Anesthesiology and Pain Medicine

Published by: Kowsar

The Preoperative Patient With a Systolic Murmur

Brian Cowie 1 , *
Author Information
1 Department of Anaesthesia, St. Vincent’s Hospital, Melbourne, Australia
Article information
  • Anesthesiology and Pain Medicine: December 01, 2015, 5 (6); e32105
  • Published Online: December 5, 2015
  • Article Type: Review Article
  • Received: August 4, 2015
  • Accepted: September 4, 2015
  • DOI: 10.5812/aapm.32105

To Cite: Cowie B. The Preoperative Patient With a Systolic Murmur, Anesth Pain Med. 2015 ; 5(6):e32105. doi: 10.5812/aapm.32105.

Abstract
Copyright © 2015, Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM). This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/) which permits copy and redistribute the material just in noncommercial usages, provided the original work is properly cited.
1. Context
2. Evidence Aquisition
3. Results
4. Conclusions
References
  • 1. Roelandt JR. The decline of our physical examination skills: is echocardiography to blame? Eur Heart J Cardiovasc Imaging. 2014; 15(3): 249-52[DOI][PubMed]
  • 2. Scherer JR. Before cardiac MRI: Rene Laennec (1781-1826) and the invention of the stethoscope. Cardiol J. 2007; 14(5): 518-9[PubMed]
  • 3. McGee S. Etiology and diagnosis of systolic murmurs in adults. Am J Med. 2010; 123(10): 913-921 e1[DOI][PubMed]
  • 4. Botker MT, Vang ML, Grofte T, Sloth E, Frederiksen CA. Routine pre-operative focused ultrasonography by anesthesiologists in patients undergoing urgent surgical procedures. Acta Anaesthesiol Scand. 2014; 58(7): 807-14[DOI][PubMed]
  • 5. Bustam A, Noor Azhar M, Singh Veriah R, Arumugam K, Loch A. Performance of emergency physicians in point-of-care echocardiography following limited training. Emerg Med J. 2014; 31(5): 369-73[DOI][PubMed]
  • 6. Cowie BS. Focused transthoracic echocardiography in the perioperative period. Anaesth Intensive Care. 2010; 38(5): 823-36[PubMed]
  • 7. Diaz-Gomez JL, Perez-Protto S, Hargrave J, Builes A, Capdeville M, Festic E, et al. Impact of a focused transthoracic echocardiography training course for rescue applications among anesthesiology and critical care medicine practitioners: a prospective study. J Cardiothorac Vasc Anesth. 2015; 29(3): 576-81[DOI][PubMed]
  • 8. Gaspar HA, Morhy SS, Lianza AC, de Carvalho WB, Andrade JL, do Prado RR, et al. Focused cardiac ultrasound: a training course for pediatric intensivists and emergency physicians. BMC Med Educ. 2014; 14: 25[DOI][PubMed]
  • 9. Kimura BJ, Amundson SA, Phan JN, Agan DL, Shaw DJ. Observations during development of an internal medicine residency training program in cardiovascular limited ultrasound examination. J Hosp Med. 2012; 7(7): 537-42[DOI][PubMed]
  • 10. Kini V, Mehta N, Mazurek JA, Ferrari VA, Epstein AJ, Groeneveld PW, et al. Focused Cardiac Ultrasound in Place of Repeat Echocardiography: Reliability and Cost Implications. J Am Soc Echocardiogr. 2015; 28(9): 1053-9[DOI][PubMed]
  • 11. Kratz T, Campo Dell'Orto M, Exner M, Timmesfeld N, Zoremba M, Wulf H, et al. Focused intraoperative transthoracic echocardiography by anesthesiologists: a feasibility study. Minerva Anestesiol. 2015; 81(5): 490-6[PubMed]
  • 12. Martin LD, Ziegelstein RC, Howell EE, Martire C, Hellmann DB, Hirsch GA. Hospitalists' ability to use hand-carried ultrasound for central venous pressure estimation after a brief training intervention: a pilot study. J Hosp Med. 2013; 8(12): 711-4[DOI][PubMed]
  • 13. Mayo PH. Training in critical care echocardiography. Ann Intensive Care. 2011; 1: 36[DOI][PubMed]
  • 14. Mozzini C, Garbin U, Fratta Pasini AM, Cominacini L. Short training in focused cardiac ultrasound in an Internal Medicine department: what realistic skill targets could be achieved? Intern Emerg Med. 2015; 10(1): 73-80[DOI][PubMed]
