Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects

Limitations of the pelvic examination for evaluation of the female pelvic organs

OBJECTIVE

To assess factors influencing an accurate pelvic examination under the best possible circumstances.

METHODS

Before undergoing laparoscopy or laparotomy, 84 women under general anesthesia underwent pelvic examinations by an attending gynecologist, a gynecology resident, and a medical student blinded to the indication for surgery. Surgical findings were compared with the examiners' findings. Dependent variables (uterine size, uterine contour, and presence of adnexal masses) and effect modifiers (examiner experience and body mass index) were analyzed.

RESULTS

The overall pelvic examination was accurate 70.2% of the time for attending gynecologists, 64.0% for residents, and 57.3% for medical students. The sensitivity to detect adnexal masses was much lower than the sensitivity to assess uterine size or uterine contour. Obesity noticeably reduced detection of adnexal masses.

CONCLUSION

The bimanual examination appears to be a limited screening test for the female upper genital tract even under the best possible circumstances. Uterine assessment appears to be more accurate than adnexal assessment.

Ultrasound stethoscopy

Miniaturization and digital techniques have resulted in the development of high-resolution, battery-powered personal ultrasound devices with excellent grey-scale and color blood flow imaging capabilities. These devices are appropriately called "ultrasound stethoscopes" and are practical to use. They extend our physical perception during a clinical examination by "seeing the invisible pathology" and allow the user to address specific clinical problems anywhere at the point-of-care. Murmurs and abnormal precordial movements can be directly related to cardiac structural, functional, and flow abnormalities. A cardiac abnormality (pericardial effusion, dilated heart, valvular disease, mass lesion) is rapidly confirmed during the clinical examination and often a specific diagnosis is made. The device can effectively assist in the initial evaluation and rapid diagnosis of potentially life-threatening conditions or in situations where quick decision-making is essential. Overall, they strengthen our clinical diagnostic accuracy and also add quantitative information. The ultrasound stethoscope allows rapid screening for left ventricular dysfunction and occult aortic abdominal aneurysm and left ventricular hypertrophy in patients with hypertension. Training may become an important issue and should focus on criteria of normalcy and identifying specific and major cardiac disorders. There is no doubt, however, that these devices will revolutionize the physical cardiac examination and diagnosis.

Hand-carried cardiac ultrasound as a tool to screen for important cardiovascular disease in an underserved minority health care clinic

The disparity in cardiovascular outcomes among racial and social strata may be, in part, because of delayed detection of cardiovascular disease in minority patients. The low cost and portability of hand-carried cardiac ultrasound devices may make screening of underserved patients for cardiac disease feasible. A general internist evaluated 153 patients at a clinic serving an underserved population with a hand-carried cardiac ultrasound device. A total of 27 cases of significant valvular heart disease or ventricular dysfunction were detected in 19 patients (12.4%). Detection of a major cardiac abnormality could not be predicted by cardiac risk factors, age, or chief symptom, whereas patients presenting for new or acute clinic visits were more likely to have an abnormality. The low cost and portability of hand-carried cardiac ultrasound devices may make them important tools for the early detection of cardiovascular disease in minority and underserved populations and, thereby, help to reduce disparities in cardiovascular outcomes.

Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologists

It is not exactly known how ED physicians perform in evaluating cardiac systolic murmurs. In 203 consecutive medical ED patients with systolic murmur, we compared the initial clinical evaluation, including auscultation, with transthoracic echocardiography. Of the 203 patients, 132 (65%) had innocent murmurs and 71 patients (35%) had valvular heart disease. Sensitivity and specificity of the initial clinical routine evaluation in diagnosing echocardiographic valvular heart disease were 82% (70%-86%) and 69% (60%-76%), respectively. Independent significant positive predictors of valvular heart disease were grade >2/6 systolic murmur (odds ratio [OR], 8.3; confidence interval [CI], 3.5-19.7, P<.001) and pathologic electrocardiogram (ECG) (OR, 8.4; CI, 3.2-22, P<.001. Patients younger than 50 years with a systolic murmur graded < or =2/6 had innocent murmurs in 98%. The initial clinical evaluation, including auscultation, by experienced ED physicians in internal medicine distinguishes well between innocent murmurs and valvular heart disease in medical patients with cardiac systolic murmurs.

