title: Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory.
abstract: OBJECTIVE
  To evaluate the utility of auscultatory screening for detecting echocardiographically confirmed rheumatic heart disease (RHD) in high-risk children in the Northern Territory, Australia.
  
  
  METHODS
  Cross-sectional screening survey.
  
  
  METHODS
  Twelve rural and remote communities in the NT between September 2008 and June 2010.
  
  
  METHODS
  1015 predominantly Indigenous schoolchildren aged 5-15 2013s.
  
  
  METHODS
  All children underwent transthoracic echocardiography, using a portable cardiovascular ultrasound machine, and cardiac auscultation by a doctor and a nurse. Sonographers and auscultators were blinded to each others' findings and the clinical history of the children. Echocardiograms were reported offsite, using a standardised protocol, by cardiologists who were also blinded to the clinical findings.
  
  
  METHODS
  Presence of a cardiac murmur as identified by nurses (any murmur) and doctors (any murmur, and "suspicious" or "pathological" murmurs), compared with echocardiogram findings. RHD was defined according to the 2012 World Heart Federation criteria for echocardiographic diagnosis of RHD.
  
  
  RESULTS
  Of the 1015 children screened, 34 (3.3%) had abnormalities identified on their echocardiogram; 24 met echocardiographic criteria for definite or borderline RHD, and 10 had isolated congenital anomalies. Detection of any murmur by a nurse had a sensitivity of 47.1%, specificity of 74.8% and positive predictive value (PPV) of 6.1%. Doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity and 5.1% PPV, and the corresponding values for doctor detection of suspicious or pathological murmurs were 20.6%, 92.2% and 8.3%. For all auscultation approaches, negative predictive value was more than 97%, but the majority of participants with cardiac abnormalities were not identified. The results were no different when only definite RHD and congenital abnormalities were considered as true cases.
  
  
  CONCLUSIONS
  Sensitivity and positive predictive value of cardiac auscultation compared with echocardiography is poor, regardless of the expertise of the auscultator. Although negative predictive value is high, most cases of heart disease were missed by auscultation, suggesting that cardiac auscultation should no longer be used to screen for RHD in high-risk schoolchildren in Australia.
authors.affiliation: Menzies School of Health Research, Darwin, NT. kathryn.roberts@menzies.edu.au
authors.forename: Kathryn V
authors.initials: KV
authors.lastname: Roberts
authors.forename: Alex D H
authors.initials: AD
authors.lastname: Brown
authors.forename: Graeme P
authors.initials: GP
authors.lastname: Maguire
authors.forename: David N
authors.initials: DN
authors.lastname: Atkinson
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Carapetis
mesh_terms: D000293:Adolescent; D017677:Age Distribution; D002648:Child; D002675:Child, Preschool; D003430:Cross-Sectional Studies; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006326:Heart Auscultation / Q000706:statistics & numerical data*; D006337:Heart Murmurs / Q000175:diagnosis*; D006801:Humans; D015994:Incidence; D008297:Male; D008403:Mass Screening / Q000379:methods*; D015876:Northern Territory; D011237:Predictive Value of Tests; D012214:Rheumatic Heart Disease / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000453:epidemiology; D018570:Risk Assessment; D012424:Rural Population; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D017678:Sex Distribution