  • 15. Panoulas VF, Daigeler AL, Malaweera AS, Lota AS, Baskaran D, Rahman S, et al. Pocket-size hand-held cardiac ultrasound as an adjunct to clinical examination in the hands of medical students and junior doctors. Eur Heart J Cardiovasc Imaging. 2013; 14(4): 323-30[DOI][PubMed]
  • 16. Spencer KT, Kimura BJ, Korcarz CE, Pellikka PA, Rahko PS, Siegel RJ. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr. 2013; 26(6): 567-81[DOI][PubMed]
  • 17. Stokke TM, Ruddox V, Sarvari SI, Otterstad JE, Aune E, Edvardsen T. Brief group training of medical students in focused cardiac ultrasound may improve diagnostic accuracy of physical examination. J Am Soc Echocardiogr. 2014; 27(11): 1238-46[DOI][PubMed]
  • 18. Tanzola RC, Walsh S, Hopman WM, Sydor D, Arellano R, Allard RV. Brief report: Focused transthoracic echocardiography training in a cohort of Canadian anesthesiology residents: a pilot study. Can J Anaesth. 2013; 60(1): 32-7[DOI][PubMed]
  • 19. Vignon P, Mucke F, Bellec F, Marin B, Croce J, Brouqui T, et al. Basic critical care echocardiography: validation of a curriculum dedicated to noncardiologist residents. Crit Care Med. 2011; 39(4): 636-42[DOI][PubMed]
  • 20. Fred HL. Hyposkillia: deficiency of clinical skills. Tex Heart Inst J. 2005; 32(3): 255-7[PubMed]
  • 21. Attenhofer Jost C, Turina J, Mayer K, Seifert B, Amann FW, Buechi M, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause∗∗Access the “Journal Club” discussion of this paper at http://www. elsevier.com/locate/ajmselect. Am J Med. 2000; 108(8): 614-20[DOI]
  • 22. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP, Guyton RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am College Cardiol. 2014; 63(22): 2438-88[DOI]
  • 23. Mangione S, Nieman LZ. Cardiac auscultatory skills of internal medicine and family practice trainees. A comparison of diagnostic proficiency. JAMA. 1997; 278(9): 717-22[PubMed]
  • 24. Mangione S. Cardiac auscultatory skills of physicians-in-training: a comparison of three English-speaking countries. Am J Med. 2001; 110(3): 210-6[DOI]
  • 25. Marijon E, Ou P, Celermajer DS, Ferreira B, Mocumbi AO, Jani D, et al. Prevalence of rheumatic heart disease detected by echocardiographic screening. N Engl J Med. 2007; 357(5): 470-6[DOI][PubMed]
  • 26. Roberts KV, Brown AD, Maguire GP, Atkinson DN, Carapetis JR. Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory. Med J Aust. 2013; 199(3): 196-9[PubMed]
  • 27. Cowie B. Three years' experience of focused cardiovascular ultrasound in the peri-operative period. Anaesthesia. 2011; 66(4): 268-73[DOI][PubMed]
  • 28. Dennis AT. Transthoracic echocardiography in obstetric anaesthesia and obstetric critical illness. Int J Obstet Anesth. 2011; 20(2): 160-8[DOI][PubMed]
  • 29. Terkawi AS, Karakitsos D, Elbarbary M, Blaivas M, Durieux ME. Ultrasound for the anesthesiologists: present and future. ScientificWorldJournal. 2013; 2013: 683685[DOI][PubMed]
  • 30. Haji DL, Royse A, Royse CF. Review article: Clinical impact of non-cardiologist-performed transthoracic echocardiography in emergency medicine, intensive care medicine and anaesthesia. Emerg Med Australas. 2013; 25(1): 4-12[DOI][PubMed]
  • 31. Neelankavil J, Howard-Quijano K, Hsieh TC, Ramsingh D, Scovotti JC, Chua JH, et al. Transthoracic echocardiography simulation is an efficient method to train anesthesiologists in basic transthoracic echocardiography skills. Anesth Analg. 2012; 115(5): 1042-51[DOI][PubMed]
  • 32. Canty DJ, Royse CF, Kilpatrick D, Bowyer A, Royse AG. The impact on cardiac diagnosis and mortality of focused transthoracic echocardiography in hip fracture surgery patients with increased risk of cardiac disease: a retrospective cohort study. Anaesthesia. 2012; 67(11): 1202-9[DOI][PubMed]