Influence of hand-carried ultrasound on bedside patient treatment decisions for consultative cardiology

To test the hypothesis that hand-carried ultrasound (HCU) may influence patient treatment on consultative cardiology rounds, 235 patients who were hospitalized (aged 65 +/- 10 years) were studied. First, routine treatment decisions regarding diagnostic workup and therapy were made from patient history, physical examination, 12-lead electrocardiogram, and chart data. Second, a goal-directed HCU study was performed in <10 minutes focusing on left ventricular global and regional function, wall thickness, and presence of pericardial effusion, followed by a reassessment of treatment decisions. HCU data influenced treatment decisions in 149 patients (63%); 50% had a change in medical therapy and 22% had a change in their diagnostic workup (most with changes in both). In all, 12 patients (5%) had an immediate change in the decision for cardiac catheterization or pericardiocentesis. Overall agreement for the above findings with subsequent full-size system echocardiography ranged from 92% to 100% (kappa 0.91-0.96). Goal-directed HCU has the potential to influence bedside patient treatment decisions and expedite health care.

Accuracy of analog telephonic stethoscopy for pediatric telecardiology

OBJECTIVE

Wide-bandwidth electronic stethoscopy is reliable and accurate for pediatric telecardiology. We tested a much less expensive and more convenient system for the same purpose, a narrow-bandwidth telephonic stethoscope (TS).

METHODS

Seventy-six consecutive patients (mean age: 10.0; standard deviation: 6.5 years) in a pediatric cardiology outpatient clinic were studied. One pediatric cardiologist examined the patients with his acoustic stethoscope (AS); a second examined them within a few minutes using a remote TS. A nurse placed the TS chest piece as directed by the remote examiner via intercom, but neither video examination nor conversation with the parent/patient were permitted. Examiners independently recorded the stethoscope findings for all heart sounds, all murmurs, and heart disease (present/absent). TS accuracy was indexed using the kappa statistic for TS/AS agreement and for TS agreement with auscultatory findings predicted from echocardiographic (echo) studies (N = 49).

RESULTS

TS/AS agreement was satisfactory for presence/absence of heart disease (kappa = 0.63) and for organic, functional, vibratory, diastolic aortic, and diastolic pulmonic murmurs (kappa range: 0.65-0.75). For other specific murmurs and all heart sounds, TS/AS agreement was either unsatisfactory (kappa < or = 0.60) or indeterminate because prevalence was 0. TS-AS agreement improved when the TS was used by the more-experienced TS examiner and with patients at least 5 years of age. When the older children were examined by the more TS-experienced examiner, the TS-echo comparison yielded kappa = 0.90, raw agreement = 0.96, sensitivity = 0.94, and specificity = 1.00.

CONCLUSIONS

In pediatric patients, a narrow-bandwidth telephonic stethoscope can accurately distinguish between functional and organic murmurs and thus can detect heart disease. Accuracy is greatest when the instrument is used by an experienced examiner with patients at least 5 years of age.

Unsuspected clinically important findings detected with a small portable ultrasound device in patients admitted to a general medicine service

OBJECTIVE

We sought to determine whether physicians with training in echocardiography could successfully use a small echocardiographic device to detect occult cardiovascular disease in patients admitted to a general medical service.

METHODS

In all, 103 consecutive patients had a physician-performed bedside echocardiographic examination with a small portable ultrasound device.

RESULTS

Of patients, 70% did not have a clinical indication for echocardiography and of these patients, 39% had an abnormal study with the portable ultrasound device. There was a high rate of false-positive examinations, but approximately 17% of patients without a clinical indication for echocardiography had an important cardiac abnormality detected, including 10% with unsuspected left ventricular systolic dysfunction.

CONCLUSIONS

Many patients on a general medical hospital ward have unsuspected, clinically important cardiac findings such as left ventricular dysfunction that can be screened for by physicians with training in echocardiography using small portable ultrasound devices.

