Mind the gap: missed valve disease diagnosis

The stethoscope is the symbol of a physician. Every patient expects their doctor to listen carefully to their heart and believes that listening with a stethoscope will identify the presence of heart disease. Unfortunately, our patient’s trust in this part of the physical examination is misplaced. There is no doubt that Rene Laennec’s invention of the stethoscope over 200 years ago transformed medical diagnosis, and this device remains useful for amplifying internal noises from several different organs in health and disease. However, the characteristics of an audible murmur are not reliable for diagnosis, despite the long-standing fascination with cardiac auscultation and valvular heart disease as expressed so eloquently by George Eliot in Middlemarch , ‘He was not much acquainted with valves of any sort, but he knew that valvae were folding-doors, and through this crevice came a sudden light startling him with his first vivid notion of the finely adjusted mechanisms in the human frame’.1 Most heart murmurs are benign, due to normal blood flow patterns or associated with transient increases in cardiac output due to pregnancy, anaemia, fever or other causes. However, some murmurs do indicate serious underlying heart disease, and distinguishing a benign from malignant murmur, or even hearing the murmur at all, is not easy. Diagnosis of heart valve disease is most important when cardiac symptoms are present. Unfortunately, symptoms due to valve disease are non-specific with many patients attributing exertional dyspnoea, dizziness, chest discomfort or …