Author + information
- M. Fuad Jan, MBBS, MD and
- A. Jamil Tajik, MD∗ ()
- ↵∗Aurora Cardiovascular Services, Aurora St. Luke's Medical Center, 2801 West Kinnickinnic River Parkway #840, Milwaukee, Wisconsin 53215
We read with interest the paper by Coffey et al. (1) reporting the results of a meta-analysis on the prevalence, incidence, and risks of aortic valve sclerosis (ASc). In this review, the authors demonstrated that ASc is common in the general population and is independently associated with an increased frequency of major adverse cardiovascular and cerebrovascular events (MACCE), as well as all-cause mortality, making it a powerful “imaging biomarker.”
The researchers analyzed studies that defined ASc as any thickening or calcification of the aortic valve—detectable by any means, such as transthoracic or transesophageal echocardiogram or computed tomography—without any significant hemodynamic effect. Although not directly addressing the results of this meta-analysis, we want to take this opportunity to address that mindful auscultation can lead one in the right direction hours, days, and even weeks before the same results can be achieved by those who rely solely on modern technology.
We have a wonderfully rich tradition of physical diagnostic signs in cardiology. However, in contemporary medicine, many have come to rely solely on clinical imaging and laboratory testing, looking at physical diagnostic signs askance and thus neglecting or even discarding knowledge acquired during clinical training. Disregard for physical diagnostic methods now pervades clinical training in the United States, and the art of physical diagnosis has been reduced to a mere vestige, with several experts contending that physical diagnosis has little to offer the modern clinician. This is particularly true of the stethoscope, which some believe should be exiled to the archives of medical history.
Without distracting the readers from the results of this meta-analysis (1), it is important to note that ASc can be identified without imaging. From the pre-revolutionary times of medicine (the revolution in academic medicine having occulted in 1968 when the intellectual approach to diagnosis and clinical examination fell into disrespect) (2), using onomatopoeia, clinicians have learned the cadence of heart murmurs, which sometimes led to rapid recognition of valvular pathology. The murmur of ASc resembles that of mild calcific aortic valve stenosis (CAVS). It is soft, early systolic, loudest in the aortic area (right second intercostal space), with radiation toward the base of the neck. It contains both high- and low-frequency components that sometimes result in a harsh or rough sound. However, other customary findings of CAVS (“pulsus parvus et tardus,” sustained apical impulse, reduced intensity of the second heart sound, and mid- to late-peaking murmur) are absent.
According to the latest American College of Cardiology and American Heart Association guidelines for valvular heart disease (3), ASc (classified as “stage A” valvular aortic stenosis) is defined on Doppler echocardiographic measurement with maximum transvalvular velocity (Vmax) of <2 m/s. In our experience, we have clearly auscultated murmurs of ASc with varying Vmax (1.4 to 2.0 m/s). It is our experience that auscultation, although poor at differentiating moderate from severe CAVS, is very reliable at detecting ASc or mild CAVS, which is later confirmed by imaging.
This meta-analysis (1) combined the results of a select group of studies (introducing selection bias) wherein ASc was diagnosed by cardiac imaging. This begs the question of “missed” diagnoses of ASc in the real-world setting, wherein individual bias of physicians prevails when they continue to argue that echocardiography should not be ordered for “innocent” systolic murmurs in patients who are asymptomatic and have otherwise normal findings on examination, for the sake of realizing cost savings. It is quite clear from the study of Coffey et al. (1) that ASc is a marker of general vascular disease, with an attendant increase in the frequency of all reported MACCE types. Indeed, by its very definition, ASc is asymptomatic and without any detectable hemodynamic effects, and yet it carries clinical importance of high magnitude. Thus, its early recognition by the stethoscope and confirmation by cardiac imaging will aid in patient satisfaction and downstream cost savings. Because the trials aimed at slowing the progression of established CAVS have been negative—the proverbial “horse is out of the barn”—detection of disease in its incipient state is required to permit more effective preventive interventions. Hence, detection of ASc by auscultation is of great importance, and the value of this bedside “auscultatory biomarker” is evident, die method ist alles.
In summary, we would like to emphasize that it is perilous to tread the path of extreme polar views wherein the warriors of physical examination (represented primarily by the stethoscope in cardiology) believe that traditional physical signs remain accurate today, whereas its adversaries advocate a coup de grace for it. Neither position, of course, is completely correct. However, we must continue to embrace modern technology because it complements rather than replaces that unique tradition of physical examination. A well-executed examination is at the heart of the physician-patient interaction—the art of medicine—and provides critical information necessary to choose the right diagnostic imaging—the science of medicine.
- American College of Cardiology Foundation
- Coffey S.,
- Cox B.,
- Williams M.
- Orient J.M.,
- Sapira J.D.
- Nishimura R.A.,
- Otto C.M.,
- Bonow R.O.,
- et al.