Beyond stethoscopes: Advancing Diagnostic Precision in

Pediatric Cardiology A narrative review

Revista Ecuatoriana de Pediatría

Editorial: Sociedad Ecuatoriana de Pediatría (Núcleo de Quito, Ecuador)

Tipo de estudio: Artículo Original

Área de estudio: Pediatría

Páginas: 46-53

Codígo DOI: https://doi.org/10.52011/RevSepEc/e235

URL: https://rev-sep.ec/index.php/johs/article/view/235

ABSTRACT

Auscultation, a diagnostic method with a rich history dating back to the time of Hippocrates, has long been

a fundamental approach to identifying pediatric heart diseases. Despite its historical signiﬁcance, the challen-

ge of distinguishing innocent murmurs from those indicating structural heart defects in neonates persists, with

conditions such as aortic stenosis, pulmonary stenosis, and atrial septal defect potentially being misinterpreted

as innocent murmurs, highlighting the limitations of traditional methods. Although cardiac auscultation remains

a cost-eﬀective pre-screening tool, its eﬀectiveness is further hindered by the subjectivity and expertise requi-

red for interpretation. A global comparison of auscultation skills among internal medicine trainees revealed

suboptimal performance, emphasizing the need for innovative solutions. The integration of technology and

Artiﬁcial Intelligence (AI) in pediatric cardiology oﬀers a promising avenue for enhancing diagnostic accuracy

and patient care. This paper explores the transformative impact of technology and AI in diagnostic cardiology

addressing the limitations of traditional auscultation.

Key Words: artiﬁcial intelligence, echocardiography, heart auscultation, heart disease, heart sound analysis.

RESUMEN

La auscultación, un método de diagnóstico con una rica historia que se remonta a la época de Hipócrates,

ha sido durante mucho tiempo un enfoque fundamental para identiﬁcar enfermedades cardíacas pediátricas.

A pesar de su importancia histórica, el desafío de distinguir los soplos inocentes de los que indican defectos

cardíacos estructurales en los neonatos persiste, y afecciones como la estenosis aórtica, la estenosis pulmonar

Muhammad Tayyab Ijaz1; Namra Ijaz2

Recibido: 10/ene/2024 - Aceptado: 12/marz/2024 - Publicado: 30/agos/2024

1. CMH Lahore Medical and Dental College, Lahore, Pakistan

2. Fatima Memorial College of Medicine & Dentistry, Lahore, Pakistan

Muhammad Tayyab Ijaz https://orcid.org/0000-0003-0242-6446

Namra Ijaz https://orcid.org/0009-0001-4924-6939

Correspondencia: Muhammad Tayyab Ijaz, / tayyabijaz2@hotmail.com

Más allá de los estetoscopios: avances en la precisión

diagnóstica en cardiología pediátrica Una revisión narrativa

Revisión de Literatura

Revista Ecuatoriana de Pediatría | ISSNe: 2737-6494

Pagína 47 | VOL.25 N°2 (2024) Mayo-Agosto

Revisión de Literatura

y el defecto del tabique auricular pueden malinterpretarse como soplos inocentes, lo que resalta las limitacio-

nes de los métodos tradicionales. Si bien la auscultación cardíaca sigue siendo una herramienta de preselec-

ción rentable, su eﬁcacia se ve obstaculizada aún más por la subjetividad y la experiencia requeridas para la

interpretación. Una comparación global de las habilidades de auscultación entre los residentes de medicina

interna reveló un desempeño subóptimo, lo que enfatiza la necesidad de soluciones innovadoras. La integra-

ción de la tecnología y la inteligencia artiﬁcial (IA) en cardiología pediátrica ofrece una vía prometedora para

mejorar la precisión del diagnóstico y la atención al paciente. Este artículo explora el impacto transformador

de la tecnología y la IA en la cardiología diagnóstica abordando las limitaciones de la auscultación tradicional.

Palabras Claves: inteligencia artiﬁcial, ecocardiografía, auscultación cardíaca, enfermedades cardíacas, aná-

lisis de los sonidos cardíacos.

Introduction

Auscultation, a long-standing and essential

method for detecting heart diseases, traces

its origins back to the ancient Greek physi-

cian, Hippocrates. In the 19th century, physi-

cians employed direct ear-to-chest contact

for screening. However, in 1816, René Laen-

nec revolutionized this practice with the in-

vention of a 31 cm-long cylindrical wooden

stethoscope1. Further modiﬁcations, such as

the incorporation of rubber tubing in 1829,

culminated in the contemporary stethosco-

pe design established in 1926.

