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Article: Echocardiography or auscultation? How to evaluate systolic murmurs.

Shub, Clarence

Canadian family physician Medecin de famille canadien

2003 Volume 49, Page(s) 163–167

Abstract: Objective: To compare cardiac physical examination with echocardiography for evaluating systolic murmurs.: Quality of evidence: Three databases were searched for studies comparing echocardiography and auscultation as to sensitivity and diagnostic ... ...

Abstract	Objective: To compare cardiac physical examination with echocardiography for evaluating systolic murmurs. Quality of evidence: Three databases were searched for studies comparing echocardiography and auscultation as to sensitivity and diagnostic accuracy: MEDLINE (Ovid Online), EMBASE, and Current Contexts. The quality of reported data is lowered by subjective interpretation of results of both cardiac physical examination and echocardiography, especially Doppler colour flow imaging. Main message: In adults, functional systolic murmurs can usually be distinguished from organic murmurs. Pathologic murmurs frequently have one or more associated clinical abnormalities. If a clinician determines a murmur is benign, results of echocardiography are very likely to be normal, especially in young and middle-aged adults. According to current guidelines, echocardiography should not be ordered for "innocent" systolic murmurs in patients who are asymptomatic and have otherwise normal findings on examination. If patients with functional systolic murmurs could be identified and not routinely referred for echocardiography, great cost savings could be realized. Conclusion: Echocardiography is not required for all patients with systolic murmurs and should not replace cardiac physical examination.
MeSH term(s)	Adult ; Echocardiography ; Echocardiography, Doppler, Color ; Family Practice ; Heart Auscultation ; Heart Murmurs/diagnosis ; Heart Murmurs/diagnostic imaging ; Humans ; Middle Aged ; Sensitivity and Specificity ; Systole
Language	English
Publishing date	2003-02
Publishing country	Canada
Document type	Comparative Study ; Journal Article ; Review
ZDB-ID	603565-6
ISSN	0008-350X
ISSN	0008-350X
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Aortic valve sclerosis and clinical outcomes: moving toward a definition.

Gharacholou, S Michael / Karon, Barry L / Shub, Clarence / Pellikka, Patricia A

The American journal of medicine

2011 Volume 124, Issue 2, Page(s) 103–110

Abstract: The presence of aortic valve sclerosis has been suggested as a marker of increased cardiovascular risk, including increased mortality. However, it remains unclear whether aortic valve sclerosis is independently associated with risk or merely a marker of ... ...

Abstract	The presence of aortic valve sclerosis has been suggested as a marker of increased cardiovascular risk, including increased mortality. However, it remains unclear whether aortic valve sclerosis is independently associated with risk or merely a marker of coexistent cardiovascular risk factors. Aortic valve sclerosis is usually diagnosed on transthoracic echocardiography, the most widely used imaging modality in observational and natural history studies of aortic valve disease. Defining aortic valve sclerosis has remained challenging due to the variable and qualitative nature of its description by ultrasound techniques. Importantly, artifacts common to ultrasound imaging and awareness of demographic and clinical history information may bias the diagnosis of aortic valve sclerosis. Because clinicians may alter treatment recommendations or follow-up based on echocardiographic reporting of aortic valve sclerosis, highlighting pitfalls of the subjective nature by which aortic valve sclerosis is identified and establishing diagnostic criteria are necessary. This review describes the diagnostic criteria for aortic valve sclerosis used in outcome studies, summarizes the epidemiological findings reporting the relationship between aortic valve sclerosis and clinical outcome, and proposes a definition of aortic valve sclerosis based on the literature.
MeSH term(s)	Aortic Valve/diagnostic imaging ; Aortic Valve/pathology ; Aortic Valve Stenosis/diagnosis ; Aortic Valve Stenosis/diagnostic imaging ; Aortic Valve Stenosis/pathology ; Cardiovascular Diseases/etiology ; Echocardiography ; Humans ; Risk Factors ; Sclerosis/diagnostic imaging ; Treatment Outcome
Language	English
Publishing date	2011-02
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	80015-6
ISSN	1555-7162 ; 1873-2178 ; 0002-9343 ; 1548-2766
ISSN (online)	1555-7162 ; 1873-2178
ISSN	0002-9343 ; 1548-2766
DOI	10.1016/j.amjmed.2010.10.012
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Article: Lambl's excrescences: is surgical excision really necessary?

