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1 From the Department of Medicine, Sunnybrook Health Science Centre, the University of Toronto, Toronto, Ontario, Canada
2 From the Division of Cardiology, Sunnybrook Health Science Centre, the University of Toronto, Toronto, Ontario, Canada
3 From the Cardiology Division, Department of Medicine, St. Joseph's Health Science Centre, the University of Toronto, Toronto, Ontario, Canada
Charmaine E. Lok, MD, Department of Medicine, Suite BW1-641, 585 University Ave, Toronto, Ontario, M5G 2C4, Canada; e-mail: c.lok{at}utoronto.ca
Study objectives: To determine the observer accuracy and interobserver agreement in identifying S4 and S3 by cardiac auscultation and whether they improve with increasing observer experience.
Design: Prospective, blinded study.
Setting: Cardiology and general internal medicine wards in a university-affiliated teaching hospital.
Patients: Forty patients with a cardiac diagnosis and 6 patients without were studied.
Measurements and results: Two cardiologists, one general internist, three senior and two junior postgraduate internal medicine trainees, blinded to the patients' characteristics, examined the patients and documented their findings on a questionnaire. Computerized phonocardiogram was obtained in all patients as a gold standard and was interpreted by a blinded, independent cardiologist. The mean positive predictive values for S4 and S3 were 51% (range, 24 to 100%) and 71% (range, 50 to 88%), respectively. The mean negative predictive values for S4 and S3 were 82% (range, 67 to 94%) and 64% (range, 56 to 85%), respectively. The overall interobserver agreements for detecting S4 was K = 0.05 (95% confidence interval [CI], 0.01 to 0.09) and S3 was K = 0.18 (95% CI, 0.13 to 0.24). There was no apparent trend in the accuracy or interobserver agreement with regard to the level of observer experience.
Conclusion: The agreement between observers and the phonocardiographic gold standard in the correct identification of S4 and S3 was poor and the lack of agreement did not appear to be a function of the experience of the observers. The overall interobserver agreement for the detection of either S4 or S3 was little better than chance alone.
Key Words: heart auscultation • phonocardiography • reliability and validity
Submitted on December 15, 1997
Accepted on April 24, 1998
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