Experienced Clinicians Improve Detection of Third and Fourth Heart Sounds by Viewing Acoustic Cardiography

Abstract

Background: Clinical assessment of diastolic heart sounds is challenging. Hypothesis: We sought to examine whether visual inspection of acoustic cardiographic tracings augments the accuracy of medical students' and physicians' detection of third and fourth heart sounds (S 3 , S 4 ) compared to auscultation alone. Methods: A total of 90 adults referred for left heart catheterization underwent digital precordial heart sound recordings by computerized acoustic cardiography. Two blinded, experienced readers using a consensus method determined the presence of the S 3 /S 4 on each file. There were 35 subjects from the following 5 groups participating in this study from 1 teaching institution: first-year medical students (n = 5), fourth-year medical students (n = 5), interns (n = 5), medicine residents (n = 5), cardiology fellows (n = 5), and attendings (n = 10). Using a computer module, each subject listened to the heart sounds alone and documented whether an S 3 /S 4 was present. Next, subjects listened to each recording in random order while viewing phonocardiographic tracings, and recorded S 3 /S 4 presence. Results: An S 3 was present in 21 patients (23%) and an S 4 in 31 patients (34%) by consensus overread in 90 recordings. Baseline accuracy for auscultation of S 3 /S 4 did not change with level of experience. While viewing the acoustic cardiogram, first-year medical students had minimal improvement in S 3 (2%) and S 4 (11%) accuracy. More experienced subjects improved S 3 accuracy by 8% to 18% and S 4 by 15% to 32% (P < .05). Accuracy was superior for S 3 compared to S 4 in all ausculatory groups. Conclusions: While listening to heart sound recordings, viewing acoustic cardiography increased subjects' accuracy in detecting diastolic heart sounds, particularly among more experienced subjects. There was greater improvement for S 4 compared to S 3 detection. BackgroundThe atrial and ventricular gallop was first described in the literature by Potain in 1880. 1 The low-pitched third heart sound (S 3 ) is known as the ventricular gallop, and occurs 0.12 to 0.16 seconds after the second heart sound in diastole. The S 3 is caused by the sudden deceleration of rapid diastolic filling into a distended or incompliant ventricle.2 The fourth

Do you hear what you see? Utilizing phonocardiography to enhance proficiency in cardiac auscultation

“…Our study is the first to compare the use of audioonly cases to audio with phonocardiogram videos for the purposes of learning cardiac auscultation skills. Michaels and colleagues demonstrated improved performance identifying gallops when clinicians used phonocardiograms concurrently with audio recordings of heart sounds compared to their first-pass attempt using audio alone [9]. Similarly, longitudinal curricula using digital phonocardiography to train cardiac auscultation in medical students [8], residents, and experienced clinicians [10] demonstrated interval improvement in these clinicians' diagnostic accuracy.…”

“…Phonocardiograms are visual representations of Original Article heart sounds that have been used for diagnosis [4,5] and have been advanced as a curricular approach to teach students the typical shape, timing, and duration of heart murmurs that correspond to specific disease processes [6,7]. Initial investigations using phonocardiography as a curricular tool showed improvements in students' ability to distinguish innocent from abnormal heart murmurs [8] and resident and attending physicians' ability to recognize diastolic gallops (e.g., S3 and S4) [9] and to accurately identify underlying diagnoses [10].…”

The utility of phonocardiograms in real-time remote cardiac auscultation using an internet-connected electronic stethoscope: Open-label randomized controlled pilot trial

“…From another previous work, 25 a phonocardiogram improved the diagnostic accuracy for detecting S3 in the classical auscultation by the experienced physicians (8–18%, P < .05). In this study the phonocardiogram improved the diagnostic accuracy for detecting S3 in the real-time remote auscultation by more than 20%, albeit statistically insignificant ( P = .14).…”

Evaluation of a digitally enhanced cardiac auscultation learning method: a controlled study

“…It offers the possibility to record cardiopulmonary sounds of real patients that can be shared with one or more students or used as a teaching tool for other learning methods based on listening to audio files [37]. Moreover, the use of an electronic stethoscope instead of a traditional stethoscope during clinical internships can improve learners' skills (up to 51.2 %) [38][39][40].…”