Melduni, Rowlens M / Klarich, Kyle W / Nesbitt, Gillian C / Shub, Clarence

Texas Heart Institute journal

2008 Volume 35, Issue 1, Page(s) 89; author reply 90

MeSH term(s)	Aortic Valve ; Cerebral Infarction/etiology ; Debridement ; Heart Valve Diseases/complications ; Heart Valve Diseases/surgery ; Heart Valve Diseases/therapy ; Humans ; Intracranial Embolism/etiology
Language	English
Publishing date	2008-04-22
Publishing country	United States
Document type	Comment ; Letter
ZDB-ID	604761-0
ISSN	1526-6702 ; 0730-2347
ISSN (online)	1526-6702
ISSN	0730-2347
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Article ; Online: Is the standard weight-based dosing of dobutamine for stress testing appropriate for patients of widely varying body mass index?

Kittipovanonth, Maytinee / Bernheim, Alain M / Scott, Christopher G / Barnes, Marion E / Shub, Clarence / Pellikka, Patricia A

Journal of cardiovascular pharmacology and therapeutics

2011 Volume 16, Issue 2, Page(s) 173–177

Abstract: Background: Although a gradual increase in heart rate (HR) during dobutamine stress testing (DST) is desired, few data exists regarding whether this is similarly achieved in patients of widely varying body mass index (BMI). Whether difference in BMI ... ...

Abstract	Background: Although a gradual increase in heart rate (HR) during dobutamine stress testing (DST) is desired, few data exists regarding whether this is similarly achieved in patients of widely varying body mass index (BMI). Whether difference in BMI contributes to variation in the hemodynamic and symptomatic response to dobutamine is also unknown. Methods: From prospectively acquired data of 2776 consecutive patients who underwent DST according to standard weight-based clinical protocol, we classified patients into 4 groups of BMI (kg/m( 2)): <25 (normal), 25 to 29.9 (overweight), 30 to 39.9 (obese), and ≥ 40 (severely obese) and compared the rate of increase of HR, mean blood pressure, and development of symptoms for the groups. Results: Age was 68 + 12 years, 52% were men, BMI was 29.8 + 6.6 kg/m(2) (range 14.5-81.4), 198 (7%) had BMI ≥ 40, and target HR was achieved in 2433 (88%). The rate of increase in HR was similar for each group of BMI after adjustment for age, gender, baseline HR, negative chronotropic use, and atropine administration. The percentage of patients in each group who achieved target HR was similar and the percentage of target HR achieved at each stage of dobutamine was essentially equivalent. Blood pressure responses and development of symptoms were similar in the 4 groups of BMI. Independent predictors of failure to achieve target HR included age, diabetes mellitus, treatment with negative chronotropic medications, and baseline HR; BMI was not a predictor (odds ratio [OR] 0.98, P = .086). Conclusion: The current weight-based protocol of dobutamine dosing for DST results in similar increases in HR and blood pressure for patients of widely varying BMI.
MeSH term(s)	Age Factors ; Aged ; Aged, 80 and over ; Blood Pressure/drug effects ; Body Mass Index ; Cardiotonic Agents/administration & dosage ; Dobutamine/administration & dosage ; Dose-Response Relationship, Drug ; Exercise Test/methods ; Female ; Heart Rate/drug effects ; Humans ; Male ; Middle Aged ; Obesity/complications ; Overweight/complications ; Prospective Studies
Chemical Substances	Cardiotonic Agents ; Dobutamine (3S12J47372)
Language	English
Publishing date	2011-06
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	1329372-2
ISSN	1940-4034 ; 1074-2484
ISSN (online)	1940-4034
ISSN	1074-2484
DOI	10.1177/1074248410384709
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Article ; Online: Sex differences in morphology and outcomes of mitral valve prolapse.

