Heartbeat: Improving diagnosis and management of aortic valve disease

Many adults with severe aortic stenosis (AS) present with end-stage disease, at a point where intervention is risky and might be futile, because the diagnosis is missed earlier in the disease course. Given the increasing prevalence of AS in our ageing populations and the effectiveness of transcatheter valve implantation for treatment of this highly mortal disease, accurate early diagnosis is increasingly important. Physicians and patients have faith that the stethoscope is an adequate approach to diagnosis of valve disease; indeed, the stethoscope is the symbol of a doctor. Yet, numerous studies have shown that cardiac auscultation is inaccurate for diagnosing the presence or severity of valve disease, regardless of training and experience. We find it difficult to acknowledge that the sounds generated by the heart, no matter how carefully listened to or recorded, simply are not a reliable reflection of the presence or severity of valve disease. In this issue of Heart , Gardezi and colleagues1 evaluated the accuracy of cardiac auscultation by experienced general practitioners in 251 adults over age 65 years undergoing echocardiography. Overall, 68% of patients had a new diagnosis of mild valvular heart disease (VHD) and 14% had significant VHD as defined by echocardiographic findings. The sensitivity of cardiac auscultation was very low, even for significant VHD (44%) with likelihood ratios that were not statistically significant (table 1). View this table: Table 1 Accuracy of cardiac auscultation by general practitioners and cardiologists in the diagnosis of VHD, compared with echocardiography as the reference standard (95% CIs in parentheses) Why are physicians so reluctant to admit that cardiac auscultation is no longer an adequate approach to diagnosis of valve disease? Certainly, we still should listen …