Highlights of ASE guideline 2015 for echo chamber quantification

Reference:  Lang, Roberto M. et al..  Recommendations for Cardiac Chamber Quantification by Echocardiography in Adults: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.  Journal of the American Society of Echocardiography , Volume 28 , Issue 1 , 1 – 39.e14

(1) Study this if you are going for recertification for echo board or if you are running the lab. Otherwise read the below.
(2) What is new is that they recognize that the division of mild, moderate or severe abnormal is empiric and has no evidence-based. The cut off needs to be adjusted based on race and sex and body size, and is not “written in stone” as it used to be. They only give these cutoffs for LV size, LV thickness, LV function, and LA size. They no longer provide severity cutoff for RV and RA and aortic size.
(2A) There is increased emphasis on degree of evidence (e.g. the size of database used to derive the measurements) and reliability/ pitfall of each measures. This will likely be on the echo board.
(3) LA volume cut off is set to 34 ml/M2 instead of 28 ml/M2. LA volume is the recommended method. However, there is a renewed recognition that LA two dimension measurement is useful due to
(4) New technology discussed: 3D measurements not mandatory; LV and RV global strain measurements are gizmo specific to different manufacturers
(5) There are a lot of new discussion on measurement techniques on RV function, which is worth a look (e.g. TAPSE, Tissue Doppler imaging for S’ wave).
(Personal note: I found that these are useful for valve cases).
(6) pitfall of aortic root size measurement is discussed: 3D TEE is now recommended for annular sizing due to ellipsoid shape. This is relevant to TAVI sizing.

Handheld ultrasound Scan: how it transformed my STEMI patient care

As a cardiologist dealing with STEMI, it is essential to have rapid and accurate assessment of patient’s clinical status:

(1) Does the patient truly have STEMI or is the EKG a false positive?

(2) Are there alternative diagnoses such as aortic dissection?

(3) Any STEMI related complications such as VSD?

(4) How can I perform the PCI safely?

In the middle of the night, it takes forever to get the echo machine. Even day time, it takes time for the echo technician to get to the ER. The ultrasound machine in the ER at the trauma bay is dedicated to FAST trauma exam, and the probe is too big to perform a proper cardiac exam (though it can be done, but it is not easy requiring multiple setting change and excellent ultrasound skill.)  Time is limited because of the emphasis of door-to-balloon tome.

VSscan transformed how I handle this high stress situation.

(Every time I takes my VScan out, I would be surrounded by ER staff and it looks really cool.)

First, in my experience thus far, for patient with borderline EKG changes or LBBB with little symptoms, a normal VScan exam effectively ruled out STEMI. However, a normal handheld ultrasound still does not rule out STEMI if the patient has typical chest pain and typical EKG changes, because I have had cases of small STEMI (usually Left circumflex) that is missed due to small territory involved. Another caveat is that if the patient has LBBB or IVCD, finding global LV impairment cannot differentiate STEMI versus non-ischemic cardiomyopathy.

The most reliable sign with high positive predictive value of STEMI (from personal experience) is that if the fall has not thinned out and there is focal regional wall motion abnormalities,especially if it correlates with EKG changes. This finding helps me plan which sequence of catheters I use during PCI. This decrease PCI procedure time.

Having information of LV function and structural abnormalities from VScan decreases procedural dye load and time. I can omit doing LV gram, which decreases the risk of VT induction and LV decompensation. In addition, knowing potential structural abnormalities such as VSD and Mitral regurgitation drives what I would do in the lab. I have seen both situation: knowing we were dealing with a VSD, we stabilized the patient on a balloon pump as the first technical maneuver and he is still alive after surgery. The acute MR patients with fulminant CHF: knowing what we were dealing with on VSscan, we initiated IABP and later ECMO to salvage MR related cardiogenic shock… he survived after valve surgery.I credit my VScan for giving us a clear picture of the problem and enabled me to select the most effective way to salvage my patients. I also had a case of a patient presenting with inferior wall MI but SBP in to the 60s. I told the ER staff not to give aspirin and plavix: with my VScan I saw pericardial effusion and ascending aorta flap; cardiac surgical consultation was called and we avoided giving the patient the usual STEMI therapy, which would have led to rapid demise.

