Knee-elbow position to detect the aortic diastolic murmur of aortic regurgitation
1
LETTERS* RESULTS OF •MEDICAL VERSUS SURGICAL TREATMENT OF UNSTABLE ANGINA PECTORIS The recent report of the National Coopera- tive Study Group to Compare Medical and Surgical Therapy 1 is important, useful, and the result of an enormous amount of very hard work. However, the Study Group evi- dently did not address (or measure) a variable of supreme importance in the prognosis and management of single-vessel coronary disease (left anterior descending [LAD] or otherwise). Two recent cases illustrate this concept. Patient A, a 64-year-old woman, had pre- viously had exercise angina and recent severe repeated rest pain with transient T-wave changes. Angiography showed a severe (>95%) proximal LAD coronary artery lesion without other important disease. The LAD coronary artery was developmentally small, supplying only a small percentage of the heart. She received a prolonged and system- atic in-hospital medical trial with repeated attempts at ambulation. We finally gave up, and she had successful surgery. Patient B, a 45-year-old man, had previ- ously had exercise angina and recent severe repeated rest pain, with transient S-T and T-wave changes. Angiography showed a se- vere (>95%) proximal LAD coronary artery lesion without other important disease. The LAD coronary artery was very large; its main trunk wrapped around the apex and supplied the entire inferoanterior portion of the heart, and numerous large branches ran to the an- terior and lateral left ventricle. We estimated that this vessel alone supplied >60% of the left ventricle. Coronary vein graft surgery was promptly recommended and accomplished. We are convinced that these patients il- lustrate a concept that must be considered in trials involving prognosis and therapy. If Patient A had had an infarction of most of her diseased vessel's territory, she would probably have had a small but detectable anterior infarction, with acceptable ventric- ular function afterwards and an excellent prognosis after recovery. If Patient B had had an infarction of most of his diseased vessel's territory and had survived, he would proba- bly have had an enormous anteroseptal transmural infarction, with dismal immediate prognosis and severely impaired function. "Single-vessel coronary disease" cannot be understood or effectively analyzed without reference to the percentage of the heart so served or its equivalent. Existing methods for measuring this variable need to be perfected and incorporated into future studies. Studies which, by their design, combine "Patient A and Patient B" may be unwittingly conceal- ing important prognostic information. A. Jarrell Ral~r, MO George W. Vetrovec, MD Richmond, Virginia * Letters (from the United States) concerning a particular article in the Journal must be received within 2 months of the article's publication, and should be limited (with rare exceptions) to 2 dou- ble-spaced typewritten pages. Two copies must be submitted. REPLY: Drs. Raper and Vetrovec are prob- ably correct in their consideration of a dif- ference in prognosis for the patient with proximal stenosis of a small or large anterior descending coronary artery. We agree with their request that methods for measuring this variable be perfected and incorporated in future studies. In fact, we argue that in ad- dition to location of stenosis, percentage of stenosis, length of stenosis, and number of stenoses in the same vessel influence prog- nosis. Interestingly, the ongoing National Heart, Lung, and Blood Institute study (Coronary Artery Surgery Study [CASS]) did make substantial changes in recording coro- nary artery anatomy for comparison in pro- spective studies. The study of LAD disease in the presence of unstable angina as reported by the Na- tional Cooperative Study Group 1 did not in- corporate the described variation in left an- terior anatomy. Certainly we as both inves- tigators and clinicians have urged that our study, which we think has had a profound influence on the early management of un- stable angina, be used in context and its findings incorporated into patient manage- ment as applicable. Thus, the management of each specific patient must continue to be individualized, although studies such as ours should provide an important point of de- parture for such management. Richard O. Russell, Jr., MD C. Richard Conti, MD Eugene Passamanl, MD For the National Cooperative Study Group 1. Unstable Angina Pectoris Study Group: National Coop- erative Study Group to Compare Medicaland Surgical Therapy. IV. Resultsin patientswith left anterior de- scending disease.Am J Cardio11981;48:517-524. LEFT VENTRICULAR ANEURYSM BY ANGIOGRAM: A PROBLEM OF DEFINITION The prognostic significance of left ventricular (LV) aneurysm from the Coronary Artery Surgery Study (CASS) has been described by Faxon et al. 1 However, the study is plagued by the common denominator in all studies attempting to look at LV aneurysm, namely, definition. In their study, the authors define LV aneurysm as a segment of LV wall pro- truding abnormally "from the expected out- line of the LV chamber." The implication is that this entity contrasts in some way to an akinetic segment of left ventricle. This may or may not be true. An aneurysm to 1 ob- server may in fact be an akinetic segment to another. Therefore, it is not surprising that Faxon et al found no difference in the mor- tality of patients with LV aneurysm com- pared with those without aneurysm, but with an equal degree of LV function. The authors may have been comparing the same group with itself. The second problem with this study is that it evaluates the angiographic analysis of 15 Participating institutions in this cooperative trial. Although