Association Between Phonocardiographic Third and Fourth Heart Sounds and Objective Measures of Left Ventricular Function

Marcus, Gregory M.; Gerber, Ivor L.; McKeown, B.; Vessey, Joshua C.; Jordan, Mark V.; Huddleston, Michele; McCulloch, Charles E.; Foster, Elyse; Chatterjee, Kanu; Michaels, Andrew D.

doi:10.1001/jama.293.18.2238

Cited by 146 publications

(66 citation statements)

References 24 publications

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“…17 We have previously shown that the S 3 is associated with objective measures of cardiac dysfunction, including reduced ejection fraction, elevated left ventricular filling pressure, and elevated BNP. 18,19 Similarly, an audible S 4 portends an adverse prognosis after acute myocardial infarction. 20 However, the ability of medical students and physicians to detect these valuable auscultatory signs has been poor.…”

Section: Discussionmentioning

confidence: 99%

Experienced Clinicians Improve Detection of Third and Fourth Heart Sounds by Viewing Acoustic Cardiography

Michaels

Khan

Moyers

2010

Clinical Cardiology

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Background: Clinical assessment of diastolic heart sounds is challenging. Hypothesis: We sought to examine whether visual inspection of acoustic cardiographic tracings augments the accuracy of medical students' and physicians' detection of third and fourth heart sounds (S 3 , S 4 ) compared to auscultation alone. Methods: A total of 90 adults referred for left heart catheterization underwent digital precordial heart sound recordings by computerized acoustic cardiography. Two blinded, experienced readers using a consensus method determined the presence of the S 3 /S 4 on each file. There were 35 subjects from the following 5 groups participating in this study from 1 teaching institution: first-year medical students (n = 5), fourth-year medical students (n = 5), interns (n = 5), medicine residents (n = 5), cardiology fellows (n = 5), and attendings (n = 10). Using a computer module, each subject listened to the heart sounds alone and documented whether an S 3 /S 4 was present. Next, subjects listened to each recording in random order while viewing phonocardiographic tracings, and recorded S 3 /S 4 presence. Results: An S 3 was present in 21 patients (23%) and an S 4 in 31 patients (34%) by consensus overread in 90 recordings. Baseline accuracy for auscultation of S 3 /S 4 did not change with level of experience. While viewing the acoustic cardiogram, first-year medical students had minimal improvement in S 3 (2%) and S 4 (11%) accuracy. More experienced subjects improved S 3 accuracy by 8% to 18% and S 4 by 15% to 32% (P < .05). Accuracy was superior for S 3 compared to S 4 in all ausculatory groups. Conclusions: While listening to heart sound recordings, viewing acoustic cardiography increased subjects' accuracy in detecting diastolic heart sounds, particularly among more experienced subjects. There was greater improvement for S 4 compared to S 3 detection. BackgroundThe atrial and ventricular gallop was first described in the literature by Potain in 1880. 1 The low-pitched third heart sound (S 3 ) is known as the ventricular gallop, and occurs 0.12 to 0.16 seconds after the second heart sound in diastole. The S 3 is caused by the sudden deceleration of rapid diastolic filling into a distended or incompliant ventricle.2 The fourth

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Section: Discussionmentioning

confidence: 99%

Experienced Clinicians Improve Detection of Third and Fourth Heart Sounds by Viewing Acoustic Cardiography

Michaels

Khan

Moyers

2010

Clinical Cardiology

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“…With the great majority of AHF patients actually being chronic heart failure patients (and thereby known to the local health care system) and with physical signs that are easily identifiable even by junior physicians, it may come as a surprise to often hear that accuracy of HF diagnosis overall is quite poor [20,21]. In one study, the combination of clinical signs had only a 58% rate of sensitivity in detecting patients with elevated pulmonary capillary wedge pressure (PCWP) [22], whereas radiographic pulmonary congestion was absent in 53% of patients with a PCWP of 16 to 29 mmHg and in 39% of patients with a PCWP of 30 mmHg [23].…”

Section: Diagnostic Challengesmentioning

confidence: 99%

Management of acute heart failure-Is there a paradigm shift around the corner?