  • 33. Loxdale SJ, Sneyd JR, Donovan A, Werrett G, Viira DJ. The role of routine pre-operative bedside echocardiography in detecting aortic stenosis in patients with a hip fracture. Anaesthesia. 2012; 67(1): 51-4[DOI][PubMed]
  • 34. White S. Routine echocardiography or invasive blood pressure monitoring for fractured neck of femur? Anaesthesia. 2013; 68(3): 300-1[DOI][PubMed]
  • 35. Garg K, Howell BW, Saltzberg SS, Berland TL, Mussa FF, Maldonado TS, et al. Open surgical management of complications from indwelling radial artery catheters. J Vasc Surg. 2013; 58(5): 1325-30[DOI][PubMed]
  • 36. Cowie B, Kluger R. Evaluation of systolic murmurs using transthoracic echocardiography by anaesthetic trainees. Anaesthesia. 2011; 66(9): 785-90[DOI][PubMed]
  • 37. Kobal SL, Trento L, Baharami S, Tolstrup K, Naqvi TZ, Cercek B, et al. Comparison of effectiveness of hand-carried ultrasound to bedside cardiovascular physical examination. Am J Cardiol. 2005; 96(7): 1002-6[DOI][PubMed]
  • 38. Butterworth J, Green JA. The anesthesiologist-directed perioperative surgical home: a great idea that will succeed only if it is embraced by hospital administrators and surgeons. Anesth Analg. 2014; 118(5): 896-7[DOI][PubMed]
  • 39. Webster NR. The anaesthetist as peri-operative physician. Editorial. Anaesthesia. 2000; 55(9): 839-40[DOI]
  • 40. Shafer SL, Donovan JF. Anesthesia & Analgesia's collection on the perioperative surgical home. Anesth Analg. 2014; 118(5): 893-5[DOI][PubMed]
  • 41. Schug SA. The surgeon and the anaesthetist: providing patient care as a perioperative team. ANZ J Surg. 2008; 78(7): 521-2[DOI][PubMed]
  • 42. Krishnamoorthy VK, Sengupta PP, Gentile F, Khandheria BK. History of echocardiography and its future applications in medicine. Crit Care Med. 2007; 35(8 Suppl)-13[DOI][PubMed]
  • 43. Etchells E, Bell C, Robb K. Does this patient have an abnormal systolic murmur? JAMA. 1997; 277(7): 564-71[PubMed]
  • 44. Munt B, Legget ME, Kraft CD, Miyake-Hull CY, Fujioka M, Otto CM. Physical examination in valvular aortic stenosis: correlation with stenosis severity and prediction of clinical outcome. Am Heart J. 1999; 137(2): 298-306[DOI][PubMed]
  • 45. Ramaraj R, Sorrell VL. Degenerative aortic stenosis. BMJ. 2008; 336(7643): 550-5[DOI][PubMed]
  • 46. Fleisher LA, Fleischmann KE, Auerbach AD, Barnason SA, Beckman JA, Bozkurt B, et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. J Am Coll Cardiol. 2014; 64(22)-137[DOI][PubMed]
  • 47. Samarendra P, Mangione MP. Aortic stenosis and perioperative risk with noncardiac surgery. J Am Coll Cardiol. 2015; 65(3): 295-302[DOI][PubMed]
  • 48. Agarwal S, Rajamanickam A, Bajaj NS, Griffin BP, Catacutan T, Svensson LG, et al. Impact of aortic stenosis on postoperative outcomes after noncardiac surgeries. Circ Cardiovasc Qual Outcomes. 2013; 6(2): 193-200[DOI][PubMed]
  • 49. Cowie B. Focused transthoracic echocardiography predicts perioperative cardiovascular morbidity. J Cardiothorac Vasc Anesth. 2012; 26(6): 989-93[DOI][PubMed]
  • 50. Tashiro T, Pislaru SV, Blustin JM, Nkomo VT, Abel MD, Scott CG, et al. Perioperative risk of major non-cardiac surgery in patients with severe aortic stenosis: a reappraisal in contemporary practice. Eur Heart J. 2014; 35(35): 2372-81[DOI][PubMed]
  • 51. Kertai MD, Bountioukos M, Boersma E, Bax JJ, Thomson IR, Sozzi F, et al. Aortic stenosis: an underestimated risk factor for perioperative complications in patients undergoing noncardiac surgery. Am J Med. 2004; 116(1): 8-13[PubMed]
  • 52. Calleja AM, Dommaraju S, Gaddam R, Cha S, Khandheria BK, Chaliki HP. Cardiac risk in patients aged >75 years with asymptomatic, severe aortic stenosis undergoing noncardiac surgery. Am J Cardiol. 2010; 105(8): 1159-63[DOI][PubMed]
