It has been our experience that instruction in physical examination of the heart in medical schools has been deteriorating since the advent of such modern diagnostic tools as two-dimensional echocardiography and nuclear imaging. At best, the teaching has been sketchy and too superficial for the student to appreciate the pathophysiological correlates. Both invasive and the noninvasive modern technologies have contributed substantially to our knowledge and understanding of cardiac physical signs and their pathophysiological correlates. However, both students and teachers alike appear to be mesmerized by technological advances to the neglect of the age-old art, as well as the substantial body of science, of cardiac physical examination. It is also sad to see reputed journals give low priority to articles related to the clinical examination.
Our experience is substantiated by a nationwide survey of internal medicine and cardiology training programs, which concluded that the teaching and practice of cardiac auscultation received low emphasis, and perhaps other bedside diagnostic skills as well (1). The state of the problem is well reflected in the concerns expressed in previous publications (2-4), including the 2001 editorial in the American Journal of Medicine (Vol. 110, pp. 233-235), entitled "Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated?", as well as in the rebuttal, "Selections from current literature. Horton hears a Who but no murmurs—does it matter?" (5). The latter goes to the extent of suggesting that auscultation be performed only when cardiac symptoms are encountered in patients. This appears to be based on an exaggerated concern for the waste of time and resources. Implicit in this statement, if one chooses to agree with it, will be the acknowledgment of one's failure as a physician—at least, a physician caring for patients.
On the contrary, we not only share the opinion of others that cardiac auscultation is a cost-effective diagnostic skill (6), we go one step further and suggest that all aspects of cardiac physical examination are very cost effective and rewarding in many ways. A properly obtained, detailed, and complete history ofthe patient's problems and a thorough physical examination are never counterproductive to the interests of the patient.
Modern technological advances are here to stay. They should be an adjunct to the clinical examination ofthe patient, but they should not be allowed to replace the physical examination. Let's not forget that many of these tools add to the rising costs ofhealth care all over the world. A well-carried-out physical examination of the heart often provides the critical information necessary to choose the right investigative tool and to avoid the unnecessary ones. Even if one ignores the cost factor, a physician caring for a patient where advanced technologies may not be accessible (at nights and on weekends in some institutions, in rural or otherwise remote locations, during power failure and timesof natural or other disasters) should be able to assess and diagnose cardiac function and probable underlying pathology using the five senses, a stethoscope, and a sphygmo-manometer.
Mackenzie integrated the jugular venous pulse as part of the cardiovascular physical examination (7). Wood further went on to show that the precise analysis of the jugular venous pulse wave forms and the measurement of the venous pressure with reference to the sternal angle is possible at the bedside (8). Interpretation of the jugular venous pulse contour and the assessment of the pressure remains yet an occult art practiced only by experienced clinicians. Poor, ill-defined, and vague terms such as jugular venous distension are commonly used and written about even in reputed journals when cardiac physical findings are mentioned.
One of the satisfying features of medicine, aside from contributing to the clinical improvement of an ailing patient, is the intellectual excitement and satisfaction of arriving at the right conclusion through proper reasoning based on clues derived from the clinical examination of the patient. In addition, not surprisingly, some of the physical signs have also been shown, in this day and age of "evidence-based medicine," to be of prognostic importance. For instance, elevated jugular venous pressure and the third heart sound in patients with symptomatic heart failure have been shown to have independent prognostic information (9). To understand the pathophysiological correlates ofvarious cardiac signs and symptoms requires the same skills of logical thinking exhibited by any good clinician at work, and their development is one benefit of such a discipline. It is all the more important when the detection of an abnormal sound or sign can be related to other cardiac measurements (10). Improper understanding ofthe pathophysiological correlates would only result in testing the wrong hypotheses and possibly obtaining a misleading conclusion.
The purpose of The Art and Science of Cardiac Physical Examination is to arm the student of cardiology with the proper techniques and understanding of the art and science of the cardiac physical examination, to dispel myths and confusion, and to help develop skills required of any astute clinician.
