The Accuracy and Interobserver Agreement in Detecting the ‘Gallop Sounds’ by Cardiac Auscultation

doi:10.1378/chest.114.5.1283

Chest

Volume 114, Issue 5, November 1998, Pages 1283-1288

https://doi.org/10.1378/chest.114.5.1283 Get rights and content

Study objectives

To determine the observer accuracy and interobserver agreement in identifying S₄ and S₃ by cardiac auscultation and whether they improve with increasing observer experience.

Design

Prospective, blinded study.

Setting

Cardiology and general internal medicine wards in a university-affiliated teaching hospital.

Patients

Forty patients with a cardiac diagnosis and 6 patients without were studied.

Measurements and results

Two cardiologists, one general internist, three senior and two junior postgraduate internal medicine trainees, blinded to the patients' characteristics, examined the patients and documented their findings on a questionnaire. Computerized phonocardiogram was obtained in all patients as a gold standard and was interpreted by a blinded, independent cardiologist. The mean positive predictive values for S₄ and S₃ were 51% (range, 24 to 100%) and 71% (range, 50 to 88%), respectively. The mean negative predictive values for S₄ and S₃ were 82% (range, 67 to 94%) and 64% (range, 56 to 85%), respectively. The overall interobserver agreements for detecting S₄ was K = 0.05 (95% confidence interval [CI], 0.01 to 0.09) and S₃ was K = 0.18 (95% CI, 0.13 to 0.24). There was no apparent trend in the accuracy or interobserver agreement with regard to the level of observer experience.

Conclusion

The agreement between observers and the phonocardiographic gold standard in the correct identification of S₄ and S₃ was poor and the lack of agreement did not appear to be a function of the experience of the observers. The overall interobserver agreement for the detection of either S₄ or S₃ was little better than chance alone.

Section snippets

Study Population

The study was approved by the Sunnybrook Health Sciences Centre Research Ethics Board and all subjects consented to participation. Newly admitted patients to the general internal medicine or cardiology wards were screened for the presence of S₄ and/or S₃ by nonobserver general internal medicine and subspecialty housestaff and/or staff. The screening process was meant to recruit patients for the study in a limited time period. To ensure that the observers remain blinded, five patients with

Results

The PCG recordings of 41 of the 46 patients were suitable for analysis. Three recordings were lost due to computer malfunction and two were technically inadequate for analysis. Among these 41 patients, the PCG detected 12 S₄ and 19 S₃. No patient had both S₄ and S₃. The diagnosis of the 12 patients found to have S₄ include 7 with unstable angina/myocardial infarction, 3 with heart failure, and 2 with valvular disease. The diagnosis of the patients with a detectable S₃ include 18 with heart

Discussion

The main finding of this study is that the accuracy of identifying S₄ and S₃ by cardiac auscultation is fair at best. In terms of the accuracy in detecting S₄, a mean PPV of 51% and mean NPV of 82% are similar to the results of a previous study of comparable size.²⁰ As might be expected, the PPVs are lower while the NPVs are higher compared with larger studies.²¹,²²

In 1952, Sloan et al²³ reported clear disagreement among three investigators in detecting the presence of S₃. To our knowledge, the

CONCLUSION

The agreement between observers and the PCG gold standard in the correct identification of S₄ and S₃ was poor and the lack of agreement did not appear to be a function of the level of training and/or experience of the observers. The overall interobserver agreement for the detection of either S₄ or S₃ was little better than chance alone.

ACKNOWLEDGMENTS

Special thanks to the following consultants and housestaff for their participation in this study: Drs. F. Ali, P. El-Helou, G. Froggatt, D. Juurlink, R. Myers, S. Shumak, M. Stanbrook, and A. Zahedi. Thanks also to Marko Katic, BA, for his expert statistical assistance, and Drs. C. Lau and D. Naylor for their inspiration and support.