  • 53. Catacutan T, Usmani A, Aneja A. Does a systolic murmur heard in the aortic area need to be further evaluated prior to elective surgery? Cleve Clin J Med. 2007; 74 Suppl 1-3[PubMed]
  • 54. McBrien ME, Heyburn G, Stevenson M, McDonald S, Johnston NJ, Elliott JR, et al. Previously undiagnosed aortic stenosis revealed by auscultation in the hip fracture population--echocardiographic findings, management and outcome. Anaesthesia. 2009; 64(8): 863-70[DOI][PubMed]
  • 55. Amaki M, Anzai T. Does major noncardiac surgery accelerate the progression of aortic stenosis? - Role of inflammation. Circ J. 2015; 79(4): 766-7[DOI][PubMed]
  • 56. Czarny MJ, Resar JR. Diagnosis and management of valvular aortic stenosis. Clin Med Insights Cardiol. 2014; 8: 15-24[DOI][PubMed]
  • 57. Lewin MB, Otto CM. The bicuspid aortic valve: adverse outcomes from infancy to old age. Circulation. 2005; 111(7): 832-4[DOI][PubMed]
  • 58. Michelena HI, Desjardins VA, Avierinos JF, Russo A, Nkomo VT, Sundt TM, et al. Natural history of asymptomatic patients with normally functioning or minimally dysfunctional bicuspid aortic valve in the community. Circulation. 2008; 117(21): 2776-84[DOI][PubMed]
  • 59. Goel SS, Ige M, Tuzcu EM, Ellis SG, Stewart WJ, Svensson LG, et al. Severe aortic stenosis and coronary artery disease--implications for management in the transcatheter aortic valve replacement era: a comprehensive review. J Am Coll Cardiol. 2013; 62(1): 1-10[DOI][PubMed]
  • 60. Otto CM, Nishimura RA. New ACC/AHA valve guidelines: aligning definitions of aortic stenosis severity with treatment recommendations. Heart. 2014; 100(12): 902-4[DOI][PubMed]
  • 61. Magne J, Lancellotti P, Pierard LA. Exercise testing in asymptomatic severe aortic stenosis. JACC Cardiovasc Imaging. 2014; 7(2): 188-99[DOI][PubMed]
  • 62. Nightingale AK, Horowitz JD. Aortic sclerosis: not an innocent murmur but a marker of increased cardiovascular risk. Heart. 2005; 91(11): 1389-93[DOI][PubMed]
  • 63. Cosmi JE, Kort S, Tunick PA, Rosenzweig BP, Freedberg RS, Katz ES, et al. The risk of the development of aortic stenosis in patients with "benign" aortic valve thickening. Arch Intern Med. 2002; 162(20): 2345-7[PubMed]
  • 64. Valentijn TM, Hoeks SE, Bakker EJ, Voute MT, Chonchol M, van de Luijtgaarden KM, et al. Influence of aortic valve calcium on outcome in patients undergoing peripheral vascular surgery. Am J Cardiol. 2012; 110(8): 1195-9[DOI][PubMed]
  • 65. Heidenreich PA, Schnittger I, Hancock SL, Atwood JE. A systolic murmur is a common presentation of aortic regurgitation detected by echocardiography. Clin Cardiolo. 2004; 27(9): 502-6[DOI]
  • 66. Lee D, Chen CH, Hsu TL, Chiang CE, Wang SP, Chang MS. Reappraisal of cardiac murmurs related to aortic regurgitation. Zhonghua Yi Xue Za Zhi (Taipei). 1995; 56(3): 152-8[PubMed]
  • 67. Lai HC, Lai HC, Lee WL, Wang KY, Ting CT, Hung CJ, et al. Impact of chronic advanced aortic regurgitation on the perioperative outcome of noncardiac surgery. Acta Anaesthesiol Scand. 2010; 54(5): 580-8[DOI][PubMed]
  • 68. Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin J3, Guyton RA, et al. 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation. 2014; 129(23)-643[DOI][PubMed]
  • 69. Bajaj NS, Agarwal S, Rajamanickam A, Parashar A, Poddar KL, Griffin BP, et al. Impact of severe mitral regurgitation on postoperative outcomes after noncardiac surgery. Am J Med. 2013; 126(6): 529-35[DOI][PubMed]
  • 70. Zoghbi W. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and doppler echocardiography. J Am Soc Echocardiograph. 2003; 16(7): 777-802[DOI]
  • 71. Grigioni F, Enriquez-Sarano M, Ling LH, Bailey KR, Seward JB, Tajik AJ, et al. Sudden death in mitral regurgitation due to flail leaflet. J Am College Cardiol. 1999; 34(7): 2078-85[DOI]