Even in less dramatic situations, knowing the LVEF based on VScan allows me to understand how stable the patient is and let me decide on how to pursue the proper PCI approach: for example, should I do multiple vessels as suggested by PRAMI and CVLPRIT trials or should I stick with the current guideline. Should I go after the side branch or stick with the main vessel? Should I chase after the distal emboli after I placed the stent? VScan information helps me decide how I approach these problems.

The second generation VScan has a dual head allowing for high frequency probe, which can be used for vascular imaging and lung ultrasound (as well as other non-cardiac usage.) With the new second generation high frequency probe, I can see its utility in performing lung ultrasound in the STEMI situation. The high frequency probe allows visualization of pulmonary edema.  Another potential utility is in patients with peripheral vascular disease and STEMI:locating the best puncture/ access site. However, I don’t have this newer generation machine and for this I still rely on CXR and vessel finder ultrasound probe on the larger ultrasound machine.

(Hey GE Healthcare: if you are read this, please give me a discount for upgrading to the new dual probe VScan. I will write a nice blog on my experience on your new probe.)

Cardiologist 2015 new tool: 3rd generation AliveCor smartphone EKG

One of the coolest gizmo that I use every day is the new 3rd generation AliveCor smartphone EKG. I have been using it in clinic and on rounds.

The new model is much cheaper than previous models: $75 vs $200. In addition, it is much smaller and much lighter. The app is excellent.

One of the first thing I notice is that I do not like my AliveCor EKG tag to be on my iPhone al the time. So I separate my AliveCor from the phone. When I actually use it, I realize I do not have to tape the ALiveCor on the phone as it was shown on the video. I just ask my patients to hold the plate with their hand resting on the table or a stable platform. I then bring my iPhone close to the ALiveCor plate.  As long as the patient is holding the plate steadily and the phone is in close proximity (within 1 cm) of the plate, Alivecor will record the tracing.

The other thing of importance is that you need to figure out which side is for the left hand and which is for the right hand. I mark the correct side on the back of the plate.

I have used it in hospital patients on non-monitored beds. It works well. I also tried it all an uncooperative demented patients and it worked fine: you just have to press the plate against the right and left hand.

The EKG is of sufficient quality for rhythm diagnosis. I am exploring whether it is useful in ischemic and non-rhythmic situation.

I also started recommending it in all my patients who have rhythm disorders and have modern smartphones.  The price is almost the same as a blood pressure machine. I explain to them that it is cheaper than copay. I ask my patients to store a bunch of tracing so I can review them on follow-up. This may be more cost effective than 30 day event monitors or non-looping chest plate. The AliveCor has a feature which will alert the patient if atrial fibrillation is present. This feature worked well on my real life testing.

Dr. Eric Toprol started that he diagnosed a case of STEMI with the AliveCor. I will verify this soon enough with my STEMI calls coming up.

To the people who care about billing, I figured that you can bill about $12 per AliveCor tracing with Medicare. However, a full 12 leads EKG pay more. So from billing point of view, it is not that great. But then, it takes me less than 30 seconds to get an EKG, and most of the time I use it patients are stunned by this technology. And after I demonstrate it, patients are surprised by the ease of its use and this motivates patients to order it.

My philosophy is: the more I enable my patients to take advantage this kind of medical advance, the more control they have over their health. No longer are my immigrant patients “uneducated”; many have become technologically sophisticated. First they have been taught to self monitor blood pressure ( I tell them to go to Amazon to get the monitor for $40) ; then they  started using pulse oximeter ($20); now they are starting to use AliveCor. As a result of this and other aggressive measures, our practice has seen substantially lower stroke and MI in the past ten years. The life expectancy for my community is now 90.11 year old: for the rest of NYC: Hispanic New Yorkers can expect to live the longest – to an age of 81.9. For whites, it’s 81.4 years, and for blacks it’s 77.2.

