Objective: Cardiac auscultation is a key clinical skill, particularly for the diagnosis of valvular heart disease (VHD). However, its utility has declined due to the widespread availability of echocardiography and diminishing emphasis on the importance of clinical examination. We aim to determine the contemporary accuracy of auscultation for diagnosing VHD in primary care. Methods: Cardiac auscultation was undertaken by one of two experienced general practitioners (primary care/family doctors) in a subset of 251 asymptomatic participants aged >65 years undergoing echocardiography within a large community-based screening study of subjects with no known VHD. Investigators were blinded to the echocardiographic findings. Newly detected VHD was classified as mild (mild regurgitation of any valve or aortic sclerosis) or significant (at least moderate regurgitation or mild stenosis of any valve). Results: Newly identified VHD was common, with mild disease in 170/251 participants (68%) and significant disease in 36/251 (14%). The sensitivity of auscultation was low for the diagnosis of mild VHD (32%) but slightly higher for significant VHD (44%), with specificities of 67% and 69%, respectively. Likelihood ratios were not statistically significant for the diagnosis of either mild or significant VHD in the overall cohort, but showed possible value for auscultation in non-overweight subjects (body mass index <25 kg/m²). Conclusion: Cardiac auscultation has limited accuracy for the detection of VHD in asymptomatic patients and is a poor diagnostic screening tool in primary care, particularly for overweight subjects. Ensuring easy access to echocardiography in patients with symptoms suggesting VHD is likely to represent a better diagnostic strategy.

Objectives: To evaluate the appropriateness of proton pump inhibitor (PPI) prescribing by conducting an audit of medical inpatients against recommended guidelines. Design: Questionnaire-based study. All medical wards were audited and different information was documented by patients' medical records review (both hospital visit notes and general practitioner's letters) and short interview, where we asked them to name the clinical reason for using PPI. Setting: This study was carried out in the setting of a regional hospital (537-bed, secondary care referral centre) in Ireland. Participants: The study participants were all consecutive medical patients admitted to the medical wards at Waterford Regional Hospital, Waterford. Main outcome measures: The appropriateness of PPI usage in our regional hospital by assessing the level of its prescribing against published guidelines (NICE, 2000). Results: During the audit period, 205 consecutive medical inpatients were assessed. Seventy-nine percent (162 out of 205) of the studied patients were found to be using PPI. For 45% ( n = 73) of patients, there was no documentation of valid indication for being on PPI. Overall, 64% of patients were prescribed PPI by hospital doctors, either during their current or previous admissions. We noted that 31% ( n = 51) of patients were taking PPI for ≥2 years and another 25% of patients were using PPI for about one year. Only 12% ( n = 20) of patients had undergone endoscopy procedures. Conclusion: Inappropriate use of PPI remains common in hospital practice. The risks of using long-term PPI must be weighed against the benefits.

### Learning objectives Valvular heart disease (VHD) is an important cause of morbidity and mortality whose prevalence is set to increase dramatically as a consequence of the increase in life expectancy in middle-income and high-income nations. Community echocardiographic screening has identified a major burden of undiagnosed VHD in older people, with some degree of valve degeneration in almost 50% and undiagnosed clinically significant (moderate–severe) disease affecting 1 in 10.1 Population statistics project an increase in the elderly population, such that there will be an estimated 4 million people aged between 75 and 84 years in the UK by 2018, while the population >85 years is set to double by 2028.2 Meanwhile, rheumatic heart disease accounts for a much higher proportion of valve pathology in developing nations and contributes to the growing worldwide prevalence.3 4 Despite wider appreciation of the emerging importance of VHD, the mechanisms underlying its development (particularly in degenerative pathology) are poorly understood, and the role of serum biomarkers in guiding clinical management in individual patients is relatively unexplored. European guidelines5 for the diagnosis and management of VHD make reference to the use of serum B-type natriuretic peptide (BNP) as a marker of prognosis in aortic stenosis (AS) and mitral regurgitation (MR), but thresholds are poorly defined, and there are no definitive recommendations on its use. As the prevalence of VHD increases, it will be increasingly important to develop our understanding of the factors that determine the rate of progression (allowing the planning of careful and efficient follow-up and timely intervention). A large proportion of …

