Association between Cardiac Auscultation and Echocardiographic Findings in Warmblood Horses

Heart murmurs are detected frequently when auscultating horses and certain murmurs can usually be linked to specific valvular regurgitations. Limited information exists about the accuracy of these broad rules in warmblood horses and the influence of grade of the regurgitation and dimensional changes on murmur intensity. This study aims to clarify the accuracy of cardiac auscultation in warmblood horses and the influence of the grade of regurgitation and dimensional changes on the loudness of the murmur. In this retrospective study, 822 warmblood horses presented for cardiac examination in a large equine referral center in northern Germany underwent a thorough cardiac auscultation. In total, 653 of these revealed one or more heart murmurs. Most common auscultatory findings were left-sided systolic murmurs (68%) or left-sided diastolic murmurs (15%). On 635 of these horses, an echocardiographic examination was performed, revealing regurgitations of the mitral valve as the most common valvular regurgitation (77%) followed by regurgitations of the aortic valve (23%). Thirty-one percent of horses that underwent echocardiographic examination displayed dimensional changes of one or more compartments of the heart, with the left atrium being most affected (21%), followed by the left ventricle (13%). The main goal of this study was to link certain auscultatory findings with results of the echocardiographic examinations, trying to determine whether auscultation and echocardiography agreed on the valve affected, as well as to find out if loudness of the murmur coincided with grade of regurgitation and presence of dimensional changes. Agreement between auscultation and cardiac ultrasound was substantial (Kappa 0.74) if one or more murmurs and regurgitations were present and almost perfect (Kappa 0.94) if only one murmur and one regurgitation were found. Auscultation was particularly well suited for detection of left-sided systolic and diastolic murmurs, with 87% of left-sided systolic murmurs being caused by a mitral valve regurgitation and 81% of left-sided diastolic murmurs originating from an aortic valve regurgitation. We found a fair agreement between the grade of regurgitation and the respective murmur. Association was particularly good between mild regurgitations and low-grade murmurs, while differentiation between moderate to severe regurgitation based upon the loudness of the murmur was less reliable. Dimensional changes were usually linked to more severe regurgitations and higher-grade murmurs. However, a direct correlation between murmur intensity and the presence or severity of dimensional changes, independent of the grade of valvular regurgitation, could not be established in this cohort of horses.

Employment of color Doppler echocardiographic video clips in a cardiac auscultation class with a cardiology patient simulator: discrepancy between students’ satisfaction and learning

Background We have provided fourth-year medical students with a three-hour cardiac auscultation class using a cardiology patient simulator since 2010. The test results of 2010-2012 revealed that as compared with aortic stenosis murmur, students correctly identified murmurs of other valvular diseases less often. We investigated whether employment of color Doppler echocardiographic video clips would improve proficiency in identifying murmurs of aortic regurgitation and mitral regurgitation, and whether students’ favorable responses to a questionnaire were associated with improved proficiency. Methods A total of 250 fourth-year medical students were divided into groups of 7-9 students in 2014 and 2015. Each group attended a three-hour cardiac auscultation class comprising a mini-lecture, facilitated training, two different auscultation tests (the second test being closer to clinical setting than the first) and a questionnaire. We provided each student with color Doppler echocardiographic videos of aortic regurgitation and mitral regurgitation using a tablet computer, which they freely referred to before and after listening to corresponding murmurs. The test results were compared with those in 2010-2012. The students had already completed the course of cardiovascular medicine, comprising lectures including those of physical examination, echocardiography, and valvular heart diseases, before participating in this auscultation training class. Results Most students indicated that the videos were useful or somewhat useful regarding aortic regurgitation (86.3%) and mitral regurgitation (85.7%). The accuracy rates were 78.4% (81.2% in 2010-2012) in aortic regurgitation and 76.0% (77.8%) in mitral regurgitation in the first test, and 83.3% (71.4%) in aortic regurgitation and 77.1% (77.6%) in mitral regurgitation in the second test, showing no significant differences as compared to 2010-2012. Overall accuracy rate of all heart sounds and murmurs in the first test and that of second/third/fourth sounds in the first and second tests were significantly lower in 2014-2015 than in 2010-2012. Conclusions Referring to color Doppler echocardiographic video clips in the way employed in the present study, which most students regarded as useful, did not improve their proficiency in identifying the two important regurgitant murmurs, revealing a discrepancy between students’ satisfaction and learning. Video clips synchronized with their corresponding murmurs may contribute toward improving students’ proficiency.

