Clinical question: To quantify the extent to which undetectable heart sounds occur in hospitalized patients who are undergoing transthoracic echocardiography and evaluate the association between patient factors and missed valvular heart disease diagnosis.
Background: Clinicians using cardiac auscultation achieve approximately a 40-70% sensitivity in detecting valvular heart disease when compared with transthoracic echocardiography. This is irrespective of the clinician’s skill set, clinician’s experience, and sophistication of the clinician’s stethoscope. However, it is uncertain what actual percentage of auscultated heart sounds are missed and if certain patient factors contribute to a missed diagnosis.
Study design: Cross-sectional study
Setting: University of Michigan Hospital
Synopsis: The study included 200 hospitalized patients (74 female) with 14% identifying as Black. The median age of 65 years (interquartile range, 55-73 years) and median body mass index (BMI) was 29 (interquartile range, 25-34). Congestive heart failure and chronic obstructive pulmonary disease were present in 74% and 50% of patients, respectively. Heart sounds were clinically undetectable at the aortic location in 15% of patients and at the mitral valve location in 65% of patients. Male gender was associated with undetectable aortic heart sounds. Female gender, especially those with a higher BMI, was associated with undetectable mitral sounds. Heart sounds were undetectable in 0% of patients with aortic stenosis, 17% with aortic regurgitation, 50% with mitral stenosis, and 62% with mitral regurgitation. Limitations of the study included the absence of a standard criterion for undetectable heart sounds, a limited convenience sample, and the lack of physiologic maneuvers performed during auscultation. The results of this study confirmed that the role of physical examination in patient care is complex, with limitations in clinical practice, and that the use of transthoracic echocardiography is superior in the detection of valvular heart disease.
Bottom Line: Transthoracic echocardiography has a better yield at determining the presence and extent of valvular heart disease among hospitalized patients in comparison to cardiac auscultation.
Citation: Jariwala N, et al. Clinically undetectable heart sounds in hospitalized patients undergoing echocardiography. JAMA Intern Med. 2022;182(1):86-87. doi:10.1001/jamainternmed.2021.6594.
Ms. Nowak is a physician assistant and registered and licensed dietitian at Atrium Health Wake Forest Baptist, Winston-Salem, N.C