Role of history and physical examination in preoperative evaluation

BACKGROUND AND OBJECTIVE

Since reports have shown that outpatient preoperative evaluation increases the quality of care and cost-effectiveness, an increasing number of patients are being evaluated purely on an outpatient basis. To improve cost-effectiveness, it would be appealing if those patients who are healthy and ready for surgery without additional testing could be easily distinguished from those who require more extensive evaluation. This paper examines whether published studies provide sufficient data to determine how detailed preoperative history taking and physical examination need to be in order to assess the health of surgical patients and to meet the objective of easy and early distinction.

METHODS

A MEDLINE search was conducted from 1991 to 2000 with respect to preoperative patient history and physical examination. Altogether, 213 articles were found, of which 29 were selected. Additionally, 38 cross-references, 7 articles on additional testing and 4 recently published papers were used.

RESULTS

It is questionable to what extent an extensive history is relevant for anaesthesia and long-term prognosis. With respect to physical examination, it seems unreasonable to diagnose valvular heart disease based on cardiac auscultation only, and it is unclear which method should be used to predict the difficulty of endotracheal intubation. The benefits of routine testing for all surgical patients before operation are extremely limited and are not advocated.

CONCLUSIONS

The amount of detail of preoperative patient history and the value of physical examination to obtain a reasonable estimate of perioperative risk remains unclear. Although not evidence based, a thorough history taking and physical examination of all patients before surgery seems important until more evidence-based guidelines become available. Diagnostic and prognostic prediction studies may provide this necessary evidence.

Using a multimedia tool to improve cardiac auscultation knowledge and skills

OBJECTIVE

Today's medical school graduates have significant deficits in physical examination skills. Medical educators have been searching for methods to effectively teach and maintain these skills in students. The objective of this study was to determine if an auscultation curriculum centered on a portable multimedia CD-ROM was effective in producing and maintaining significant gains in cardiac auscultatory skills.

DESIGN

Controlled cohort study.

PARTICIPANTS

All 168 third-year medical students at 1 medical school in an academic medical center.

INTERVENTIONS

Students were tested before and after exposure to 1 or more elements of the auscultation curriculum: teaching on ward/clinic rotations, CD-ROM comprehensive cases with follow-up seminars, and a CD-ROM 20-case miniseries. The primary outcome measures were student performance on a 10-item test of auscultation skill (listening and identifying heart sound characteristics) and a 30-item test of auscultation knowledge (factual questions about auscultation). A subset of students was tested for attenuation effects 9 or 12 months after the intervention.

RESULTS

Compared with the control group (1 month clinical rotation alone), students who were also exposed to the CD-ROM 20-case miniseries had significant improvements in auscultation skills scores (P < .05), but not knowledge. Additional months of clerkship, comprehensive CD-ROM cases, and follow-up seminars increased auscultation knowledge beyond the miniseries alone (P < .05), but did not further improve auscultation skills. Students' auscultation knowledge diminished one year after the intervention, but auscultation skills did not.

CONCLUSION

In addition to the standard curriculum of ward and conference teaching, portable multimedia tools may help improve quality of physical examination skills.

Physician-performed point-of-care echocardiography using a laptop platform compared with physical examination in the cardiovascular patient

OBJECTIVES

The purpose of this study was to compare the results of physical examinations (PEs) performed by board-certified cardiologists with the results of point-of-care (POC) echocardiography in a group of patients with cardiovascular disease.

BACKGROUND

Although cardiovascular PE is crucial in the evaluation of patients with suspected heart disease, the skills required to diagnose abnormal cardiovascular findings have been declining. Echocardiography is a powerful noninvasive cardiovascular diagnostic tool; however, echocardiographic evaluation of patients is not performed at the time of patient encounter (POC echocardiography), beacuse current platforms are cumbersome and expensive for individual physician use. The development of miniaturized echocardiographic equipment has the potential to overcome some of these limitations.

METHODS

Thirty-six subjects had a complete cardiovascular examination by four board-certified cardiologists. The physicians subsequently imaged each patient using a miniaturized echocardiographic platform. The yield of PE and POC echocardiography were compared using a complete echocardiographic study as the gold standard, performed on an upper-end platform.

