Diagnostic accuracy of heart auscultation for detecting valve disease: a systematic review

Objective The objective of this study was to determine the diagnostic accuracy in detecting valvular heart disease (VHD) by heart auscultation, performed by medical doctors. Design/methods A systematic literature search for diagnostic studies comparing heart auscultation to echocardiography or angiography, to evaluate VHD in adults, was performed in MEDLINE (1947–November 2021) and EMBASE (1947–November 2021). Two reviewers screened all references by title and abstract, to select studies to be included. Disagreements were resolved by consensus meetings. Reference lists of included studies were also screened. The results are presented as a narrative synthesis, and risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. Main outcome measures Sensitivity, specificity and likelihood ratios (LRs). Results We found 23 articles meeting the inclusion criteria. Auscultation was compared with full echocardiography in 15 of the articles; pulsed Doppler was used as reference standard in 2 articles, while aortography and ventriculography was used in 5 articles. One article used point-of-care ultrasound. The articles were published from year 1967 to 2021. Sensitivity of auscultation ranged from 30% to 100%, and specificity ranged from 28% to 100%. LRs ranged from 1.35 to 26. Most of the included studies used cardiologists or internal medicine residents or specialists as auscultators, whereas two used general practitioners and two studied several different auscultators. Conclusion Sensitivity, specificity and LRs of auscultation varied considerably across the different studies. There is a sparsity of data from general practice, where auscultation of the heart is usually one of the main methods for detecting VHD. Based on this review, the diagnostic utility of auscultation is unclear and medical doctors should not rely too much on auscultation alone. More research is needed on how auscultation, together with other clinical findings and history, can be used to distinguish patients with VHD. PROSPERO registration number CRD42018091675.

[1]  B. Prendergast,et al.  2021 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the Task Force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). , 2022, Revista espanola de cardiologia.

[2]  J. Landefeld,et al.  Approach to the Patient with a Murmur. , 2022, The Medical clinics of North America.

[3]  G. Úrrutia,et al.  The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. , 2021, Revista espanola de cardiologia.

[4]  B. Prendergast,et al.  2021 ESC/EACTS Guidelines for the management of valvular heart disease. , 2021, European heart journal.

[5]  R. Steeds,et al.  Community-based aortic stenosis detection: clinical and echocardiographic screening during influenza vaccination , 2021, Open Heart.

[6]  E. Mayo-Wilson,et al.  The PRISMA 2020 statement: an updated guideline for reporting systematic reviews , 2021, BMJ.

[7]  Sergio Gamaza-Chulián,et al.  Physical examination in aortic stenosis. Correlation with echocardiographic and peripheral Doppler echocardiography findings , 2020 .

[8]  James D. Thomas,et al.  A Deep Learning Algorithm for Automated Cardiac Murmur Detection Via a Digital Stethoscope Platform , 2020, medRxiv.

[9]  A. Patnaik.  The Diastolic Murmurs , 2019, Indian Journal of Cardiovascular Disease in Women WINCARS.

[10]  Albinas Naudžiūnas,et al.  A Comparison of Electronic and Traditional Stethoscopes in the Heart Auscultation of Obese Patients , 2019, Medicina.

[11]  J. Chambers,et al.  Murmur clinic: validation of a new model for detecting heart valve disease , 2018, Heart.

[12]  C. Otto.  Mind the gap: missed valve disease diagnosis , 2018, Heart.

[13]  B. Prendergast,et al.  Cardiac auscultation poorly predicts the presence of valvular heart disease in asymptomatic primary care patients , 2018, Heart.

[14]  Jeroen J. Bax,et al.  Educational needs and application of guidelines in the management of patients with mitral regurgitation. A European mixed-methods study , 2018, European heart journal.

[15]  Brian D Nicholson,et al.  Overtesting and undertesting in primary care: a systematic review and meta-analysis , 2018, BMJ Open.

[16]  Alan S. Brown,et al.  ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 Appropriate Use Criteria for Multimodality Imaging in Valvular Heart Disease: A Report of the American College of Cardiology Appropriate Use Criteria Task Force, American Association for Thoracic Surgery, American Heart Association, American Society , 2018, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[17]  E. E. van der Wall.  The stethoscope: celebration or cremation after 200 years? , 2016, Netherlands Heart Journal.

[18]  J. Parras,et al.  Diagnostic Ability of Physical Examination in Aortic Valve Stenosis , 2015 .

[19]  B. Silverman.  Handheld Ultrasound is a Valuble Bedside Tool Which Can Supplement the Bedside Cardiac Exam but not Replace It. , 2015, JACC. Cardiovascular imaging.

[20]  S. Kaul,et al.  Handheld ultrasound versus physical examination in patients referred for transthoracic echocardiography for a suspected cardiac condition. , 2014, JACC. Cardiovascular imaging.

[21]  Alec Vahanian,et al.  Epidemiology of acquired valvular heart disease. , 2014, The Canadian journal of cardiology.

[22]  A. Ionescu,et al.  Appropriateness of use criteria for transthoracic echocardiography: are they relevant outside the USA? , 2014, European heart journal cardiovascular Imaging.

