Prevalence of iatrogenic heart murmurs in a population of apparently healthy cats.

OBJECTIVES: To determine the prevalence of iatrogenic heart murmurs in a population of apparently healthy cats and to investigate factors that may predispose cats to iatrogenic murmurs. MATERIALS AND METHODS: Apparently healthy cats presenting for routine examinations were prospectively enrolled. Following a physical examination to confirm there were no abnormalities, a cardiac examination was performed before and during a provocative manoeuvre performed independently by two clinicians. The provocative manoeuvre was performed on the right side of the chest wall by applying gentle pressure with a stethoscope to ascertain whether a murmur became audible, graded using a modified descriptive scale (soft/moderate). The cat's heart rate before and during the provocative manoeuvre and their age, sex, body condition score and bodyweight were recorded. RESULTS: One hundred and six cats were prospectively enrolled. The average prevalence of iatrogenic murmurs was 28.2% with good interobserver agreement recorded on both the presence (kappa 0.67 and 0.62) and grade of the murmur (kappa 0.6 and 0.53). A significant association was noted between age and body condition score, with iatrogenic murmurs more likely in cats with increasing age and decreasing body condition score. There was no association between heart rate and the presence of an iatrogenic murmur. CLINICAL SIGNIFICANCE: Iatrogenic murmurs are a common finding in cats with increasing prevalence noted in older and lean cats. Iatrogenic murmurs should therefore be considered as a differential diagnosis in a cat when an audible soft systolic right-sided murmur occurs with gentle pressure application to the chest wall during auscultation.

Coronary artery fistula in adults: Incidence and appearance on cardiac computed tomography and comparison of detectability and hemodynamic effects with those on transthoracic echocardiography.

BACKGROUND: The widespread use of cardiac computed tomography (CT) has increased the incidental discovery of fistulas of the coronary artery (CAF). This condition is rare and can affect hemodynamic parameters, but few reports focus on its hemodynamic effects. We investigated the frequency and types of CAF on CT and compared them with those of transthoracic echocardiography (TTE) to evaluate the detectability of CAF and its hemodynamic effects. MATERIALS AND METHODS: We retrospectively evaluated cardiac CT images of 6789 adult patients who underwent imaging from January 1, 2013 through September 30, 2019 at our institution. We assessed the CT images for the presence of CAF and compared our findings with those obtained by TTE in control cases without CAF. RESULTS: The prevalence of CAF determined with cardiac CT was 0.91%, with the left anterior descending artery (67.7%) as the most common site of origin and the main pulmonary artery (82.3%) as the most common origin of drainage. The incidence of aneurysm accompanying CAF was 48.4%. Color Doppler in TTE demonstrated abnormal flow that would suggest the presence of CAF of only 23.1%. Echocardiographic findings of hemodynamics did not differ significantly between patients with and without CAF nor between elderly and non-elderly patients with CAF. CONCLUSIONS: Our study revealed differing prevalence and types of CAF from those reported using coronary angiography and little impact of CAF on hemodynamics. Color Doppler in TTE did not readily depict abnormal flow that might suggest the presence of a fistula, but cardiac CT allowed noninvasive and comprehensive assessment of CAF. Thus, we believe the acquisition of cardiac CT is necessary to establish the cause of continuous murmur that is not identified with TTE.

Bridging the Cardiac Needs of a Large, Underserved Immigrant and Resettled Refugee Population.