Avierinos, Jean-François / Inamo, Jocelyn / Grigioni, Francesco / Gersh, Bernard / Shub, Clarence / Enriquez-Sarano, Maurice

Annals of internal medicine

2008 Volume 149, Issue 11, Page(s) 787–795

Abstract: Background: Mitral valve prolapse is more common in women than in men, but men more often have surgery for severe regurgitation.: Objective: To compare morphology and outcomes of mitral valve prolapse in men and women.: Design: Retrospective ... ...

Abstract	Background: Mitral valve prolapse is more common in women than in men, but men more often have surgery for severe regurgitation. Objective: To compare morphology and outcomes of mitral valve prolapse in men and women. Design: Retrospective cohort study. Setting: The Mayo Clinic, Rochester, Minnesota. Patients: 4461 women and 3768 men who received a diagnosis of mitral valve prolapse by echocardiography from 1989 to 1998 (896 Olmsted County residents and 7333 referred patients). Measurements: Mitral prolapse characteristics (localization, leaflet thickening or flail, regurgitation), ventricular and atrial characteristics, cardiac surgery, and mortality. Results: Compared with men, women had less posterior prolapse (22% vs. 31%), less flail (2% vs. 8%), more leaflet thickening (32% vs. 28%), and less frequent severe regurgitation (10% vs. 23%) (P<0.001 for all comparisons). Regardless of the severity of regurgitation, left ventricular and atrial diameters were smaller in women than in men but were larger in women after normalization to body surface area. Among patients with severe regurgitation, women were less likely than men to undergo cardiac valve surgery (52% vs. 60%; adjusted risk ratio, 0.79 [95% CI, 0.74 to 0.84]). At 15 years, women with no or mild mitral regurgitation had better odds of survival than men (87% vs. 77%; adjusted risk ratio, 0.82 [CI, 0.76 to 0.89]), but those with severe regurgitation had worse survival than men (60% vs. 68%; adjusted risk ratio, 1.13 [CI, 1.01 to 1.26]). The survival rate 10 years after surgery was similar in women and men (77% vs. 79%; P=0.14). Observations in Olmsted County patients and referred patients were similar. Limitation: Diagnoses were based on echocardiography, and clinical data at initial diagnosis, reason for index echocardiography, and cause of all deaths were lacking. Conclusion: Morphology and severity of mitral valve prolapse differ according to sex. Among patients with severe regurgitation, women have higher mortality and lower surgery rates than men.
MeSH term(s)	Age Factors ; Cohort Studies ; Echocardiography, Doppler, Color ; Female ; Humans ; Male ; Mitral Valve Insufficiency/diagnostic imaging ; Mitral Valve Insufficiency/pathology ; Mitral Valve Insufficiency/surgery ; Mitral Valve Prolapse/diagnostic imaging ; Mitral Valve Prolapse/pathology ; Mitral Valve Prolapse/surgery ; Retrospective Studies ; Sex Factors ; Survival Analysis ; Treatment Outcome
Language	English
Publishing date	2008-11-28
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	336-0
ISSN	1539-3704 ; 0003-4819
ISSN (online)	1539-3704
ISSN	0003-4819
DOI	10.7326/0003-4819-149-11-200812020-00003
Database	MEDical Literature Analysis and Retrieval System OnLINE

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Article ; Online: Prognostic significance of ST-segment elevation during dobutamine stress echocardiography.

Arruda, Ana Lucia M / Barretto, Rodrigo B M / Shub, Clarence / Chandrasekaran, Krishnaswamy / Pellikka, Patricia A

American heart journal

2006 Volume 151, Issue 3, Page(s) 744.e1–744.e6

Abstract: Background: Limited data are available concerning the significance of ST-segment elevation during dobutamine stress echocardiography (DSE). The purpose of this study was to assess the prognostic significance of new ST-segment elevation during DSE and ... ...