References (32)

GrayzelJ.
Gallop rhythm of heart: I. Atrial gallop, ventricular gallop and systolic sound
Am J Med
(1960)
LuisadaAA et al.
Controversial and changing aspects of auscultation
Am J Cardiol
(1964)
ShahPM et al.
Gallop rhythm: hemodynamic and clinical correlation
Am Heart J
(1969)
RihalCS et al.
The utility of clinical, electrocardiographic, and roentgenographic variables in the prediction of left ventricular function
Am J Cardiol
(1995)
GuyattGH et al.
A controlled trial of digoxin in congestive heart failure
Am J Cardiol
(1988)
StapletonJF.
The third heart sound of heart failure: valuable only when heard
Chest
(1987)
IshmailAA et al.
Interobserver agreement by auscultation in the presence of a third heart sound in patients with congestive heart failure
Chest
(1987)
HeldP et al.
Audibility of an artificial third heart sound in relation to its frequency, amplitude, delay from the second heart sound and the experience of the observer
Am J Cardiol
(1984)
KindigJR et al.
Acoustical performance of the stethoscope: a comparative analysis
Am Heart J
(1982)
PotainPC.
Du bruit de galop
Gaz D Hop
(1880)

ReddyPS et al.

Normal and abnormal heart sounds in cardiac diagnosis: II. Diastolic sounds

Curr Probl Cardiol

(1985)

ShaverJA.

Cardiac auscultation: a cost effective diagnostic skill

Curr Probl Cardiol

(1995)

AbdullaAM et al.

Clinical significance and hemodynamic correlates of the third heart sound gallop in aortic regurgitation

Circulation

(1981)

FollandED et al.

Implications of third heart sounds in patients with valvular heart disease: the Veterans Affairs Cooperative Study on Valvular Heart Disease

N Engl J Med

(1992)

PatelR et al.

Implications of an audible third heart sound in evaluation of cardiac function

West J Med

(1993)

CampanaC et al.

Predictors of prognosis in patients awaiting heart transplantation

J Heart Lung Transplant

(1993)

Cited by (110)

