to echocardiography for cardiac diagnosis. Indian Heart J 2016; 69:141-145. [PMID: 28460759 PMCID: PMC5414939 DOI: 10.1016/j.ihj.2016.07.020] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 07/09/2016] [Accepted: 07/27/2016] [Indexed: 11/28/2022] Open
Abstract
Objective To find out the accuracy of cardiac auscultation using non-digital stethoscope in physical diagnosis of cardiac diseases. Methods We enrolled 104 consecutive patients with abnormal cardiac auscultatory findings attending cardiology clinic and not previously evaluated by echocardiography. One time detailed cardiac physical examination followed by echocardiography within 1 month was undertaken. Agreement between two methods was calculated using mean pair percentage agreement, kappa statistics (κ) and calculation of 95% confidence interval (CI) for kappa statistics. Results Using kappa statistics, there was almost perfect agreement between cardiac auscultation and echocardiography for the detection of mitral stenosis (κ = 0.865; CI 0.76–0.97) and ventricular septal defect (κ = 0.872; CI = 0.73–1.01). Substantial agreement was noted for aortic stenosis (κ = 0.752; CI = 0.56–0.94), pulmonary stenosis (κ = 0.647; CI = 0.33–0.97) and atrial septal defect (κ = 0.646; CI = 0.32–0.97), while moderate agreement was found for mitral regurgitation (κ = 0.470; CI = 0.30–0.64), aortic regurgitation (κ = 0.456; CI = 0.25–0.66) and tricuspid regurgitation (κ = 0.575; CI = 0.38–0.77). For combined mitral stenosis and mitral regurgitation lesions, almost perfect agreement was found for mitral stenosis (κ = 0.842; CI = 0.691–0.993) while fair agreement noted for mitral regurgitation (κ = 0.255; CI = −0.008 to 0.518). Conclusion Careful clinical auscultation using a stethoscope remains a valuable tool for cardiac diagnosis. Decision on initial diagnosis and management of valvular and congenital heart diseases should be based on clinical examination and integrating such information with echocardiography as required.
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Affiliation(s)
- Ashish Patel
- Department of Medicine, M.G.M. Medical College, Indore, M.P., India
| | | | - Anil Bharani
- Department of Medicine, M.G.M. Medical College, Indore, M.P., India.
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12
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Haemophilus parainfluenzae Mural Endocarditis: Case Report and Review of the Literature. Case Rep Infect Dis 2016; 2016:3639517. [PMID: 27382494 PMCID: PMC4921150 DOI: 10.1155/2016/3639517] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 05/08/2016] [Indexed: 11/17/2022] Open
Abstract
Haemophilus parainfluenzae, which uncommonly causes endocarditis, has never been documented to cause mural involvement. A 62-year-old immunocompetent female without predisposing risk factors for endocarditis except for poor dentition presented with fever, emesis, and dysmetria. Echocardiography found a mass attached to the left ventricular wall with finger-like projections. Computed tomography showed evidence of embolic phenomena to the brain, kidneys, spleen, and colon. Cardiac MRI revealed involvement of the chordae tendineae of the anterior papillary muscles. Blood cultures grew Haemophilus parainfluenzae. The patient was treated successfully with ceftriaxone with resolution of symptoms, including neurologic deficits. After eleven days of antibiotics a worsening holosystolic murmur was discovered. Worsening mitral regurgitation on echocardiography was only found three weeks later. Nine weeks after presentation, intraoperative evaluation revealed chord rupture but no residual vegetation and mitral repair was performed. Four weeks after surgery, the patient was back to her baseline. This case illustrates the ability of Haemophilus parainfluenzae to form large mural vegetations with high propensity of embolization in otherwise normal cardiac tissue among patients with dental risk factors. It also underscores the importance of physical examination in establishing a diagnosis of endocarditis and monitoring for progression of disease.
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13
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Lai LS, Redington AN, Reinisch AJ, Unterberger MJ, Schriefl AJ. Computerized Automatic Diagnosis of Innocent and Pathologic Murmurs in Pediatrics: A Pilot Study. CONGENIT HEART DIS 2016; 11:386-395. [DOI: 10.1111/chd.12328] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Lillian S.W. Lai
- Children's Hospital of Eastern Ontario, University of Ottawa; Ottawa Ontario Canada
| | - Andrew N. Redington
- The Heart Institute, Cincinnati Children's Hospital Medical Center; Cincinnati Ohio USA
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14
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Bank I, Vliegen HW, Bruschke AVG. The 200th anniversary of the stethoscope: Can this low-tech device survive in the high-tech 21st century? Eur Heart J 2016; 37:3536-3543. [PMID: 26908946 DOI: 10.1093/eurheartj/ehw034] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Revised: 12/15/2015] [Accepted: 01/21/2016] [Indexed: 11/14/2022] Open
Abstract
In 1816, Laennec discovered that auscultation of the heart and lungs could effectively be performed by placing a hollow cylinder (initially made of a roll of paper) between the chest of the patient and the ear of the examiner. This was the first step in the development of the stethoscope, which was a breakthrough in the diagnosis and management of cardiac and pulmonary patients. Technical improvements of the stethoscope followed and in cardiac patients auscultation soon became a major diagnostic tool. In the second half of the 20th century, new powerful non-invasive diagnostic modalities were developed and the interest in auscultation declined. As a result, the auscultatory skills of students and physicians at all levels of training decreased to a disappointingly low level. We now must decide whether we should stimulate the use of and proficiency in auscultation or if we should accept the further decline and eventual abolishment of this component of the physical examination. Reviewing the literature and taking into consideration the setting in which the patients are presented, including the availability of advanced diagnostic facilities, we conclude that the time-honoured stethoscope, in spite of its limitations, still has potential as a patient-friendly, effective, and economical instrument in medical practice. However, new initiatives are required to train students, physicians and allied health professionals in cardiac auscultation to avoid misinterpretations that may harm the patients and generate extra costs. To be successful such programs will require wide support from the medical community.
