50 Years Ago in The Journal of Pediatrics: Auscultation in the Diagnosis of Intracardiac Acyanotic Congenital Heart Disease

Abstract

Kaplan S, Daoud G. J Pediatr 1961;60:746-53In an article as true today, with some minor exceptions, as it was in 1961, Kaplan and Daoud describe the auscultatory findings in atrial septal defect, ventricular septal defect, endocardial cushion defect, aortic stenosis, and pulmonic stenosis. These descriptions are based on precise correlations of cardiac catheterization pressure recordings with phonocardiograms. At the time, the emerging technical advances related to both cardiac surgery and catheterization made accurate diagnosis of congenital heart disease in youth critically important. Studies of school-based screening for congenital defects with tape recordings were conducted in the 1960s. In the 1980s, skilled auscultation was determined to have a sensitivity and specificity for distinguishing children with normal hearts from children with congenital heart defects <95% to 98%, test characteristics rarely achieved in clinical medicine today.Why then, in an era when phonocardiograms can be found on the internet, do attempts to teach auscultation “fall on deaf ears”? One certain reason is expressed by Kaplan and Daoud: “Cardiac auscultation is an art in which competence is acquired with experience and effort.” Because primary correction of congenital heart defects occurs in infancy and rheumatic heart disease (another excellent source of chronic murmurs) is no longer highly prevalent, the number of patients with pathologic murmurs is dramatically reduced, thus the ability to experience these murmurs in training or in practice has declined. A second reason is the emergence of echocardiography as an accurate diagnostic tool. Less well-appreciated is echocardiograms having much poorer specificity, because of the diagnosis of many transient or insignificant conditions. Third, as discussed by Kaplan and Daoud, auscultation is only marginally useful in chronic follow-up of patients.Although the clinical role of auscultation is diminished, it remains an extraordinarily useful, though underused, diagnostic skill. Hundreds of thousands of echocardiograms would not be done and millions of health care dollars would be saved if findings of an innocent murmur or the recognition of a variably split second heart sound were given the diagnostic prominence they deserve. If only there was a way to put auscultation on board certification exams…. Kaplan S, Daoud G. J Pediatr 1961;60:746-53 In an article as true today, with some minor exceptions, as it was in 1961, Kaplan and Daoud describe the auscultatory findings in atrial septal defect, ventricular septal defect, endocardial cushion defect, aortic stenosis, and pulmonic stenosis. These descriptions are based on precise correlations of cardiac catheterization pressure recordings with phonocardiograms. At the time, the emerging technical advances related to both cardiac surgery and catheterization made accurate diagnosis of congenital heart disease in youth critically important. Studies of school-based screening for congenital defects with tape recordings were conducted in the 1960s. In the 1980s, skilled auscultation was determined to have a sensitivity and specificity for distinguishing children with normal hearts from children with congenital heart defects <95% to 98%, test characteristics rarely achieved in clinical medicine today. Why then, in an era when phonocardiograms can be found on the internet, do attempts to teach auscultation “fall on deaf ears”? One certain reason is expressed by Kaplan and Daoud: “Cardiac auscultation is an art in which competence is acquired with experience and effort.” Because primary correction of congenital heart defects occurs in infancy and rheumatic heart disease (another excellent source of chronic murmurs) is no longer highly prevalent, the number of patients with pathologic murmurs is dramatically reduced, thus the ability to experience these murmurs in training or in practice has declined. A second reason is the emergence of echocardiography as an accurate diagnostic tool. Less well-appreciated is echocardiograms having much poorer specificity, because of the diagnosis of many transient or insignificant conditions. Third, as discussed by Kaplan and Daoud, auscultation is only marginally useful in chronic follow-up of patients. Although the clinical role of auscultation is diminished, it remains an extraordinarily useful, though underused, diagnostic skill. Hundreds of thousands of echocardiograms would not be done and millions of health care dollars would be saved if findings of an innocent murmur or the recognition of a variably split second heart sound were given the diagnostic prominence they deserve. If only there was a way to put auscultation on board certification exams….