May 28, 1997

The Rational Clinical Examination: Detecting Abnormal Systolic Murmurs-Reply

Author Affiliations

The Toronto Hospital and University of Toronto Toronto, Ontario

JAMA. 1997;277(20):1594. doi:10.1001/jama.1997.03540440028024

In Reply.  —I agree with both Dr Fosnocht and Dr Ali that education and research on the clinical examination remain important goals.Fosnocht identifies 2 potentially relevent studies that were not included in our article. The first study,1 which was published after we completed our manuscript, reinforces 1 conclusion of our article: the clinical examination by cardiologists is accurate for ruling in and ruling out an abnormal systolic murmur.The second study,2 published in 1994, was not included in our article because of several methodological concerns. First, the study outcome was not solely related to systolic murmurs. Outcomes included "any pathologic valve or myocardial findings that could potentially alter the management of the patient... all (reported) trace regurgitant lesions were considered significant by the echocardiographers." The sample, therefore, included patients with isolated diastolic murmurs or myocardial abnormalities such as left ventricular hypertrophy.Second, the prediction model used by Fink et