Abstract	Background: Limited data are available concerning the significance of ST-segment elevation during dobutamine stress echocardiography (DSE). The purpose of this study was to assess the prognostic significance of new ST-segment elevation during DSE and its relationship to angiographic severity of coronary artery disease (CAD). Methods: From 4240 consecutive patients who had DSE, we identified 134 (3%) patients with new stress-induced ST-segment elevation > or =1 mm in at least two contiguous electrocardiographic leads. Significant CAD was considered as > or =50% diameter obstruction by angiography. Follow-up was obtained for cardiac events. Results: Age was 69 +/- 10 years; 84 (63%) were men. ST-segment elevation developed in the anterior leads in 55 (41%), inferior leads in 100 (75%), and lateral leads in 54 (40%); 56 (42%) had ST elevation in more than one region. Dobutamine stress echocardiography was abnormal in all patients; 115 (86%) had ischemia. Coronary angiography was obtained in 69 (51%) patients. Stenosis was > or =70% diameter in 68 (99%) patients and multivessel in 53 (77%). Follow-up (2.6 +/- 2.8 years) was obtained in all 134 patients. Events occurred in 103 (77%) patients, including death in 53, coronary revascularization in 33, myocardial infarction in 12, and unstable angina in 5. Event-free survival was 55% at 2 years, 38% at 4 years, and 28% at 5 years. Conclusions: Patients with stress-induced ST-segment elevation during DSE commonly have severe CAD and are at high risk for events during follow-up. These patients should be considered for coronary angiography.
MeSH term(s)	Aged ; Coronary Angiography ; Coronary Artery Disease/diagnosis ; Coronary Artery Disease/diagnostic imaging ; Echocardiography, Stress ; Electrocardiography ; Female ; Hemodynamics ; Humans ; Male ; Middle Aged ; Multivariate Analysis ; Prognosis ; Retrospective Studies
Language	English
Publishing date	2006-03
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80026-0
ISSN	1097-6744 ; 0002-8703
ISSN (online)	1097-6744
ISSN	0002-8703
DOI	10.1016/j.ahj.2005.10.013
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Article: Safety of exercise stress testing in patients with abnormal concentrations of serum potassium.

Modesto, Karen M / Møller, Jacob E / Freeman, William K / Shub, Clarence / Bailey, Kent R / Pellikka, Patricia A

The American journal of cardiology

2006 Volume 97, Issue 8, Page(s) 1247–1249

Abstract: The objective of this study was to determine the safety of performing exercise stress testing in patients with abnormal serum potassium concentrations. Data were reviewed from 9,084 patients (mean age 63 +/- 12 years) referred for exercise ... ...

Abstract	The objective of this study was to determine the safety of performing exercise stress testing in patients with abnormal serum potassium concentrations. Data were reviewed from 9,084 patients (mean age 63 +/- 12 years) referred for exercise echocardiography who had serum potassium measured <48 hours before the test were reviewed, and the occurrence of arrhythmias during stress testing was determined. Of 10,272 studies, 9,067 (88%) were in patients with normokalemia and 1,205 (12%) were in patients with abnormal serum potassium concentrations: 309 (26%) with hypokalemia (mean 3.4 +/- 0.16 mmol/L) and 896 (74%) with hyperkalemia (mean 5.1 +/- 0.19 mmol/L). Ventricular and supraventricular ectopy were common during exercise. Only 1 patient (potassium 4.9 mmol/L) had sustained ventricular tachycardia; all other episodes were nonsustained. Although ventricular and supraventricular ectopy are common during exercise testing, life-threatening arrhythmias are not. Exercise testing is generally safe despite mild to moderate hypokalemia or hyperkalemia.
MeSH term(s)	Age Factors ; Echocardiography ; Exercise Test ; Female ; Humans ; Hyperkalemia/epidemiology ; Hypokalemia/epidemiology ; Male ; Middle Aged ; Multivariate Analysis ; Potassium/blood ; Safety ; Sex Factors ; Stroke Volume ; Tachycardia, Ventricular/epidemiology
Chemical Substances	Potassium (RWP5GA015D)
Language	English
Publishing date	2006-04-15
Publishing country	United States
Document type	Journal Article ; Research Support, Non-U.S. Gov't
ZDB-ID	80014-4
ISSN	1879-1913 ; 0002-9149
ISSN (online)	1879-1913
ISSN	0002-9149
DOI	10.1016/j.amjcard.2005.11.049
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Article: Hypertensive response to exercise: a potential cause for new wall motion abnormality in the absence of coronary artery disease.

