Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory

Roberts, Kathryn V., Brown, Alex D.H., Maguire, Graeme P., Atkinson, David N., and Carapetis, Jonathan R. (2013) Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory. Medical Journal of Australia, 199 (3). pp. 196-199.

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Objectives: To evaluate the utility of auscultatory screening for detecting echocardiographically confirmed rheumatic heart disease (RHD) in high-risk children in the Northern Territory, Australia.

Design: Cross-sectional screening survey.

Setting: Twelve rural and remote communities in the NT between September 2008 and June 2010.

Participants: 1015 predominantly Indigenous schoolchildren aged 5–15 years.

Intervention: All children underwent transthoracic echocardiography, using a portable cardiovascular ultrasound machine, and cardiac auscultation by a doctor and a nurse. Sonographers and auscultators were blinded to each others' findings and the clinical history of the children. Echocardiograms were reported offsite, using a standardised protocol, by cardiologists who were also blinded to the clinical findings.

Main outcome measures: Presence of a cardiac murmur as identified by nurses (any murmur) and doctors (any murmur, and "suspicious" or "pathological" murmurs), compared with echocardiogram findings. RHD was defined according to the 2012 World Heart Federation criteria for echocardiographic diagnosis of RHD.

Results: Of the 1015 children screened, 34 (3.3%) had abnormalities identified on their echocardiogram; 24 met echocardiographic criteria for definite or borderline RHD, and 10 had isolated congenital anomalies. Detection of any murmur by a nurse had a sensitivity of 47.1%, specificity of 74.8% and positive predictive value (PPV) of 6.1%. Doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity and 5.1% PPV, and the corresponding values for doctor detection of suspicious or pathological murmurs were 20.6%, 92.2% and 8.3%. For all auscultation approaches, negative predictive value was more than 97%, but the majority of participants with cardiac abnormalities were not identified. The results were no different when only definite RHD and congenital abnormalities were considered as true cases.

Conclusions: Sensitivity and positive predictive value of cardiac auscultation compared with echocardiography is poor, regardless of the expertise of the auscultator. Although negative predictive value is high, most cases of heart disease were missed by auscultation, suggesting that cardiac auscultation should no longer be used to screen for RHD in high-risk schoolchildren in Australia.

Item ID: 32367
Item Type: Article (Research - C1)
ISSN: 1326-5377
Funders: Australian Government, Children First Foundation, Kiwanis Clubs of Australia, Cabrini Health, Charles Darwin University, National Health and Medical Research Council of Australia (NHMRC), Margaret Ross Chair of Indigenous Health
Date Deposited: 23 Apr 2014 01:46
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1102 Cardiovascular Medicine and Haematology > 110201 Cardiology (incl Cardiovascular Diseases) @ 100%
SEO Codes: 92 HEALTH > 9201 Clinical Health (Organs, Diseases and Abnormal Conditions) > 920103 Cardiovascular System and Diseases @ 20%
92 HEALTH > 9203 Indigenous Health > 920303 Aboriginal and Torres Strait Islander Health - Health System Performance (incl. Effectiveness of Interventions) @ 60%
92 HEALTH > 9202 Health and Support Services > 920203 Diagnostic Methods @ 20%
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