Roseto effect: Everyone lives in a village. How closely knit community lowers cardiac mortality.

When I was visiting Navajo reserve in Arizona last year, I was fascinated by how similar the Navajo and ethnic Chinese custom are similar. ( For those who don’t know, I am a village heart doctor in Brooklyn Chinatown.) When you introduce yourself in the Navajo reserve, you tell people your name and which clan you are from. This is similar to Chinese: they often tell me which village in China they are from and asked me which village I am from.

Navajos believe in Hózhó, or “Walking in Beauty”: “The word embodies the idea of striving for balance and harmony together with beauty and order. Every aspect of Navajo life, whether secular or spiritual in nature, is connected to hózhó. As humans we straddle the border between health and sickness, good and evil, happiness and sadness. According to the Navajo worldview, the purpose of life is to achieve balance, in a continual cycle of gaining and retaining harmony. Through this exhibition, we will explore one aspect of Navajo creativity that exemplifies hózhó ­ their basketry. When hózhó has been lost, a ceremony is held to restore balance. Baskets are a necessary part of ceremonies that re-establish hózhó. They are the material expressions of the essence of the Navajo worldview. In order for weavers to make baskets that are beautiful, they themselves must “walk in beauty” or live in hózhó.”

Navajo reserve is plagued by many diseases such as alcoholism and diabetes, as well as suicide. The Navajo explanation is that they have lost their ancient way and lost the balance between the land and the people. Diabetes, gun violence, and alcoholism are the result when people lost this balance.

There was a mysterious outbreak of febrile illness in Navajo reverse in the 1990s: young patients would die rapidly from a flu like illness. CDC was initially stumped. As described by Dr. Lori Arviso’s book “The Scapel and the Silver Bear”, the medicine man observed that the reason was because of the recent rainfall has caused a larger than usual piñon crop, resulting in lack of balance in nature. The medicine man said that sand painting with a mouse has been used as the traditional therapy for this rapidly fatal disease. The medicine man told CDC to “look to the mouse”. So CDC started looking at rodent population and realized that the higher than usual crop of piñon resulted in higher rodent population, leading to outbreak of rodent hantavirus.

There is a movement in the Navajo community to return to “Walking in Beauty”, in order to rid it from the epidemics of modern diseases.

In contrast, Italian immigration to US left their homeland and migrated to a strange land. Despite such trauma, they remain united as close family. Roseto was one of the tightest knit Pennsylvania small town where many settle.  The story of the town of Rosetto is fascinating. This town was almost 100% Italian has the lowest cardiac mortality compared with many small towns.

From Wikipedia:

The Roseto effect was first noticed in 1961 when the local Roseto doctor encountered Dr. Stewart Wolf, then head of Medicine of the University of Oklahoma, and they discussed, over a couple of beers, the unusually low rate of myocardial infarction in Roseto compared with other locations.Many studies followed, including a 50-year study comparing nearby Bangor and Nazareth. As the original authors had predicted, as the Bangor cohort shed their Italian social structure and became more Americanized in the years following the initial study, heart disease rose.

From 1954 to 1961, Roseto had nearly no heart attacks for the elsewhere high-risk group of men 55 to 64, and men over 65 enjoyed a death rate of 1% while the national average was 2%. Widowers outnumbered widows, too.

These statistics were at odds with a number of other factors observed in the community. They smoked unfiltered stogies, drank wine “with seeming abandon” in lieu of milk and soft drinks, skipped the Mediterranean diet in favor of meatballs and sausages fried in lard with hard and soft cheeses. The men worked in the slate quarries where they contracted illnesses from gases and dust. Roseto also had no crime, and very few applications for public assistance.

This is in spite of their bad diets. Researchers have looked into why they have unexpectedly low mortality despite high conventional risk factors in the 1969s. The answer is that these Italuans am have very tight knit family and tat this strong family bondage helped lower overall mortality.

