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Pre-operative detection of valvular heart disease by anaesthetists
W A van Klei1, C J Kalkman, M Tolsma
1University Medical Centre Utrecht, Department Peri-operative Care and Emergency Medicine, PO Box 85500, 3508 GA Utrecht, The Netherlands. w.a.vanklei@umcutrecht.nl
Insights
Pre-operative cardiac auscultation detected heart murmurs in 4.2% of patients. Murmurs in patients aged 40 or older may indicate valvular heart disease, necessitating further echocardiography.
Area of Science:
- Cardiology
- Pre-operative Medicine
- Diagnostic Accuracy
Background:
- Pre-operative evaluation is crucial for identifying potential cardiac risks.
- The diagnostic value of cardiac auscultation in detecting valvular heart disease (VHD) in non-cardiac surgery patients requires clarification.
Purpose of the Study:
- To estimate the prevalence of heart murmurs in adult non-cardiac surgery patients.
- To identify factors associated with murmur detection.
- To determine the positive predictive value of cardiac auscultation for VHD and guide its appropriate use.
Main Methods:
- Prospective study of 2522 adult patients undergoing non-cardiac surgery.
- Cardiac auscultation for murmur detection.
- Multivariable logistic regression for factor analysis.
- Echocardiography for VHD diagnosis in patients with murmurs.
Main Results:
- A cardiac murmur was detected in 4.2% of patients.
- Age and general physical impression were independently associated with murmur detection (p<0.01).
- Echocardiography revealed VHD in 70% of patients with murmurs (95% CI: 59-79%), with aortic valve abnormalities being most common (39%).
- Murmurs in patients under 40 years never indicated VHD.
Conclusions:
- Pre-operative cardiac auscultation has a moderate positive predictive value for VHD.
- Routine cardiac auscultation is recommended primarily for patients aged 40 years and older.
- Echocardiography is essential for confirming VHD in selected patients with murmurs.
Abstract:
We prospectively estimated the prevalence of heart murmurs in 2522 consecutive adult non-cardiac surgery patients during pre-operative evaluation. Factors that contribute to the detection of a heart murmur were identified, and echocardiography was used to evaluate to what extent a murmur reflected presence of valvular heart disease. A cardiac murmur was detected in 106 patients (prevalence 4.2%, 95% CI: 3.5-5.1%). Multivariable logistic regression analyses showed that age and general physical impression were independently associated with detecting a murmur (p-values < 0.01). In 83 (79%) of the patients with a murmur, an echocardiographic diagnosis was available: 39% had aortic valve abnormalities, 24% had mitral valve regurgitation, 7% had other valvular heart disease and 30% did not have any abnormality. Thus, 58 of the 83 patients had valvular heart disease (positive predictive value using routine cardiac auscultation for diagnosing VHD: 70%, 95% CI: 59-79%). Murmurs in patients younger than 40 years never reflected valvular heart disease. Pre-operative cardiac auscultation seems only reasonable in patients aged 40 years or older. Subsequent echocardiography in these selected patients is necessary.
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