  • 72. Nishimura RA, Otto C. 2014 ACC/AHA valve guidelines: earlier intervention for chronic mitral regurgitation. Heart. 2014; 100(12): 905-7[DOI][PubMed]
  • 73. Lang RM, Badano LP, Mor-Avi V, Afilalo J, Armstrong A, Ernande L, et al. Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging. Eur Heart J Cardiovasc Imaging. 2015; 16(3): 233-70[DOI][PubMed]
  • 74. Stroumpoulis KI, Pantazopoulos IN, Xanthos TT. Hypertrophic cardiomyopathy and sudden cardiac death. World J Cardiol. 2010; 2(9): 289-98[DOI][PubMed]
  • 75. Hreybe H, Zahid M, Sonel A, Good CB, Shaver J, Saba S. Noncardiac surgery and the risk of death and other cardiovascular events in patients with hypertrophic cardiomyopathy. Clin Cardiol. 2006; 29(2): 65-8[DOI]
  • 76. Cowie B, Kluger R, Rex S, Missant C. The utility of transoesophageal echocardiography for estimating right ventricular systolic pressure. Anaesthesia. 2015; 70(3): 258-63[DOI][PubMed]
  • 77. De Bonis M, Taramasso M, Lapenna E, Alfieri O. Management of tricuspid regurgitation. F1000Prime Rep. 2014; 6: 58[DOI][PubMed]
  • 78. Price LC, Montani D, Jais X, Dick JR, Simonneau G, Sitbon O, et al. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Eur Respir J. 2010; 35(6): 1294-302[DOI][PubMed]
  • 79. Kaw R, Pasupuleti V, Deshpande A, Hamieh T, Walker E, Minai OA. Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med. 2011; 105(4): 619-24[DOI][PubMed]
  • 80. Meyer S, McLaughlin VV, Seyfarth HJ, Bull TM, Vizza CD, Gomberg-Maitland M, et al. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey. Eur Respir J. 2013; 41(6): 1302-7[DOI][PubMed]
  • 81. Minai OA, Yared JP, Kaw R, Subramaniam K, Hill NS. Perioperative risk and management in patients with pulmonary hypertension. Chest. 2013; 144(1): 329-40[DOI][PubMed]
  • 82. Wijeysundera DN, Beattie WS, Karkouti K, Neuman MD, Austin PC, Laupacis A. Association of echocardiography before major elective non-cardiac surgery with postoperative survival and length of hospital stay: population based cohort study. BMJ. 2011; 342[DOI][PubMed]
  • 83. Wijeysundera DN, Austin PC, Beattie WS, Hux JE, Laupacis A. Outcomes and processes of care related to preoperative medical consultation. Arch Intern Med. 2010; 170(15): 1365-74[DOI][PubMed]
  • 84. Via G, Hussain A, Wells M, Reardon R, ElBarbary M, Noble VE, et al. International evidence-based recommendations for focused cardiac ultrasound. J Am Soc Echocardiogr. 2014; 27(7): 683 e1-683 e33[DOI][PubMed]
  • 85. Martin LD, Howell EE, Ziegelstein RC, Martire C, Shapiro EP, Hellmann DB. Hospitalist performance of cardiac hand-carried ultrasound after focused training. Am J Med. 2007; 120(11): 1000-4[DOI][PubMed]
  • 86. Hellmann DB, Whiting-O'Keefe Q, Shapiro EP, Martin LD, Martire C, Ziegelstein RC. The rate at which residents learn to use hand-held echocardiography at the bedside. Am J Med. 2005; 118(9): 1010-8[DOI][PubMed]
  • 87. Siqueira VN, Mancuso FJ, Campos O, De Paola AA, Carvalho AC, Moises VA. Training Program for Cardiology Residents to Perform Focused Cardiac Ultrasound Examination with Portable Device. Echocardiography. 2015; 32(10): 1455-62[DOI][PubMed]
  • 88. Expert Round Table on Echocardiography in ICU. International consensus statement on training standards for advanced critical care echocardiography. Intensive Care Med. 2014; 40(5): 654-66[DOI][PubMed]
  • 89. Royse CF, Seah JL, Donelan L, Royse AG. Point of care ultrasound for basic haemodynamic assessment: novice compared with an expert operator. Anaesthesia. 2006; 61(9): 849-55[DOI][PubMed]
  • 90. Charron C, Vignon P, Prat G, Tonnelier A, Aegerter P, Boles JM, et al. Number of supervised studies required to reach competence in advanced critical care transesophageal echocardiography. Intensive Care Med. 2013; 39(6): 1019-24[DOI][PubMed]
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