OBJECTIVE: To describe a monthly outreach pediatric cardiology clinic established to better understand the cardiac needs of immigrant/resettled refugee children. STUDY DESIGN: Data obtained between 2014 and 2017 from a monthly pediatric cardiology clinic at a Federally Qualified Health Center were analyzed using descriptive statistics. RESULTS: A total of 366 patients (222 male, 61%) were evaluated. Indications for referral included murmur (242, 66%), nonexertional symptoms (31, 9%), exertional symptoms (16, 4%), history of cardiac surgery/transcatheter interventions (15, 4%), previous diagnosis of heart conditions without intervention (13, 4%), arrhythmia/bradycardia (13, 4%), and others (36, 10%). Echocardiograms were performed on 136 patients (67 were abnormal, 49%). The most common final diagnoses include innocent murmur in 201 (55%), simple congenital heart disease in 61 (16%), complex congenital heart disease in 3 (1%), and acquired heart disease in 3 (1%). A total of 15 patients (4%) were ultimately determined to require surgical or cardiac catherization as an intervention. Patients have been followed for a median of 0.7 years (range 0-3.3 years). CONCLUSIONS: Rates of abnormal echocardiograms suggest a greater likelihood of congenital or acquired heart disease at time of initial consultation compared with nonimmigrant/refugee populations. The most common indication for referral to the outreach pediatric cardiology clinic was a murmur. Collaborative efforts between physicians and support services are essential in assisting this vulnerable population access pediatric subspecialty care.

Neonatalogist-performed echography in neonatology: a Tunisian experience.

INTRODUCTION: Echocardiography is an important tool for diagnosis of cardiac abnormalities that can impact the management and outcome of the sick newborn in the intensive care unit. A preliminary echocardiogram performed by the neonatologist under the supervision of a paediatric cardiologist for interpretation and review is an alternate when there is not a cardiologist on site. The aim of this study was to evaluate frequency of use, neonatal characteristics, and indications of neonatologist-performed echocardiography in a Tertiary Neonatal Care Centre in Tunisia. METHODS: Prospective observational study in a tertiary Neonatal Intensive Care Unit (NICU) in Monastir (Tunisia) from April 2015 to February 2017.An echocardiography was indicated in these situations: cyanosis, signs of circulatory shock, clinical signs of heart failure, presence of a murmur, arrhythmia, and abnormal pulses in upper and/or lower extremities, suspected persistent pulmonary hypertension in neonates, clinically suspected patent ductus arteriosus, maternal diabetes mellitus and polymalformative syndrome. The findings of echocardiography were confirmed by pediatric cardiologist in case of structural or functional cardiac abnormalities. RESULTS: 675 echocardiography were performed among them 535 were normal and 25 revealed a persistent arterial duct treated with E2 postaglandins (Prostine®) or paracetamol according to a pre-established protocol. 80 Congenital heart diseases were retained, which represented an incidence of 7 ‰ live births. The second time of our work consisted to study the 55 cases of cardiac diseases confirmed after exclusion of atrial communication. The antenatal diagnosis was made in 11% of cases. The main signs indicating the echocardiogram were the heart murmur (22 cases) followed by cyanosis (6 cases). A malformation association and / or a chromosomal aberration have been noted in 36% of cases. For half of the patients, the cardiac ultrasound was performed before the first 24 hours of life. This examination was completed by a thoracic angioscan in 9 patients. 31% of newborns had an infusion of Prostaglandins for an average duration of 11 days [2-60 days]. One-third of newborns (35 cases) required respiratory assistance. A palliative surgery was made in 7 cases and curative one in 4 cases. The average age at the time of the intervention was 20 days. The neonatal mortality rate was 40%. CONCLUSION: Echocardiography is being utilized progressively on the neonatal unit, and has been indicated to have a high return for both structural and functional cardiac abnormalities. It is important to encourage collaboration with pediatric cardiologists to establish standards for training and to develop guidelines for clinical practice in order to improve neonatal care.

Consultorio de orientaciòn de cardilogía: epidemiología y perfil de la población / Cardiology guidance clinic: Epidemiology and profile of the population