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Affiliation(s)
- Ivan Bank
- Center for Innovation in Medical Education, Leiden University Medical Center, Leiden, The Netherlands.,Department of Internal Medicine, Lange Land Hospital, Zoetermeer, The Netherlands
| | - Hubert W Vliegen
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Albert V G Bruschke
- Department of Cardiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
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Gulič TG, Makuc J, Prosen G, Dinevski D. Pocket-size imaging device as a screening tool for aortic stenosis. Wien Klin Wochenschr 2015; 128:348-53. [PMID: 26659701 DOI: 10.1007/s00508-015-0904-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 11/18/2015] [Indexed: 12/14/2022]
Abstract
AIM The aim of this study was to assess the usefulness of a pocket-size imaging device in the hands of a noncardiologist as a screening tool for diagnosing aortic stenosis in individuals with newly discovered systolic murmur. METHODS AND RESULTS A total of 200 consecutive patients with systolic murmur were included; a limited focused cardiac ultrasound was performed with a pocket-size imaging device and compared to standard echocardiography. It was performed by a noncardiologist with no formal training in echocardiography. In all, 150 patients had morphological changes on the aortic valve, 77 had more than mild aortic stenosis, 30 had more than mild mitral regurgitation, 64 patients had more than moderate hypertrophy, 113 had more than moderately enlarged left atriums, and 3 had severely enlarged left ventricles. There were no significant difference in recognizing severe changes between Vscan focused cardiac ultrasound and comprehensive echocardiography. CONCLUSION Pocket-size ultrasound imaging devices without continuous and pulse wave Doppler modalities can, even in the hands of a noncardiologist with limited cardiac ultrasound instructions with high sensitivity and specificity, be a useful tool for detecting more than mild aortic stenosis and more than mild mitral regurgitation. As such a focused cardiac ultrasound can be an extension of physical examinations for patients with newly discovered systolic murmur.
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Affiliation(s)
- Tatjana Golob Gulič
- Department of Cardiosurgery, University Clinical Center Maribor, Ljubljanska 5, 2000, Maribor, Slovenia.
| | - Jana Makuc
- Department of Internal Medicine, General Hospital Slovenj Gradec, Slovenj Gradec, Slovenia
| | - Gregor Prosen
- Center for Emergency Medicine, Community Health Center Maribor, Maribor, Slovenia
| | - Dejan Dinevski
- Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Caputo C, Prior D, Inder WJ. The need for annual echocardiography to detect cabergoline-associated valvulopathy in patients with prolactinoma: a systematic review and additional clinical data. Lancet Diabetes Endocrinol 2015; 3:906-13. [PMID: 25466526 DOI: 10.1016/s2213-8587(14)70212-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Present recommendations by the US Food and Drug Administration advise that patients with prolactinoma treated with cabergoline should have an annual echocardiogram to screen for valvular heart disease. Here, we present new clinical data and a systematic review of the scientific literature showing that the prevalence of cabergoline-associated valvulopathy is very low. We prospectively assessed 40 patients with prolactinoma taking cabergoline. Cardiovascular examination before echocardiography detected an audible systolic murmur in 10% of cases (all were functional murmurs), and no clinically significant valvular lesion was shown on echocardiogram in the 90% of patients without a murmur. Our systematic review identified 21 studies that assessed the presence of valvular abnormalities in patients with prolactinoma treated with cabergoline. Including our new clinical data, only two (0·11%) of 1811 patients were confirmed to have cabergoline-associated valvulopathy (three [0·17%] if possible cases were included). The probability of clinically significant valvular heart disease is low in the absence of a murmur. On the basis of these findings, we challenge the present recommendations to do routine echocardiography in all patients taking cabergoline for prolactinoma every 12 months. We propose that such patients should be screened by a clinical cardiovascular examination and that echocardiogram should be reserved for those patients with an audible murmur, those treated for more than 5 years at a dose of more than 3 mg per week, or those who maintain cabergoline treatment after the age of 50 years.
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Affiliation(s)
- Carmela Caputo
- Department of Endocrinology, St Vincent's Hospital Melbourne, Melbourne, Australia.
| | - David Prior
- Department of Cardiology, St Vincent's Hospital Melbourne, Melbourne, Australia; Department of Medicine, St Vincent's Hospital Melbourne, Melbourne, Australia
| | - Warrick J Inder
- Department of Diabetes and Endocrinology, The University of Queensland, Brisbane, Australia; Princess Alexandra Hospital, and School of Medicine, The University of Queensland, Brisbane, Australia
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Boeuf MC, Rohel G, Lamour G, Piquemal M, Paleiron N, Fouilland X, Le Nestour C, Vinsonneau U, Paez S, Paule P. [Diagnosis of a systolic murmur among young asymptomatic patient: An assessment of professional practices for the expertise in military medicine]. Ann Cardiol Angeiol (Paris) 2015; 64:352-61. [PMID: 26482624 DOI: 10.1016/j.ancard.2015.09.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 09/03/2015] [Indexed: 11/19/2022]
Abstract
UNLABELLED The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients. MATERIALS AND METHODS During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis. RESULTS Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner. DISCUSSION Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients. CONCLUSION Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise.
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Affiliation(s)
- M-C Boeuf
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - G Rohel
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - G Lamour
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - M Piquemal
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - N Paleiron
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - X Fouilland
- Centre médical des armées de Brest-Lorient, BCRM de Brest, CC 74, 29240 Brest cedex 9, France
| | - C Le Nestour
- Centre médical des armées de Brest-Lorient, BCRM de Brest, CC 74, 29240 Brest cedex 9, France
| | - U Vinsonneau
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France
| | - S Paez
- Centre médical des armées de Brest-Lorient, BCRM de Brest, CC 74, 29240 Brest cedex 9, France
| | - P Paule
- Service de cardiologie, hôpital d'instruction des armées Clermont-Tonnerre, BCRM de Brest, CC 41, 29240 Brest cedex 9, France.
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Friederichs H, Weissenstein A, Ligges S, Möller D, Becker JC, Marschall B. Combining simulated patients and simulators: pilot study of hybrid simulation in teaching cardiac auscultation. ADVANCES IN PHYSIOLOGY EDUCATION 2014; 38:343-347. [PMID: 25434018 DOI: 10.1152/advan.00039.2013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Auscultation torsos are widely used to teach position-dependent heart sounds and murmurs. To provide a more realistic teaching experience, both whole body auscultation mannequins and torsos have been used in clinical examination skills training at the Medical Faculty of the University of Muenster since the winter term of 2008-2009. This training has since been extended by simulated patients, which are normal, healthy subjects who have undergone attachment of the electronic components of the auscultation mannequins to their chests to mimic pathophysiological conditions ("hybrid models"). The acceptance of this new learning method was examined in the present pilot study. In total, 143 students in their second preclinical year who were participating in auscultation training were randomized into an intervention group (hybrid models) and a control group (auscultation mannequins). One hundred forty-two (99.3%) of these students completed a self-assessment Likert-scale questionnaire regarding different teaching approaches (where 1 = "very poor" to 100 = "very good"). The questionnaire focused on the "value of learning" of different teaching approaches. Direct comparison showed that students evaluated the hybrid models to be significantly more effective than the auscultation mannequins (median: 83 vs. 64, P < 0.001). The cardiac auscultation training was generally assessed positively (median: 88). Additionally, verbal feedback was obtained from simulated patients and tutors (trained students who had successfully passed the course a few semesters earlier). Personal feedback showed high satisfaction from student tutors and simulated patients. Hybrid simulators for teaching cardiac auscultation elucidated positive responses from students, tutors, and simulated patients.