As I become more familiar with the Chinese American community, I become much more aware of the importance of tightly knit community as a protection against cardiac disorder. When I treat one patient, I become aware that this patient belongs to the whole village. I found that if I take advantage of this dynamics and social force, my patients are more likely to stay well. Firstly, they are more likely to follow the lifestyle advice.   Secondly, ,any new immigrants come to me with cardiac problems that have psychosocial origin. They have stopped “Walking in Beauty”, having lost touch of their homeland and the familiarity of their ancestral home, and moved to this land called America.  My role as a healer is to reconnect them to this new community and make them realize that they are not alone in the new land. We all belong to the same village, just like the Italian immigrants in Roseto Pennsylvania.

When I used to see the Upper East Side rich people, I realize many of these people are unhappy. Many of them are isolated in their own world. They may be rich and powerful, but the are not happy like my villager patients. My community may not be rich, but the people in my community are tightly knit. Therefore, despite the wealth gap, my Chinese patients live longer than the rich Upper East Side people. I routinely see patients who are 90 year old and above, who are healthy and happy.  One guy even ran on my treadmill and I got bored watching him because he just kept going. Another 99 year old walked into my room and he looked like a 70 year old man.

My secret to seeing my patients stay healthy even after 90 year old: treat them like a family member in the same village, focus on health not sickness, emphasize lifestyle while minimizing unnecessary medications and procedures, personal responsibility in health, and above all, encourage development of strong community bond.

NYC Cardiology: Survival Guide

The recent book by Sandeep Janhaur “Doctored” touched a raw nerve in many cardiologists. In the book, he described how he tried to survive as a academic cardiologist in NYC. Because of its low salary, to support a family he needs to moonlight at private doctors office. In the office, his boss, a primary care doctor, ordered echo and stress test on everyone. It was all about money. He could not stomach it and decided to leave New York City to practice in Long Island.

The question is: how does one survive as a cardiologists in NYC?

As Frank Sanatra said:

If I can make it there,I’ll make it anywhere.

It’s up to you, New York, New York.

I work in NYC. I love NYC. But it is not easy to be a cardiologist here.

In NYC there are the so called national leaders in cardiology. These cardiologists are clinically very talented. However, there are talented cardiologists everywhere else in United States too. What is different about these famous NYC cardiologists is that they are hyper competitive. They are able to survive NYC because they can market themselves above their competition.  Many of them are like Dr. Oz: showmanship is what distinguishes these cardiologists. These are the big sharks. These cardiologists are not known for their empathy for the common people, but they are very good at attracting rich donors.

OK, so you are not a famous cardiologist, can you still make it in NYC?  Many young people have the mistaken notion that you can make a living by being a good doctor and let your reputation builds.  It takes too long and you would be crushed before you cannot make enough money to pay rent. Your children will go to public schools in NYC, and your children will be subjected to the bureaucratic treatment of NYC Dept of Education.

Or perhaps you can join an established group of cardiologists: but most of these senior cardiologists like to slaves working for them and they have a way of keeping the young associates from becoming full partners.  Many Manhattan cardiologists have a nasty habit of firing their associates when it is about time they become partners.  It is the New York corporate way: junior serfs’ role is to enrich the senior slave-master.

Then there are the “outreach” cardiologists. They are either hired or sponsored by big hospitals. They would pay rent to primary care doctors (“Payola”) and they will go to these offices to do echo and nuclear stress to squeeze cardiac procedures. By themselves their reputation cannot get patients so they pay finder fee to the referring primary physicians. The hospital get high reimbursement for the procedures and profit margin used to be high. These rental cardiologists function like real estate agents. They have an incentive to ramp up any legally justifiable procedures so they can pay the rent to the primary care.  New York City is a very commercial city and this is just an extension of the same commercial mentality. Of course, it ramps up the cost of the system and may lead to legally justifiable procedures that may not be to the best interest to the patients.  The fate of most outreach cardiologists is that nobody really knows who they are: patients don’t know them and they are an expendable commodity. When the pay-for-outcome reimbursement scheme starts, these outreach cardiologists will be easy to be downsized by the hospitals. Their only hope is that they are highly productive: able to make deals with many primary care doctors while being able to get a lot of revenues for each patient. Some cardiologists can become very good at this game: one cardiologist goes to thirty different primary care practice and legend has it that he is one of the highest paid cardiologist in NYC. The game was summarized for me recently by one such master outreach cardiologist: “you put one dollar into the slot machine, and you get five dollars back. So all you have to do is to keep feeding the slot machine”

I am not going to bore you my sob story. I am stuck here. I lived with my in-law’s place for years and put my children to NYC public school because I did not make enough money. But I was able to practice cardiology the way I wanted. I treat my patients like how I would treat my family.