Introducción: Las cardiopatías congénitas (CC) son las anomalías congénitas más frecuentes. Representan el 0,8-1,2% de todos los defectos del nacimiento y tienen una prevalencia de alrededor de 5,8 por cada 1000 personas. El Servicio de Cardiología del Hospital Garrahan es un centro de referencia nacional y de países limítrofes donde se realizan 18000 consultas anuales. Los pacientes que concurren por primera vez se atienden en el consultorio de orientación. Objetivo: Describir la epidemiologia y perfil de los pacientes que asisten diariamente al consultorio de orientación de cardiología infantil en un hospital pediátrico de tercer nivel de Buenos Aires. Métodos: Entre septiembre de 2017 y febrero de 2018 se recolectaron los datos de 1000 pacientes atendidos en forma consecutiva en el consultorio de orientación de cardiología. A la totalidad de los pacientes se les realizó anamnesis, examen físico cardiovascular, electrocardiograma, y en los casos en los que se consideró necesario, saturometría, radiografía de tórax y/o ecocardiograma. Las variables a considerar fueron edad, procedencia, presencia o ausencia de cardiopatías congénitas o adquiridas, soplo, cianosis, insuficiencia cardíaca, estado nutricional, síndromes genéticos asociados, métodos diagnósticos e indicaciones terapéuticas implementadas. Se subdividió la población en cinco grupos: Grupo A (pacientes con cardiopatía congénita), Grupo B (cardiopatías operadas), Grupo C (miocardiopatías), Grupo D (arritmias), Grupo E (corazón sano). Resultados: La edad mediana fue 4.86 años (0.03 a 18.9 años). El 64% de los pacientes procedían de la provincia de Buenos Aires. Los motivos de consulta fueron: interconsultas internas 29.5%, derivación por cardiopatía 27.2%, soplo 17.6%, síncope 7%, segunda opinión 5.1%, arritmias 4.8%, precordialgia 3.1%, palpitaciones 2.6%, episodio paroxístico 1.4%, cardiomegalia 0.7%, disnea 0.5%, mal progreso de peso 0.3%. El 10.6% tenían un síndrome genético. Grupo A: 252 pacientes con una edad mediana de 1.9 años. Las cardiopatías acianóticas con hiperflujo pulmonar fueron las más frecuentes (66.66%, 168/252). Grupo B: 51 pacientes, 23.52%(12/51) fueron Fallot reparados en otra institución. Grupo C: 22 pacientes, siendo la miocardiopatía hipertrófica la más frecuente. Grupo D: 47 pacientes, la preexcitación ventricular fue el hallazgo más frecuente (34,04%, 16/47). Grupo E: 628 pacientes, 45.70% (287/628) derivados por pediatras del área ambulatoria, principalmente para valoración de pacientes con enfermedades sistémicas o síndromes genéticos. Conclusión: Los motivos de derivación al consultorio de orientación de cardiología fueron muy diversos. La mayoría de los pacientes provenían de provincia de Buenos Aires. Solamente el 37.2% presentó algún problema cardiológico de base. El 91% de los pacientes que consultaron por soplo, no tuvieron cardiopatía. El grupo correspondiente a los pacientes con cardiopatías no operadas (grupo A) fue el de menor edad (mediana de 1.9 años) y las cardiopatías simples no cianóticas con hiperflujo pulmonar representaron el 66.66% de las cardiopatías. La implementación del ecocardiograma portátil en el consultorio de orientación permitió confirmar el diagnóstico y definir la conducta terapéutica en el 29.4% de los pacientes durante la primer consulta (AU)