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Affiliation(s)
| | | | - Sandra Ligges
- Institute of Biostatistics and Clinical Research, Muenster, Germany
| | - David Möller
- University of Muenster, Studienhospital, Muenster, Germany
| | - Jan C Becker
- University of Muenster, Institute of Medical Education, Muenster, Germany
| | - Bernhard Marschall
- University of Muenster, Institute of Medical Education, Muenster, Germany
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Perlini S, Salinaro F, Santalucia P, Musca F. Simulation-guided cardiac auscultation improves medical students' clinical skills: the Pavia pilot experience. Intern Emerg Med 2014; 9:165-72. [PMID: 22767224 DOI: 10.1007/s11739-012-0811-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2012] [Accepted: 06/21/2012] [Indexed: 11/27/2022]
Abstract
Clinical evaluation is the cornerstone of any cardiac diagnosis, although excessive over-specialisation often leads students to disregard the value of clinical skills, and to overemphasize the approach to instrumental cardiac diagnosis. Time restraints, low availability of "typical" cardiac patients on whom to perform effective bedside teaching, patients' respect and the underscoring of the value of clinical skills all lead to a progressive decay in teaching. Simulation-guided cardiac auscultation may improve clinical training in medical students and residents. Harvey(©) is a mannequin encompassing more than 50 cardiac diagnoses that was designed and developed at the University of Miami (Florida, USA). One of the advantages of Harvey(©) simulation resides in the possibility of listening, comparing and discussing "real" murmurs. To objectively assess its teaching performance, the capability to identify five different cardiac diagnoses (atrial septal defect, normal young subject, mitral stenosis with tricuspid regurgitation, chronic mitral regurgitation, and pericarditis) out of more than 50 diagnostic possibilities was assessed in 523 III-year medical students (i.e. at the very beginning of their clinical experience), in 92 VI-year students, and in 42 residents before and after a formal 10-h teaching session with Harvey(©). None of them had previously experienced simulation-based cardiac auscultation in addition to formal lecturing (all three groups) and bedside teaching (VI-year students and residents). In order to assess the "persistence" of the acquired knowledge over time, the test was repeated after 3 years in 85 students, who did not repeat the formal 10-h teaching session with Harvey(©) after the III year. As expected, the overall response was poor in the "beginners" who correctly identified 11.0 % of the administered cardiac murmurs. After simulation-guided training, the ability to recognise the correct cardiac diagnoses was much better (72.0 %; p < 0.001 vs. baseline). Rather unexpectedly, before the tutorial, the performance of VI-year students and of residents was not significantly different from their III-year colleagues, since the two groups correctly identified 14.2 and 16.2 % of the diagnoses, respectively. After the tutorial, the VI-year students and the residents also improved their overall performance (to 73.1 and 76.1 %, respectively; p < 0.001 for both when compared to before the tutorial). The persistence of this capability after 3 years was remarkable, since the 85 students who repeated the test without any further exposure to the 10-h teaching session with Harvey(©) correctly identified 68.4 % of the possible cardiac diagnoses (p < 0.001 vs. baseline). These data underscore the importance of clinical training in order to improve auscultation skills in our academic setting, prompting to redesign teaching curricula. Simulation-based cardiac auscultation should be considered as the "missing link" between formal lecturing and bedside teaching of heart sounds and murmurs.
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Affiliation(s)
- Stefano Perlini
- Clinica Medica II, Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, P. le Golgi 19, 27100, Pavia, Italy,
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Chambers J, Kabir S, Cajeat E. Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals. Br J Gen Pract 2014; 64:e105-11. [PMID: 24567615 PMCID: PMC3905412 DOI: 10.3399/bjgp14x677167] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2013] [Revised: 10/16/2014] [Accepted: 12/02/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Heart disease is difficult to detect clinically and it has been suggested that echocardiography should be available to all patients with possible cardiac symptoms or signs. AIM To analyse the results of 2 years of open access echocardiography for the frequency of structural heart disease according to request. DESIGN AND SETTING Retrospective database analysis in a teaching hospital open access echocardiography service. METHOD Reports of all open access transthoracic echocardiograms between January 2011 and December 2012 were categorised as normal, having minor abnormalities, or significant abnormalities according to the indication. RESULTS There were 2343 open access echocardiograms performed and there were significant abnormalities in 29%, predominantly valve disease (n = 304, 13%), LV systolic dysfunction (n = 179, 8%), aortic dilatation (n = 80, 3%), or pulmonary hypertension (n = 91, 4%). If echocardiography had been targeted at a high-risk group, 267 with valve disease would have been detected (compared to 127 with murmur alone) and 139 with LV systolic dysfunction (compared to 91 with suspected heart failure alone). Most GP practices requested fewer than 10 studies, but 6 practices requested over 70 studies. CONCLUSION Open access echocardiograms are often abnormal but structural disease may not be suspected from the clinical request. Uptake by individual practices is patchy. A targeted expansion of echocardiography in patients with a high likelihood of disease is therefore likely to increase the detection of clinically important pathology.
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Affiliation(s)
- John Chambers
- Adult Echocardiography, Cardiothoracic Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
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21
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Abstract
Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.
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Affiliation(s)
- Rosario V Freeman
- Division of Cardiology, University of Washington, Seattle 98109, USA.
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22
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Roelandt JRTC. The decline of our physical examination skills: is echocardiography to blame? Eur Heart J Cardiovasc Imaging 2013; 15:249-52. [PMID: 24282219 DOI: 10.1093/ehjci/jet195] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- J R T C Roelandt
- Thoraxcenter, Erasmus Medical Center, Gravendijkwal 230, 3015 GE Rotterdam, The Netherlands
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23
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Arden C, Chambers JB, Sandoe J, Ray S, Prendergast B, Taggart D, Westaby S, Grothier L, Wilson J, Campbell B, Gohlke-Bärwolf C, Mestres CA, Rosenhek R, Pibarot P, Otto CM. Can we improve the detection of heart valve disease? Heart 2013; 100:271-3. [DOI: 10.1136/heartjnl-2013-304223] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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Seeing is not believing, but hearing is: The stethoscope is still useful. Int J Cardiol 2013; 165:1-2. [DOI: 10.1016/j.ijcard.2012.11.114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2012] [Accepted: 11/28/2012] [Indexed: 11/24/2022]
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25
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Yorgun H, Canpolat U, Aytemir K, Modesti PA. Acute mitral regurgitation due to flail mitral leaflet mimicking: a diagnosis of pneumonia. Intern Emerg Med 2013. [PMID: 23179328 DOI: 10.1007/s11739-012-0873-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Hikmet Yorgun
- Department of Cardiology, Hacettepe University Faculty of Medicine, Altındağ, 06100, Ankara, Turkey
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Abstract
The aim of this article is to provide a perspective on the relative importance and contribution of different imaging modalities in patients with valvular heart disease. Valvular heart disease is increasing in prevalence across Europe, at a time when the clinical ability of physicians to diagnose and assess severity is declining. Increasing reliance is placed on echocardiography, which is the mainstay of cardiac imaging in valvular heart disease. This article outlines the techniques used in this context and their limitations, identifying areas in which dynamic imaging with cardiovascular magnetic resonance and multislice CT are expanding.