Pater

Severin²

2013

WJCD

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It has become increasingly apparent that the looming epidemic of heart failure calls for systematic treatment approaches tailored to the needs of individual patient phenotypes. Although chronic heart failure (CHF) therapies are continuously evolving based on the increasing understanding of the involved etiology, acute heart failure (AHF) therapies are still based on hemodynamic improvements and symptom alleviation. Guidelines on AHF management have highlighted that the currently administered AHF therapies lack evidence and have raised concerns on the safety and efficacy of some of the hitherto accepted treatment modalities. Additionally, the high mortality and morbidity rates associated with the current AHF therapies also add to the imperative need to re-visit AHF management. The last decade has witnessed a paradigm shift in the way we define and diagnose AHF. Apart from it being recognized as a distinct clinical entity, research has also led to new data on the pathophysiological changes associated with AHF. These developments along with the limited short-and long-term effects of currently used therapies may herald a paradigm shift in the way we plan and deliver management strategies to treat the pathological progression of heart failure.

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“…The ability of the acoustic cardiography system to amplify the recorded sounds and determine their frequencies makes S4 detection more reliable than it is with auscultation. Also, acoustic cardiography provides an automated interpretation of the diagnostic findings so that a high level of skill in either heart sound detection or ECG interpretation is not required [29] . The findings of the present pilot study showed that, at similar diagnostic specificities, the sensitivities of the exercise-related S4 exceeded those of exercise-related ST segment depression for detecting CAD.…”

Section: B Amentioning

confidence: 99%

Acoustic cardiography to improve detection of coronary artery disease with stress testing

Züber

Erné²

2010

WJC

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AIM:To assess if performance of 12-lead exercise tolerance testing (ETT) can be improved by simultaneous acoustic cardiography and to compare the diagnostic performances of electrocardiography (ECG) during ETT and acoustic cardiography for detection or exclusion of angiographically proven coronary artery disease (CAD). METHODS:We conducted an explorative study with retrospective data analysis using a convenience sample of consecutive patients (n = 59, mean age: 62 years) from an outpatient clinic in Switzerland, who were referred for ETT by their general practitioner on suspicion of CAD, and in whom, coronary angiography was carried out. Measurements included sensitivity, specificity, likelihood ratios and receiver operating characteristic curves. A standard, symptom-limited, 12-lead ECG exercise tolerance test was performed by independent persons with simultaneous acoustic cardiography and subsequent cardiac angiography for determination of significant CAD. RESULTS:Thirty-four of the 59 adult subjects (58%) had a final diagnosis of CAD by angiography, and in 25 subjects, CAD was excluded by angiography. Sensitivity/specificity of ST segment depression in the group was 29%/92%, whereas the most powerful acoustic cardiographic parameter was the strength of the fourth heart sound (S4), with corresponding sensitivity/specificity of 53%/92%. The disjunctive combination of the S4 and ST depression had sensitivity/specificity of 68%/84%. CONCLUSION:In this preliminary pilot study, the use of acoustic cardiography alone during ETT or disjunctively with ST depression has been shown to be a simple and convenient method for the detection of CAD, which was superior to ST depression on the standardized ECG.

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Association Between Phonocardiographic Third and Fourth Heart Sounds and Objective Measures of Left Ventricular Function

Cited by 146 publications

References 24 publications

Experienced Clinicians Improve Detection of Third and Fourth Heart Sounds by Viewing Acoustic Cardiography

Experienced Clinicians Improve Detection of Third and Fourth Heart Sounds by Viewing Acoustic Cardiography

Management of acute heart failure-Is there a paradigm shift around the corner?

Acoustic cardiography to improve detection of coronary artery disease with stress testing

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