Systemic leak in sepsis: the role of advanced echocardiographic technique

Capillary leak syndrome (From “Mystery Diagnosis,” a show on the Discovery Health Channel)

One of my clinical observation is that patients in sepsis often have severe edema and anasarca. In the NEJM published cases of Ebola, all the patients have edema, despite being severely dehydrated. Therefore, the postulated mechanism is that of leaky capillaries. However, I did a literature search and surprisingly there are few studies on this commonly seen clinical phenomenon.

Many inexperienced housestaff would give Lasix to these patients, resulting in worsening kidney function. However, it is not even clear what to do. In the old days, we used to give iv 25% human albumin. But the evidence is limited (see for example this review), except in cirrhosis post paracentesis for ascites. There is no evidence to support its use in trauma, burn, and ICU sepsis.

The leaky capillary state has also been seen with Clarkson Syndrome (Idiopathic capillary leak syndrome.) Recently, NIH researchers published an article in the journal Blood, describing the involvement of vascular endothelial growth factor (VEGF) and angiopoietin 2 (Ang2).  They showed that inhibition of angiopoietin 2 with neutralizing antibody can inhibit the leaky capillaries in their in vitro model. Noteworthy is the fact that inflammation is not part of Clarkson Syndrome, and therefore it is unclear how it translates into therapeutic in sepsis related capillary leak.

The role of a cardiologist in this consult situation is to properly rule out CHF as the etiology of the anasarca.  Physical exam is a unreliable guide for fluid status, according to JAMA rational examination article.  Postural hypotension and tachycardia is often missing (sensitivity=33%, though specificity is 98%). Tongue being moist is negatively predictive (negative likelihood ratio, 0.3); while the axilla dryness is somewhat predictive of dehydration (positive likelihood ratio, 2.8)   The liberal use of ultrasound to assess IVC size, as well as the use of pulse pressure variation can help address this dilemma.

In my practice, I found that liberal use of handheld ultrasound, such as with VScan, enable me to be able to gauge volume status on daily round.   Journal of American Society of Echocardiography had a nice review on more advanced technique for the measurement of RA pressure.  Here is what is in the article:

” These parameters yield more accurate results when estimating low or high RAP: IVC diameter < 2.1 cm and collapse > 50% correlates with a normal RAP of 0 to 5 mm Hg. IVC diameter < 2.1 cm with < 50% collapse and IVC diameter > 2.1 cm with > 50% collapse correspond to an intermediate RAP of 5 to 10 mm Hg. IVC diameter > 2.1 cm with < 50% collapse suggests a high RAP of 15 mm Hg. The guidelines recommend using midrange values of 3 mm Hg for normal and 8 mm Hg for intermediate RAP. If there is minimal collapse of the IVC (<35%) and/or secondary indices of elevated RAP are present (Table 3, discussed next), the guidelines recommend upgrading to the higher pressure limit (i.e., 5 and 10 mm Hg in the cases of normal and intermediate RAPs, respectively). Patients with low compliance with deep inspirations may have diminished IVC collapse, and a “sniff” maneuver causing a sudden decrease in intrathoracic pressure and by that accentuating the normal inspiratory response might be required to differentiate those with true diminished IVC collapsibility from those with normal collapsibility.”

Other indexes in echo for RA pressure include:

Indices of elevated RAP
• Dilated IVC with diminished respiratory collapse
• Tricuspid E/e′ ratio > 6
• Diastolic flow predominance in the SVC, jugular vein, or hepatic veins
• Bulging interatrial septum to the left atrium
• Dilated right atrium

IVC size (fSeptember 2013Volume 26, Issue 9, Pages 1033–1042)

From JASE 2013: A. Systematic inflow of SVC into RA: normal S> D==> normal RA pressure. B. Systmatic inflow of hepatic vein by PW Doppler. D> S suggesting elevated RA pressure.