In more than 50% of children and adoles-

cents, auscultation reveals innocent heart

murmurs, with the highest frequency obser-

ved between the ages of 3-6 years and

8-12 years2. A murmur is an abnormal sound

arising from turbulent blood ﬂow, which

occurs due to increased ﬂow or structural

heart defects that disrupt the normal har-

monious ﬂow of blood. This phenomenon

is usually absent in normal vascular con-

ditions, where blood ﬂow is smooth and

silent. These are further classiﬁed into inno-

cent and pathological murmurs. Innocent

murmurs are asymptomatic and occur in

anatomically and physiologically normal

hearts. The diverse nature of murmurs, in

terms of timing, duration, intensity, pitch,

and shape, is linked to various structural

heart diseases, enabling their identiﬁcation

and understanding3,4,5.

Organic murmurs, associated with con-

ditions such as aortic stenosis, pulmonary

stenosis, and atrial septal defect (ASD), can

be mistaken for innocent murmurs. Distin-

guishing between these types demands a

high level of expertise in cardiac ausculta-

tion, as other non-cardiac conditions, such

as supraclavicular or carotid murmurs, may

mimic the murmur of aortic stenosis, coarc-

tation, carotid stenosis, or subclavian artery

stenosis.

Cardiac murmurs oﬀer invaluable insights

into cardiovascular pathologies. While car-

diac auscultation is a widely accessible

method, its eﬀectiveness relies on expert

interpretation, posing challenges in resour-

ce-constrained settings. Limited access to

clinical experts and infrastructure hinders

widespread screening and management of

cardiac diseases in such environments.

Is there a need for improved ausculta-

tion in pediatric population?

Congenital heart anomalies (CHA) pose a

signiﬁcant challenge in pediatric healthcare,

occurring at an incidence rate of 0.8 to 1%

per 1000 live births6,7. Although traditional

screening methods, such as second-trimes-

ter ultrasonography and postnatal clinical

examination, are used, their detection rates

for CHA are limited, resulting in undiagnosed

cases, particularly with the trend of early

hospital discharge. It is estimated that over

half of children with CHA remain undiagno-

sed despite routine clinical examinations8,9,10.

A signiﬁcant proportion of neonates with

audible murmurs in the neonatal period

have structural heart defects, making it di-

ﬃcult to distinguish innocent from organic

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heart murmurs based on auscultative cha-

racteristics11. This distinction is essential for

healthcare professionals involved in heart

disease screening.

In a study involving over 900 children with

innocent-sounding murmurs at a pediatric

cardiology clinic, abnormal ﬁndings in me-

dical history, physical examination, or diag-

nostic tests showed 67% sensitivity but only

38% speciﬁcity for detecting structural heart

lesions in infants under six weeks. Sensitivi-

ty increased to 100% in infants older than

six weeks, but speciﬁcity decreased to 28%.

While this information is helpful in ruling out

structural causes of an innocent murmur in

older infants and children, it lacks utility in

younger infants12. A Norwegian study revea-

led that only 10% of children referred to

a cardiac center for investigating a car-

diac murmur were diagnosed with a con-

genital cardiac lesion, with 71% of referrals

made by general practitioners, and only

17% providing a diagnosis13. The diagnosis

of an innocent heart murmur in children

and adolescents is based on speciﬁc cri-

teria, including the absence of abnormal

physical examination ﬁndings (except the

murmur), a negative review of systems, a

history without risk-increasing features for

structural heart disease, and distinctive aus-

cultatory characteristics14,15. These criteria

do not apply to newborns or infants under

one year of age, as a higher prevalence of

asymptomatic structural heart disease exists

within this population16. It is recommended

that, in situations where the classiﬁcation of

an innocent murmur is unclear, a referral for

echocardiography or to a pediatric cardio-

logist be considered.

Pediatric cardiologists exhibit a higher level

of accuracy in identifying structural heart

defects in infants and children presenting

with heart murmurs; their sensitivity in de-

tecting pathological heart murmurs in new-

borns ranges from 80.5% to 94.9%, with

speciﬁcity varying between 25% and 92%17.

