Responses

PDF

Original research article
Murmur clinic: validation of a new model for detecting heart valve disease
Compose Response

Plain text

  • No HTML tags allowed.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Lines and paragraphs break automatically.
Author Information
First or given name, e.g. 'Peter'.
Your last, or family, name, e.g. 'MacMoody'.
Your email address, e.g. higgs-boson@gmail.com
Your role and/or occupation, e.g. 'Orthopedic Surgeon'.
Your organization or institution (if applicable), e.g. 'Royal Free Hospital'.
Statement of Competing Interests

PLEASE NOTE:

  • Responses are moderated before posting and publication is at the absolute discretion of BMJ, however they are not peer-reviewed
  • Once published, you will not have the right to remove or edit your response. Removal or editing of responses is at BMJ's absolute discretion
  • If patients could recognise themselves, or anyone else could recognise a patient from your description, please obtain the patient's written consent to publication and send them to the editorial office before submitting your response [Patient consent forms]
  • By submitting this response you are agreeing to our full [Response terms and requirements]

Vertical Tabs

Other responses

Jump to comment:

  • Published on:
    misattribution of the source of an aortic systolic murmur

    One of the potential benefits of point of care ultrasonography is that it might mitigate the risk of misattribution of the source of an aortic systolic murmur elicited by auscultation in patients who have clinically significant aortic stenosis(AS). When the murmur of AS is loudest at the cardiac apex there is a risk that it might be misattributed to mitral regurgitation(MR), especially in the presence of atrial fibrillation(AF)(1), given the fact that it is MR, rather than AS, which is a commoner cause of AF. The corollary is to attribute the murmur to severe anaemia(2)(when that murmur is elicited(by auscultation) in a patient who has iron deficiency anaemia attributable to chronic blood loss associated with Heyde's syndrome(3).
    Severe AS-associated hypertension(with systolic blood pressure up to nearly 200 mm Hg)(4) can also dominate clinical decision-making to the exclusion of a focus on AS. Diagnostic confusion is compounded by the fact that hypertension, in its own right, can be the underlying cause of a systolic murmur, sometimes even in the absence of post mortem evidence of calcification at the bases of the cups "nor any other abnormality"(5). The caveat is that, exceptionally, the association of hypertension and a systolic murmur(with suprasternal radiation) may be a late presentation of coarctation of the aorta(6). In the latter example echocardiography revealed a normal looking non-stenotic valve with mild regurgitation(6).
    Refer...

    Show More
    Conflict of Interest:
    None declared.
  • Published on:
    a role for point of care scanning in the emergency context

    Point of care scanning for heart murmurs should be made available, not only in heart murmur clinics, but also in the emergency context so as to expedite timely identification of murmurs attributable to cardiovascular disorders that require urgent interventional management . The following are some examples:-
    (i) Acute aortic or mitral valvular regurgitation. The former is typically attributable either to aortic dissection or to Infective endocarditis(IE), and the latter is typically attributable to papillary muscle rupture. In both contexts the murmur is typically soft or even clinically inaudible(1)(2), but timely surgical intervention is life-saving.
    (ii) Ischaemic cerebral infarct attributable to IE-related septic embolus. In some of these patients no murmur can be clinically detected(3). Nevertheless, identification of a murmur would raise the index of suspicion for IE.. If further evidence is obtained to support the diagnosis of IE, thrombolyis would be avoided because of the associated risk of haemorrhagic transformation of the septic crebral infract(3), and thrombectomy would be the safer strategy(4).
    References
    (1) Stout KK., Verrier ED
    Acute valvular regurgitation
    Circulation 2009;119:3232-3241
    (2) Hamirani YS., Dietl CA., Voyles V et al
    Acute aortic regurgitation
    Circulation 2012;126:1121-1126
    (3) Walker KA., Sampson JB., Skalabrin EJ., Majersik JJ
    Clinical characteristics and thrombolytic outc...

    Show More
    Conflict of Interest:
    None declared.