Introduction: Congenital heart defects (CHD) are the most common congenital abnormalities. They account for 0.8-1.2% of all birth defects and have a prevalence of around 5.8 per 1000 people. The Department of Cardiology of Garrahan Hospital is a national and bordering-country reference center, receiving 18000 consultations annually. Patients seen for the first time are assessed at the cardiology guidance clinic. Objective: To describe the epidemiology and profile of patients who seen daily at the child cardiology guidance clinic of a third-level pediatric hospital in Buenos Aires. Methods: Between September 2017 and February 2018, data from 1000 patients consecutively seen at the cardiology guidance clinic were collected. All patients underwent anamnesis, cardiovascular physical examination, electrocardiogram and, if considered necessary, pulse oximetry, chest x-ray, and/or echocardiogram. The variables considered were age, place of origin, presence or absence of congenital or acquired heart disease, murmur, cyanosis, heart failure, nutritional status, associated genetic syndromes, diagnostic methods, and treatment. The population was divided into five groups: Group A (patients with congenital heart defects), Group B (operated cardiopathies), Group C (myocardiopathies), Group D (arrhythmias), Group E (healthy heart). Results: Median age was 4.86 years (0.03 to 18.9 years). Overall, 64% of patients came from the province of Buenos Aires. The reasons for consultation were: internal consultations 29.5%, cardiac shunt 27.2%, murmur 17.6%, syncope 7%, second opinion 5.1%, arrhythmias 4.8%, precordialgia 3.1%, palpitations 2.6%, paroxysmal episode 1.4%, cardiomegaly 0.7%, dyspnea 0.5%, 0.3% poor weight gain. A genetic syndrome was identified in 10.6%. Group A: 252 patients with a median age of 1.9 years. Acyanotic congenital heart defect with pulmonary hyperflow was the most common (66.66%, 168/252). Group B: 51 patients, 23.52% (12/51) had tetralogy of Fallot repaired at another institution. Group C: 22 patients, in whom hypertrophic cardiomyopathy was the most common. Group D: 47 patients, in whom ventricular preexcitation was the most common finding (34.04%, 16/47). Group E: 628 patients, 45.70% (287/628) referred by pediatricians from the outpatient clinics, mainly for the assessment of systemic diseases or genetic syndromes. Conclusion: The reasons for referral to the cardiology guidance clinic were varied. Most of the patients came from the province of Buenos Aires. Only 37.2% had an underlying heart disease. Of the patients who consulted because of a murmur, 91% did not suffer from heart disease. The group of patients with congenital heart disease who had not undergone surgery (group A) was the youngest (median 1.9 years) and simple non-cyanotic heart disease with pulmonary hyperflow accounted for 66.66% of heart diseases. The implementation of the portable echocardiography in the guidance clinic confirmed the diagnosis and defined the management in 29.4% of patients during the first consultation (AU)

Prevalence and diagnostic characteristics of non-clinical mitral regurgitation murmurs in North American Whippets.

OBJECTIVES: To assess the prevalence of functional ejection murmurs and murmurs of mitral regurgitation (MR) due to myxomatous mitral valve disease in healthy whippets; to assess the diagnostic value of auscultation to detect MR; and investigate the relationship between age and presence of echocardiographically documented MR (MRecho). ANIMALS: A total of 200 healthy client-owned Whippets, recruited at national shows between 2005 and 2009 were involved in this study. METHODS: Cross-sectional study. Dogs were examined by auscultation by one examiner and Doppler echocardiography by another, and results were compared. Prevalence of types of murmurs and MRecho were calculated and correlated to age. Accuracy of auscultation to predict MRecho was calculated. RESULTS: Left-sided systolic heart murmurs were detected in 185/200 (93%) of dogs. Left apical systolic murmurs (Lapex) were detected in 57/200 (29%) and left basilar systolic murmurs (Lbase) in 128/200 of the dogs (64%). MRecho was present in 76/200 (38%) dogs. Prevalence MRecho was correlated with age (r = 0.96, p=0.0028). Mitral regurgitation detected by echocardiography was present in 12/78 (15%) of the dogs ≤ 2 years of age and in 59% of the dogs at 7-8 years old. Detection of Lapex predicted MRecho with sensitivity 65%, specificity 94%, positive predictive value 86%, and negative predictive value 81%; and accuracy improved when only dogs with more intense Lapex (grade ≥ 3/6) were considered. CONCLUSIONS: Systolic murmurs are common in North American Whippets and this breed exhibits a high prevalence of MRecho, which may be documented at a relatively early age. Whippets with non-clinical MRecho may not be identifiable by auscultation alone; echocardiographic examination may be required to exclude a diagnosis of MR. Louder heart murmurs allow more accurate localization in this population.

Infective endocarditis in Principal Hospital of Dakar: a retrospective study of 42 cases over 10 years.