The screening of heart disease by cardiac auscultation and electrocardiography examination in pregnant women in Puskesmas Tegalrejo, Yogyakarta, Indonesia

Women adapt to pregnancy through multi-organ system physiologic changes, including cardiovascular adaptations. These changes affect those with pre-existing cardiovascular problems differently, and subsequently lead to higher probability of death caused by cardiovascular diseases during pregnancy. Therefore, detection of cardiovascular disease early in pregnancy is important to lower maternal morbidity and mortality by providing prompt and adequate management. This study aimed to evaluate and test the feasibility of integrating 12-lead electrocardiogram (ECG) examination and antenatal care (ANC) screening as a simple and effective method for early detection of heart abnormality in pregnant woman. Pregnant women were recruited in this study in any trimester who attended ANC for a routine pregnancy examination in Puskesmas Tegalrejo Yogyakarta. The subjects underwent primary screening which focused on cardiac auscultation and 12-lead ECG examinations, and those who had abnormal findings were further followed-up in secondary screening by using trans-thoracic echocardiography to confirm heart abnormality. A total of 523 pregnant women from Puskesmas Tegalrejo were included in this study. 15 (2.8%) pregnant woman were suspected to have heart abnormalities; from those, 3 (0.5%) were found with heart murmurs with abnormal ECG readings, 1 (0.19%) had heart murmurs with normal ECG results, and 11 (2.1%) had abnormal ECG readings only. The secondary screening of those patients resulted in 1 (0.19%) pregnant woman who was diagnosed with Atrial Septal Defect. Our study found that among 15 patients identified with suspected ECG abnormalities, one mother who underwent ANC was newly diagnosed with a pre-existing cardiac abnormality. Our study concluded this screening method is a simple and feasible integrated heart screening program that can be implemented widely. We hope this integrated heart screening program may benefit pregnant women who may have cardiac abnormalities to be detected as early as possible, thus reducing maternal morbidity and mortality.

The Utility of Real-Time Remote Auscultation Using an Internet-Connected Electronic Stethoscope: An Open-Label Randomized Controlled Pilot Trial

Objective: This study aimed to assess the utility of real-time remote auscultation using the cardiopulmonary simulators.Methods: In this open-label, randomized controlled trial, the researchers randomly assigned general internal medicine doctors to the real-time remote auscultation group (intervention group) or the classical auscultation group (control group). In the training session, participants listened to five different lung sounds and five cardiac sounds in a previously determined order with the correct classification. In the test session, participants had to classify the five lung sounds and five cardiac sounds in random order. For both sessions, the intervention group auscultated at a distance of 220 m, with an Internet-connected electronic stethoscope while watching the auscultation places on the computer screen. The control group performed direct auscultation using a classical stethoscope. The primary outcome was the total test score.Results: Twenty participants were included in the study. The total test scores of lung auscultation in the intervention (86%) and control (90%) groups were not significantly different (P = .54). The total test score of cardiac auscultation in the control group (94%) was superior to that in the intervention group (72%, P < .05). Valvular diseases were not misclassified as normal sounds in real-time remote cardiac auscultation. Discussion and Conclusions: The utility of real-time remote lung auscultation using an Internet-connected electronic stethoscope was comparable to that of classical lung auscultation. Classical cardiac auscultation was superior to real-time remote cardiac auscultation. However, real-time remote cardiac auscultation is useful for classifying valvular diseases and normal sounds. Trial Registration: UMIN-CTR UMIN000043153; https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000049259 The date of first registration:28/01/2021

Age of puppies at referral to veterinary cardiology specialists for murmur investigation

Background Cardiac auscultation is an important screening test at the first health examination of puppies because most clinically relevant congenital cardiac anomalies cause a loud murmur from birth. This retrospective study aimed to investigate the age at which dogs with suspected congenital cardiac anomalies were referred to a veterinary cardiology specialist for murmur investigation. A secondary aim was to establish the time interval between the visit to the cardiologist and the first available murmur documentation. The digital archive of a veterinary teaching hospital was searched for dogs with congenital cardiac anomalies and puppies with innocent murmurs during a 5-year period. Dogs had to be referred because of a murmur, and they had to undergo physical examination and echocardiography by a veterinary cardiology specialist. The health certificate section of the pet passport, and the medical records from the referring veterinarian, were reviewed to identify the date when the murmur was first documented. Results Of the 271 included dogs, 94% had a congenital cardiac anomaly and 6% had an innocent murmur. The dogs’ median age was 190 days when they were examined by the cardiologist. Only 10% of the dogs were referred by the breeder’s veterinarian, while 90% of the dogs were referred by the new owner’s veterinarian. The median age of the first available murmur documentation by a first opinion veterinary practitioner was 95 days. Conclusions Only 10% of the puppies in the present study were referred to a veterinary cardiology specialist for murmur investigation before they were sold to a new owner. Referral prior to re-homing would have been feasible if the murmur had been detected and documented by the breeder’s veterinarian, if referral was offered by the breeder’s veterinarian and the referral was accepted by the breeder.