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Affiliation(s)
- W S Choo
- Penang Medical College, Georgetown, Malaysia
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27
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Vukanovic-Criley JM, Hovanesyan A, Criley SR, Ryan TJ, Plotnick G, Mankowitz K, Conti CR, Criley JM. Confidential testing of cardiac examination competency in cardiology and noncardiology faculty and trainees: a multicenter study. Clin Cardiol 2011; 33:738-45. [PMID: 21184557 DOI: 10.1002/clc.20851] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Many reported studies of medical trainees and physicians have demonstrated major deficiencies in correctly identifying heart sounds and murmurs, but cardiologists had not been tested. We previously confirmed these deficiencies using a 50-question multimedia cardiac examination (CE) test featuring video vignettes of patients with auscultatory and visible manifestations of cardiovascular pathology (virtual cardiac patients). Previous testing of 62 internal medical faculty yielded scores no better than those of medical students and residents. HYPOTHESIS In this study, we tested whether cardiologists outperformed other physicians in cardiac examination skills, and whether years in practice correlated with test performance. METHODS To obviate cardiologists' reluctance to be tested, the CE test was installed at 19 US teaching centers for confidential testing. Test scores and demographic data (training level, subspecialty, and years in practice) were uploaded to a secure database. RESULTS The 520 tests revealed mean scores (out of 100 ± 95% confidence interval) in descending order: 10 cardiology volunteer faculty (86.3 ± 8.0), 57 full-time cardiologists (82.0 ± 3.3), 4 private-practice cardiologists (77.0 ± 6.8), and 19 noncardiology faculty (67.3 ± 8.8). Trainees' scores in descending order: 150 cardiology fellows (77.3 ± 2.1), 78 medical students (63.7 ± 3.5), 95 internal medicine residents (62.7 ± 3.2), and 107 family medicine residents (59.2 ± 3.2). Faculty scores were higher in those trained earlier with longer practice experience. CONCLUSIONS Academic and volunteer cardiologists outperformed other medical faculty, as did cardiology fellows. Lower scores were observed in more recently trained faculty. Remote testing yielded scores similar to proctored tests in comparable groups previously studied. No significant improvement was seen after medical school with residency training.
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Affiliation(s)
- Jasminka M Vukanovic-Criley
- Department of Medical Education, St. Mary Medical Center and David Geffen School of Medicine at UCLA, Long Beach, California 90813, USA.
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Nakamura RK, Rishniw M, King MK, Sammarco CD. Prevalence of echocardiographic evidence of cardiac disease in apparently healthy cats with murmurs. J Feline Med Surg 2011; 13:266-71. [PMID: 21276739 DOI: 10.1016/j.jfms.2010.12.007] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2010] [Indexed: 11/16/2022]
Abstract
The objective of this prospective study was to determine the prevalence of echocardiographic evidence of heart disease in apparently healthy cats with heart murmurs. Thirty-two privately owned domestic cats were examined. All cats were considered healthy on the basis of history and physical examination, except for the finding of a heart murmur on auscultation. Cats on any medications (besides regular flea, tick and heartworm preventative) or that were pregnant or lactating were excluded from this study. The prevalence of echocardiographic evidence of heart disease in this population of cats was 53%. Therefore, identification of a heart murmur on routine physical examination in apparently healthy cats warrants further investigation.
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Affiliation(s)
- Reid K. Nakamura
- Advanced Veterinary Care Center, 15926 Hawthorne Blvd, Lawndale, CA 90260, USA
| | - Mark Rishniw
- Cornell University, College of Veterinary Medicine, Campus Road, Ithaca, NY 14853, USA
| | - Megan K. King
- Center for Animal Referral and Emergency Services, 2010 Cabot Blvd West Suite D, Langhorne, PA 19047, USA
| | - Carl D. Sammarco
- Red Bank Veterinary Hospital, 197 Hance Avenue, Tinton Falls, NJ 07724, USA
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Vörös K, Nolte I, Hungerbühler S, Reiczigel J, Ehlers J, Tater G, Mischke R, Zimmering T, Schneider M. Sound recording and digital phonocardiography of cardiac murmurs in dogs by using a sensor-based electronic stethoscope. Acta Vet Hung 2011; 59:23-35. [PMID: 21354939 DOI: 10.1556/avet.59.2011.1.3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The goals of this study were to present a technique of digitalised sound recordings and phonocardiograms (dPCGs), and to analyse its diagnostic capabilities. Heart sounds of 20 dogs were auscultated in vivo (on-line) and recorded with dPCGs by two authors using a Welch Allyn Meditron Stethoscope System. Sound recordings were auscultated off-line and blindly by four different observers having various auscultatory experiences, then listened to while viewing dPCGs. The results were compared to echocardiographic diagnoses. There was a significant agreement (p < 0.001) between on-line and off-line auscultatory findings regarding the four observers, ranging from 45% to 75% (weighted kappa values: 0.72 to 0.87). The best agreement was achieved by Observer 1 having the highest experience. Significant differences (p < 0.05) were found between Observer 1 and Observer 4 (with the lowest experience) in judging the quality of the murmurs during the off-line and blind auscultation. However, there were only minimal differences (95% to 100% agreements) in dPCG analyses among the four observers regarding intensity and quality of the murmurs while simultaneously listening to and viewing the dPCGs. Significant correlations were found between the traditional '0 to 6 scale' and a new '0 to 3 scale' murmur intensity gradings by all observers (correlation coefficients 0.640 to 0.908; p < 0.01 to p < 0.001). Analysis of dPCGs might be a valuable, additional tool helping with the diagnosis of canine cardiac murmurs, especially for those with less cardiological experience.