Infective Endocarditis (IE) is an endocardial infection usually caused by bacteria that affects not only the native heart valves but also, with increasing frequency intravascular implanted devices and congenital heart diseases. Despite medical advances, IE remains a life-threatening disease with substantial morbidity and mortality. In Africa, its diagnosis and treatment are still a major challenge in clinical practice. The objective of this work was to study the epidemiological, clinical features, diagnostic techniques currently used in medical practice and the range of micro-organisms that are responsible. This was a retrospective study done at Principal Hospital of Dakar. We include all patients who were admitted with clinical manifestations of definite or possible IE according to the extended DUKE criteria between January 1st, 2005 and December 31st, 2014. We collected and analyzed epidemiological, clinical, paraclinical and outcomes data of 42 patients. Hospital prevalence of IE was 0.078% (42/53711). The mean age was 27.5+/- 18 years with a sex ratio (M/F) of 0.55. IE were more common in patients with damaged or abnormal heart valves (78.6%) and in thoses with underlying structural defects (14.3%). The most common presenting symptoms were fever (90%) and cardiac murmurs (81%). Extracardiac clinical manifestations were very rare. The usual laboratory parameters of inflammation were elevated in 90% of patients. Blood cultures were negative in 50% of cases and positive in 21.4%. The main organism found was Staphylococcus aureus. Echocardiography found vegetations in 95.2% of cases, chamber enlargement in 73.8% and mitral regurgiation in 83.3%. Broad-spectrum penicillins including ampicillin and gentamycine were used for all patients. Major complications were heart failure (47.6%). Strokes and cerebral abcess (23.8%) and Vascular emboli 14.3%. Hospital mortality was 31%. IE remains a life-threatening disease with hight mortality despites improved techniques of diagnosis and modern antibiotics.

Registry report of structural and functional cardiac abnormalities diagnosed by echocardiography in an asymptomatic population.

BACKGROUND: The epidemiology of heart disease is changing, with rheumatic heart disease becoming less common but degenerative valve disorders, heart failure and atrial fibrillation (AF) increasing. OBJECTIVE: We sought to determine the prevalence of structural cardiac abnormalities in the apparently symptom-free adult population within our prospective echocardiography (echo) registry. METHODS: Our echo registry comprised echo studies and associated demographic and clinical data obtained prospectively from 362 consecutive asymptomatic subjects aged 50-74 years and without known heart disease referred between 2011 and 2012 from general practices in the South East of England. RESULTS: 221 echo abnormalities were detected in 178 (49%) subjects (46% men; mean (±SD) age 63.9±9.2 years; 98% Caucasian). A major abnormality was detected in seven subjects: four had a large secundum atrial septal defect, one had critical aortic stenosis, one severe mitral regurgitation and one features of hypertrophic cardiomyopathy. Twelve subjects had left ventricular systolic dysfunction with an ejection fraction (EF) <50% (of whom 10 had EF <40%). Four subjects had AF. Minor echo abnormalities were evident in the remaining 171 (47%) subjects. Abnormalities were commoner in patients with cardiovascular risk factors or a history of cardiac disease than in those without (53% vs 38%). In multivariate analyses stratified by gender, for women, increased age (F=33.3, p<0.001) and systolic blood pressure (F=9.2, p=0.003) were associated with abnormal echo findings; for men, increased age (F=12.0, p<0.001) and lower cholesterol (F=4.2, p=0.042) predicted an increase in abnormal findings on echo. CONCLUSIONS: Unrecognised cardiac abnormalities are very common in middle-aged men and women with no overt symptoms. Echo offers the potential to identify the need for early intervention and treatment to improve cardiovascular outcomes.

[The prevalence of symptomatic infantile heart disease at Louga Regional Hospital, Senegal]. / Prevalence des cardiopathies infantiles symptomatiques au Centre Hospitalier Régional de Louga, Senegal.