there was a 93% interobserver agreement within participating institutions in regard to segmental wall motion abnor- mality, the authors do not tell us what the agreement was in terms of definition of an- eurysm. Third, although the authors use an angio- graphic definition of aneurysm, they quote several pathologic studies in defining the natural history of this entity. It is probable that there is a certain degree of discrepancy between angiographic and pathologic aneu- rysms. Until an adequate method is determined to account for cardiac motion, which may simulate aneurysmal bulging in a patient with an akinetic segment, the definition of LV aneurysm will remain somewhat arbitrary. Any study that attempts to define the natural history of LV aneurysm will, to a certain ex- tent, be misleading in its conclusions. Thus, any results that are drawn from the study of Faxon et al, I believe, should be taken with extreme caution. Barry F. Ureisky, MD Pittsburgh, Pennsylvania 1. Faxon DP, Ryan TJ, Davis KB, McCabe CH, Myers W, Lesperance J, Shaw R, Tong TGL. Prognostic signifi- cance of angibgraphically documented left ventricular aneurysm from the Coronary Artery Surgery Study (CASS). Am J Cardio11982;50:157-164. KNEE-ELBOW POSITION TO DETECT THE AORTIC OIASTOLIC MURMUR OF AORTIC REGURGITATION Fifteen years ago one of us (DK) tried to convince a group of medical students that a patient had an aortic diastolic murmur. In the classic sitting-up, leaning-forward position, with the breath held in expiration, I heard the murmur but they did not. I asked the patient to turn to the knee- elbow position and, pressing the stethoscope from below, on his sternum, the murmur be- came more audible. The first 2 students could hear the murmur easily, but alas the patient became tired and laid himself on his belly. We continued to press the stethoscope from be- neath, on the sternum, and the murmur was even more audible. Since then, when looking for an aortic di- astolic murmur we put the patients on their abdomen, turn the head to the side opposite to our standing position, press the stetho- scope blindly between the breasts, choose the most audible point, and ask them to stop breathing in expiration. We find that this is a much more comfort- able way to hear the murmur for the patient and for the inexperienced ear, rather than use of the squatting position or isometric exer- cise, which accentuates the murmur but is noisy. The patient is better able to remain quiet without much distress. We have been unable to find this method of auscultation previously described. David Kohn Edith FlataU Dan Schiller Omar Daher Afula, Israel 918
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Transcript of Knee-elbow position to detect the aortic diastolic murmur of aortic regurgitation
LETTERS*
R E S U L T S OF •MEDICAL V E R S U S S U R G I C A L T R E A T M E N T OF
U N S T A B L E ANGINA PECTORIS The recent report of the National Coopera- tive Study Group to Compare Medical and Surgical Therapy 1 is important, useful, and the result of an enormous amount of very hard work. However, the Study Group evi- dently did not address (or measure) a variable of supreme importance in the prognosis and management of single-vessel coronary disease (left anterior descending [LAD] or otherwise). Two recent cases illustrate this concept.
Patient A, a 64-year-old woman, had pre- viously had exercise angina and recent severe repeated rest pain with transient T-wave changes. Angiography showed a severe (>95%) proximal LAD coronary artery lesion without other important disease. The LAD coronary ar tery was developmentally small, supplying only a small percentage of the heart. She received a prolonged and system- atic in-hospital medical trial with repeated a t tempts at ambulation. We finally gave up, and she had successful surgery.
Patient B, a 45-year-old man, had previ- ously had exercise angina and recent severe repeated rest pain, with transient S-T and T-wave changes. Angiography showed a se- vere (>95%) proximal LAD coronary artery lesion without other important disease. The LAD coronary artery was very large; its main trunk wrapped around the apex and supplied the entire inferoanterior portion of the heart, and numerous large branches ran to the an- terior and lateral left ventricle. We estimated tha t this vessel alone supplied >60% of the left ventricle. Coronary vein graft surgery was promptly recommended and accomplished.
We are convinced tha t these patients il- lustrate a concept tha t must be considered in trials involving prognosis and therapy. If Pat ient A had had an infarction of most of her diseased vessel's territory, she would probably have had a small but detectable anterior infarction, with acceptable ventric- ular function afterwards and an excellent prognosis after recovery. If Patient B had had an infarction of most of his diseased vessel's territory and had survived, he would proba- bly have had an enormous anteroseptal transmural infarction, with dismal immediate prognosis and severely impaired function.
"Single-vessel coronary disease" cannot be understood or effectively analyzed without reference to the percentage of the heart so served or its equivalent. Existing methods for measuring this variable need to be perfected and incorporated into future studies. Studies which, by their design, combine "Pat ient A and Pat ient B" may be unwittingly conceal- ing important prognostic information.
A. Jarrell Ral~r, MO George W. Vetrovec, MD
Richmond, Virginia
* Letters (from the United States) concerning a particular article in the Journal must be received within 2 months of the article's publication, and should be limited (with rare exceptions) to 2 dou- ble-spaced typewritten pages. Two copies must be submitted.