Development of a Finger-Ring-Shaped Hybrid Smart Stethoscope for Automatic S1 and S2 Heart Sound Identification

Cardiac auscultation is one of the most popular diagnosis approaches to determine cardiovascular status based on listening to heart sounds with a stethoscope. However, heart sounds can be masked by visceral sounds such as organ movement and breathing, and a doctor’s level of experience can more seriously affect the accuracy of auscultation results. To improve the accuracy of auscultation, and to allow nonmedical staff to conduct cardiac auscultation anywhere and anytime, a hybrid-type personal smart stethoscope with an automatic heart sound analysis function is presented in this paper. The device was designed with a folding finger-ring shape that can be worn on the finger and placed on the chest to measure photoplethysmogram (PPG) signals and acquire the heart sound simultaneously. The measured heart sounds are detected as phonocardiogram (PCG) signals, and the boundaries of the heart sound variation and the peaks of the PPG signal are detected in preprocessing by an advanced Shannon entropy envelope. According to the relationship between PCG and PPG signals, an automatic heart sound analysis algorithm based on calculating the time interval between the first and second heart sounds (S1, S2) and the peak of the PPG was developed and implemented via the manufactured prototype device. The prototype device underwent accuracy and usability testing with 20 young adults, and the experimental results showed that the proposed smart stethoscope could satisfactorily collect the heart sounds and PPG signals. In addition, within the developed algorithm, the device was as accurate in start-points of heart sound detection as professional physiological signal-acquisition systems. Furthermore, the experimental results demonstrated that the device was able to identify S1 and S2 heart sounds automatically with high accuracy.

Pocket-sized Ultrasound versus Cardiac Auscultation in Diagnosing Cardiac Valve Pathologies: A Prospective Cohort Study

Background: Pocket-sized ultrasound devices are used to perform focused ultrasound studies (POCUS). We compared valve malfunction diagnosis rate by cardiac auscultation to POCUS (insonation), both conducted by medical students. Methods: A prospective cohort study was conducted among patients with and without clinically relevant valve dysfunction. Recruitment to the study group was based on the presence of at least one valve pathology of at least moderate severity identified on recent echocardiography study that was required for clinical reasons. Three final-year medical students examined the patients. Each patient underwent auscultation and a POCUS using a pocket-sized ultrasound machine. Sensitivity was defined as the percentage of patients correctly identified as having a valve disorder. Specificity was defined as correct identification of the absence of valve pathology. Results: The study included 56 patients. In 18 (32%), no valve pathology was found. Nineteen patients (34%) had at least two valvular pathologies. Sixty valve lesions were present in the whole cohort. Students' sensitivity for detecting any valve lesion was 32% and 64% for auscultation and insonation; respectively, specificity was similar. The sensitivity for diagnosing mitral regurgitation, mitral stenosis, and aortic regurgitation rose significantly by using POCUS compared to auscultation alone. When using POCUS, Students identified valve pathologies in 22 cases (39%) from the patients with at least two valve dysfunctions, and none when using auscultation. Conclusions: Final-year medical students' competency to detect valve dysfunction by performing cardiac auscultation is poor. Cardiac ultrasound-focused training significantly improved medical students' sensitivity for diagnosing a variety of valve pathologies.

Field screening of murmurs and arrhythmias in performance Argentine polo ponies

Polo is a high-intensity sport, and the horses who participate in it are known to receive a high workload on their hearts. Having cardiac disorders can impair their athletic performance or even increase the risk of collapsing during the game. In sport horses, murmurs and arrhythmias are commonly-found physiological conditions; nevertheless, many of them are related to heart diseases. Though numerous studies on murmurs and arrhythmias have been done among several kinds of horses, the information in polo horses is still limited. This study was done to investigate the prevalence of murmurs and arrhythmias in performance Argentine polo ponies by field screening with fast and convenient methods. A hundred and ninety-six performance Argentine polo ponies (162 mares and 34 geldings) with ages between 6 – 20 years old were included in this study. Cardiac auscultation with a simple stethoscope was done to detect and grade murmurs, and electrocardiography with an iPhone ECG (electrocardiogram) recorder was done at the same time to find if there were any arrhythmias. The results showed 98 ponies (50%) that probably had cardiac abnormalities, these could be divided into 61 ponies (31.1%) with only murmurs, 18 ponies (9.2%) with only arrhythmias, and 19 ponies (9.7%) with both murmurs and arrhythmias. In conclusion, murmurs and arrhythmias were found frequently by field screening of this study; cardiac examination should not be overlooked, and those ponies with murmurs and/or arrhythmias should be examined further to determine whether they were pathologic or not.