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EDITORIALS: John Chambers Aortic stenosis BMJ 2005; 330: 801-802 [Full text]

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Increased recognition of aortic stenosis in developing countries

Uma Viswanathan Nair, Arunraj Kaimal, SHO, Y.G. Bangor   (8 April 2005)

Aortic Stenosis

oscar m jolobe   (11 April 2005)

WHEAT FROM THE CHAFF-CARDIAC DIAGNOSIS

BM Hegde   (12 April 2005)

Aortic Sclerosis:time to say goodbye

Jonathan P Fox   (14 April 2005)

Aortic stenosis in the elderly

Ramachandran Sivakumar, Partha Ghosh, Consultant Physician and Shahid A Khan, Consultant Physician, Department of care of elderly, Lister Hospital, Stevenage, UK.   (23 April 2005)

Aortic Stenosis and Non-cardiac Surgery

Saroj Das, Vikram Reddy Vattipally   (27 April 2005)

The case for earlier surgery in aortic stenosis

Stephen Billing, Simon Howarth, Jago Kitcat, and Samer Nashef.   (3 May 2005)

Increased recognition of aortic stenosis in developing countries 8 April 2005
Uma Viswanathan Nair, FP2 SHO Ysbyty Gwynedd , Bangor, North Wales, LL57 2PW, Arunraj Kaimal, SHO, Y.G. Bangor Send response to journal: Re: Increased recognition of aortic stenosis in developing countries	One advantage of getting medical training in a developing country is the increased chance of being familiar to conditions, which are thought to be often unrecognised or rare in developed countries. In India from an undergraduate level, students are trained to develop their clinical examination skills to detect even the milder symptoms of some conditions, especially when the screening procedures remains expensive, despite a high prevalence of the condition and availability of potentially curable treatment options. Aortic stenosis is a classic example of this. Aortic stenosis constitutes about 8% of all congenital lesions in the paediatric clinics of India. In addition to this a high prevalence of rheumatic fever makes aortic stenosis, a condition, which is to be screened by routine clinical examination in all age and socioeconomic groups. Unlike in a developed country even recognised aortic stenosis is an important cause of anaesthetic, obstetric and paediatric mortality in states of South India. Ability to recognise the clinical symptoms of valvular heart disease is an absolute requirement to pass the internal and university practical examinations of general medicine, paediatrics and gynaecology, from the third year of MBBS onwards in the southern state of Kerala in India. In a case of aortic stenosis (severe) missing a heaving apical impulse, palpable fourth cardiac sound, a palpable systolic thrill at second right inter-costal space, at supra-sternal notch or on the carotid arteries will be severely penalised even at 3rd or 4th year in the medical school in an internal assessment. By the final year of MBBS the student should be able to demonstrate his clinical competency in detecting more subtle positive and negative signs of AS like normal S1, delayed A2, normal splitting and paradoxical splitting and ejection systolic (diamond shaped) murmurs of mild, moderate and severe nature to get through the university examination. There are several patients coming specifically for the examinations with all the classical signs of valvular heart disease. In fact the post graduate departments in each university hospital maintains a long list of such patients for the purpose of university examination. Medical students from developed countries should utilise their elective placement as an opportunity to get more familiarity with clinical conditions they have seen only in text books, by choosing university hospitals in developing countries where excellent training facilities are available. The senior overseas clinicians working in NHS also could contribute their experience, to the clinical training of medical students and other professionals like specialist nurses. This would be a valuable step in early detection and treatment of aortic stenosis , and would contribute to the secondary and tertiary prevention of epidemic of AS, anticipated by Dr. Chambers. Ref. Aortic stenosis is common but often unrecognised. John Chambers BMJ Volume 330 . 9 April 2005 Competing interests: None declared
Aortic Stenosis 11 April 2005