Ha, Jong-Won / Juracan, Eldyn M / Mahoney, Douglas W / Oh, Jae K / Shub, Clarence / Seward, James B / Pellikka, Patricia A

Journal of the American College of Cardiology

2002 Volume 39, Issue 2, Page(s) 323–327

Abstract: Objectives: We sought to characterize patients with a hypertensive response during exercise echocardiography and its effect on results of the test.: Background: A hypertensive response to exercise has been shown to cause false-positive results in ... ...

Abstract	Objectives: We sought to characterize patients with a hypertensive response during exercise echocardiography and its effect on results of the test. Background: A hypertensive response to exercise has been shown to cause false-positive results in perfusion imaging, radionuclide angiography and exercise electrocardiography, but its influence on exercise echocardiography has not been reported. Methods: We identified 548 of 6,686 patients who had coronary angiography within four weeks after exercise echocardiography from 1992 through 1996. Echocardiographic results from 132 patients (24%) with a hypertensive response to exercise, defined as systolic blood pressure (SBP) >220 mm Hg for men and SBP >190 mm Hg for women or as an increase in diastolic blood pressure (DBP) >10 mm Hg or DBP >90 mm Hg during exercise echocardiography, were compared with those from 416 patients without a hypertensive response. Results: Of 132 patients with a hypertensive response to exercise, 108 patients had exercise echocardiographic results positive for ischemia. Of these patients, 24 (22%) were found to have no significant coronary artery disease (CAD). In contrast, of 320 patients with positive exercise echocardiographic results without a hypertensive response, 39 (12%) patients did not have significant CAD. Among the false-positive results, new wall motion abnormalities were extensive in 15 of 24 (63%) hypertensive responders involving >25% of segments compared with 14 of 39 non-hypertensive responders (36%, p = 0.012). Conclusions: An excessive rise in blood pressure during exercise is associated with a greater likelihood of new or worsening abnormalities with exercise, which may be observed in the absence of angiographically significant coronary artery stenosis.
MeSH term(s)	Aged ; Coronary Angiography ; Echocardiography, Stress ; Exercise Test ; Female ; Hemodynamics ; Humans ; Hypertension/physiopathology ; Male ; Middle Aged ; Myocardial Contraction
Language	English
Publishing date	2002-01-16
Publishing country	United States
Document type	Journal Article
ZDB-ID	605507-2
ISSN	1558-3597 ; 0735-1097
ISSN (online)	1558-3597
ISSN	0735-1097
DOI	10.1016/s0735-1097(01)01743-0
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Article ; Online: Natural history of asymptomatic mitral valve prolapse in the community.

Avierinos, Jean-François / Gersh, Bernard J / Melton, L Joseph / Bailey, Kent R / Shub, Clarence / Nishimura, Rick A / Tajik, A Jamil / Enriquez-Sarano, Maurice

Circulation

2002 Volume 106, Issue 11, Page(s) 1355–1361

Abstract: Background: The outcome of mitral valve prolapse (MVP) is controversial, with marked discrepancies in reported complication rates.: Methods and results: We conducted a community study of all Olmsted County, Minn, residents first diagnosed with ... ...

