The diagnosis of heart disease by clinical assessment alone

Evaluating the effectiveness of a structured, simulator-assisted, peer-led training on cardiovascular physical examination in third-year medical students: a prospective, randomized, controlled trial

Background: Previous research suggests that cardiac examination skills in undergraduate medical students frequently need improvement. There are different ways to enhance physical examination (PE) skills such as simulator-based training or peer-assisted learning (PAL). Aim: The aim of this study was to evaluate the effectiveness of a structured, simulator-assisted, peer-led training on cardiovascular PE. Methods: Participants were third-year medical students at Leipzig University Faculty of Medicine. Students were randomly assigned to an intervention group (IG) and a control group (CG). In addition to standard curricular training, IG received a peer-led, simulator-based training in cardiac PE. Participant performance in cardiac PE was assessed using a standardized checklist with a maximum of 25 points. Primary outcome was assessed via checklist point distribution. Results: 89 students were randomised to either CG (n=43) or IG (n=46) with 70 completing the study. Overall, IG students performed significantly better than CG students did (max. points: 25, M±SD in IG was 17±3, in CG 12±4, p<.0001). Simple mistakes such as not using the stethoscope correctly were more frequent in CG students. Prior experience did not lead to a significant difference in performance. Conclusions: Structured, peer-led and simulator-assisted teaching sessions improve cardiac PE skills in this setting compared to control students that did not receive this training.

Development of a Smartphone App for Visualizing Heart Sounds and Murmurs

BACKGROUND

Auscultation is one of the basic techniques for the diagnosis of heart disease. However, the interpretation of heart sounds and murmurs is a highly subjective and difficult skill.

OBJECTIVES

To assist the auscultation skill at the bedside, a handy phonocardiogram was developed using a smartphone (Samsung Galaxy J, Android OS 4.4.2) and an external microphone attached to a stethoscope.

METHODS AND RESULTS

The Android app used Java classes, "AudioRecord," "AudioTrack," and "View," that recorded sounds, replayed sounds, and plotted sound waves, respectively. Sound waves were visualized in real-time, simultaneously replayed on the smartphone, and saved to WAV files. To confirm the availability of the app, 26 kinds of heart sounds and murmurs sounded on a human patient simulator were recorded using three different methods: a bell-type stethoscope, a diaphragm-type stethoscope, and a direct external microphone without a stethoscope. The recorded waveforms were subjectively confirmed and were found to be similar to the reference waveforms.

CONCLUSIONS

The real-time visualization of the sound waves on the smartphone may help novices to readily recognize and learn to distinguish the various heart sounds and murmurs in real-time.

Cultural adaptation and reliability analysis of the Modified Dyspnea Index for the Brazilian culture

This study aims to present the cross-cultural adaptation process of the Modified Dyspnea Index to the Brazilian culture and to investigate its content validity and reliability. This process included the steps of translation, back translation and review by two experts to assess semantic, conceptual, idiomatic, cultural and metabolic equivalence. The Index of Content Validity was used to evaluate the extent of inter-observer agreement. A Guide to implement the Modified Dyspnea Index was developed and validated. Two different professionals assessed the reliability of the Brazilian version of the Modified Dyspnea Index, according to the inter-observer equivalence criterion, with 31 patients, indicating a Kappa coefficient=0.960 (p<0.001). In conclusion, the Brazilian version of MDI presented evidence of interobserver equivalence when applied by different health professionals in the population of cardiac patients.

The impact of computer-assisted auscultation on physician referrals of asymptomatic patients with heart murmurs

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.

Teaching cardiac auscultation: effectiveness of a patient-centered teaching conference on improving cardiac auscultatory skills

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.

Does hormonal status influence the clinical presentation of acute coronary syndromes in women?

BACKGROUND

Previous studies suggest that the clinical presentation of acute coronary syndromes (ACS) may differ between women and men. It is not known if different clinical presentations may be explained by hormonal status in women with ACS. Our objective was to compare the clinical presentation of ACS between premenopausal (PRE) women and post-menopausal women with hormone replacement therapy (HRT) and without (POST).

METHODS

This was a prospective study of consecutive women admitted with a diagnosis of ACS (myocardial infarction [MI] or unstable angina). All women answered a detailed questionnaire that included a list of 27 clinical symptoms. Symptom results were adjusted for age and current coronary event diagnosis.

RESULTS

Seventy-three Caucasian women were studied. No differences were found in terms of the frequency of reported typical symptoms of ACS between PRE (n = 23), HRT (n = 32), and POST (n = 18). However, PRE more often reported atypical chest symptoms than HRT and POST women (57% vs. 31% vs. 22%, PRE vs. HRT vs. POST, respectively, p = 0.05). HRT and POST women experienced substernal chest pain more frequently than PRE (44% vs. 78% vs. 83%, p = 0.03). In contrast, PRE more frequently tended to experience chest pressure (57% vs. 31% vs. 39%, p = 0.2) or chest pain in other locations (22% vs. 3% vs. 6%, p = 0.06). HRT and POST groups reported more frequent indigestion-like pain/discomfort (22% vs. 50% vs. 56%, p = 0.04) and midback pain (35% vs. 63% vs. 72%, p = 0.04) during ACS compared with PRE women. POST experienced sudden fatigue more frequently than PRE and HRT (61% vs. 53% vs. 89%, p = 0.03).

CONCLUSIONS

Our results suggest that almost all women admitted with ACS experienced typical chest symptoms but frequently reported both typical and atypical symptoms. Independently of age, atypical chest symptoms occurred more frequently in premenopausal women than in postmenopausal women with or without HRT.

Aortic Stenosis and Autonomic Dysfunction: Co-Conspirators in Syncope

Autonomic dysfunction and aortic stenosis share several clinical characteristics, including, in severe cases, syncope. Both illnesses tend to manifest later in life, and most cases are idiopathic in origin. In a short period of 4 weeks, the authors noted that three patients out of 36 referrals for autonomic dysfunction also had histories of aortic valve replacement due to stenosis. In each case, similar presenting symptoms of fatigue, light-headedness, and syncope were attributed to aortic stenosis without mention of autonomic failure as a possible contributor. The authors propose that patients for whom symptoms of aortic valve stenosis are not relieved by surgical intervention may have concomitant autonomic dysfunction contributing significantly to their symptoms. Furthermore, the two conditions may comprise a dangerous combination, aortic stenosis causing physical obstruction of ventricular outflow, and autonomic dysfunction causing decreased venous return and insufficient cardiac filling. It may be beneficial for patients with aortic stenosis who present with syncope to be considered for possible autonomic dysfunction to address both potential pathophysiologies contributing to the syncope.