From JASE 2013 Doppler evaluation of tricuspid inflow. (E/E’ of tricuspid inflow using tissue Doppler imaging. The E/e′ ratio is >6, which suggests an elevated RAP of >10 mm Hg.) (A) (Top) Tricuspid inflow velocity Doppler recording (E = 84 cm/sec). (Bottom) Tricuspid annular velocity (e′) using DTI is 15 cm/sec in a patient with normal RAP. The E/e′ ratio is

I also found it useful to measure JVP using high frequency ultrasound probe with patient sitting at 45 degree. This really becomes important if the patient has a fat neck and you cannot see the JVP, as is often the case if patient has anasarca.

Measurement of JVP. From JASE 2013. September 2013Volume 26, Issue 9, Pages 1033–1042. Noninvasive Evaluation of Right Atrial Pressure

Thus, cardiologists play a role in the management of these sick sepsis patients who are developing edema….  incidentally, note that there is a tendency away from using invasive lines to directly measure the RA pressure, especially after the 2014 PROCESS trial at NEJM showing that goal directed therapy is not superior to non-invasive clinical management.

Therefore, cardiologists have advanced echo techniques that can assist management of these patients. Unfortunately, most cardiologists are too busy to read journals and/ or they have limited hand-on echo experience. Their echo technicians just give them the standard views, which is OK, but they are not utilizing the full ability of modern echocardiographic techniques.

A new clinical trial has been initiated by Hamilton, Ontario, Canada Critical Care group: Furosemide and albumin for diuresis of edema (FADE).  The inclusion criteria is as follows: The target population is one of critically ill adults with hypoalbuminemia who are in a recovery phase of critical illness and judged by the treating physician to be volume overloaded, based on clinical findings, such as peripheral edema, delayed weaning, or chest radiographic findings of interstitial or pleural fluid. Thus, inclusion criteria include: (1) admission to ICU; (2) age ≥ 18 years; (3) hemodynamic stability for at least 24 hours, defined as the absence of persistent (>1 hour) hypotension (systolic blood pressure < 90 mmHg) and tachycardia (heart rate >110), not currently on vasopressors, received less than 2 l crystalloid or colloid boluses or two units of packed red blood cells, maintenance fluids excluded; (4) hypoproteinemia, defined as serum albumin < 30 g/l, or total protein < 60 g/l; (5) clinical decision by the caregiving team to diurese at least 3 l of net fluid balance within the next 72 hours, for any reason.

At the present time, my approach is as follows:

(1) if a septic patient is developing edema, it is a sign of ongoing inflammation. It is not necessarily a sign of fluid overload

(2) This would prompt the use of examination of postural BP/HR, if possible, and the use of handheld ultrasound looking for volume status.

(3) A diligent search for reversible cause of inflammation and malnutrition would be initiated

(4) I do not routinely treat these patients with diuretic unless there is clear sign of fluid overload, or the limb edema is so severe that it is triggering other complications such as infection.

(5) I routinely look out for abdominal compartment syndrome (intra-abdominal hypertension) due to massive ascites. While bladder pressure monitor is not routinely done outside of trauma unit, this can be easily done in the MICU (see Uptodate write up. And if suspected, I would treat it like ascites from liver failure: paracenetsis followed by using albumin. There is some data suggesting that colloid is superior to crystalloid in this scenario because it prevents increase in intra-abdominal pressure.

I know I sounded like a Critical Care specialist, but I feel that it is important for cardiologists to be aware of what is going on in other organ systems in order to be an effective consultant.