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Affiliation(s)
| | - Ingo Nolte
- 1 University of Veterinary Medicine Hanover Small Animal Clinic Bünteweg 9 D-30559 Hanover Germany
| | - Stephan Hungerbühler
- 1 University of Veterinary Medicine Hanover Small Animal Clinic Bünteweg 9 D-30559 Hanover Germany
| | - Jenő Reiczigel
- 3 Szent István University Department of Biomathematics and Informatics, Faculty of Veterinary Science Budapest Hungary
| | - Jan Ehlers
- 2 University of Veterinary Medicine Hanover E-Learning Consultant Bünteweg 9 D-30559 Hanover Germany
| | - Guy Tater
- 1 University of Veterinary Medicine Hanover Small Animal Clinic Bünteweg 9 D-30559 Hanover Germany
| | - Reinhard Mischke
- 1 University of Veterinary Medicine Hanover Small Animal Clinic Bünteweg 9 D-30559 Hanover Germany
| | - Tanja Zimmering
- 1 University of Veterinary Medicine Hanover Small Animal Clinic Bünteweg 9 D-30559 Hanover Germany
| | - Matthias Schneider
- 4 Justus-Liebig University Giessen Small Animal Clinic, Veterinary Faculty Giessen Germany
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McElhinney E. Factors which influence nurse practitioners ability to carry out physical examination skills in the clinical area after a degree level module - an electronic Delphi study. J Clin Nurs 2010; 19:3177-87. [DOI: 10.1111/j.1365-2702.2010.03304.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Gordillo-Higuero A. Varón de edad avanzada con soplo sistólico. Propuesta de un esquema de diagnóstico diferencial. Semergen 2010. [DOI: 10.1016/j.semerg.2009.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Weisse AB. Absolutely the Last Word on Physical Diagnosis: Not! Proc (Bayl Univ Med Cent) 2010; 23:301-3. [DOI: 10.1080/08998280.2010.11928638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Mahnke C. Automated heartsound analysis/computer-aided auscultation: a cardiologist's perspective and suggestions for future development. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2010; 2009:3115-8. [PMID: 19963568 DOI: 10.1109/iembs.2009.5332551] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Heart disease is a major cause of worldwide morbidity and mortality. Properly performed, the cardiac auscultatory examination (listening to the heart with a stethoscope) is an inexpensive, widely available tool in the detection and management of heart disease. Unfortunately, accurate interpretation of heartsounds by primary care providers is fraught with error, leading to missed diagnosis of disease and/or excessive costs associated with evaluation of normal variants. Therefore, automated heartsound analysis, also known as computer aided auscultation (CAA), has the potential to become a cost-effective screening and diagnostic tool in the primary care setting. A cardiologist's suggestions for CAA system design and algorithmic development are provided.
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Affiliation(s)
- C Mahnke
- Tripler Army Medical Center, Pediatric Department (Cardiology), 1 Jarrett White Rd, Honolulu, HI 96859, USA.
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Sztajzel JM, Picard-Kossovsky M, Lerch R, Vuille C, Sarasin FP. Accuracy of cardiac auscultation in the era of Doppler-echocardiography: A comparison between cardiologists and internists. Int J Cardiol 2010; 138:308-10. [DOI: 10.1016/j.ijcard.2008.06.066] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 06/28/2008] [Indexed: 10/21/2022]
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Nielsen T, Mølgaard H, Ringsted C, Eika B. The development of a new cardiac auscultation test: How do screening and diagnostic skills differ? MEDICAL TEACHER 2010; 32:56-61. [PMID: 19241211 DOI: 10.3109/01421590802572767] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
BACKGROUND Newly qualified doctors are expected to be able to conduct a cardiac auscultation unassisted, but studies show conflicting results regarding cardiac auscultation skills. METHODS A two-part test instrument was designed containing innovative recordings of heart sounds from patients with common cardiac murmurs as well as healthy controls. A total number of 109 participants were tested, representing four levels of clinical experience. The content validity of the test instrument was studied by a postal questionnaire to 114 clinical teachers at the University Hospital of Aarhus, Denmark. RESULTS A significant correlation was found between level of experience and the ability to diagnose the conditions from which the murmurs originated (r = 0.45, P < 0.0001). No correlation was found between level of experience and the ability to identify persons with cardiac murmurs from healthy controls. All groups showed a tendency to interpret healthy heart sounds as cardiac murmurs. CONCLUSIONS Diagnostic ability was found to correlate positively with clinical experience, whereas the ability to distinguish cardiac murmurs from normal heart sounds seems independent of clinical experience.
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Affiliation(s)
- Tommy Nielsen
- Faculty of Health Sciences, Aarhus University, Denmark.
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Fraser K, Peets A, Walker I, Tworek J, Paget M, Wright B, McLaughlin K. The effect of simulator training on clinical skills acquisition, retention and transfer. MEDICAL EDUCATION 2009; 43:784-789. [PMID: 19659492 DOI: 10.1111/j.1365-2923.2009.03412.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
CONTEXT Prior research has demonstrated that residents have poor clinical skills in cardiology and respirology. It is not clear how these skills can be improved because the number of patients with suitable clinical findings whose cooperation might help residents to better develop these clinical skills is limited. Objectives Our objective was to evaluate the effect of training on a cardiorespiratory simulator (CRS) on skills acquisition, retention and transfer. METHODS We randomly allocated 146 students to CRS training in either chest pain or dyspnoea and compared each student's performance on the clinical presentation in which he or she had received CRS training with performance on the control presentation. RESULTS Immediately after training, students were more accurate in identifying abnormal clinical findings on the CRS (70.0% versus 52.2%; d = 7.6, P < 0.0001) and showed improved diagnostic performance (72.1% versus 55.6%; d = 4.3, P = 0.0007) on the training clinical presentation. At the end of the course they were still better at identifying abnormal findings (57.1% versus 51.7%; d = 2.5, P = 0.004) and diagnosing correctly (50.0% versus 38.1%; d = 3.0, P = 0.002) on problems included in the training clinical presentation. However, they showed no difference between training and control presentations in diagnostic performance when required to transfer their skills between problems (45.9% versus 43.8%; P = 0.5) or in performance on multiple-choice questions (64.1% versus 63.6%; P = 0.8). CONCLUSIONS Students can acquire and retain clinical skills with CRS training, but demonstrate limited ability to transfer these to other problems. Further studies are needed to explore ways of improving learning and transfer with CRS training.
