title: A bedside clinical prediction rule for detecting moderate or severe aortic stenosis.
abstract: OBJECTIVE
  To evaluate a bedside clinical prediction rule for detecting moderate or severe aortic stenosis.
  
  
  METHODS
  Cross-sectional study with independent comparison to a diagnostic reference standard, doppler echocardiography.
  
  
  METHODS
  Urban university hospital.
  
  
  METHODS
  Consecutive hospital inpatients (n = 124) who had been referred for echocardiography.
  
  
  RESULTS
  Participants were examined by a third-year general internal medicine resident and a staff general internist. We hypothesized in advance that absence of a murmur over the right clavicle would rule out aortic stenosis, while the presence of three or four associated findings (slow carotid artery upstroke, reduced carotid artery volume, maximal murmur intensity at the second right intercostal space, and reduced intensity of the second heart sound) would rule in aortic stenosis. Study physicians were unaware of echocardiographic findings. The outcome was echocardiographic moderate or severe aortic stenosis, defined as a valve area of 1.2 cm2 or less, or a peak instantaneous gradient of 25 mm Hg or greater. Absence of a murmur over the right clavicle ruled out aortic stenosis (likelihood ratio [LR] 0.10; 95% confidence interval [CI] 0.01, 0.44). The presence of three or four associated findings ruled in aortic stenosis (LR 40; 95% CI 6.6, 240). If a murmur was present over the right clavicle, but no more than two associated findings were present, then the examination was indeterminate (LR 1.8; 95% CI 0.93, 2.9).
  
  
  CONCLUSIONS
  A clinical prediction rule, using simple bedside maneuvers, accurately ruled in and ruled out aortic stenosis.
authors.affiliation: Department of Medicine, Toronto Hospital, Ont, Canada.
authors.forename: E
authors.initials: E
authors.lastname: Etchells
authors.forename: V
authors.initials: V
authors.lastname: Glenns
authors.forename: S
authors.initials: S
authors.lastname: Shadowitz
authors.forename: C
authors.initials: C
authors.lastname: Bell
authors.forename: S
authors.initials: S
authors.lastname: Siu
mesh_terms: D000328:Adult; D000368:Aged; D001024:Aortic Valve Stenosis / Q000175:diagnosis* / Q000000981:diagnostic imaging; D002983:Clinical Competence; D016001:Confidence Intervals; D003430:Cross-Sectional Studies; D015150:Echocardiography, Doppler; D005260:Female; D006337:Heart Murmurs / Q000175:diagnosis* / Q000000981:diagnostic imaging; D006785:Hospitals, University; D006801:Humans; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D009864:Ontario; D010808:Physical Examination; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D014505:Urban Population