Estimated plasma volume is not a robust indicator of the severity of congestion in patients with heart failure
2023, American Journal of the Medical Sciences
Congestion is the main cause of morbidity and a prime determinant of survival in patients with heart failure (HF). However, the assessment of congestion is subjective and estimation of plasma volume (ePV) has been suggested as a more objective measure of congestion. This study aimed to explore the relationships and interactions between ePV, the severity of congestion and survival using a nationwide registry.
Of the 1054 patients with HF enrolled in the registry, 769 had sufficient data to calculate ePV (using the Duarte, Kaplan, and Hakim equations) and relative plasma volume status (rPVS), and these patients were subsequently included in the present analysis. The severity of congestion was assessed using a 6-point congestion score (CS). Patients were divided into three groups according to the degree of congestion.
Out of four equations tested, only ePV_Duarte and rPVS were statistically higher in patients with severe congestion as compared to patients with no congestion (p<0.001 for both). Both ePV_Duarte (r = 0.197, p<0.001) and rPVS (r = 0.153, p<0.001) showed statistically significant correlations with CS and both had a modest accuracy (70.4% for ePV_Duarte and 69.4% for rPVS) to predict a CS ≥3. After a median follow up of 496 days, both ePV_Duarte (OR:1.14,95%CI:1.03–1.26, p = 0.01) and rPVS (OR:1.02, 95%CI:1.00–1.03, p = 0.03) were associated with all-cause mortality after adjusting for demographic and clinical variables. However, none of the indices were associated with mortality following the introduction of CS to the models (p>0.05 for both).
Elevated ePV_Duarte and rPVS were indicators of congestion but with a limited robustness, and either parameter could be clinically useful when a comprehensive clinical evaluation of congestion is not feasible.
VExUS Nexus: Bedside Assessment of Venous Congestion
2021, Advances in Chronic Kidney Disease
Citation Excerpt :
However, the optimal strategies for noninvasive evaluation of venous congestion are still being developed. The evaluation of venous congestion relies on physical examination findings that can be insensitive or poorly reproducible even among experienced clinicians.7-9 Although JVP usually reflects right atrial pressure (RAP), measurement is often limited by body habitus or respiratory pathology.
Organ dysfunction in the setting of heart failure is mainly determined by backward transmission of increased right atrial pressure. Although traditional point-of-care ultrasound applications such as inferior vena cava and lung ultrasound have been increasingly incorporated in the clinical care of congestive heart failure, they do not directly evaluate the hemodynamic consequences of high right atrial pressure on organ blood flow. Congestion induces alterations in the venous flow patterns of abdominal organs that can be readily assessed using Doppler imaging. These alterations have been consistently associated with congestive organ dysfunction and adverse clinical outcomes. In this article, we provide a comprehensive overview of the bedside assessment of venous congestion using Doppler imaging. The review focuses mainly on the normal and abnormal Doppler patterns of the hepatic, portal, and intrarenal veins along with clinical examples of how to incorporate this tool in the management of patients with venous congestion.
Ambulatory Monitoring of Heart Sounds via an Implanted Device Is Superior to Auscultation for Prediction of Heart Failure Events
2020, Journal of Cardiac Failure
Citation Excerpt :
Snapshot measurement: auscultation clearly requires the presence of a trained medical professional, and the HSs heard reflect the patient's condition only at that moment; Subjectivity/interobserver variation: The interpretation of HSs has significant interobserver variability10,11; and Human hearing limitation8: A typical human can hear sounds only between 20 Hz and 20k Hz.
We compared the relationship between the third heart sound (S3) measured by an implantable cardiac device (devS3) and auscultation (ausS3) and evaluated their prognostic powers for predicting heart failure events (HFEs).
In the MultiSENSE study, devS3 was measured daily with continuous values, whereas ausS3 was assessed at study visits with discrete grades. They were compared among patients with and without HFEs at baseline and against each other directly. Cox proportional hazard models were developed between follow-up visits and over the whole study. Simulations were performed on devS3 to match the limitations of auscultation. We studied 900 patients, of whom 106 patients experienced 192 HFEs. Two S3 sensing modalities correlated with each other, but at baseline, only devS3 differentiated patients with or without HFEs (P < 0.0001). The prognostic power of devS3 was superior to that of ausS3 both between follow-up visits (HR = 5.7, P < 0.0001, and 1.7, P = 0.047, respectively) and over the whole study (HR = 2.9, P < 0.0001, and 1.4, P = 0.216, respectively). Simulation results suggested this superiority may be attributed to continuous monitoring and to subaudible measuring capability.
S3 measured by implantable cardiac devices has stronger prognostic power to predict episodes of future HFEs than that of auscultation.
Prognostic Significance of Longitudinal Clinical Congestion Pattern in Chronic Heart Failure: Insights From TIME-CHF Trial
2019, American Journal of Medicine
The relationship between longitudinal clinical congestion pattern and heart failure outcome is uncertain. This study was designed to assess the prevalence of congestion over time and to investigate its impact on outcome in chronic heart failure.
A total of 588 patients with chronic heart failure older than 60 years of age with New York Heart Association (NYHA) functional class ≥ II from the TIME-CHF study were included. The endpoints for this study were survival and hospitalization-free heart failure survival. Orthopnea, NYHA ≥ III, paroxysmal nocturnal dyspnea, hepatomegaly, peripheral pitting edema, jugular venous distension, and rales were repeatedly investigated and related to outcomes. These congestion-related signs and symptoms were used to design a 7-item Clinical Congestion Index.
Sixty-one percent of patients had a Clinical Congestion Index ≥ 3 at baseline, which decreased to 18% at month 18. During the median [interquartile range] follow-up of 27.2 [14.3-39.8] months, 17%, 27%, and 47% of patients with baseline Clinical Congestion Index of 0, 1-2, and ≥ 3 at inclusion, respectively, died (P < .001). Clinical Congestion Index was identified as an independent predictor of mortality at all visits (P < .05) except month 6 and reduced hospitalization-free heart failure survival (P < .05). Successful decongestion was related to better outcome as compared to persistent congestion or partial decongestion (log-rank P < 0.001).
The extent of congestion as assessed by means of clinical signs and symptoms decreased over time with intensified treatment, but it remained present or relapsed in a substantial number of patients with heart failure and was associated with poor outcome. This highlights the importance of appropriate decongestion in chronic heart failure.
Prognostic value of acoustic cardiography in patients with chronic heart failure
2016, International Journal of Cardiology
Rapid risk stratification in patients with heart failure is critically important but challenging. The aim of our study is to ascertain whether acoustic cardiography can identify heart failure (HF) patients at high risk for mortality.
A total of 474 HF patients were enrolled into our study (76 ± 11 years old). Acoustic cardiographic parameters included S3 score (ie, third heart sound exists) and systolic dysfunction index (SDI) (correlated closely with left ventricular systolic dysfunction). The event-free survival curves were plotted by Kaplan–Meier method. Cox regression analysis was used to identify independent predictors for all-cause mortality.
During a mean follow-up of 484 days, 169 (35.7%) patients died and 126 (26.6%) were due to cardiac causes. After controlling for age, systolic blood pressure, hemoglobin, blood urea nitrogen, albumin, as well as ACEI and beta-blocker treatment in multivariate Cox regression analysis, SDI ≥ 5 and S3 score ≥ 4 were both independent predictors for all-cause mortality. Kaplan–Meier analysis showed that HF patients with SDI ≥ 5 or S3 score ≥ 4 had a significantly lower survival (52.2% vs. 69.2%, Log-rank χ² = 18.07, P < 0.001; 56.8% vs. 68.6%, Log-rank χ² = 10.58, P = 0.001, respectively) than those with lower SDI or S3 score.
Acoustic cardiography could serve as a cost-effective and time-efficient tool to identify HF patients at high risk for mortality who might benefit from aggressive monitoring and intervention. It may improve assessment and initial disposition decisions in HF management.
Beyond auscultation: Acoustic cardiography in clinical practice
2014, International Journal of Cardiology
Cardiac auscultation by stethoscope is widely used but limited by low sensitivity and accuracy. Phonocardiogram was developed in an attempt to provide quantitative and qualitative information of heart sounds and murmurs by transforming acoustic signal into visual wavelet. Although phonocardiogram provides objective heart sound information and holds diagnostic potentials of different heart problems, its examination procedure is time-consuming and it requires specially trained technicians to operate the device. Acoustic cardiography (AUDICOR, Inovise Medical, Inc., Portland, OR, USA) is a major recent advance in the evolution of cardiac auscultation technology. The technique is more efficient and less operator-dependent. It synchronizes cardiac auscultation with ECG recording and provides a comprehensive assessment of both mechanical and electronic function of the heart. The application of acoustic cardiography is far beyond auscultation only. It generates various parameters which have been proven to correlate with gold standards in heart failure diagnosis and ischemic heart disease detection. Its application can be extended to other diseases, including LV hypertrophy, constrictive pericarditis, sleep apnea and ventricular fibrillation. The newly developed ambulatory acoustic cardiography is potentially used in heart failure follow-up in both home and hospital setting. This review comprehensively summarizes acoustic cardiographic research, including the most recent development.

