Gupta Saurabh, Michaels Andrew D
Division of Cardiology, Department of Medicine, University of Utah, Salt Lake City, Utah 84132-2401, USA.
Clin Cardiol. 2009 Feb;32(2):69-75. doi: 10.1002/clc.20431.
Poor performance by physicians-in-training and interobserver variability between physicians has diminished clinicians' confidence in the value of the fourth heart sound (S4).
We sought to determine if accurate auscultation of an S4 improves with advancing levels of experience.
We performed a prospective study of 100 patients undergoing left heart catheterization. Patients underwent blinded auscultation by 4 physicians (each from 1 of 4 different levels of experience), computerized acoustic cardiography, measurement of B-type natriuretic peptide (BNP) levels, echocardiography for measurement of left ventricular ejection fraction (LVEF), and cardiac catheterization for measurement of left ventricular end-diastolic pressure (LVEDP).
While cardiology fellows', residents', and interns' auscultatory findings demonstrated no significant agreement with acoustic cardiography, an S4 auscultated by cardiology attendings had moderate diagnostic accuracy with acoustic cardiography (odds ratio [OR]: 2.31; receiver-operating-characteristic [ROC] area: 0.60). The sensitivities of the S4 were low (39%-46%) for identifying patients with abnormal measures of left ventricular filling pressure (BNP and LVEDP, respectively), and the specificities were fair (76%-80%) with acoustic cardiography. The S4 was not associated with abnormal LVEF. None of the ausculatory groups performed as well as acoustic cardiography in separating patients based on objective measures of left ventricular filling pressure. Acoustic cardiography had the lowest (superior) negative likelihood ratios compared to any ausculatory group.
The S4 auscultated by cardiology attendings demonstrated superior diagnostic test characteristics compared with internal medicine housestaff and cardiology fellows. Correlations between the S4 and measures of ventricular filling pressure were superior for acoustic cardiography compared to the auscultator groups.
实习医生表现不佳以及医生之间的观察者间变异性降低了临床医生对第四心音（S4）价值的信心。
我们试图确定随着经验水平的提高，S4的准确听诊是否会改善。
我们对100例接受左心导管检查的患者进行了一项前瞻性研究。患者由4名医生（分别来自4个不同经验水平中的1个）进行盲法听诊、计算机化心音图检查、测量B型利钠肽（BNP）水平、超声心动图测量左心室射血分数（LVEF）以及心脏导管检查测量左心室舒张末期压力（LVEDP）。
虽然心脏病学进修医生、住院医生和实习医生的听诊结果与心音图检查无显著一致性，但心脏病学主治医生听诊到的S4在心音图检查中有中等诊断准确性（优势比[OR]：2.31；受试者工作特征[ROC]曲线下面积：0.60）。对于识别左心室充盈压异常测量值（分别为BNP和LVEDP）的患者，S4的敏感性较低（39%-46%），在心音图检查中特异性一般（76%-80%）。S4与异常LVEF无关。在根据左心室充盈压的客观测量值对患者进行区分方面，没有一个听诊组的表现与心音图检查一样好。与任何听诊组相比，心音图检查的阴性似然比最低（更好）。
与内科住院医生和心脏病学进修医生相比，心脏病学主治医生听诊到的S4显示出更好的诊断测试特征。与听诊组相比，在心音图检查中S4与心室充盈压测量值之间的相关性更好。
