Teixeira Isabella Silveira, Borges Vinícius Lima, Viola Natan, Moreira Henrique Turin, Pazin Filho Antonio, Schmidt André, Marin-Neto José Antônio, Romano Minna Moreira Dias
Faculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto, SP - Brasil.
Arq Bras Cardiol. 2025 Feb;122(2):e20240272. doi: 10.36660/abc.20240272.
Complementary diagnostic examinations have replaced the importance of Physical Examination (PE) in Clinical Decision-making (CDM). 1. Medical clinical practice has lost confidence in Physical Examination (PE) compared to complementary diagnostic examinations (CE). More importance has been deposited on Echocardiography (ECHO) in cardiac valvular dysfunction scenarios. No studies have measured the impact of cardiac PE in Clinical Decision-making (CDM). 2. Discrepancies between PE findings and ECHO reports are common and may impact CDM in different forms. 3. PE has proven essential to enhancing diagnosis confidence and grading of dysfunction in cardiac valvular dysfunctions. ECHO still plays a significant importance in CDM, even when discordant from physical examination. 4. The number of solicitations of an invasive test such as Cardiac Catheterization (CATE) is influenced by PE. The number of orderings was higher when volunteers did not perform a PE.
To evaluate the impact of cardiovascular PE in scenarios of cardiac valvular diseases.
An interventional study with volunteers' patients having or not having the opportunity to perform PE in scenarios of valvopathies. The PE was simulated in a high-fidelity cardiopulmonary simulator. Volunteers received questions about CDM before and after receiving an ECHO Concordant or ECHO Discordant report. Cohen´s kappa coefficient and square contingency tables compared diagnostic accuracy. ANOVA tests compared the number of requested tests; the significance level was set as p < 0.05.
Sixty volunteers performed 239 clinical observations in 4 valvular dysfunctions. The diagnostic accuracy of valvular dysfunction was good (kappa = 0.935, p < 0.001). After receiving ECHO reports, the accuracy was worse without PE (p = 0.0047). The confidence level in diagnosis was 28.18% higher when PE was performed (p < 0.01). However, after receiving ECHO reports, diagnostic confidence levels were only 4% higher in the group with PE (p = 0.03). There were significantly more CATE requests when PE was not performed (p = 0.0326). The indication of valvular intervention was not related to having or not having the opportunity to perform PE (79 with PE vs 78 without PE, p = 0.0607), but was influenced by ECHO Concordant vs ECHO Discordant reports (p < 0.001).
Performing PE enhanced diagnosis confidence in valvulopathy scenarios and correct dysfunction grading. Treatment decisions were more based on ECHO reports than on PE when they were discordant, and requests for CATE increased when volunteers had no chance to perform PE.
在临床决策（CDM）中，辅助诊断检查已取代了体格检查（PE）的重要性。1. 与辅助诊断检查（CE）相比，医学临床实践对体格检查（PE）的信心有所丧失。在心脏瓣膜功能障碍的情况下，超声心动图（ECHO）被赋予了更高的重要性。尚无研究衡量心脏体格检查在临床决策（CDM）中的影响。2. 体格检查结果与超声心动图报告之间的差异很常见，可能以不同形式影响临床决策。3. 体格检查已被证明对于提高心脏瓣膜功能障碍的诊断信心和功能障碍分级至关重要。即使与体格检查结果不一致，超声心动图在临床决策中仍起着重要作用。4. 诸如心导管检查（CATE）等侵入性检查的申请数量受体格检查的影响。当志愿者未进行体格检查时，申请数量更高。
评估心血管体格检查在心脏瓣膜疾病情况下的影响。
一项干预性研究，让患有瓣膜病的志愿者患者有或没有机会进行体格检查。在高保真心肺模拟器中模拟体格检查。志愿者在收到超声心动图结果一致或不一致的报告之前和之后会收到有关临床决策的问题。使用Cohen's kappa系数和方形列联表比较诊断准确性。方差分析测试比较了所需检查的数量；显著性水平设定为p < 0.05。
60名志愿者对4种瓣膜功能障碍进行了239次临床观察。瓣膜功能障碍的诊断准确性良好（kappa = 0.935，p < 0.001）。收到超声心动图报告后，未进行体格检查时的准确性较差（p = 0.0047）。进行体格检查时，诊断的置信度高28.18%（p < 0.01）。然而，收到超声心动图报告后，进行体格检查的组中诊断置信度仅高4%（p = 0.03）。未进行体格检查时，心导管检查的申请明显更多（p = 0.0326）。瓣膜干预的指征与是否有机会进行体格检查无关（进行体格检查的有79例，未进行体格检查的有78例，p = 0.0607），但受超声心动图结果一致与不一致报告的影响（p < 0.001）。
进行体格检查可提高瓣膜病情况下的诊断信心并正确进行功能障碍分级。当两者不一致时，治疗决策更多地基于超声心动图报告而非体格检查，并且当志愿者没有机会进行体格检查时，心导管检查的申请会增加。