RESULTS

Cardiac examination failed to detect 59% of the overall cardiovascular findings. Physician-performed echocardiography with the prototype device missed 29% of the overall cardiovascular pathology. When considering only the major cardiovascular findings, the cardiologists' PEs still failed to correctly detect 43%. Point-of-care echocardiography reduced this to 21% without significant interphysician variation.

CONCLUSIONS

Point-of-care echocardiography using a miniaturized echocardiographic platform substantially improved the detection of important cardiovascular pathology compared with PE. Use of this device by a cardiovascular specialist with training in echocardiography as a routine adjunct to PE appears to be useful.

Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries

PURPOSE

Cardiac auscultation is suffering from a declining interest caused by competing diagnostic technology and, possibly, inadequate teaching and testing of physicians-in-training. Because access to technology, traditional teaching practices, and methods of trainees' assessment vary among different countries, we speculated that trainees' proficiency in auscultation might also vary.

SUBJECTS AND METHODS

We tested the cardiac auscultatory skills of 314 internal medicine residents (189 from the United States, 89 from Canada, and 36 from England) from 14 programs. All participants were asked to listen by stethophones to 12 prerecorded cardiac events and to answer a multiple-choice questionnaire. They also completed a survey concerning attitudes toward cardiac auscultation and auscultatory teaching received during training.

RESULTS

Mean (+/- SD) identification scores for the 12 cardiac events ranged from 0% to 58% for American trainees (mean 22% +/- 12%), 0% to 58% for Canadians (mean 26% +/- 13%), and 0% to 42% for British trainees (mean 20% +/- 12%). Canadians' cumulative scores were slightly but significantly greater than those of American (P = 0.02) and British house officers (P = 0.05). British house officers improved the most during the 3 years of training (P < 0.05). Canadian and British trainees had received more auscultatory teaching during medical school and residency; they had also used audiotapes more frequently (all P < 0.001).

CONCLUSIONS

Auscultatory proficiency was poor in all three countries. Although there were slight differences among countries, the most striking finding was the consistent inaccuracy of all trainees. This suggests that variables other than teaching and testing affect proficiency.

Bedside cardiac examination: constancy in a sea of change

The general trend in the recent literature has been to highlight the difficulties and shortcomings of the physical examination and to attribute these difficulties to deficiencies in training rather than to intrinsic weaknesses in auscultation itself. The call is for better training. Given the advice of the authors mentioned above, individual training may be warranted at the postgraduate level and in the large community of practicing internists and cardiologists. Although not proven, it is likely that individual training with computer technology, audiotape instruction, or simulator technology such as described in the following paragraphs would be effective at improving bedside clinical diagnosis and cost-effective patient care in the postgraduate, continuing medical education setting. The advances in auscultation during the last few years have been more incremental than fundamental. There is ongoing research into the mechanism of production of S3 and S4, and mathematical modeling techniques have recently been used with some success in evaluating the vibrations of S3 and S4 as forced, damped oscillations of a viscoelastic system. Analysis of sound energy with the technique of spectral waveform analysis, which investigates the frequency content of sound signals, has been used for many years in the study of cardiovascular sound. By the use of various methods of mathematical analysis, investigators have found potentially useful information in spectral sound patterns of prosthetic valves, murmur characteristics, and even potentially hemodynamic information from heart sounds. Despite the mathematical advances, there are still disturbing drawbacks to some of the analytic techniques, such as the production of mathematical terms containing "negative energy." Although the potential of obtaining significant clinical information from spectral analysis of heart sound recordings is attractive, the clinical usefulness of such techniques remains virtually nonexistent. Similar to the recent advances in auscultation, the technical advances in the design of the stethoscope have also been more incremental than fundamental. There are at least 3 recently introduced electronic stethoscopes that have the capability of amplification and filtration and that claim noise reduction. Because their introduction is recent, no information is available in the peer-review literature regarding their clinical performance; therefore their place in the clinical arena remains to be elucidated--perhaps a boon for patient care providers with specific hearing defects and perhaps useful in noisy clinical environments. Peer-review literature has not shown clear superiority of one type of acoustic stethoscope over another. The teaching of auscultation has been an area of recognized importance in patient care since the inception of auscultation as a medical art. Attempts to facilitate practitioner learning in the performance and interpretation of auscultation have advanced through the decades limited only by the technical infrastructure of the day. The availability of recorded heart sounds and murmurs appeared shortly after the availability of recording and playback devices, with first vinyl and later tape recordings. In 1974, technology was employed to create a virtual patient named "Harvey," an engineered cardiology patient simulator that reproduces many of the physical findings of the cardiology examination. Later, with the advent of commercially available CD-ROM devices, newer, better-integrated teaching devices have been developed, some of them outstanding in their clarity and quality. Despite the obvious value of such instructional aids that are best used in the individual setting, there is evidence that the classroom is still of significant value in teaching auscultation. However, nowhere else in the practice of medicine is a mentor approach more valuable than in learning auscultation. (ABSTRACT TRUNCATED)