The accuracy of a pediatric cardiologist in

identifying pathological murmurs depends

on several factors, including diagnostic

conﬁdence. In newborns presenting with a

heart murmur, it may be deemed unneces-

sary to perform an echocardiography if a

pediatric cardiologist can conﬁdently diag-

nose an innocent murmur18. Nonetheless,

considering the relatively high prevalence

of structural heart disease in asymptomatic

newborns with murmurs, further diagnostic

measures should be considered.

This underscores the urgent need to enhan-

ce medical practitioners’ ability to identify

murmurs indicative of structural heart di-

sease. Having received FDA approval for

aiding physicians in detecting abnormal

heart murmurs, Computer-aided ausculta-

tion (CAA) emerges as a potential solution

to this dilemma.

Is digital technology required in auscul-

tation devices?

Cardiac auscultation with stethoscopes re-

mains a widely used and cost-eﬀective me-

thod for cardiac pre-screening. However,

its diagnostic sensitivity and accuracy are

limited due to the expertise and experien-

ce required for accurate interpretation, and

the data acquired through auscultation is

subjective and lacks a permanent, objective

record. This information is challenging to re-

plicate among diﬀerent examiners, leading

to substantial disagreement among medi-

cal professionals19,20,21. Furthermore, inade-

quate training of healthcare professionals

in cardiac auscultation has been raised as

a concern over the past decade. Despite

the potential cost-eﬀectiveness of cardiac

auscultation, both students and clinicians

often demonstrate incompetence in perfor-

ming it eﬀectively22. A research study was

conducted with 314 senior internal medi-

cine and family practice residents from di-

verse training programs across the United

States. The ﬁndings revealed that only 20%

of abnormal heart sounds were accurately

identiﬁed from auscultatory tapes. Although

residents who received formal auscultatory

training demonstrated greater conﬁdence,

their accuracy did not signiﬁcantly increa-

se23. Moreover, a comparison of ausculta-

tion skills among internal medicine trainees

in the U.S., Canada, and Britain indicated

suboptimal performance in all three coun-

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tries, with slightly better results in Canada24.

Therefore, the development of tools for au-

tomated classiﬁcation of speciﬁc murmur

types is necessary and clinically signiﬁcant.

While experienced cardiologists can suc-

cessfully distinguish speciﬁc heart sound

patterns, young and inexperienced physi-

cians face challenges in making accurate

diagnoses through auscultation.

Recent innovation in cardiac diagnostics

Echocardiography

In light of the limitations associated with

auscultation, phonocardiography was

developed. The visual representation of

acoustic data allowed for a more accura-

te assessment of the timing and acoustic

characteristics of heart sounds and mur-

murs compared to traditional auscultation25.

Echocardiography has experienced signiﬁ-

cant advancements since its inception over

30 years ago, when Keidel pioneered the

use of ultrasound to explore the heart26.

The introduction of two-dimensional echo-

cardiography signiﬁcantly revolutionized the

ﬁeld, enabling real-time and cross-sectio-

nal imaging. The transition from M-mode to

two-dimensional imaging, coupled with the

integration of Doppler and color ﬂow, has

established echocardiography as an indis-

pensable diagnostic tool in cardiology27. The

progression towards three-dimensional (3D)

imaging represents a notable development,

providing real-time volumetric imaging and

enhancing accuracy in evaluating cardiac

chamber volumes. This technology oﬀers

comprehensive views of cardiac structures,

facilitating surgical interventions and posto-

perative assessments. The ongoing reﬁne-

ment of 3D imaging ensures its integration

into routine clinical practice28.

While echocardiography oﬀers numerous

beneﬁts, primary care physicians should

also be cognizant of its limitations. Approxi-

mately 5% to 10% of studies may be in-

suﬃcient for interpretation due to patient

demographics and the echocardiography

lab’s experience. Additionally, operator de-

pendence is a concern, aﬀecting data ac-

quisition and interpretation. Reproducibility

can be challenging, and there are no stan-

dard criteria for age-related valve changes.

The qualitative and subjective nature of

color ﬂow imaging in valvular regurgitation

grading adds to these concerns, although

quantitative techniques are emerging. It is

also worth noting that diagnostic errors are

common in pediatric echocardiography

conducted in community-based adult labs29.

