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October 1995

Precision and Accuracy of Clinical and Radiological Signs in Premature Infants at Risk of Patent Ductus Arteriosus

Author Affiliations

From the Departments of Pediatrics (Drs Davis, Turner-Gomes, Way, and Schmidt), Nursing (Ms Cunningham), and Clinical Epidemiology and Biostatistics (Mr Roberts and Dr Schmidt), McMaster University, Hamilton, Ontario.

Arch Pediatr Adolesc Med. 1995;149(10):1136-1141. doi:10.1001/archpedi.1995.02170230090013

Objective:  To determine the precision (interobserver agreement) and accuracy (agreement with criterion standard) of clinical and radiological signs in premature infants at risk of patent ductus arteriosus (PDA) with left-to-right shunting.

Design:  Masked comparison of clinical and radiological examination with Doppler flow echocardiography (criterion standard).

Setting:  Neonatal intensive care unit.

Patients:  One hundred infants with birth weights less than 1750 g were studied once between days 3 and 7 of life. A third of the cohort was intubated at the time of study.

Intervention:  Five independent observers noted the presence or absence of an increased pulse volume, an active precordium, a heart murmur, a cardiothoracic ratio greater than 60%, increased pulmonary vascular markings on a concurrent chest x-ray film, and a relative increase of the cardiothoracic ratio compared with that from the previous chest x-ray film. Pulsed and color flow Doppler echocardiography was performed within 4 hours. All 100 tapes were reviewed by a second pediatric cardiologist.

Results:  Twenty-three infants had a PDA with left-to-right shunting. The precision of clinical signs was modest, with average κ values of 0.15 fκr pulse volume, 0.32 for precordium, and 0.41 for murmur. Pulse quality (43%) and murmur (42%) had the highest mean sensitivities. Corresponding specificities were 74% for pulse volume and 87% for murmur. The combination of a cardiac murmur with an abnormal pulse volume had the highest positive predictive value (77%). The radiological examination did not improve the observers' ability to distinguish between patients with and without PDA.

Conclusions:  The precision and accuracy of clinical and radiological signs of a PDA with left-to-right shunting are unsatisfactory. Therefore, Doppler flow echocardiography is required to diagnose PDA confidently in preterm infants between days 3 and 7 of life.(Arch Pediatr Adolesc Med. 1995;149:1136-1141)