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Affiliation(s)
- Kristin Fraser
- Office of Undergraduate Medical Education, University of Calgary, Calgary, Alberta, Canada
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Watrous RL, Thompson WR, Ackerman SJ. The impact of computer-assisted auscultation on physician referrals of asymptomatic patients with heart murmurs. Clin Cardiol 2008; 31:79-83. [PMID: 18257026 DOI: 10.1002/clc.20185] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND As many as 50-70% of asymptomatic children referred for specialist evaluation or echocardiography because of a murmur have no heart disease. HYPOTHESIS Computer-assisted auscultation (CAA) can improve the sensitivity and specificity of referrals for evaluation of heart murmurs. METHODS Seven board-certified primary care physicians were evaluated both without and with use of a computer-based decision-support system using 100 prerecorded patient heart sounds (55 innocent murmurs, 30 pathological murmurs, 15 without murmur). The sensitivity and specificity of their murmur referral decisions relative to American College of Cardiology/American Heart Association (ACC/AHA) guidelines, and sensitivity and specificity of murmur detection and characterization (innocent versus pathological) were measured. RESULTS Sensitivity for detection of murmurs significantly increased with use of CAA from 76.6 to 89.1% (p <0.001), while specificity remained unaffected (80.0 versus 81.0%). Computer-assisted auscultation improved sensitivity of correctly identifying pathological murmur cases from 82.4 to 90.0%, and specificity of correctly identifying benign cases (with innocent or no murmurs) from 74.9 to 88.8%. (p <0.001). Referral sensitivity increased from 86.7 to 92.9%, while specificity increased from 63.5 to 78.6% using CAA (p <0.001). CONCLUSIONS Computer-assisted auscultation appears to be a promising new technology for informing the referral decisions of primary care physicians.
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Affiliation(s)
- Raymond L Watrous
- Zargis Medical Corporation, 2 Research Way, Princeton, NJ 08540, USA.
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Watrous RL. Computer-aided auscultation of the heart: from anatomy and physiology to diagnostic decision support. CONFERENCE PROCEEDINGS : ... ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL CONFERENCE 2008; 2006:140-3. [PMID: 17946792 DOI: 10.1109/iembs.2006.259757] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
There is a clear and present need for computer-aided auscultation of the heart which arises from the highly informative nature of heart sounds, the inherent difficulty of auscultation and increasing pressure in healthcare for rapid, accurate, objective, documented and cost-effective patient evaluation and diagnostic decision making. There are advanced signal processing technologies that hold promise for developing computer-aided auscultation solutions that are intuitive, efficient, informative and accurate. Computer-aided auscultation offers an objective, quantitative and cost-effective tool for acquiring and analyzing heart sounds, providing archival records that support the patient evaluation and referral decision as well as serial comparisons for patient monitoring. There is the further promise of new quantitative acoustic measures and auscultatory findings that have more precise correlation with underlying physiological parameters. These solutions are being developed with the benefits of a rich literature of clinical studies in phonocardiography, the added insights derived from echocardiography, and advances in signal processing technology.
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Criley JM, Keiner J, Boker JR, Criley SR, Warde CM. Innovative web-based multimedia curriculum improves cardiac examination competency of residents. J Hosp Med 2008; 3:124-33. [PMID: 18438809 DOI: 10.1002/jhm.287] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Proper diagnosis of cardiac disorders is a core competency of internists. Yet numerous studies have documented that the cardiac examination (CE) skills of physicians have declined compared with those of previous generations of physicians, attributed variously to inadequate exposure to cardiac patients and lack of skilled bedside teaching. With growing concerns about ensuring patient safety and quality of care, public and professional organizations are calling for a renewed emphasis on the teaching and evaluation of clinical skills in residency training. OBJECTIVE The objective of the study was to determine whether Web training improves CE competency, whether residents retain what they learn, and whether a Web-based curriculum plus clinical training is better than clinical training alone. Journal of Hospital Medicine 2008;3:124-133. (c) 2008 Society of Hospital Medicine. DESIGN This was a controlled intervention study. PARTICIPANTS The intervention group (34 internal and family medicine interns) participated in self-directed use of a Web-based tutorial and three 1-hour teaching sessions taught by a hospitalist. Twenty-five interns from the prior year served as controls. MEASUREMENTS We assessed overall CE competency and 4 subcategories of CE competency: knowledge, audio skills, visual skills, and audio-visual integration. RESULTS The over mean score of the intervention group significantly improved, from 54 to 66 (P = .002). This improvement was retained (63.5, P = .05). When compared with end-of-year controls, the intervention group had significantly higher end-of-year CE scores (57 vs. 63.5, P = .05), knowledge (P = .04), and audio skills (P = .01). At the end of the academic year, all improvements were retained (P <or= .04) except visual skills (P = .75). CONCLUSIONS A Web-based interactive educational program with minimal hospitalist involvement led to significant improvement in CE competence and was better than clinical training alone.
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Movahed MR, Ebrahimi R. The prevalence of valvular abnormalities in patients who were referred for echocardiographic examination with a primary diagnosis of "heart murmur". Echocardiography 2007; 24:447-51. [PMID: 17456061 DOI: 10.1111/j.1540-8175.2007.00425.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION The prevalence of valvular abnormality and innocent murmur in patients who are referred for echocardiographic evaluation with the diagnosis of "murmur" is not known. The goal of this study was to evaluate the prevalence of valvular abnormalities in such patients. METHODS We retrospectively reviewed the echocardiograms that were referred with the primary ordering diagnosis of "murmur," for the presence of valvular abnormalities. For comparison, we used other documented primary reasons for echocardiographic referral, such as chest pain, shortness of breath, etc. RESULTS In this cohort, 7,684 echocardiogram reports documented primary diagnostic reasons for echocardiographic referral. A total of 3,460 echocardiogram reports (45%) were coded "murmur" as the primary reason for the study referral. There was a higher prevalence of female patient referrals for heart murmur evaluation (61.8% vs. 38.2%). Although, patients with murmur had a higher prevalence of valvular abnormalities, compared to other reasons for echocardiographic examination, the prevalence of valvular abnormality was less than 50% (48.6% vs. 35.5%) in both groups. Despite the higher number of female patients referred with the diagnosis of murmur, the percentage of abnormal valves was lower in women (45.6% vs. 53.4% in men). CONCLUSION The prevalence of valvular abnormalities in patients who were referred with the diagnosis of murmur for echocardiographic examination was less than 50%, with a lesser degree found in women. Routine utilization of echocardiography for evaluation of all murmurs may be unwarranted.
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Affiliation(s)
- Mohammad-Reza Movahed
- Department of Medicine, Sarver Heart Center, University of Arizona Medical Center, Tucson, Arizona 85724, USA.
