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• Predictive value of cardiac auscultation for the assessment of valvular heart disease
  Lucia Baris, Boudewijn Klop, Jaap van Waning and Ewout-Jan van den Bos
  Published on: 8 February 2019

• Published on: 8 February 2019

  Predictive value of cardiac auscultation for the assessment of valvular heart disease

  • Lucia Baris, Research fellow Erasmus MC
  • Other Contributors:
    • Boudewijn Klop, Cardiology resident
    • Jaap van Waning, Cardiology resident
    • Ewout-Jan van den Bos, Cardiologist

  Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
  However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.

  References
  1. Gardezi S...

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  Gardezi and colleagues (1) report on the limited accuracy for detection of valvular heart disease (VHD) by cardiac auscultation in asymptomatic patients in primary care. VHD was categorized as either mild or significant and cardiac auscultation was dichotomized in either a present or absent murmur. The authors propose a low sensitivity and modest specificity of cardiac auscultation by general practitioners and by cardiologists to assess VHD.
  However, the authors underestimated the specificity and positive predictive value of cardiac auscultation for the assessment of VHD. Patients with a cardiac murmur in whom, by transthoracic echocardiography, mild VHD was detected were included in the ‘negative’ group for assessing significant VHD and more importantly, vice versa. By doing so, many murmurs are classified as false-positive although VHD was present, either mild or significant. We believe that the “true negative” group only includes those patients without any VHD on echocardiography. This would increase the specificity of cardiac auscultation by general practitioners from 67% to 76% and from 81% to 93% for cardiologists, which results in much higher positive predictive values for significant VHD. While it does not change the reported low sensitivity of cardiac auscultation, which remains rather unsatisfactory, this perspective would make the conclusions of this paper at least a little less detrimental to the good old stethoscope.

  References
  1. Gardezi SKM, Myerson SG, Chambers J, Coffey S, d'Arcy J, Hobbs FDR, et al. Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients. Heart. 2018;104(22):1832-5.

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  Conflict of Interest:
  None declared.

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