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50 Years Ago in THE JOURNAL OF PEDIATRICS

Auscultation in the Diagnosis of Intracardiac Acyanotic Congenital Heart DiseaseKaplan S, Daoud G. J Pediatr 1961;60:746-53

In an article as true today, with someminor exceptions, as it was in 1961, Kaplan andDaoud describe the auscultatoryfindings in atrial septal defect, ventricular septal defect, endocardial cushion defect, aortic stenosis, and pulmonic

stenosis. These descriptions are based on precise correlations of cardiac catheterization pressure recordings with pho-nocardiograms. At the time, the emerging technical advances related to both cardiac surgery and catheterization madeaccurate diagnosis of congenital heart disease in youth critically important. Studies of school-based screening for con-genital defects with tape recordings were conducted in the 1960s. In the 1980s, skilled auscultation was determined tohave a sensitivity and specificity for distinguishing children with normal hearts from children with congenital heartdefects <95% to 98%, test characteristics rarely achieved in clinical medicine today.

Why then, in an era when phonocardiograms can be found on the internet, do attempts to teach auscultation “fallon deaf ears”? One certain reason is expressed by Kaplan and Daoud: “Cardiac auscultation is an art in which com-petence is acquired with experience and effort.” Because primary correction of congenital heart defects occurs ininfancy and rheumatic heart disease (another excellent source of chronic murmurs) is no longer highly prevalent,the number of patients with pathologic murmurs is dramatically reduced, thus the ability to experience these murmursin training or in practice has declined. A second reason is the emergence of echocardiography as an accurate diagnostictool. Less well-appreciated is echocardiograms having much poorer specificity, because of the diagnosis of many tran-sient or insignificant conditions. Third, as discussed by Kaplan and Daoud, auscultation is only marginally useful inchronic follow-up of patients.

Although the clinical role of auscultation is diminished, it remains an extraordinarily useful, though underused,diagnostic skill. Hundreds of thousands of echocardiograms would not be done and millions of health care dollarswould be saved if findings of an innocent murmur or the recognition of a variably split second heart sound were giventhe diagnostic prominence they deserve. If only there was a way to put auscultation on board certification exams..

Samuel S. Gidding, MDNemours Cardiac Center

A. I. DuPont Hospital for ChildrenWilmington, Delaware

10.1016/j.jpeds.2011.11.045

easures, and Neurocognitive Functioning in 735