The patient with a systolic murmur: severe aortic stenosis may be missed during cardiovascular examination

Significant aortic stenosis is prevalent amongst elderly people. It may be subclinical, manifesting only as a murmur, but can still cause unexpected death with little warning after symptoms develop. Recent studies have highlighted the unreliability of the classical clinical signs of severe aortic stenosis, leading to concern that some patients may not be referred appropriately for echocardiography. Here, we review the evidence for the accuracy of each sign. We suggest that the assessment of the patient with a systolic murmur should be reappraised, and offer guidelines toward improving the recognition of aortic stenosis in the community.

Prevalence and diagnostic value of precordial murmurs for valvular regurgitation in obese patients treated with dexfenfluramine

Echocardiography is recommended for the detection of valvular regurgitation in asymptomatic users of anorexigens with a heart murmur. To determine the prevalence and diagnostic value of heart murmurs for valvular regurgitation, 223 patients receiving dexfenfluramine therapy for 6.9 months and 189 matched controls underwent history and cardiac auscultation by experienced noncardiologists unaware of echocardiography. Color Doppler echocardiograms were interpreted by 3 observers unaware of patients' clinical data. The frequency of at least mild regurgitation of any valve and abnormal regurgitation (moderate mitral or tricuspid or mild aortic regurgitation) were determined. Heart murmurs heard in 31 dexfenfluramine users (14%) and in 20 controls (11%) were all systolic and of grade I to II/VI intensity. Mild or worse regurgitation of any valve showed a trend in patients (18% vs 11.6% in controls, odds ratio [OR] 1.66, confidence interval [CI] 0.95 to 2.9, p = 0.08), but abnormal regurgitation (includes Food and Drug Administration grade regurgitation) was more common in patients (9% vs 3% in controls, OR 3.0, CI 1.18 to 7.65, p = 0.02). In dexfenfluramine users, heart murmurs were associated with at least mild or abnormal regurgitation (OR 3.1 and 3.05, 95% CI 1.34 to 7.13 and 1.1 to 8.67; p = 0.008 and 0.036, respectively), had a specificity of 89% and 88%, negative predictive value of 85% and 93%, but sensitivity of 37% and 30%, and positive predictive value of 35% and 19%, respectively. Most valves missed by cardiac auscultation had normal morphology and mild regurgitation. Finally, heart murmurs had better diagnostic value for either type of valvular regurgitation than heart murmurs and clinical variables or clinical variables alone. In summary, in dexfenfluramine users the prevalence of heart murmurs was low and their absence predicted absence of mild or worse regurgitation of any valve or abnormal valvular regurgitation. Therefore, cardiac auscultation should be the screening method of choice for detecting valvular regurgitation in users of anorexigens.

Echocardiography in the evaluation of systolic murmurs of unknown cause

PURPOSE

Systolic murmurs are common, and it is important to know whether physical examination can reliably determine their cause. Therefore, we prospectively assessed the diagnostic accuracy of a cardiac examination in patients without previous echocardiography who were referred for evaluation of a systolic murmur.

SUBJECTS AND METHODS

In 100 consecutive adults (mean [+/- SD] age of 58 +/- 22 years) who were referred for a systolic murmur of unknown cause, the diagnostic accuracy of the cardiac examination by cardiologists (without provision of clinical history, electrocardiogram, or chest radiograph) was compared with the results of echocardiography.

