Dr Richard Bogle PhD FRCP FESC FACC DHMSA
Consultant Cardiologist
  • Home
  • NHS Practice
    • NHS Practice
    • St Helier Hospital
    • Epsom Cardiac Day Unit
    • St George's Hospital Radial Lounge
    • Echocardiography
  • Biography
    • Qualifications
    • About me >
      • Curriculum vitae
    • Appraisal and Revalidation
    • BCIS Angioplasty Audit
    • Publications
    • Recent abstracts
    • Research
    • Charitable activity
  • The Heart
    • Cardiac Investigations >
      • AliveCor ECG monitor
      • Guide to investigations for suspected angina
      • CT calcium scoring
      • Electrocardiogram (ECG)
      • Exercise treadmill test
      • Echocardiogram
      • Valve disease
      • Coronary Angiography
      • Pressure Wire Studies
      • Intra-vascular Ultrasound
    • Arrhythmias >
      • Atrial fibrillation >
        • Stroke Risk in AF
        • New Oral Anticoagulants
        • Presentations on AF
      • Atrial flutter
      • Pre-excitation syndromes
      • Ventricular ectopic beats
      • Ventricular arrhythmias
      • Pacemaker
      • DC Cardioversion
    • Cardiomyopathy
    • Coronary heart disease >
      • Cardiac syndrome X
      • Coronary Angioplasty
      • Coronary bypass surgery
    • Dizziness and blackouts
    • Fitness to fly
    • Fitness to drive
    • Heart Failure
    • Hypertension >
      • Patients guide to blood pressure medication
      • Home blood pressure monitors
      • Hypertension diet
      • Laragh's method
      • Renal sympathetic ablation for hypertension
      • Conn's Syndrome
    • Heart Screening >
      • Sports Cardiology
      • Cardiovascular Disease Risk
    • Medications >
      • Glyceryl trinitrate
    • Patient information leaflets
  • News and Links
  • Miscellany
    • History of Medicine
    • History of Coronary Angiography and Angioplasty
    • Stamps in Cardiology
    • A History of Medicine in 100 Objects
    • BSE Acceditation Course Introduction
    • BSE Acceditation Course Physics
    • BSE Acceditation Course Anatomy and Function
    • BSE Acceditation Course Mitral
    • BSE Acceditation Course Aortic
    • BSE Acceditation Course Congenital
    • BSE Acceditation Course Pericardium
  • Blog
  • RACPC Form
  • Cardiology Teaching St Helier Hospital

Requiem for cardiac auscultation?

15/11/2014

0 Comments

 
Picture
We frequently have medical students attached to our service. They spend two weeks trying to develop skills in clinical examination of the heart. On rounds we talk about the x and y descents of the jugular venous pulse, reverse splitting of the second heart sounds and the sound of a tumour plop in a patient with an left atrial myxoma. Time is spent trying to identify murmurs, assess their haemodynamic significance  and find the physical signs of cardiac disease. But clinical cardiac examination comes from a bygone era originated before the advent of modern imaging techniques. Would the doyenne of British cardiology, Dr Paul Wood, have spent so much time perfecting the art of cardiac examination with the stethoscope if he had been able to get an echocardiogram instead. It might be a neat party trick to diagnose first degree heart block  from the intensity of the first heart sound but now we make this diagnosis accurately and reliably from the ECG.

What is the value of the stethoscope in modern cardiac assessment and are we entering an era when cardiac examination is simply not relevant to good patient care?  Universal availability of echocardiography and the ability of most younger cardiologists to perform bedside screening echo with a handheld machines leads me to wonder what the stethoscope adds to the assessment of the heart in 2014.

A recent paper in the American Journal of Cardiology looked at some of these questions by interviewing doctors and cardiac patients about their attitudes to cardiac examination.  123 patients were interviewed and 74% of them expected to undress from the waist up when they visited a cardiologist and 50% expected to undress every time and be examined. Importantly 98% patients felt better after they had been examined.  They surveyed 135 health care professionals. Nearly half of practitioners rarely or never undressed the patient to examine the heart and 80% rarely or never examined them in the left lateral decubitus position. Most cardiologists however routinely palpated the apex, carotid artery, radial artery, and the peripheral pulses and listed to the heart.