The management of congenital or acquired infantile heart diseases in sub-Saharan African countries still presents problems, particularly with diagnosis and access to surgical treatment. Our objectives were to describe the heart diseases observed in the paediatric setting of the Louga Regional Hospital (LRH) and report their short-term evolution. In the study period from 1 July 2009 to 31 December 2012, 82 children out of 18,815 presented with heart disease, which was a prevalence of 4.3/1,000. There was a female predominance, with a ratio of 1.2. The most frequent presenting conditions were dyspnoea at 47.5%, followed by heart murmurs at 35.3%, and congestive heart failure at 13.4%. Congenital heart diseases were the most frequent, representing 69.5% of the cases, followed by acquired heart diseases at 29.3%, and mixed-type cases at 1.2%. The most frequently encountered congenital heart diseases were ventricular septal defect (24.4%), followed by atrioventricular septal defect (12.2%), tetralogy of Fallot (9.8%) and patent ductus arteriosus (7.3%). Acquired heart disease was represented by rheumatic heart disease, found in 25.6% of the cases, and tuberculous pericarditis in 3.7%. The mortality rate was high, with 20 children dying (24.4%) during the study period. Only 13 out of 82 patients (15.9%) were operable and surgery was carried out in France, courtesy of the association Humanitarian Mécénat Chirurgie Cardiaque. Infantile heart diseases were therefore not very frequent in the paediatric unit of Louga Regional Hospital. However, congenital heart disease was more frequent than acquired heart disease, with a high mortality rate. Access to surgery remains limited.

Prevalence and clinical significance of cardiac murmurs in schoolchildren.

OBJECTIVE: To determine the prevalence and clinical significance of heart murmurs detected during heart disease screening among apparently healthy schoolchildren. DESIGN: Cross-sectional study. SETTING: 32 elementary schools in Dongguan City of China. PATIENTS: 81,213 schoolchildren aged 5-13 years from different elementary schools. MAIN OUTCOME MEASURES: The prevalence and clinical significance of heart murmurs among schoolchildren. RESULTS: Murmurs were detected in 2193 schoolchildren (2.7%), of whom 215 had a structural heart disease (SHD). Of patients who had SHD, 198 children had congenital heart disease (CHD), 12 had mitral valve prolapse and 5 had rheumatic heart disease. In patients who had CHD, the most common diagnosis was a ventricular septal defect. With respect to sex, SHDs were equally distributed between males and females. Of the schoolchildren who had a murmur, 1797 (81.9%) had a murmur with the loudness of grade 1 or 2 and 396 (18.1%) had a murmur with the loudness of grades 3-6. The prevalence of SHD fell significantly with increasing age. CONCLUSIONS: The study suggested that apparently healthy schoolchildren with grade ≤2 cardiac murmurs are least likely to have underlying SHD, especially in those aged ≥10 years. However, echocardiography should be performed in younger schoolchildren with cardiac murmur grade ≥3.

Prevalence of physiological heart murmurs in a population of 95 healthy young adult dogs.

OBJECTIVES: To determine the prevalence of physiological heart murmurs in healthy young adult dogs. MATERIALS AND METHODS: Healthy dogs aged between 1 and 5 years were enrolled prospectively. All participating dogs underwent physical examination, urinalysis, blood testing and blood pressure measurement. Cardiac auscultations were performed by three independent examiners. Dogs with heart murmurs underwent echocardiography, to exclude cardiovascular abnormalities. RESULTS: Of 109 dogs evaluated, 95 completed the study. Heart murmurs were detected in 22 dogs. Interobserver agreement for murmur detection was moderate to fair (weighted kappa 0 · 29-0 · 56). On the basis of two different sets of echocardiographic criteria, physiological heart murmurs were diagnosed in 6 and 11 dogs, respectively, giving a prevalence of 6-12%. All physiological heart murmurs were systolic and low-grade (I-III/VI). Most were louder towards the left heart base and some radiated up to the thoracic inlet. The epidemiological features of dogs with physiological heart murmurs did not differ significantly from those of dogs without murmurs (P > 0 · 10). CLINICAL SIGNIFICANCE: This study shows that physiological heart murmurs may not be limited to growing dogs or specific breeds, as they were commonly encountered in this population of healthy young adult dogs.

Prevalencia de soplo cardíaco e hipertensión en saharauis acogidos en España / Prevalence of heart murmur and arterial hypertension in Saharan's given refuge in Spain

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Comparison of systemic health conditions between African American and Caucasian complete denture patients.