Abstract	Background: The outcome of mitral valve prolapse (MVP) is controversial, with marked discrepancies in reported complication rates. Methods and results: We conducted a community study of all Olmsted County, Minn, residents first diagnosed with asymptomatic MVP between 1989 and 1998 (N=833). Diagnosis, motivated by auscultatory findings (n=557) or incidental (n=276), was always confirmed by echocardiography with the use of current criteria. End points analyzed during 4581 person-years of follow-up were mortality (n=96, 19+/-2% at 10 years), cardiovascular morbidity (n=171), and MVP-related events (n=109, 20+/-2% at 10 years). The most frequent primary risk factors for cardiovascular mortality were mitral regurgitation from moderate to severe (P=0.002, n=131) and, less frequently, ejection fraction <50% (P=0.003, n=31). Secondary risk factors independently predictive of cardiovascular morbidity were slight mitral regurgitation, left atrium > or =40 mm, flail leaflet, atrial fibrillation, and age > or =50 years (all P<0.01). Patients with only 0 or 1 secondary risk factor (n=430) had excellent outcome, with 10-year mortality of 5+/-2% (P=0.17 versus expected), cardiovascular morbidity of 0.5%/y, and MVP-related events of 0.2%/y. Patients with > or =2 secondary risk factors (n=250) had mortality similar to expected (P=0.20) but high cardiovascular morbidity (6.2%/y, P<0.01) and notable MVP-related events (1.7%/y, P<0.01). Patients with primary risk factors (n=153) showed excess 10-year mortality (45+/-9%, P=0.01 versus expected), high morbidity (18.5%/y, P<0.01), and high MVP-related events (15%/y, P<0.01). Conclusions: Natural history of asymptomatic MVP in the community is widely heterogeneous and may be severe. Clinical and echocardiographic characteristics allow separation of the majority of patients with excellent prognosis from subsets of patients displaying, during follow-up, high morbidity or even excess mortality as direct a consequence of MVP.
MeSH term(s)	Aged ; Cardiovascular Diseases/epidemiology ; Cardiovascular Diseases/etiology ; Cardiovascular Diseases/mortality ; Disease-Free Survival ; Female ; Follow-Up Studies ; Humans ; Male ; Middle Aged ; Mitral Valve Prolapse/complications ; Mitral Valve Prolapse/diagnosis ; Mitral Valve Prolapse/diagnostic imaging ; Mitral Valve Prolapse/mortality ; Prognosis ; Risk Factors ; Survival Rate ; Ultrasonography
Language	English
Publishing date	2002-09-10
Publishing country	United States
Document type	Journal Article ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	80099-5
ISSN	1524-4539 ; 0009-7322 ; 0069-4193 ; 0065-8499
ISSN (online)	1524-4539
ISSN	0009-7322 ; 0069-4193 ; 0065-8499
DOI	10.1161/01.cir.0000028933.34260.09
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Article ; Online: Exercise-Echocardiography–Derived Pulmonary Artery Pressure Slope in Borderline and Mild to Moderate Pulmonary Arterial Hypertension

Naser M. Ammash / Michael D. McGoon / Clarence Shub / James B. Seward / Jae K. Oh / Michael J. Krowka / Patricia A. Pellikka / Brenda S. Moon / Kent R. Bailey / Christina M. Wood / A. Jamil Tajik

Clinical Medicine Insights : Cardiology, Vol 2, Pp 235-

2008 Volume 244

Abstract: Objective: Examine pulmonary artery systolic pressure (PASP) response to exercise in isolated borderline and mild to moderate pulmonary arterial hypertension (PAH).Methods: Doppler stress echocardiography was performed in 32 healthy volunteers with ... ...

Abstract	Objective: Examine pulmonary artery systolic pressure (PASP) response to exercise in isolated borderline and mild to moderate pulmonary arterial hypertension (PAH).Methods: Doppler stress echocardiography was performed in 32 healthy volunteers with resting PASP of 29 mm Hg or less, 39 with resting PASP between 30 and 40 mm Hg, and 7 with resting PASP between 41 and less than 60 mm Hg. All subjects had otherwise normal echocardiograms.Results: Rate of increase in PASP with exercise was positively associated with resting PASP (P 0.001), increased age (P 0.001), and estrogen use among women (P = 0.001). On multivariate analysis, PASP slope was independently related (P = 0.03) to resting PASP and inversely associated with exercise time (P 0.001).Conclusions: Patients with borderline and mild to moderate resting PAH have an exaggerated PASP response to exercise. PASP slope is a strong independent predictor of exercise time. Outcome studies are needed to determine the prognostic significance of this finding.
Keywords	blood pressure ; echocardiography ; exercise ; hypertension ; pulmonary ; pressure ; stress ; Diseases of the circulatory (Cardiovascular) system ; RC666-701 ; Specialties of internal medicine ; RC581-951 ; Internal medicine ; RC31-1245 ; Medicine ; R ; DOAJ:Cardiovascular ; DOAJ:Medicine (General) ; DOAJ:Health Sciences
Subject code	610 ; 796
Language	English
Publishing date	2008-01-01T00:00:00Z
Publisher	Libertas Academica
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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