View all citing articles on Scopus

View full text

Chest

Clinicai Investigations: CardiologyThe Accuracy and Interobserver Agreement in Detecting the ‘Gallop Sounds’ by Cardiac Auscultation

Study objectives

Design

Setting

Patients

Measurements and results

Conclusion

Section snippets

Study Population

Results

Discussion

CONCLUSION

ACKNOWLEDGMENTS

Am J Med

Am J Cardiol

Am Heart J

Am J Cardiol

Am J Cardiol

Chest

Chest

Am J Cardiol

Am Heart J

Du bruit de galop

Gaz D Hop

Normal and abnormal heart sounds in cardiac diagnosis: II. Diastolic sounds

Curr Probl Cardiol

Cardiac auscultation: a cost effective diagnostic skill

Curr Probl Cardiol

Clinical significance and hemodynamic correlates of the third heart sound gallop in aortic regurgitation

Circulation

Implications of third heart sounds in patients with valvular heart disease: the Veterans Affairs Cooperative Study on Valvular Heart Disease

N Engl J Med

Implications of an audible third heart sound in evaluation of cardiac function

West J Med

Predictors of prognosis in patients awaiting heart transplantation

J Heart Lung Transplant

Clinicai Investigations: Cardiology
The Accuracy and Interobserver Agreement in Detecting the ‘Gallop Sounds’ by Cardiac Auscultation