PURPOSE: To compare prevalence of systemic health conditions (SHC) between African American and Caucasian edentulous patients presenting for complete dentures (CD) at an urban dental school. METHODS: The study included patients presenting for CD 1/1-12/31/2010, ages 20 to 64 years, and either African American or Caucasian. Covariates included: age group, gender, employment status, Medicaid status, smoking history, and alcohol consumption. SHC included at least one of the following: arthritis, asthma, cancer, diabetes, emphysema, heart attack, heart murmur, heart surgery, hypertension, or stroke. RESULTS: The group (n = 88) was 44.3% African American, 65.9% ≥50, 45.5% male, 22.7% employed, and 67.0% with at least one SHC. African Americans were older (p = 0.001) and more likely to have one or more SHC (p = 0.011). Patients with at least one SHC were older (p = 0.018) and more likely female (p = 0.012). The total sample logistic regression model assessing SHC yielded only gender as statistically significant (males < OR 0.32, 95% CI 0.11 to 0.92). Caucasian males were less likely to have SHC (OR 0.17, 95% CI 0.04 to 0.77), and Caucasians ≥50 were more likely (OR 5.36, 95% CI 1.19 to 24.08). African Americans yielded no significant associations. CONCLUSIONS: Among selected completely edentulous denture patients at an urban dental school, two out of three patients had at least one SHC. This exploratory study suggests there may be health status differences between African American and Caucasian patients in this setting, calling for further study.

Risk assessment for incident heart failure in individuals with atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is a strong risk factor for heart failure (HF); HF onset in patients with AF is associated with increased morbidity and mortality. Risk factors that predict HF in individuals with AF in the community are not well established. METHODS AND RESULTS: We examined clinical variables related to the 10-year incidence of HF in 725 individuals (mean 73.3 years, 45% women) with documented AF in the Framingham Heart Study. Event rates for incident HF (n = 161, 48% in women) were comparable in women (4.30 per 100 person-years) and men (3.34 per 100 person-years). Age, body mass index, ECG LV hypertrophy, diabetes, significant murmur, and history of myocardial infarction were positively associated with incident HF in multivariable models (C-statistic 0.71; 95% confidence interval 0.67-0.75). We developed a risk algorithm for estimating absolute risk of HF in AF patients with good model fit and calibration (adjusted calibration χ2 statistic 7.29; P(χ2) = 0.61). Applying the algorithm, 47.6% of HF events occurred in the top tertile in men compared with 13.1% in the bottom tertile, and 58.4% in women in the upper tertile compared with 18.2% in the lowest category. For HF type, women had a non-significantly higher incidence of HF with preserved EF compared with men. CONCLUSIONS: We describe advancing age, LV hypertrophy, body mass index, diabetes, significant heart murmur, and history of myocardial infarction as clinical predictors of incident HF in individuals with AF. A risk algorithm may help identify individuals with AF at high risk of developing HF.

Management of asymptomatic cardiac murmurs in term neonates.

Approximately 2 % of newborn infants are noted to have cardiac murmur on routine postnatal examination. Our aim was to look at current evidence and practice in the management of asymptomatic cardiac murmur in term neonates. We performed a systematic literature review and a telephone survey of all neonatal units in the United Kingdom (UK). The systematic review of the literature did not support the routine practice of four-limb blood pressure (BP), chest X-ray (CXR), and electrocardiogram (ECG) in the assessment of asymptomatic cardiac murmur in term neonates. The survey had participation from 132 (68 %) of 193 neonatal units in the UK. In an asymptomatic term neonate with cardiac murmur, 124 (94 %) units perform pulse oximetry, 100 units (76 %) measure four-limb BP, 36 units (27 %) perform a CXR, and 52 units (39 %) perform an ECG. Eight-six units (65 %) have availability of in-house echocardiography services provided mainly by paediatricians with cardiology interest in special care units and neonatologists in neonatal intensive care units. Currently there is wide variation in practice in the management of asymptomatic cardiac murmur in term neonates. There is no evidence to support the routine use of four-limb BP, CXR, and ECG in the assessment of asymptomatic cardiac murmur in term neonates. Based on the evidence available, both structured clinical examination (including determining presence and quality of bilateral femoral pulses) and universal use of pulse oximetry are most important in identifying CHD in asymptomatic term neonates with cardiac murmur before discharge home.