Why do we examine the heart? Patients expect it and importantly feel better after it but if the valve of the cardiac examination is to diagnose illness can it be replaced by technology such as echocardiography and ECG. Physical examination might be more cost effective than echocardiography but most cardiologists will request this tests anyway and we shouldn't forget that the cost of medical care is also the cost of error, or uncertainty which are both greater if you rely on physical examination alone.

Perhaps the physical examination is essential as part of the enhancing the doctor-patient relationship. Sometimes patients complain that they weren't assessed thoroughly "The doctor didn't even bother to examine me".  Experienced bedside evaluation allows efficient gathering of diagnostic information there and then at the clinic visit and its ritualistic features deepen engagement with the patient.  The waning of bedside skills may also lead to delay and error in diagnosis and subject patients to unnecessary testing.

Is physical examination accurate? Cardiologists examining 100 consecutive patients with systolic murmurs concluded that the physical exam could differentiate a functional murmur from an organic murmur. If the examination included inspection, palpation and auscultation in the context of symptoms and history most structural cardiac abnormalities were accurately detected or in the differential diagnosis. When a murmur was determined to be benign usually the echocardiographic results were normal.

My impression is that doctors have less confidence in the accuracy of the bedside cardiac examination and as it takes less than 30 seconds to order an echocardiogram it is obvious why the cardiac exam is abbreviated, demeaned and discredited however I suspect it will continue to be used as patients expect it and feel better for it.

0 Comments

    RSS Feed

    Picture

    Dr Richard Bogle

    The opinions expressed in this blog are strictly those of the author and should not be construed as the opinion or policy of my employers nor recommendations for your care or anyone else's. Always seek professional guidance instead.

    Archives

    November 2019
    March 2016
    February 2016
    May 2015
    April 2015
    March 2015
    February 2015
    January 2015
    December 2014
    November 2014
    October 2014
    September 2014
    August 2014
    July 2014
    June 2014
    May 2014
    April 2014
    March 2014
    February 2014
    January 2014
    November 2013
    October 2013
    August 2013
    July 2013
    June 2013
    May 2013
    April 2013
    March 2013
    February 2013
    January 2013

    Categories

    All
    Ablation
    Acute Coronary Syndromes
    Acute Coronary Syndromes
    Adherence
    Angioplasty
    Anticoagulants
    Arrhythmia
    Association
    Atherosclerosis
    Atrial Fibrillation
    Auenbrugger
    Bergamot
    Brugada
    Calcium Channel Blockers
    Cancer
    Cardiovascular Risk
    Chest Pain
    Cholesterol
    Cleveland Street
    Clinical Examination
    Colchicine
    Compliance
    Concordance
    Congenital Heart Disease
    Coronary Artery Disease
    Coronary Artery Disease
    C-reactive Protein
    Decision Aids
    Diet
    Ectopics
    Eggs
    Ezetimibe
    Frailty
    Frank's Sign
    Guidelines
    Hawthorne Effect
    Heart Failure
    History Of Medicine
    Hypertension
    ICD
    Internet
    Interventional Cardiology
    Joseph Rogers
    Lipids
    Malaria
    Marathon
    Medicines
    Nice Guidelines
    Nitrovasodilators
    NOAC
    Nudge
    Nutrition
    OCT
    Palpitations
    Pharmacy
    Pressure Wire
    Proteus
    Salt
    Smoking
    Spironolactone
    Statins
    Statistics
    Stent
    Stress
    Stroke
    Syndrome X
    Takotsubo
    Valve-disease
    Vein Grafts
    Ventricular Ectopics
    VF/VT
    Warfarin
    Weekend Working
    Workhouse

    View my profile on LinkedIn
Return to home page

Privacy Statement
Disclaimer
© Dr Richard Bogle 2020
patient feedback
Photo used under Creative Commons from peddhapati