Pediatric cardiologists can accurately use physical examination to identify pathologic murmurs in neonates

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Beland MJ. Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr 2009;154:50-4.

Back to Article Outline

Question 

Among neonates with suspected congenital heart disease (CHD), how accurate is the clinical assessment as performed by pediatric cardiologists?

Back to Article Outline

Design 

Prospective cohort.

Back to Article Outline

Setting 

Montreal Children's Hospital, Canada.

Back to Article Outline

Participants 

Neonates (n = 201, median age 12 days [range 2-31 days]) referred for outpatient evaluation of a heart murmur.

Back to Article Outline

Intervention 

After a clinical evaluation, the cardiologist documented whether the murmur was “likely innocent” or “likely pathologic.” The cardiologist repeated his/her assessment after electrocardiography was performed.

Back to Article Outline

Outcomes 

Sensitivity and specificity of cardiologist evaluation, with echocardiography used as the gold standard.

Back to Article Outline

Main Results 

The prevalence of CHD in this population was 56% (113 of 201). Clinical assessment alone identified patients with CHD with a sensitivity of 80.5% (95% CI, 73.2-87.8), specificity of 90.9% (95% CI, 84.9-96.9), positive likelihood ratio of 8.8 (95% CI, 4.8-28.3), and negative likelihood ratio of 0.21 (95% CI, 0.13-0.32). The addition of an electrocardiogram did not improve these test characteristics. Features that were predictive of CHD were murmur quality (P < .0001), location (P = .02), and timing (P = .04). No patients requiring catheter or surgical intervention were missed by clinical assessment.

Back to Article Outline

Conclusions 

The prevalence of CHD in this referral population was high. Clinical assessment detected all complex CHD, although some simple lesions were missed. Murmur quality, location, and timing were predictive of CHD.

Back to Article Outline

Commentary 

Given the current economic climate and the emphasis placed by the Obama administration on reform of the United States health care system on the basis of reigning in costs, this study is timely. Ninety-one of the 113 infants with CHD were accurately identified. Of the 22 false-negative results, 15 were believed to have peripheral pulmonic stenosis (PPS), and only 7 were classified as innocent murmurs. None of the misdiagnosed patients had significant lesions that would require early intervention. Only 8 of the 201 infants evaluated were thought to have CHD where none existed. Interestingly, the years of physician practice did not impact diagnostic accuracy, nor did having an ECG before the examination. This study extends previous published observations to a group of particularly difficult patients. The neonatal cardiac examination is often quite challenging because of heart and respiratory rate, movement, and the soft quality of many murmurs. The data presented here underscore the value of having an exam performed by a trained subspecialist, particularly when the murmur is present in an otherwise healthy-appearing neonate, before obtaining expensive diagnostic testing. On the basis of the confidence of the practitioner in their assessment, one could also argue that conservative observation without performing an echocardiogram would be an appropriate course of action in several cases. In an era of increasing focus on cost containment, the role of the subspecialist remains very important in reducing unnecessary expensive testing. This role is even more relevant when considering the increasing complexity of pediatrics and the reduction of the time a general pediatrician spends learning basic cardiology skills during their training.