136 Gp auscultation for diagnosing valvular heart disease

Abstract

recorded were age, gender, number of blood cultures taken and the final diagnosis stated in the discharge summary. Results 112 episodes were identified in 72 females and 40 males (mean age 40 years, range<1-97). The mean number of blood cultures was 2.57 (range1-12) and 85 (76%) patients had only one blood culture taken. The infections recorded are shown in Figure 1. The cause of the bacteraemia was not stated in 33 (29.5%) cases. Community acquired pneumonia (n=31) was the commonest infection, followed by catheterrelated bloodstream infection (n=8) and then IE and soft-tissue infection (both n=7). Details of the streptococcal species are shown in Table 1 and the results have been divided using age less than or greater than 18 years. 50% of bacteraemias were caused by oral streptococci. IE was confirmed in only 7 (1.2%).Abstract 135 Figure 1 Conclusions Among all streptococcal bacteraemias, IE is an uncommon cause but is more common when considering oral streptococci in adults (12.5%) compared with those aged less than 18 years (0%). Oral streptococci remain an important cause of IE particularly in adults. This diagnosis should be considered even if only one blood culture is taken and is positive. The high rate of single blood culture sampling (76%) may be an unintended consequence of the Surviving Sepsis campaign and the drive to initiating empirical antibiotic therapy earlier. Under these circumstances the reliability of the Duke criteria will be reduced. Ideally, patients at increased risk of IE require multiple blood cultures if they have a significant pyrexial illness in order to determine if a sustained bacteraemia is present. Introduction Cardiac auscultation is an important clinical skill used by physicians in assessing and diagnosing valvular heart disease (VHD). The widespread use of echocardiography in the last three decades has coincided with a perceived decline in the utility of auscultation, particularly by general physicians. The ability of generalists to identify VHD in an unselected population has not been well characterised, so we aimed to determine the accuracy of auscultation in primary care for diagnosing VHD. Methods 251 participants aged 65 and over who were participating in the OxValve population cohort study were included. They were recruited from two participating GP surgeries and had no previous diagnosis of VHD. The participants underwent cardiac auscultation during the OxValve study visit by two experienced General Practitioners (GPs), neither of whom had a specialist interest in cardiology. A 5-point Likert scale was used to rate the ability to hear heart sounds (1=not at all; 5=perfectly) in addition to the presence or absence of a murmur, type of murmur and the ability to make a diagnosis based upon the auscultation findings. This was compared to transthoracic echocardiography performed at the same visit, but GPs were blind to the echocardiogram result, which was performed after auscultation. VHD was categorised as mild (either mild regurgitation [excluding trace/physiological] or...

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“…AS could be detected in approximately half of those patients (8 of 18 patients; 44.4%), confirming the low sensitivity and specificity of auscultation with regard to detecting VHD. 23 Nevertheless, our data indicate a significant opportunity to identify patients with AS based on cardiac auscultation, as a positive auscultation finding would have a 20% likelihood of identifying a patient with mild or moderate AS (30 patients with a murmur, resulting in 13 referrals with a 44.5% likelihood of AS detection). In the majority of subjects where either a referral decision was taken or where subjects were supposed to be further reviewed within practice, a murmur was detected (15 of 20 patients), indicating that auscultation results were most likely the main driver for a referral decision.…”

Algorithm for Predicting Valvular Heart Disease from Heart Sounds in an Unselected Cohort

“…Myerson et al found similar results in their 2017 study of unselected and asymptomatic participants aged 65 or older with no previous VHD diagnosis, where GPs identified significant VHD (moderate to severe regurgitation or at least mild stenosis) with AUC of only 0.5635 .Clinical ImplicationsThe fact that AS was detected reliably in a cohort representative of the general population has promising health care implications. AS, whether it is asymptomatic or not, is associated with poor prognosis when left untreated, and presence of symptoms are not reliable indicators of disease-severity.…”

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“…2a). Despite its limitations with regards to sensitivity and specificity to diagnose valvular heart disease, chest auscultation represents an important diagnostic measure to support the diagnosis of suspected aortic valve stenosis [16,17]. Recently published data confirm a low rate of auscultation in Europe and therefore suggest that a significant proportion of patients with aortic valve stenosis may not be referred for echocardiography [11,18,19].…”