Archives Internal Medicine article-some good news about the third heart sound and practice

The March 27,2006 issue of the Archives of Internal Medicine published an article that happily tended to confirm some of my biases. ( "Relationship between Accurate Auscultation of a Clinically Useful third heart sound and Level of experience." Marcus,G et al. Arch Int Med. vol 166,March 27, 2006 p.617-622)

The authors studied the auscultatory prowess in regard to detection of a third heart sound (S3))of docs at various levels of experience-from intern to cardiac fellow to attending cardiologist) by having them examine 100 patients shortly after cardiac cath and constructed correlations with LV ejection fraction, BNP and echocardiography.

Findings include:

The finding of a S3 by auscultation is very specific for heart failure (HF).In other words a S3 goes a long way to ruling in heart failure but it is not very sensitive- so not great at ruling out HF.

A cardiologist's perception of an S3 is as good as a phonocardiogram.

And here is the one I really like -Cardiologists and cardiology fellows do better than interns and residents in internal medicine. Who would have thought?

Yes Virginia, practice and experience matter and sometimes the physical exam may be of value.

We speak now of third sounds-in an earlier era we talked more about " gallops " and "gallop rhythms". Dr. George Burch in his 1953 text " A Primer of Cardiology" says a " protodiastolic gallop rhythm is present when the gallop sound occurs early in diastole"..It is due to an exaggerated third heart sound and is common in congestive heart failure."

The medical language of the 1950s did not include the words sensitivity and specificity but the cardiologists and internists of the day knew that a gallop usually ruled in heart failure.

Practice and experience do matter and Dr. David L Simel who wrote the editorial discussing the article wondered if the current trend in reduced house staff training time will be counterproductive in creating an environment wherein that practice and repetition can take place. I think the answer is obvious, of course it will- absent some major effort on the part of the training program to remedy that,given the recent history of ACGME to pile more and more new requirements to be carried out in less and less time.