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Iversen K, Søgaard Teisner A, Dalsgaard M, Greibe R, Timm HB, Skovgaard LT, Hróbjartsson A, Copenhagen O, Copenhagen S, Copenhagen K. Effect of teaching and type of stethoscope on cardiac auscultatory performance. Am Heart J 2006; 152:85.e1-7. [PMID: 16824835 DOI: 10.1016/j.ahj.2006.04.013] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2005] [Accepted: 04/13/2006] [Indexed: 11/16/2022]
Abstract
BACKGROUND Auscultation of the heart is a routine procedure. It is not known whether auscultatory skills can be improved by teaching or with the use of an advanced stethoscope. METHODS This study was a randomized trial with a 2 x 2 factorial design. Seventy-two house officers were randomized to a simple or an advanced stethoscope and to a 4-hour course in auscultation or no course. The doctors auscultated 20 patients' hearts and categorized findings as normal or as one or more of 5 categories of heart diseases. Patients were selected such that 16 had a known heart disease as well as a corresponding murmur and 4 had no heart disease or murmur. Auscultatory performance was assessed as concordance with echocardiographic findings and interobserver variation. RESULTS Doctors using the advanced stethoscope diagnosed 35% of the patients correctly, as compared with doctors using the simple stethoscope who did 33% of the patients (P = .27). Similarly, 34% of the patients were diagnosed correctly by doctors who had received teaching as compared with 33% of those who were by doctors who had received no teaching (P = .41). The kappa values were higher for doctors who had received teaching for aortic stenosis (0.43 vs 0.28, P = .004) and ventricular septum defect (0.07 vs 0.01, P = .003). There was no difference between groups for any other single murmur or for the detection of murmurs as such. CONCLUSION Heart auscultation findings were in poor accordance with echocardiographic findings and had high interobserver variation. Neither outcome improved to any important extent with the subjects' use of an advanced stethoscope or attending of a course in heart auscultation.
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Affiliation(s)
- Kasper Iversen
- Clinic of Cardiology, Rigshospitalet, Copenhagen Ø, Denmark.
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Andrisevic N, Ejaz K, Rios-Gutierrez F, Alba-Flores R, Nordehn G, Burns S. Detection of heart murmurs using wavelet analysis and artificial neural networks. J Biomech Eng 2006; 127:899-904. [PMID: 16438225 DOI: 10.1115/1.2049327] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This paper presents the algorithm and technical aspects of an intelligent diagnostic system for the detection of heart murmurs. The purpose of this research is to address the lack of effectively accurate cardiac auscultation present at the primary care physician office by development of an algorithm capable of operating within the hectic environment of the primary care office. The proposed algorithm consists of three main stages. First; denoising of input data (digital recordings of heart sounds), via Wavelet Packet Analysis. Second; input vector preparation through the use of Principal Component Analysis and block processing. Third; classification of the heart sound using an Artificial Neural Network. Initial testing revealed the intelligent diagnostic system can differentiate between normal healthy heart sounds and abnormal heart sounds (e.g., murmurs), with a specificity of 70.5% and a sensitivity of 64.7%.
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Affiliation(s)
- Nicholas Andrisevic
- Department of Electrical and Computer Engineering, University of Minnesota, Duluth, MN 55812, USA.
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March SK, Bedynek JL, Chizner MA. Teaching cardiac auscultation: effectiveness of a patient-centered teaching conference on improving cardiac auscultatory skills. Mayo Clin Proc 2005; 80:1443-8. [PMID: 16295024 DOI: 10.4065/80.11.1443] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES To assess the cardiac auscultatory skills of health care professionals before and after an actual (not simulated) patient-centered cardiac auscultation conference and to determine the effectiveness of this clinical teaching method on Improving diagnostic proficiency. SUBJECTS AND METHODS Seventy-eight participants at a conference on cardiac auscultation completed preconference and postconference examinations on their ability to diagnose a wide variety of heart sounds and murmurs. Among those tested, 46 (59%) were physicians: 17 (22%) were cardiologists, 19 (24%) were medical Interns or residents, 7 (9%) were cardiology fellows, 2 (3%) were general practitioners, and 1 (1%) was a pediatrician. Thirty-two (41%) of this group of respondents were nonphysicians: 14 (18%) were nurse practitioners, 9 (12%) were nurses, 6 (8%) were physician assistants, 2 (3%) were medical students, and 1 (1%) was a nonmedical professional. All participants were tested on 14 clinically Important cardiac auscultatory events directly recorded from actual (not simulated) patients and transmitted via wireless Infrared stethophones. The auscultatory events tested were wide physiologic splitting of S2 in right bundle branch block, fixed S2 splitting and systolic murmur in atrial septal defect, midsystolic click and late systolic murmur of mitral valve prolapse, S4 gallop, S3 gallop, opening snap of mitral stenosis, innocent systolic murmur, systolic murmur of mitral regurgitation, systolic murmur of tricuspid regurgitation, systolic murmur of hypertrophic obstructive cardiomyopathy, continuous murmur of patent ductus arteriosus, pericardial friction rub, prosthetic valve sounds, and alternation of heart sounds, heart murmurs, and the S3 gallop in congestive heart failure. RESULTS On the basis of the analysis of the 78 participants who completed preconference and postconference evaluations of the 14 selected cardiac auscultatory events, a preconference Identification score of 26.3% and a postconference score of 44.7% were observed. This represents a statistically significant overall Improvement in diagnostic proficiency (P < .001). CONCLUSIONS Cardiac auscultatory skills among today's health care professionals are extremely poor, regardless of the level and/or type of training of the professional. An actual (not simulated) patient-centered teaching conference is an effective clinical method of improving cardiac auscultatory skills and diagnostic proficiency of health care professionals.
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Affiliation(s)
- S Kimara March
- Department of Internal Medicine, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905, USA.
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Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, Neuman Y, Mirocha J, Kar S, Forrester JS, Siegel RJ. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol 2005; 96:1002-6. [PMID: 16188532 DOI: 10.1016/j.amjcard.2005.05.060] [Citation(s) in RCA: 246] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2005] [Revised: 05/12/2005] [Accepted: 05/12/2005] [Indexed: 02/06/2023]
Abstract
This study compared the accuracy of cardiovascular diagnoses by medical students operating a small hand-carried ultrasound (HCU) device with that of board-certified cardiologists using standard physical examinations. Sixty-one patients (38% women; mean age 70 +/- 19 years) with clinically significant cardiac disease had HCU studies performed by 1 of 2 medical students with 18 hours of training in cardiac ultrasound and physical examinations by 1 of 5 cardiologists. Diagnostic accuracy was determined by standard echocardiography. Two-hundred thirty-nine abnormal findings were detected by standard echocardiography. The students correctly identified 75% (180 of 239) of the pathologies, whereas cardiologists found 49% (116 of 239) (p <0.001). The students' diagnostic specificity of 87% was also greater than cardiologists' specificity of 76% (p <0.001). For nonvalvular pathologies (115 findings), students' sensitivity was 61%, compared with 47% for cardiologists (p = 0.040). There were 124 clinically significant valvular lesions (111 regurgitations, 13 stenoses). Students' and cardiologists' sensitivities for recognizing lesions that cause a systolic murmur were 93% and 62% (p <0.001), respectively. Students' sensitivity for diagnosing lesions that produce a diastolic murmur was 75%; cardiologists recognized 16% of these lesions (p <0.001). The diagnostic accuracy of medical students using an HCU device after brief echocardiographic training to detect valvular disease, left ventricular dysfunction, enlargement, and hypertrophy was superior to that of experienced cardiologists performing cardiac physical examinations.