RESULTS

The echocardiographic findings included a normal examination (functional murmur) in 21 patients, aortic stenosis in 29 patients, mitral regurgitation in 30 patients, left or right intraventricular pressure gradient in 11 patients, mitral valve prolapse in 11 patients, ventricular septal defect in 4 patients, hypertrophic obstructive cardiomyopathy in 3 patients, and associated aortic regurgitation in 28 patients. In 28 (35%) of the 79 patients with organic heart disease, more than one abnormality was found; combined aortic and mitral valve disease was the most frequent combination (n = 22). The sensitivity of the cardiac examination was acceptable for detecting ventricular septal defect (100% [4 of 4]), isolated mitral regurgitation (88% [26 of 36]), aortic stenosis (71% [21 of 29]), and a functional murmur (67% [14 of 21]), but not for intraventricular pressure gradients (18% [2 of 11]), aortic regurgitation (21% [6 of 28]), combined aortic and mitral valve disease (55% [6 of 11]), and mitral valve prolapse (55% [12 of 22]). In 6 patients, the degree of aortic stenosis was misjudged on the clinical examination, mainly because of a severely diminished left ventricular ejection fraction. Significant heart disease was missed completely in only 2 patients.

CONCLUSION

In adults with a systolic murmur of unknown cause, a functional murmur can usually be distinguished from an organic murmur. However, the ability of the cardiac examination to assess the exact cause of the murmur is limited, especially if more than one lesion is present. Thus, echocardiography should be performed in patients with systolic murmurs of unknown cause who are suspected of having significant heart disease.

Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome

BACKGROUND AND METHODS

The goal of this study was to examine the ability of physical examination to predict valvular aortic stenosis severity and clinical outcome in 123 initially asymptomatic subjects (mean age 63 +/- 16 years, 70% men) followed up for a mean of 2.5 +/- 1.4 years.

RESULTS

Doppler aortic jet velocity correlated with systolic murmur intensity (P =.003) and timing (P =.0002), a single second heart sound (P =.01), and carotid upstroke delay (P <.0001) and amplitude (P <.0001). However, no physical examination findings had both a high sensitivity and a high specificity for the diagnosis of severe valvular obstruction. Clinical end points were reached in 56 subjects (46%), including 8 deaths and 48 valve replacements for symptom onset. Univariate predictors of outcome included carotid upstroke delay (P =.0008) and amplitude (P =.0006), systolic murmur grade (P <.0001) and peak (P =.0003), and a single second heart sound (P =.003). On multivariate Cox regression analysis, the only physical examination predictor of outcome was carotid upstroke amplitude (P =.0001).

CONCLUSIONS

Although physical examination findings correlate with stenosis severity, echocardiography still is needed to exclude severe obstruction reliably when this diagnosis is suspected.

Aortic root disease and valve disease associated with ankylosing spondylitis

OBJECTIVES

This study sought to determine the prevalence, characteristics, relation to clinical features and evolution of aortic root disease and valve disease associated with ankylosing spondylitis (AKS).

BACKGROUND

Aortic root disease and valve disease are common in patients with AKS, but their clinical and prognostic implications have not been well defined.

METHODS

Forty-four outpatients with AKS and 30 age- and gender-matched healthy volunteers underwent initial transesophageal echocardiography and rheumatologic evaluations. Twenty-five patients underwent clinical and echocardiographic follow-up 39+/-10 months later.

RESULTS

Aortic root disease and valve disease were common in patients (82%) as compared with controls (27%; p < 0.001). Aortic root thickening, increased stiffness and dilatation were seen in 61%, 61% and 25% of patients, respectively. Valve thickening (41% for the aortic and 34% for the mitral valve) manifested predominantly (74%) as nodularities of the aortic cusps and basal thickening of the anterior mitral leaflet, forming the characteristic subaortic bump. Valve regurgitation was seen in almost half of patients, and 40% had moderate lesions. Except for the duration of AKS, aortic root disease and valve disease were unrelated to the activity, severity or therapy of AKS. During follow-up of 25 patients, in up to 24% new aortic root or valve abnormalities developed, in 12% existing valve regurgitation worsened significantly and in 20% abnormalities resolved. Twenty percent of patients developed heart failure, underwent valve replacement, had a stroke or died, as compared with 3% of control subjects.

