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Appreciation of Precordial Cardiac Murmur on Examination Relative to Knowledge of Valvular Heart Disease

Background:Skills associated with physical examination have continued to decline as practitioners have become increasingly reliant on advanced imaging modalities. Our study sought to determine if documentation of valvular heart disease on echocardiography resulted in an increased appreciation and documentation of precordial murmur. Method:A standardized echocardiography interpretation system was queried for all transthoracic echocardiograms (TTE) performed for purposes other than evaluation of valvular pathology, with finding of mild to severe mitral regurgitation (MR). Manual chart review compared the auscultatory identification of murmur before TTE and after TTE. Results:We examined the charts of 238 patients who underwent 609 examinations. Overall, 294 (48.3%) physical examinations occurred within a primary care location, 222 (36.5%) within a cardiology location, and 93 (15.3%) within a medicine subspecialty location. The overall identification of a murmur was documented in 203 (33.3%) examinations. The appreciation of murmur before and after TTE was 25.7% versus 23.2% (P = 0.64) for mild MR to 52.9% versus 75.8% (P = 0.09) for severe MR. There was no significant difference in pre-TTE versus post-TTE appreciation of murmur for cardiologists (52.0 vs. 56.7%, P = not significant) or primary care providers (25.3 vs. 22.1%, P = not significant). The kappa value of interobserver agreement ranged from 0.45 ± 0.16 for severe MR down to 0.02 ± 0.04 for mild MR. Conclusion:The appreciation of murmur was related to skill of the provider, subspecialization in cardiology, and severity of regurgitation, but not to the documentation of MR through TTE. Although the veracity of the providers in this study is reassuring, it is worrisome that less than 33% of patients with MR have appreciable murmur on examination.