From electronic stethoscope back to physical exam basics and beyond

Many years ago, I started imagining what the new clinician will be using as their diagnostic tool for 21st century. My requirement is that it has to improve my diagnostic accuracy, not just because it is “cool”.

temp 2(From: 3M Littman website)

I became interested in 3M Littman electronic stethoscope and I used one in my daily practice for almost 2 years. It really helped me hear some subtle sounds that I would not be able to hear with my Littmann Master Cardiology stethoscope. However, there were three significant problems. Firstly, after two years, the plastic parts started falling apart; the stethoscope could not withstand prolonged rough handling in an ER environment. Secondly, when battery runs out, it is quite a hassle. Thirdly, it is expensive and I lose stethoscopes every 2 year… and it would be painful to replace if I left it on the ward.

temp 1(From Thinklabs)

Recently, Thinklabs, a Colorado-based company, developed a new electronic stethoscope that has superior audio quality and  features no “tubes”. Sounds are transmitted via wire and the frequency filter is much more sophisticated than the conventional stethoscope.

 (From Thinklab)

The scope has been featured in a recent New York Times article on how to examine Ebola patients. The challenge is how to disinfect a stethoscope. This is not an uncommon problem in our ICU. In many ICUs, a cheap disposable stethoscope is used to avoid cross contamination of patients, who are often colonized with resistant bacteria. These cheap stethoscopes are often inadequate to listen to cardiac murmurs. So many of us would be a glove on our own good stethoscope if we really want to listen to that subtle murmur, and use lots of disinfectant afterwards while hoping the scope would not be destroyed by the bleach. Because the new Thinklab scope uses wire to transmit sound, disinfection may be easier.  However, the challenge with Ebola patients have led many doctors to question whether they really need a stethoscope at all.  According to NYT, “several doctors working in Africa described stethoscopes as helpful but not indispensable there. Heart and lung ailments are not among the typical initial Ebola symptoms, which usually include fever, aches, vomiting and diarrhea.” I remember that during my interventional cardiology fellowship training, many of us would not carry a stethoscope on the ward: we are proceduralists and we use our hands to do things.

Dr. Eric Strong, a Stanford School of Medicine attending physician who has one of the best YouTube medical channels, reviewed the Thinklabs One stethoscope. After using it for six months, his conclusion is that it is the best electronic stethoscope around.  However, it still has problem with white noise transmission and the software is still weak. The small earbud headphone is not durable.

For myself, I returned to using Littmann Master Cardiology because it is durable, sounds great, not dependent on battery, and inexpensive to replace.

(Despite many general cardiologists mocking interventionalists for their lack of physical exam acumens, one of the fellow from my interventional cardiology year, Dr. Ajay Agarwal, was able to clinch the correct cardiac diagnosis of an adult congenital heart patient with his stethoscope while the famous Chief of Cardiology missed the diagnosis with echo. To this day, I am still amazed by his ability and I convinced myself to make efforts in understanding this neglected tool of medicine.)


After more than ten years of practice and dedicated effort to improve my diagnostic ability with my stethoscope, I came to realize that “You only see what you know.” Unless you know what you are listening for, you will miss the diagnosis.     I exam everyone carefully before each echo and I became very good due to constant feedback.  I also studied the best textbooks in cardiac physical exam. The best book to learn the old arts of cardiac exam is the book by Jules Constant called “Bedside Cardiology”. The fact that it is now out of print speaks to the demise of the importance of physical exam in America. If every physician knows how to exam the patients properly, US health care system will save a lot of money on unnecessary tests. I used “. Another book that I used was Perloff’s “Physical Examination of the Heart and Circulation.” The book was the suggested textbook for the live case portion of the Canadian Royal College Exam for cardiology, and it helped me gain the basics. The last book that I found useful was Dr. Henry Marriott’s “Bedside Cardiac Diagnosis”. The book is also out of print but it is amazing that books on physical exam do not get out-of-date easily.