Background and Objectives: The epidemiological data regarding mortality rates of adults with sarcoidosis and non-ischemic cardiovascular disease (CVD) are limited. A retrospective observational analysis was conducted to identify trends and disparities related to sarcoidosis and non-ischemic cardiovascular disease mortality among the adult US population from 1999 to 2022. Methods: We used the Centers for Disease Control and Prevention (CDC) WONDER database to extract death certificate data for the adult US population (≥25 years). The age-adjusted mortality rates (AAMRs) per 100,000 persons were calculated, and annual percent changes (APCs) were determined using Joinpoint. Results: Between 1999 and 2022, 23,642 deaths were identified related to non-ischemic CVD + sarcoidosis. The overall AAMR increased from 0.2 (95% CI, 0.2 to 0.3) in 1999 to 0.5 (95% CI, 0.5 to 0.6) in 2022. Females had a higher AAMR than males (0.6 vs. 0.5). Non-Hispanic (NH) blacks had the highest AAMR, followed by NH whites and Hispanic or Latinos. The southern region had the highest AAMR (0.7: 95% CI, 0.6–0.7), followed by the Midwest (0.6, 95% CI, 0.54–0.669), the Northeast (0.5, 95% CI, 0.5 to 0.6), and the West (0.4; 95% CI, 0.3–0.4). Urban and rural areas had comparable mortality rates (0.5 vs. 0.6). People aged 65+ had the highest AAMRs. Conclusions: The overall mortality rates for non-ischemic CVD and sarcoidosis have increased in the US from 1999 to 2022. Females and NH blacks had higher AAMRs, while a minimal variation was observed based on geographical regions. Early diagnosis and prompt management are the keys to reducing the mortality burden of non-ischemic CVD plus sarcoidosis.

Transcatheter aortic valve replacement (TAVR) is considered more effective than surgical aortic valve implantation for patients with a small aortic annulus (SAA), however, the comparative efficacy of different transcatheter heart valves (THVs) remains uncertain. A literature search was performed across databases from their inception until June 2024 to identify eligible randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. Clinical outcomes were evaluated using a random-effects model to pool risk ratios (RRs) with 95 % confidence intervals (CIs). The analysis included 10 studies with 2,960 patients. BEVs were associated with a significantly smaller indexed effective orifice area (MD: −0.18, 95 % CI: −0.27 to −0.10), and a higher transvalvular mean pressure gradient (MD: 5.07, 95 % CI 3.43 to 6.71) than SEVs. The risk for prosthesis-patient mismatch (PPM) (RR = 1.89, 95 % CI: 1.42 to 2.51) and severe PPM (RR = 2.80, 95 % CI: 1.96 to 4.0) was significantly higher for patients receiving BEVs than those receiving SEVs. Although nonsignificant differences were observed between BEVs and SEVs regarding 30-day and 1-year all-cause mortality, 30-day stroke rates, vascular complication, paravalvular leak, and permanent pacemaker implantation (p > 0.05), patients receiving BEVs were associated with a significantly increased risk of 1-year cardiovascular mortality (RR = 1.61, 95 % CI: 1.05 to 2.47) compared to those receiving SEVs. In patients with SAA, BEVs demonstrated worse hemodynamic performance as determined by the higher risk of moderate and severe PPM compared to SEVs. Moreover, the use of BEVs was associated with a higher risk of 1-year cardiovascular mortality.

Introduction Cardiac auscultation is an important clinical skill used by physicians in assessing and diagnosing valvular heart disease (VHD). The widespread use of echocardiography in the last three decades has coincided with a perceived decline in the utility of auscultation, particularly by general physicians. The ability of generalists to identify VHD in an unselected population has not been well characterised, so we aimed to determine the accuracy of auscultation in primary care for diagnosing VHD. Methods 251 participants aged 65 and over who were participating in the OxValve population cohort study were included. They were recruited from two participating GP surgeries and had no previous diagnosis of VHD. The participants underwent cardiac auscultation during the OxValve study visit by two experienced General Practitioners (GPs), neither of whom had a specialist interest in cardiology. A 5-point Likert scale was used to rate the ability to hear heart sounds (1=not at all; 5=perfectly) in addition to the presence or absence of a murmur, type of murmur and the ability to make a diagnosis based upon the auscultation findings. This was compared to transthoracic echocardiography performed at the same visit, but GPs were blind to the echocardiogram result, which was performed after auscultation. VHD was categorised as mild (either mild regurgitation [excluding trace/physiological] or aortic sclerosis) or significant (moderate/severe regurgitation or at least mild stenosis). Standard measures of diagnostic accuracy were calculated. Results 82 murmurs were heard by the GPs (80 systolic; 2 diastolic). Echocardiography identified mild VHD in 174 (69%) of the 251 participants, with more significant VHD present in 37 (15%). The ability to hear a murmur on auscultation was not related to age, BMI or heart rate (table 1). Auscultation had a sensitivity of 32% and specificity of 67% for diagnosing mild VHD, which improved slightly for significant VHD to a sensitivity of 43%, and specificity of 69% (table 2). The area under the curve on receiver operating characteristics (ROC) analysis was 0.50 for mild VHD and 0.56 for significant VHD (Figure-1) suggesting limited discriminatory ability. Conclusion GP auscultation has only moderate accuracy for diagnosing valvular heart disease in an unselected population, and the presence of an isolated murmur would not be a reliable indicator of valve disease. This study did not include patients with cardiovascular symptoms however, in whom the presence of a murmur may be more significant, and for whom echocardiography might be more appropriate. The accuracy of cardiac auscultation in diagnosing significant VHD ROC curve for significant VHD Area under the curve = 0.56 (95% CI 0.46 – 0.66) The likelihood of hearing of murmur on auscultation and its relationship with age, BMI & heart rate