[23]  S. Kabir,et al.  Detection of heart disease by open access echocardiography: a retrospective analysis of general practice referrals. , 2014, The British journal of general practice : the journal of the Royal College of General Practitioners.

[24]  J. Chambers,et al.  Identifying Heart Valve Disease In Primary Care: Differences Between Practice In Germany, France And The United Kingdom , 2014 .

[25]  E. Mathiesen,et al.  Echocardiographic screening of the general population and long-term survival: a randomized clinical study. , 2013, JAMA internal medicine.

[26]  L. B. Boonman-de Winter,et al.  Benefits of an open access echocardiography service: a Dutch prospective cohort study , 2013, Netherlands Heart Journal.

[27]  M. Wright,et al.  Principles for high-quality, high-value testing , 2012, Evidence-Based Medicine.

[28]  Susan Mallett,et al.  QUADAS-2: A Revised Tool for the Quality Assessment of Diagnostic Accuracy Studies , 2011, Annals of Internal Medicine.

[29]  Warren J Manning,et al.  ACCF/ASE/AHA/ASNC/HFSA/HRS/SCAI/SCCM/SCCT/SCMR 2011 Appropriate Use Criteria for Echocardiography. A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Society of Echocardiography, American Heart Association, American Society of Nuclear Cardiology, , 2011, Journal of the American College of Cardiology.

[30]  Robert O. Bonow,et al.  Appropriate use criteria: echocardiography , 2011 .

[31]  B Bridgewater,et al.  Valvular heart disease: the next cardiac epidemic , 2010, Heart.

[32]  Steven McGee,et al.  Etiology and diagnosis of systolic murmurs in adults. , 2010, The American journal of medicine.

[33]  C. Hassager,et al.  Heart Murmur and N-Terminal Pro-Brain Natriuretic Peptide as Predictors of Death in 2977 Consecutive Hospitalized Patients , 2008, The American journal of the medical sciences.

[34]  E. Etchells,et al.  A bedside clinical prediction rule for detecting moderate or severe aortic stenosis , 1998, Journal of General Internal Medicine.

[35]  E. Kinney.  Causes of false-negative auscultation of regurgitant lesions , 1988, Journal of General Internal Medicine.

[36]  J. Gardin,et al.  Burden of valvular heart diseases: a population-based study , 2006, The Lancet.

[37]  A. Hrõbjartsson,et al.  Effect of teaching and type of stethoscope on cardiac auscultatory performance. , 2006, American heart journal.

[38]  T. Naqvi,et al.  Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. , 2005, The American journal of cardiology.

[39]  E. Shry,et al.  Appreciation of Precordial Cardiac Murmur on Examination Relative to Knowledge of Valvular Heart Disease , 2005, Cardiology in review.

[40]  Serge Reichlin,et al.  Initial clinical evaluation of cardiac systolic murmurs in the ED by noncardiologists. , 2004, The American journal of emergency medicine.

[41]  Philippe Ravaud,et al.  A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease. , 2003, European heart journal.

[42]  H. Brunner-La Rocca,et al.  Echocardiography in the evaluation of systolic murmurs of unknown cause. , 2000, The American journal of medicine.

[43]  R. Gibbons,et al.  ACC/AHA Guidelines for the Management of Patients With Valvular Heart Disease. Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). , 1998, The Journal of heart valve disease.

[44]  M. Crawford,et al.  Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects. , 1996, The American journal of cardiology.

[45]  J A Shaver,et al.  Cardiac auscultation: a cost-effective diagnostic skill. , 1995, Current problems in cardiology.

[46]  G. Guyatt,et al.  Users' Guides to the Medical Literature: III. How to Use an Article About a Diagnostic Test: B. What Are the Results and Will They Help Me In Caring for My Patients? , 1994 .

[47]  G. Guyatt,et al.  Users' guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. , 1994, JAMA.

[48]  P. Rahko.  Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography. , 1989, Annals of internal medicine.

[49]  M. Cerqueira,et al.  Left ventricular function in ischemic mitral regurgitation--a precatheterization assessment. , 1988, American heart journal.

[50]  A. DeMaria,et al.  Detection of aortic insufficiency by standard echocardiography, pulsed Doppler echocardiography, and auscultation. A comparison of accuracies. , 1986, Annals of internal medicine.

[51]  D. Meyers,et al.  Duplex pulsed Doppler echocardiography in mitral regurgitation , 1986, Journal of clinical ultrasound : JCU.

[52]  D. Meyers,et al.  Auscultation, M-mode echocardiography and pulsed Doppler echocardiography compared with angiography for diagnosis of chronic aortic regurgitation. , 1985, The American journal of cardiology.

[53]  D. Morris.  Valve disease. , 1979, Medical times.

[54]  J. Ross,et al.  Preoperative assessment of aortic regurgitation in patients with mitral valve disease. , 1967, The American journal of cardiology.

[55]  S. A. Levine.  AUSCULTATION OF THE HEART* , 1948, The Heart bulletin.

[56]  A. R. Freeman,et al.  The Clinical Significance of the Systolic Murmur: A Study of 1000 Consecutive Non-Cardiac Cases , 1933 .