REPLY: Drs. Raper and Vetrovec are prob- ably correct in their consideration of a dif- ference in prognosis for the patient with proximal stenosis of a small or large anterior descending coronary artery. We agree with their request that methods for measuring this variable be perfected and incorporated in future studies. In fact, we argue t h a t in ad- dition to location of stenosis, percentage of stenosis, length of stenosis, and number of stenoses in the same vessel influence prog- nosis. Interestingly, the ongoing National Heart, Lung, and Blood Institute study (Coronary Artery Surgery Study [CASS]) did make substantial changes in recording coro- nary artery anatomy for comparison in pro- spective studies.
The study of LAD disease in the presence of unstable angina as reported by the Na- tional Cooperative Study Group 1 did not in- corporate the described variation in left an- terior anatomy. Certainly we as both inves- tigators and clinicians have urged that our study, which we think has had a profound influence on the early management of un- stable angina, be used in context and its findings incorporated into pat ient manage- ment as applicable. Thus, the management of each specific pat ient must continue to be individualized, although studies such as ours should provide an important point of de- parture for such management.
Richard O. Russell, Jr., MD C. Richard Conti, MD
Eugene Passamanl, MD For the National Cooperative Study Group
1. Unstable Angina Pectoris Study Group: National Coop- erative Study Group to Compare Medical and Surgical Therapy. IV. Results in patients with left anterior de- scending disease. Am J Cardio11981;48:517-524.
LEFT V E N T R I C U L A R A N E U R Y S M BY ANGIOGRAM: A P R O B L E M OF
DEFINIT ION The prognostic significance of left ventricular (LV) aneurysm from the Coronary Artery Surgery Study (CASS) has been described by Faxon et al. 1 However, the study is plagued by the common denominator in all studies attempting to look at LV aneurysm, namely, definition. In their study, the authors define LV aneurysm as a segment of LV wall pro- truding abnormally "from the expected out- line of the LV chamber." The implication is tha t this entity contrasts in some way to an akinetic segment of left ventricle. This may or may not be true. An aneurysm to 1 ob- server may in fact be an akinetic segment to another. Therefore, it is not surprising tha t Faxon et al found no difference in the mor- tality of patients with LV aneurysm com- pared with those without aneurysm, but with an equal degree of LV function. The authors may have been comparing the same group with itself.
The second problem with this study is that it evaluates the angiographic analysis of 15 Participating institutions in this cooperative trial. Although there was a 93% interobserver agreement within participating institutions
in regard to segmental wall motion abnor- mality, the authors do not tell us what the agreement was in terms of definition of an- eurysm.
Third, although the authors use an angio- graphic definition of aneurysm, they quote several pathologic studies in defining the natural history of this entity. I t is probable tha t there is a certain degree of discrepancy between angiographic and pathologic aneu- rysms.
Until an adequate method is determined to account for cardiac motion, which may simulate aneurysmal bulging in a patient with an akinetic segment, the definition of LV aneurysm will remain somewhat arbitrary. Any study that attempts to define the natural history of LV aneurysm will, to a certain ex- tent, be misleading in its conclusions. Thus, any results tha t are drawn from the study of Faxon et al, I believe, should be taken with extreme caution.
Barry F. Ureisky, MD Pittsburgh, Pennsylvania
1. Faxon DP, Ryan TJ, Davis KB, McCabe CH, Myers W, Lesperance J, Shaw R, Tong TGL. Prognostic signifi- cance of angibgraphically documented left ventricular aneurysm from the Coronary Artery Surgery Study (CASS). Am J Cardio11982;50:157-164.
K N E E - E L B O W POSIT ION TO DETECT THE AORTIC OIASTOLIC
M U R M U R OF AORTIC REGURGITAT ION
Fifteen years ago one of us (DK) tried to convince a group of medical students that a patient had an aortic diastolic murmur. In the classic sitting-up, leaning-forward position, with the breath held in expiration, I heard the murmur but they did not.
I asked the pat ient to turn to the knee- elbow position and, pressing the stethoscope from below, on his sternum, the murmur be- came more audible. The first 2 students could hear the murmur easily, bu t alas the patient became tired and laid himself on his belly. We continued to press the stethoscope from be- neath, on the sternum, and the murmur was even more audible.
Since then, when looking for an aortic di- astolic murmur we put the patients on their abdomen, turn the head to the side opposite to our standing position, press the stetho- scope blindly between the breasts, choose the most audible point, and ask them to stop breathing in expiration.
We find that this is a much more comfort- able way to hear the murmur for the patient and for the inexperienced ear, rather than use of the squatting position or isometric exer- cise, which accentuates the murmur but is noisy. The pat ient is bet ter able to remain quiet without much distress.
We have been unable to find this method of auscultation previously described.
David Kohn Edith FlataU Dan Schiller Omar Daher Afula, Israel
918