This work is a culmination of long-standing experience in teaching and training physicians and physicians-to-be, as well as other students of cardiology. In fact, we have offered annually and continually refine a course of the same title at our institution in Toronto for more than 25 years. The course has always been well received and appreciated for both teaching methods and content. We utilize audiorecordings of heart sounds and murmurs, as well as videorecordings of jugular and precordial pulsations with simultaneously recorded sounds and flow signals for timing, all from actual patients collected over many years of clinical practice. Video display of the actual sounds and murmurs provides a real-time playback effect, and multiple listening devices with infrared transmission ofsounds enhances the group teaching and learning experience. Refinements in the course have been stimulated by enthusiastic and inquisitive students and trainees and aided by our own research and studies, particularly with reference to the jugular venous flows and pulsations, as well as to precordial pulsations.
The organization of the material presented in this volume, The Art and Science of Cardiac Physical Examination, warrants some elaboration. We believe that the presentation helps integrate the science with concepts useful for logical application in clinical situations. The teaching method adopted is somewhat unique and, we believe, totally original in some sections. This is most evident in chapters on jugular venous pulse or precordial pulsations, as well as in the chapter on arterial pulse. Our approach to the interpretation ofjugular venous pulsations highlights the proper method for integrating art with science at the bedside. We believe that it is different in many ways from other books describing cardiac examination. Every important topic has a summary of salient and practical points directed toward clinical assessment. These serve as a quick review as well as pointing to concepts that need reinforcement.
Many illustrations of sounds and murmurs used in the text are derived from digital display of actual audiorecordings from patients. The pathophysiology of some of the important clinical cardiac conditions is shown in flow diagrams as well as in tabular format, permitting logical review and reinforcement. References at the end ofeach chapter were carefully chosen for their now classic approaches as well as for their diverse perspectives.
A special chapter covering local and systemic manifestations ofcardiovascular disease, written by our colleague and friend Dr. Franklin B. Saksena, has been carefully illustrated and exhaustively documented from the literature.
The audio and the videorecordings of sounds and murmurs provided on the companion CD capture the jugular and the precordial pulsations from patients with the range of cardiac problems most likely to be encountered clinically. The CD is playable on any up-to-date computer, both Mac and PC. We intend that these videorecordings enhance learning both for an individual or a group of students and trainees in cardiology. They provide a real-time playback effect of heart sounds and murmurs displayed on an oscilloscope. Another unique feature in the videofiles is the presentation of simultaneous recordings of two-dimensional echocardiographic images with the audiorecordings of heart murmurs from a few patients with specific cardiac lesions.
Thus, we present The Art and Science of Cardiac Physical Examination with a firm conviction that it will be an invaluable asset in learning and teaching clinical cardiology.
Narasimhan Ranganathan, mbbs, frcp(c), facp, facc, faha
Vahe Sivaciyan, md, frcp(c)
1. Mangione S, Nieman LZ, Gracely E, Kaye D. The teaching and practice of cardiac auscultation during internal medicine and cardiology training. A nationwide survey. Ann Intern Med 1993;119:47-54.
2. Schneiderman H. Cardiac auscultation and teaching rounds: how can cardiac auscultation be resuscitated? Am J Med 2001;110:233-235.
3. Lok CE, Morgan CD, Ranganathan N. The accuracy and interobserver agreement in detecting the 'gallop sounds' by cardiac auscultation. Chest 1998;114:1283-1288.
4. Tavel ME. Cardiac auscultation.A glorious past—but does it have a future? Circulation 1996;93:1250-1253.
5. Kopes-Kerr CP. Selections from current literature. Horton hears a Who but no murmurs—does it matter? Fam Pract 2002; 19:422-425.
6. Shaver, JA. Cardiac auscultation: a cost-effective diagnostic skill. Curr Probl Cardiol 1995; 7:441530.
7. Mackenzie J. The study of the pulse. London, Pentland, 1902.
8. Wood P. Diseases of the Heart and Circulation. Philadelphia, J.B. Lippincott, 1956.
9. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001; 345:574-581.
10.. Marcus GM, Gerber IL, McKeown BH, et al. Association between phonocardiographic third and fourth heart sounds and objective measures of left ventricular function. JAMA 2005; 293:2238-2244.
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