A decision aid for referring patients with systolic murmurs for echocardiography

Utility of physical examination and comparison to echocardiography for cardiac diagnosis

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.

A systematic review of trends and patterns of congenital heart disease in children in Nigeria from 1964-2015

BACKGROUND

Congenital heart diseases cause significant childhood morbidity and mortality. Several restricted studies have been conducted on the epidemiology in Nigeria. No truly nationwide data on patterns of congenital heart disease exists.

OBJECTIVES

To determine the patterns of congenital heart disease in children in Nigeria and examine trends in the occurrence of individual defects across 5 decades.

METHOD

We searched PubMed database, Google scholar, TRIP database, World Health Organisation libraries and reference lists of selected articles for studies on patterns of congenital heart disease among children in Nigeria between 1964 and 2015. Two researchers reviewed the papers independently and extracted the data. Seventeen studies were selected that included 2,953 children with congenital heart disease.

RESULTS

The commonest congenital heart diseases in Nigeria are ventricular septal defect (40.6%), patent ductus arteriosus (18.4%), atrial septal defect (11.3%) and tetralogy of Fallot (11.8%). There has been a 6% increase in the burden of VSD in every decade for the 5 decades studied and a decline in the occurrence of pulmonary stenosis. Studies conducted in Northern Nigeria demonstrated higher proportions of atrial septal defects than patent ductus arteriosus.

CONCLUSIONS

Ventricular septal defects are the commonest congenital heart diseases in Nigeria with a rising burden.

The prevalence of valvular abnormalities in patients who were referred for echocardiographic examination with a primary diagnosis of "heart murmur"

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.

Anesthesia for older patients with hypertrophic cardiomyopathy: is there cause for concern?

Hypertrophic cardiomyopathy (HCM) may remain clinically silent and undiagnosed until patients reach advanced age. We describe 2 older patients with previously undetected and probable late-onset HCM whose preoperative cardiac examination revealed only the presence of a systolic murmur. Both patients were diagnosed with HCM by perioperative echocardiography. We provide an algorithm for the evaluation of murmurs detected during the preoperative anesthesia evaluation, with emphasis on the clinical characteristics of HCM, and we discuss the perioperative management of these patients. In addition, recent findings concerning the natural progression of HCM are discussed, revealing differences between HCM in younger patient populations and that in older patient populations and its implications for anesthetic management.

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.

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.

Systolic ejection murmurs in the era of modern cardiology: what do we really know?

The basics of pulsatile ejection dynamics are reviewed in order to clarify the relationships among left ventricular and aortic pressures, intra-left ventricular and aortic flow velocities, and cardiovascular sound. The principles of turbulent flow are examined using the Reynolds number concept, and the evidence for cause-and-effect relationships between turbulent flow and murmur generation is presented. Examples of hemodynamics and phonocardiography are given for normal subjects and are compared to patients with aortic stenosis and hypertrophic cardiomyopathy. The concepts presented are used to analyze the results of a new study suggesting increased intraventricular velocities as a new cause for systolic murmurs in adults.

Utilization of echocardiography by internists and cardiologists: a comparative study

OBJECTIVE

To compare the utilization of echocardiography as a diagnostic tool by internists and cardiologists.

DESIGN

Retrospective study.

SETTING

Tertiary care university hospital.

METHODS

Indications and clinical utility of echocardiographic studies ordered by cardiologists (group A, n = 301) and internists (group B, n = 297) were compared by chart review. The two groups of patients were analyzed to determine if the studies detected new cardiac pathology and/or altered patient management.

RESULTS

The proportion of studies with abnormal results were similar in both groups (19% versus 14%, P > 0.05). The results of echocardiography, however, led to a change in management more often when the study was ordered by cardiologists (16% versus 10%, P < 0.05). A significantly greater proportion of studies were ordered for evaluation of valvular function by internists (44% versus 33%, P < 0.05). Echocardiography detected valvular abnormalities in a similar proportion of cases in groups A and B (14% versus 10%, P > 0.05). However, diagnostic yield was very poor when the study was performed in patients with suspected mitral valve prolapse in both groups. Cardiologists utilized echocardiography more often for evaluation of left ventricular function (35% versus 18%, P < 0.01) and in the setting of atherosclerotic heart disease for detecting wall motion abnormalities (14% versus 5%, P < 0.01).

CONCLUSION

Diagnostic yield of echocardiography is similar when ordered by internists and cardiologists. With the information obtained, management is altered in a slightly greater proportion of cases involving a cardiologist. This may be due to utilization of echocardiography more often for estimating left ventricular function and for detecting wall motion abnormalities by cardiologists.