More recently, Steven McGee published an interesting book called “Evidence-Based Physical Diagnosis“. This book goes well with JAMA rational clinical examination series. The books do give quantitation to various clinical signs. However, the problem with this numerical approach is that if you have a combination of physical signs, the likelihood ratio of the disease does not equal to the multiplication product of these likelihood ratios because of such factor as “co-linerality”. In other words, you cannot use a simple multivariate model, but you need a neural network based on the individual clinical signs because of interactions among the signs. Few of these studies tackle the problem of interactions. Just like in artificial intelligence, you need a lot of training sample to develop a good neural network algorithm, in real life medicine, you need a lot of clinical exposure and experience to develop your own “neural network” that can take into accounts of all the different interactions among clinical factors.

An interesting book on physical exam is the Sapira’s “Art and Science of Bedside Diagnosis.” It is not a cardiology book per se, but it has a lot of interesting pearls. This book is not suitable for beginning student. Other books which I found helpful were the MRCP PACES books by Oxford: when I was younger I went to UK and took a course in physical exams to pass their MRCP live cases. During the exam, the candidate was given a patient with some obscure diseases, and the candidate needed to make a diagnosis based on physical exam alone. I learned that the key to making a physical diagnosis is that (a) you need to be expert in the technique; (b) you need to be able to integrate your findings. Because I was trained in New York, UK trainees mocked me because from the UK perspective, Americans only order tests and they don’t know how to examine patients.


After mastering the basics and after dedicated efforts to improve my physical exam ability using classical technique, I started exploring expansion of my repertoire. My expansion took several approaches:

(1) Can unlimited use of ultrasound augment day-to-day clinical practice in the ER, the ward, and ambulatory setting?  Based on my experience for the last 10 years, my answer is “YES” and it made me a stronger physical diagnostician even without ultrasound because of the immediate feedback. In my mind, all young physicians need to learn ultrasound exam as their basic training. Some of my medicine residents are already using ultrasound in ER to look for CHF and pneumothorax, in addition to wall motion of the heart. I carry a handheld ultrasound to the ward and ER. For STEMI patients, the 15 second ultrasound exam helps me strategize my PCI: is the patients likely to crash during PCI? Is there severe MR that I cannot hear on my stethoscope and therefore I need to think surgery? I actually had a case of aortic dissection with rupture masquerading as inferior wall STEMI that I diagnosed on my VScan.

(2) What can we learn from traditional Chinese medicine (TCM) physical exam approach? Can we learn from pulse exam, tongue exam, and other facets of traditional Chinese medicine technique?  My answer is again: “YES”. As an example, patients with C diff colitis have different tongue color than other patients; and my hypothesis is that tongue color reflects the gut flora. That is why the smell of a GI bleed patient is different from a liver patient: the gut flora probably develop different smells due to flora change, and you can both smell it and see it in the patients’ tongue. As to pulse exam, there is more to the pulse than heart rate and rhythm. I first learned this from Dr. Jay Cohn, the previous Chief of Cardiology at University of Minnesota. He is known as the pioneer of ACE-inhibitor therapy in CHF with numerous early publications in NEJM. However, he also developed a less well known technique that study can analyze the radial pulse waveform in order to analyze the stiffness of large and small vessels. Taking his work as my cue, I started analyzing pulse wave the same way his machine would study the pulse contour, but instead of using a machine, I used my own fingers. Then I started realizing that the pulse contour patterns were actually described in Chinese physical exam textbook, especially related to the description of its 28 (or 29) pulse pattern.  The facial color also became important to our daily clinical exam.

(3) I learn to re-appreciation of forgotten Western classical physical sign. Clinical experience also taught us many signs that have been taught in old textbooks but lose in newer edition of “Bate”. Examples include the Frank’s sign and Xanthelasma as predictor for heart diseases. While Frank’s sign is not known to most American physicians, it is well known in among UK MRCP exam candidates. I first learned this sign from a Chinese fortune face reader, who told one of my patient to see me because this is a sign of “short life”. Other example includes blood pressure and heart rate response to Valsalva as described in Sapira and Jule Constants’ book. Old medical textbooks are full of pearls.

(4) IPhone Health kit also presents with new possibilities and I am excited by the availability of new bio-sensors. I have been using the third generation Alivecor on my iPhone and I recommended this to many of my patients. I envision that many of my patients will be using these sensors and I will be able to monitor their health even more closely.