oscar m jolobe, retired geriatrician 1 The Lodge 842 Wilmslow Road, Didsbury, Manchester, M20 2RN Send response to journal: Re: Aortic Stenosis	I endorse the clinical issues raised by the author(1). Furthermore, given the fact that angina may be the first manifestation of critical aortic stenosis(2), clinicians need to be reminded that the clinical evaluation of a patient with angina is not complete until the murmur of aortic stenosis has been elicited by auscultation at the usual site of maximum intensity, namely the second or third right intercostal space, with the patient leaning forward, breath held in expiration(2). In view of the fact that the site of maximum intensity may vary, auscultation should also be performed at the lower left sternal border and at the apex(3)(4). If this were to be a routine on domiciliary visits, outpatient clinics, and ward rounds, more cases of critical aortic stenosis would be identified. Yours sincerely OMP Jolobe (retired geriatrician) References (1) Chambers J Aortic stenosis British Medical Journal 2005:330:801-2 (2) Braunwald E Valvular Heart Disease in Harrison's Principles of Internal Medicine 14th Edition 1998 Chapter 237 Editors: Fauci AS., Braunwald E., Isselbacher KJ., Martin JB., Kasper DL., Hauser SL., Longo DL McGraw-Hill Health Professions Division, New York, San Francisco, Washington DC (3) Thibault G., Desanctis RM., Buckley MJ Aortic Stenosis in The Practice of Cardiology 2nd Edition 1989 Editors: Eagle K., Haber E., DeSanctis RM., Austen WG Little, Brown and Co Boston/Toronto (4) Schire V Auscultation: aortic stenosis in Clinical Cardiology 1971 Chapter 4 page 79-80 Editor Schrire V Staples Press London Competing interests: None declared
WHEAT FROM THE CHAFF-CARDIAC DIAGNOSIS 12 April 2005
BM Hegde, Retd. Vice Chancellor MANGALORE-575004, India. Send response to journal: Re: WHEAT FROM THE CHAFF-CARDIAC DIAGNOSIS	Dear Editor, The above caption was the title of an excellent study of sixty years of cardiology teaching experience at the St. Andrews University Hospital in Scotland, where three generations of teachers had recorded their experiences on bed side teaching of cardiology, published in the BMJ, if my memory does not fail me, in the year 1975(?8). The study clearly showed that over the years the stress on clinical findings was fading and subtleties were taught unnecessarily, e.g.: the reverse splitting of the second sound and many extra sounds etc and a plethora of murmurs! The study did show that all these were counter productive. If good bedside cardiology was taught to graduate students, the need to make diagnosis of aortic stenosis in the mortuary would not arise, as most of them could be diagnosed on the bedside. “Proper listening to the patient and reading the referral letter, would give away the accurate final diagnosis in more than eighty per cent of patients,” was the conclusion of another excellent prospective study of the ROLE OF HISTORY TAKING ETC. IN THE OUT PATIENT DIGNOSIS, a landmark study published in the BMJ in 1975. If I am not mistaken, Prof. John Hampton was the lead author. I still remember that wonderful letter written by Late Evan Bedford, one of the founding fathers of modern cardiology, in the 40s about a young girl, whom I had the good fortune of reviewing in 1978, at the Middlesex Hospital cardiology out patient clinic. The letter to the G.P. had said: "This healthy and fit child has a faint mid-sytolic murmur and an additional sound before that. I wonder what that is! However, I am sure that this girl will have a normal life. To be on the safer side, please keep sending her back once in five years for review, just in case." A great clinician that he was, he was prophetic. And, he was dead right. Our echo in 1978 did show a good billowing mitral leaflet with hardly any regurgitation. His prophetic prognostication had also been proven right. She had no problems at all in 1978. That was the greatness of good clinicians and great brains that we had in the past. Thank God, they were not sold to technology as we are today. Today’s students are overwhelmed by the array of scopes and scanners and forget the hapless patient on the bedside. Today students (and teachers) need to have retraining in auscultation. A few years ago that was exactly the topic of the Key note address to the American College of Cardiology annual meet in Boston, by Prof.Proctor Harvey, on HOW TO AUSCULTATE THE HEART. Believe me, that was a great hit with the audience. Moral of the story is: "let us not forget clinical bedside cardiology". "Histry repeats itself and if you do not learn from history, you will have to relive history." wrote the great Roman thinker, Cicero. Yours ever, bmhegde Competing interests: Has been teaching clincial cardiology for four decades.
Aortic Sclerosis:time to say goodbye 14 April 2005
