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Heart murmurs in the general population: diagnostic value and prevalence from the Tromsø Study
Anne Herefoss Davidsen1, Stian Andersen2, Peder Andreas Halvorsen2
1Department of Community Medicine, UiT The Arctic University of Norway, Tromsø, Norway anne.h.davidsen@uit.no.
Insights
Heart auscultation by general practitioners detected murmurs in 23% of adults, showing high specificity but limited sensitivity for valvular heart disease (VHD). Echocardiography is recommended for older or high-risk individuals.
Area of Science:
- Cardiology
- Diagnostic Accuracy
- Primary Care Medicine
Background:
- Heart auscultation is a cost-effective method for detecting valvular heart disease (VHD).
- Previous studies on diagnostic accuracy had limitations such as small sample sizes and specialist-led investigations.
- There is a lack of robust population-based data on the prevalence and accuracy of auscultation for VHD.
Purpose of the Study:
- To assess the prevalence of heart murmurs in a general adult population.
- To evaluate the diagnostic accuracy of heart auscultation for identifying VHD using echocardiography as the gold standard.
Main Methods:
- A diagnostic accuracy study was conducted on 2082 participants aged ≥40 years.
- General practitioners (GPs) recorded and classified heart sounds, blinded to echocardiographic results.
- Clinically significant VHD was defined based on specific criteria for aortic stenosis, aortic regurgitation, and mitral regurgitation.
Main Results:
- Heart murmurs were detected in 23% of participants; 19% had significant VHD, but only 35.5% of those with VHD had an audible murmur.
- Systolic murmurs showed 100% sensitivity for aortic stenosis but lower sensitivity for other VHDs. Specificity for distinct murmurs was high (>94%).
- Older age (≥70), male sex, and previous myocardial infarction were associated with VHD in individuals with murmurs.
Conclusions:
- Heart auscultation by GPs has high specificity but limited sensitivity for diagnosing VHD in the general adult population.
- Auscultation is a valuable initial screening tool, particularly for aortic stenosis.
- Echocardiography should complement auscultation in older or high-risk individuals for comprehensive VHD diagnosis.
Background:
Heart auscultation is a widely used and cost-effective clinical tool for detecting valvular heart disease (VHD), particularly in primary care. However, existing evidence on its diagnostic accuracy is limited by small sample sizes, specialist-led studies and high-prevalence settings. Robust population-based data are lacking. This study aimed to assess the prevalence and diagnostic accuracy of heart murmurs for identifying VHD in a general adult population, using echocardiography as the reference standard.
Methods:
We conducted a diagnostic accuracy study within the Seventh Tromsø Study (2015-2016), involving 2082 participants aged ≥40 years (mean age 63 years). Heart sounds were recorded at four chest locations and independently classified by general practitioners (GPs) blinded to echocardiographic results. Murmurs were graded and categorised as systolic or diastolic. Clinically significant VHD was defined as ≥mild aortic stenosis (AS) or ≥moderate aortic regurgitation (AR) or mitral regurgitation (MR). We calculated sensitivity, specificity, predictive values and likelihood ratios for murmur detection.
Results:
GPs detected heart murmurs in 487 participants (23%). Significant VHD was identified in 392 participants (19%), but only 139 of them (35.5%) had an audible murmur. Systolic murmurs detected all cases of AS (sensitivity 100%, specificity 78%). Sensitivity was lower for AR (43%) and MR (29%), while specificity of distinct murmurs exceeded 94% across all VHD types. Diastolic murmurs were rare (n=9) but highly specific (>99%). Among participants with murmurs, age ≥70 years (OR 2.0, 95% CI 1.2 to 3.4), male sex (OR 3.3, 95% CI 2.0 to 5.3) and previous myocardial infarction (OR 2.3, 95% CI 1.0 to 5.2) were independently associated with VHD.
Conclusion:
In this general adult population, heart auscultation by GPs identified murmurs in nearly one in four individuals and showed high specificity but limited sensitivity for diagnosing VHD. Auscultation remains a valuable initial screening tool-especially for AS-but should be complemented by echocardiography in older or high-risk individuals.
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