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Abstract
Thorough and timely anesthesia preoperative evaluation is essential for good patient outcomes. Perioperative care is becoming more complex and comprehensive, while older and sicker patients are being considered for major thoracic surgery. In addition to pulmonary and wound care, prevention of cardiac complications with beta-blocker therapy, multimodal pain control, tighter glycemic control, nutritional support, and prevention of thromboembolism are important perioperative goals. Early identification of significant medical and nonmedical issues allows for complete evaluation and planning and decreases the likelihood of delays, cancellations, and complications. Good communication and preparation benefit everyone. The implementation of an anesthesia preoperative assessment program or clinic can help achieve these important goals.
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Affiliation(s)
- Clifford A Schmiesing
- Department of Anesthesia, Stanford University Medical Center, 300 Pasteur Drive, H3524, Stanford, CA 94305, USA.
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Lessard E, Glick M, Ahmed S, Saric M. The patient with a heart murmur: evaluation, assessment and dental considerations. J Am Dent Assoc 2005; 136:347-56; quiz 380-1. [PMID: 15819349 DOI: 10.14219/jada.archive.2005.0176] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Heart murmurs, a common finding in dental patients, are of major concern to dental professionals because certain dental procedures occasionally can induce severe cardiovascular complications. Murmurs may indicate existing heart disease that is a risk factor for infective endocarditis following a dental procedure, as well as more severe heart conditions such as congenital heart disease, atrial fibrillation or congestive heart failure. TYPES OF STUDIES REVIEWED This review article is based on data published in peer-reviewed journals, including practice guidelines published by major dental and medical professional organizations. RESULTS Echocardiography is the primary means of evaluating heart murmurs, and all dental professionals should become familiar with major aspects of an echocardiogram. Understanding the medical evaluation and assessment of a heart murmur fosters better communication with other health care professionals and results in improved patient care. CLINICAL IMPLICATIONS Beyond the need to administer antibiotic prophylaxis, the dentist also needs to address the underlying causes of a patient's heart murmur. By providing dental care to such patients, oral health care providers become part of the patient's overall health care team.
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Affiliation(s)
- Eric Lessard
- Oral Medicine, University of Medicine & Dentistry of New Jersey, Newark, USA
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Decara JM, Kirkpatrick JN, Spencer KT, Ward RP, Kasza K, Furlong K, Lang RM. Use of hand-carried ultrasound devices to augment the accuracy of medical student bedside cardiac diagnoses. J Am Soc Echocardiogr 2005; 18:257-63. [PMID: 15746716 DOI: 10.1016/j.echo.2004.11.015] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Hand-carried ultrasound (HCU) devices used by cardiologists as extensions of the physical examination have been shown to improve the accuracy of bedside diagnoses. We tested the feasibility of teaching medical students to use HCU devices to make bedside cardiac diagnoses and compared the accuracy of their HCU and physical examinations. METHODS In all, 10 fourth-year medical students enrolled in a 4-week medical school course on the cardiac examination. Students examined 12 standardized patients at 3 different time intervals: (1) on day 1 of the course; (2) on day 10 after review of cardiac physical examination using traditional teaching methods; and (3) after instruction on the use of HCU devices. Students were scored at each time interval for primary findings (most salient) and all findings, accounting for both errors of commission and omission. Scores could range from +12 to -12 for primary findings and from +22 to -22 for all findings. A perfect score was +12 for primary findings and +22 for all findings. RESULTS The average score for all students at baseline was -3.2 +/- 3.1 and -5.7 +/- 4.8 for primary and all findings, respectively. A significant improvement in the scores was noted with use of the HCU device (2.6 +/- 3.1 and 5.2 +/- 6.6 for primary and all findings, respectively) compared with the baseline and two subsequent physical examinations. CONCLUSION Instruction of fourth-year medical students on the use of HCU device is feasible and results in significantly more accurate bedside diagnoses.
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Affiliation(s)
- Jeanne M Decara
- Department of Medicine and Section of Cardiology, University of Chicago Hospitals, IL, USA.
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Liu SC, Chang WT, Huang CH, Weng TI, Ma Matthew HM, Chen WJ. The value of portable ultrasound for evaluation of cardiomegaly patients presenting at the emergency department. Resuscitation 2005; 64:327-31. [PMID: 15733762 DOI: 10.1016/j.resuscitation.2004.09.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2004] [Revised: 09/22/2004] [Accepted: 09/22/2004] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The purpose of this study was to evaluate the value of a hand-carried portable ultrasound device in the emergency department for patients with cardiomegaly and evaluate its impact on diagnosis and treatment. We compared the results of the portable ultrasound with the results of physical examination and with standard echocardiograph (SE) in the cardiomegaly patients in emergency department. BACKGROUND Recently, small portable ultrasound devices have been introduced, and they need more extensive study to evaluate their application. METHODS We used the OptiGo (Agilent Technologies, Andover, MA) portable device to evaluate emergency patients, and compared it with two SE devices available for this study, the Hewlett Packard (Sono 5500; Andover, MA) or the Vingmed (System V; Horten, Norway). Each of 100 patients was studied by physical examination first then examined with the portable ultrasound and standard echocardiography. The yields from physical examination and portable echocardiography were compared and results of the standard and portable were also compared. RESULTS There were a total of 243 cardiovascular findings detected by the standard echocardiographic examination in the 100 patients studied. Cardiac examination failed to detect 40% of the overall findings but the portable device missed only 17% of all findings. The portable device evaluated 201 conditions correctly (83%) and missed relevant clinical findings in 37 (17%) as compared to standard echocardiography, but in only 12 (5%) were these findings of major importance As an overall measure of diagnostic value, the portable device would have added to clinical judgment, thus boosting diagnostic accuracy from 62% to 83%. CONCLUSIONS Portable ultrasound technology can provide rapid, readily available and important clinical information for emergency physicians in the management of emergency patients with cardiomegaly.
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Affiliation(s)
- Shih-Chi Liu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
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