How Cardiovascular Physical Examination Impacts Clinical Decision-Making in Various Scenarios of Cardiac Valvular Diseases.

Abstract

Background: Complementary diagnostic examinations have replaced the importance of Physical Examination (PE) in Clinical Decision-making (CDM). 1. Medical clinical practice has lost confidence in Physical Examination (PE) compared to complementary diagnostic examinations (CE). More importance has been deposited on Echocardiography (ECHO) in cardiac valvular dysfunction scenarios. No studies have measured the impact of cardiac PE in Clinical Decision-making (CDM). 2. Discrepancies between PE findings and ECHO reports are common and may impact CDM in different forms. 3. PE has proven essential to enhancing diagnosis confidence and grading of dysfunction in cardiac valvular dysfunctions. ECHO still plays a significant importance in CDM, even when discordant from physical examination. 4. The number of solicitations of an invasive test such as Cardiac Catheterization (CATE) is influenced by PE. The number of orderings was higher when volunteers did not perform a PE.

Objective: To evaluate the impact of cardiovascular PE in scenarios of cardiac valvular diseases.

Methods: An interventional study with volunteers' patients having or not having the opportunity to perform PE in scenarios of valvopathies. The PE was simulated in a high-fidelity cardiopulmonary simulator. Volunteers received questions about CDM before and after receiving an ECHO Concordant or ECHO Discordant report. Cohen´s kappa coefficient and square contingency tables compared diagnostic accuracy. ANOVA tests compared the number of requested tests; the significance level was set as p < 0.05.

Results: Sixty volunteers performed 239 clinical observations in 4 valvular dysfunctions. The diagnostic accuracy of valvular dysfunction was good (kappa = 0.935, p < 0.001). After receiving ECHO reports, the accuracy was worse without PE (p = 0.0047). The confidence level in diagnosis was 28.18% higher when PE was performed (p < 0.01). However, after receiving ECHO reports, diagnostic confidence levels were only 4% higher in the group with PE (p = 0.03). There were significantly more CATE requests when PE was not performed (p = 0.0326). The indication of valvular intervention was not related to having or not having the opportunity to perform PE (79 with PE vs 78 without PE, p = 0.0607), but was influenced by ECHO Concordant vs ECHO Discordant reports (p < 0.001).

Conclusions: Performing PE enhanced diagnosis confidence in valvulopathy scenarios and correct dysfunction grading. Treatment decisions were more based on ECHO reports than on PE when they were discordant, and requests for CATE increased when volunteers had no chance to perform PE.