CONCLUSIONS

Aortic root disease and valve disease are common in patients with AKS, are unrelated to clinical features of AKS, can resolve or progress over time and are associated with clinically important cardiovascular morbidity.

A bedside clinical prediction rule for detecting moderate or severe aortic stenosis

OBJECTIVE

To evaluate a bedside clinical prediction rule for detecting moderate or severe aortic stenosis.

DESIGN

Cross-sectional study with independent comparison to a diagnostic reference standard, doppler echocardiography.

SETTING

Urban university hospital.

PARTICIPANTS

Consecutive hospital inpatients (n = 124) who had been referred for echocardiography.

MEASUREMENTS AND MAIN RESULTS

Participants were examined by a third-year general internal medicine resident and a staff general internist. We hypothesized in advance that absence of a murmur over the right clavicle would rule out aortic stenosis, while the presence of three or four associated findings (slow carotid artery upstroke, reduced carotid artery volume, maximal murmur intensity at the second right intercostal space, and reduced intensity of the second heart sound) would rule in aortic stenosis. Study physicians were unaware of echocardiographic findings. The outcome was echocardiographic moderate or severe aortic stenosis, defined as a valve area of 1.2 cm2 or less, or a peak instantaneous gradient of 25 mm Hg or greater. Absence of a murmur over the right clavicle ruled out aortic stenosis (likelihood ratio [LR] 0.10; 95% confidence interval [CI] 0.01, 0.44). The presence of three or four associated findings ruled in aortic stenosis (LR 40; 95% CI 6.6, 240). If a murmur was present over the right clavicle, but no more than two associated findings were present, then the examination was indeterminate (LR 1.8; 95% CI 0.93, 2.9).

CONCLUSION

A clinical prediction rule, using simple bedside maneuvers, accurately ruled in and ruled out aortic stenosis.

Valvular disease associated with systemic illness

The connective tissue diseases are immune-mediated inflammatory diseases that manifest predominantly with symptoms and signs of musculoskeletal and mucocutaneous inflammation. They frequently affect the heart valves, pericardium, and myocardium. In patients with AKS, the aortic root and conduction system are also frequently involved. Echocardiographic series in these patients have demonstrated that valvular disease is highly prevalent and associated with substantial morbidity and mortality (Table 1). The prevalence rates of clinically detected valvular disease, however, are either unknown or low. This discrepancy is related to lack of awareness, overshadowing of the cardiovascular manifestations by the inflammatory symptoms and signs of the musculoskeletal system, lack of systematic application of the history and cardiovascular physical examination, and high sensitivity of echocardiography for detecting subclinical abnormalities. Several valvular abnormalities have been identified as unique to a specific disease. Libman-Sacks vegetations, valve nodules, and subaortic bump are characteristic of SLE, RA, and AKS (see Table 1). The valvular complications and respective therapy are similar to those of other causes of valvular disease; however, the associated morbidity and mortality of these complications in these patients are high. The worse prognosis of valvular disease in these patients is related to the chronicity and debilitating nature of their illness, their high prevalence of multisystem disease, and immunosuppression. These factors underscore the importance of early recognition, prevention of complications, and proper clinical or echocardiographic follow-up. The distinctive echocardiographic characteristics of the valve abnormalities associated with the connective tissue diseases may allow their differentiation from other common valvulopathies, such as infective endocarditis, rheumatic valvular disease, and degenerative valvular disease (Table 2). Despite the clinical and prognostic implications of valvular disease associated with the connective tissue diseases, incomplete data are available about pathogenesis, relation to clinical features of the primary disease, evolution, and effect of steroid or cytotoxic therapy. Echocardiography, especially TEE, has the potential to redefine the prevalence rates and to characterize better the valve abnormalities associated with these conditions. Finally, future large cross-sectional and longitudinal studies using clinical and echocardiographic data may help to define better the presence, evolution, and therapy of the valvular disease associated with the connective tissue diseases.