The utility of outpatient echocardiography for evaluation of asymptomatic murmurs in children.

OBJECTIVE: The purpose of this study is to review sedated outpatient echocardiograms performed to evaluate asymptomatic murmurs in children between the ages of 1 month and 4 years and describe outcomes of tests done to determine if utility varies among age of study and referral type (primary care physician vs. pediatric cardiologist.) We aim to describe the yield in a contemporary cohort which has increased availability and quality of diagnostic aids such as fetal ultrasound, newborn pulse oximetry, and neonatal echocardiography. DESIGN: Retrospective cohort study. SETTING: Cincinnati Children's Hospital Medical Center: Outpatient Echocardiography Laboratory. PATIENTS: Children between 1 month and 4 years of age with asymptomatic murmurs who are referred for outpatient echocardiogram for evaluation of murmur. OUTCOME MEASURES: Primary diagnosis of echocardiography studies, classified into severity score. Results. Four hundred sixty-two sedated echocardiograms were studied. Six (1%) echocardiograms showed severe pathology, and no severe pathology was shown in the echocardiograms ordered at the age of over 6 months old. The yield of studies decreased as age increased. The incidence of abnormal pathology was higher among tests ordered by cardiologists, across all severity levels (P < .0001). CONCLUSIONS: Among echocardiograms ordered for children over 1 year of age with an asymptomatic murmur, there was no severe and little moderate disease. Cardiac disease is significantly less likely when echocardiograms are ordered without referral to a pediatric cardiologist. The workup for asymptomatic murmurs does not require an echocardiogram, and these results may aid clinicians when deciding whether evaluation of a child should include this study.

Clinical signs and left atrial size in cats with cardiovascular disease in general practice.

OBJECTIVES: To evaluate population characteristics, clinical signs and simple echocardiographic measurements of a general practice population of cats, in identifying characteristics that reliably distinguish cats with heart disease from others, including those with respiratory disease, using widely available techniques. METHODS: Cats presented with heart disease (n=103), respiratory disease (n=19) and a normal group (n=29) were prospectively recruited. All cats were subject to full clinical examination, echocardiography and additional diagnostic procedures as appropriate to establish definitive diagnosis. Cats were classified as Group 1: no heart disease ± respiratory disease; Group 2: heart disease with no clinical signs; Group 3: heart disease with clinical signs. Murmur, gallop sound and arrhythmia prevalence and left atrial size were compared between the groups. RESULTS: Low heart rates prevailed in Group 3. Murmurs were prevalent in Group 2, but in Group 3 prevalence was significantly lower. Dyspnoea, gallop sounds, arrhythmias and left atrial diameter were significantly different between groups. CLINICAL SIGNIFICANCE: Heart rate is unreliable for diagnosing heart failure in cats. Absence of murmur is prevalent in cats with clinical signs of heart failure, but arrhythmia and gallop sounds are prevalent. Echocardiographic measurement of left atrial diameter >16.5 mm may distinguish heart failure from respiratory disease in general practice.

Genome-wide analysis of mitral valve disease in Cavalier King Charles Spaniels.

The Cavalier King Charles Spaniel (CKCS) is prone to severe early onset mitral valve disease. In this study, 36 purebred CKCS dogs were evaluated for mitral valve murmur and divided into early and late onset groups. A genome-wide genetic approach was used to assess whether the condition is determined by a small number of genetic factors. There were no regions of highly discrepant homo/heterozygosity in the two groups. Similarly, there was no evidence for loci associated with mitral valve murmur in a genome-wide association study. This analysis suggests that familial occurrence of mitral valve murmur in the CKCS breed is not due to a single major gene effect, indicating that breeding strategies to eliminate the disease cannot be based on genotype information at this time.