Jonathan P Fox, consultant physician and cardiologist PR8 6PN Send response to journal: Re: Aortic Sclerosis:time to say goodbye	Having worked for over a decade in an area with a very high incidence of aortic stenosis where hardly a cath list goes by without an aortic valve to cross I fully support most of what Is highlighted by John Chalmers. However I would take issue with his continued use of the term of "aortic Sclerosis". Firstly as he indicates the differentiation from stenosis is made by echocardiography rather than clinical examination however well performed. This in its self requires the need for referal and investigation. Secondarily there is a substantial conversion rate (16%) between the two which requires the clinician to remain vigilant. By continuing to use this outmoded term I feel he perpetuates the underdiagnosis of the very important condition he describes. I would suggest all murmurs suggestive of aortic valve disease should be assessed by a competant physician backed up with access to good quality echocardiographic facilties with the term of aortic sclerosis firmly relegated to the history books. Jonathan Fox, Consultant Physician and Cardiologist, Southport Competing interests: None declared
Aortic stenosis in the elderly 23 April 2005
Ramachandran Sivakumar, Specialist Registrar Lister Hospital, Partha Ghosh, Consultant Physician and Shahid A Khan, Consultant Physician, Department of care of elderly, Lister Hospital, Stevenage, UK. Send response to journal: Re: Aortic stenosis in the elderly	The editorial by J Chambers (1) is timely and relevant to our ageing population. We would like to add that clinical signs of aortic stenosis change with age (2) and may significantly contribute to under recognition of aortic stenosis particularly in octogenerians. Firstly, systolic thrill is rare in elderly patients resulting in aortic stenotic murmurs being mistaken for a functional murmur. Secondly, aortic stenotic murmur is often high pitched and musical (3) and best heard at the apex and thereby often mistaken for mitral regurgitation murmur. These factors make bedside diagnosis difficult even for the experienced with specialised training in cardiology. Contrary to the impression which can be inferred from the article there is very little evidence for comparative performance of auscultatory skills between cardiologists and general physicians particularly when dealing with the elderly with aortic stenosis. One recent study found that the clinical ability of the cardiologists to assess the exact cause of the murmur was limited, especially when more than one lesion was present.(4) Apical aortic stenotic murmurs are often misdiagnosed in octogenarians as mitral regurgitation and there is a perception that valve surgery is unlikely to be offered to these patients. Increased co- morbidity further discourages clinicians from investigating systolic murmurs and referring aortic stenosis for surgery. However, percutaneous aortic valve replacement is on the horizon and may benefit these patients (5). References: 1. Chambers J. Aortic stenosis. BMJ. 2005; 330(7495):801-2. 2. Roelandt JRTC and Meeter K. Diagnosis and management of valvular heart disease in the elderly. Cardiology in the elderly 1993; 1:235-243. 3. Channer KS and Smith GH. In Brocklehurst JC, ed. Valvular heart disease. Textbook of Geriatric medicine and Gerontology. Churchill Livingstone 4th edition 1992: 220-230. 4. Attenhofer CH, Turina J, Mayer K, et al. Echocardiography in the evaluation of systolic murmurs of unknown cause. Am J Med 2000; 108:614–20 5. Cribier A, Eltchaninoff H, Tron C, et al. Early experience with percutaneous transcatheter implantation of heart valve prosthesis for the treatment of end-stage inoperable patients with calcific aortic stenosis. J Am Coll Cardiol 2004; 18;43(4):698-703. Competing interests: None declared
Aortic Stenosis and Non-cardiac Surgery 27 April 2005
Saroj Das, Consultant Vascular Surgeon The Hillingdon Hospital NHS Trust, Vikram Reddy Vattipally Send response to journal: Re: Aortic Stenosis and Non-cardiac Surgery	Dr. Chambers(1) article is an eye opener for clinicians to a problem that is serious particularly in elderly people. The magnitude of the problem has far reaching implications on clinical practice, NHS economy and health status of elderly people .Risk modification appears to have no impact on the progression of aortic stenosis. In vascular and orthopaedic surgery, majority of the patients are above 65 years of age; the average age being 71.3 for vascular surgery (2) and 74 for orthopaedic surgery for knee replacement(3). Aortic stenosis, in addition to ischemic heart disease, is likely to be more frequent in these patients. While it is possible to identify aortic stenosis by routine preoperative assessment including echo- cardiography, some cases will remain undetected in an emergency. Even if it is diagnosed clinically we do not know how it is going to influence subsequent management in an emergency. The dilemma is - should all patients above the age of 65 years undergo screening with echo and intensive cardiac evaluation prior to major non-cardiac surgery given the limitation of our resources. There will be an overwhelming demand on the cardiologists and cardiac surgeons, as these patients will be waiting for urgent non-cardiac surgery. It is also likely to have a significant impact on our clinical practice. We will be engaged more and more in surgery as prevention in asymptomatic patients of carotid stenosis, aortic aneurysms and aortic stenosis. Informed consent during outpatient consultation may become inappropriate in the absence of sufficient information, such as silent aortic stenosis, that can complicate outcome of an otherwise successful surgery. While the benefit of this exercise outweighs the risk, persuading asymptomatic patients to have surgery can become a daunting task. Robust guidelines regarding appropriateness of aortic valve surgery in these patients may become helpful. References: 1.Chambers J. BMJ Apr 2005; 330: 801-802 2.National vascular database 2004, Vascular Society of Great Britain and Ireland. 3.Bandolier, 103 Competing interests: None declared
The case for earlier surgery in aortic stenosis 3 May 2005
Stephen Billing, Consultant Cardiothoracic Surgeon New Cross Hospital, Wolverhampton WV10 0QP, Simon Howarth, Jago Kitcat, and Samer Nashef. Send response to journal: Re: The case for earlier surgery in aortic stenosis	EDITOR – We read with interest Chambers’ recent editorial on aortic stenosis (1). The problem is not only failure to recognise aortic stenosis, but also failure to refer for surgery sufficiently early. We reviewed all patients undergoing aortic valve replacement (AVR) in a single institution over a 12-month period to assess whether those patients who present acutely for AVR have a similar outcome to elective surgery. During the study period 332 patients underwent AVR, 59 (17.8%) of these on an urgent basis. The principal reason for urgency was left ventricular (LV) failure (36 patients). Seven (11.9% [4.8 to 24.4%]) of the urgent patients died in hospital, an increased mortality rate compared with elective (2.9% [1.3 to 5.8%], p=0.003). Interestingly, the elective AVR mortality was significantly lower than predicted by EuroSCORE (6.4%), whereas the mortality rate for urgent AVR was consistent with EuroSCORE prediction (9.3%). Moreover, there were 5 further deaths in the urgent group within 12 months (overall mortality 20.3%). The non-elective patients had a prolonged stay in intensive care (p<0.001) and in hospital (median 10 days vs 8 days, p=0.009). Patients with decompensated LV function were investigated further by GP questionnaire (response rate 89%). Twenty-five (69%) of these 36 patients had a known murmur, for a median of 11 months (range 2 months to 40 years), and 30 patients (83%) had been symptomatic (median 9 months, range 1 month to 8 years). These data support the customary view that there is a symptomatic phase before LV function declines, and such patients may have a better outcome with more timely referral for elective surgery. We agree that asymptomatic patients with aortic stenosis merit closer attention. Many patients adapt their lifestyle to avoid progressive symptoms, and the incidence of sudden death in asymptomatic severe aortic stenosis is 5% (2). Exercise testing is an important and safe investigation in asymptomatic severe aortic stenosis (3). The strong correlation between the outcome of exercise testing and event-free survival (2), makes it a potent indicator for intervention. With appropriate follow-up, the patient who has been known to have a murmur for 20 years and yet presents late with decompensated LV function should be a character from the past. References 1 Chambers J. Aortic stenosis: Is common but often unrecognised. BMJ 2005;330:801-2. 2 Amato MCM, Moffa PJ, Werner KE, Ramires JAF. Treatment decision in asymptomatic aortic valve stenosis: role of exercise testing. Heart 2001;86:381-6. 3 Otto CM, Burwash IG, Legget ME, Munt BI, Fujioka M, Healy NL, et al. Prospective study of asymptomatic valvular aortic stenosis: Clinical, echocardiographic and exercise predictors of outcome. Circulation 1997;95:2262-70. Competing interests: None declared