Acoustic cardiography

The acoustic cardiography technology,

which is a more recent advancement,

enables the simultaneous acquisition of

both electrocardiogram (ECG) and car-

diac acoustical data. This user-friendly and

cost-eﬀective approach allows for a detai-

led assessment of the left ventricular func-

tion during systole and diastole. The present

system oﬀers a computerized analysis and

graphical portrayal of its ﬁndings. Its medi-

cal applications extend to the evaluation of

illnesses such as heart failure, ischemia, car-

diac arrhythmias, and the optimization of

cardiovascular medication and equipment

therapies30.

The application of acoustic cardiography,

which utilizes digital data for automated

interpretation, eliminates the necessity for

specialized expertise in heart sound or

ECG data analysis. By employing standardi-

zed sensor locations, uniform ﬁltering, and

processing, this approach surpasses the la-

bor-intensive nature of traditional phonocar-

diography. The Audicor® technology allows

for continuous recording of concurrent

sound and ECG data, facilitating cardiovas-

cular monitoring and optimizing cardiac sy-

nchronization therapy devices. Studies have

demonstrated its eﬃcacy in assessing sys-

tolic and diastolic function in heart failure

patients, as well as in monitoring patients

undergoing cardiotoxic chemotherapy 31.

Additionally, its early detection capability

for acutely decompensated heart failure in

emergency units has been showcased by

Collins et al32,33. The cost-eﬀectiveness and

user-friendly nature of acoustic cardiogra-

phy make it a practical tool for mass scree-

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ning, particularly in regions with prevalent

diseases such as rheumatic heart disease34.

Overall, acoustic cardiography emerges as

a reliable and cost-eﬀective alternative to

echocardiographic methods, demonstrating

comparable eﬃcacy to invasive cardiac

catheterization and noninvasive echocar-

diography. By seamlessly integrating with

routine ECG testing, it swiftly addresses the

unmet clinical need for expedited and ac-

curate diagnoses in emergency settings.

Artiﬁcial Intelligence and Machine Lear-

ning

Artiﬁcial intelligence has become increasin-

gly prevalent in the ﬁeld of computer-aided

diagnosis in recent years. Artiﬁcial Intelligen-

ce (AI) manifests as a type of intelligen-

ce displayed by devices, emulating human

cognitive functions such as learning and

problem-solving. Machine Learning (ML),

a subset of AI, involves creating and tra-

ining mathematical models using extensive

datasets. The healthcare sector has increa-

singly integrated ML, utilizing algorithmic

advancements and the abundance of “big

data” to enhance diagnostics, improve test

reliability, reduce errors related to cogniti-

ve bias, engage patients, and streamline

administration35. In cardiovascular medicine,

ML applications have expanded to include

conditions like heart failure, cardiomyopathy,

hypertension, and coronary artery disease,

with recent focus on mitral and tricuspid

valve disorders36,37,38.

Particularly noteworthy is the progress made

in detecting and classifying heart sounds

using artiﬁcial neural networks (ANNs) and

deep neural networks (DNNs). Jou-Kou

Wang et al. proposed a novel algorithm,

the temporal attentive pooling–convolutio-

nal recurrent neural network (TAP-CRNN)

model, for automatically identifying systolic

murmurs in patients with ventricular septal

defects (VSD)39.

In the ﬁeld of medical imaging, a signiﬁcant

challenge is the reliance on skilled opera-

tors for tasks such as image acquisition, in-

terpretation, and decision-making. Artiﬁcial

Intelligence (AI) presents a transformative

solution, utilizing Machine Learning (ML)

to acquire expertise in rule learning and

pattern recognition from diverse datasets.

These datasets include essential factors like

pixel density, brightness, vector movement,

and measurements. Segmentation allows

for the division of images or volumes into

landmarks, facilitating automated measure-

ments of 2D dimensions or Doppler veloci-

ties, thereby enhancing reproducibility and

eﬃciency40,41. Furthermore, the implementa-

tion of deep learning algorithms reduces

the reliance on highly trained individuals,

oﬀering automated analysis of chamber vo-

lumes and function42. Additionally, AI’s ability

to facilitate remote training enables skill de-

velopment without the need for in-person

contact, which is particularly beneﬁcial in

underserved communities43.

Super Stethoscopes

Furthermore, Shimpei et al.44 introduced the

Super StethoScope, a device designed to

capture and record both electrocardio-

graphic and heart sounds, which facilitates

the detection of heart rate variability and

enhances the signal-to-noise ratio in the

audible frequency range, while also captu-

ring heart sounds across both audible and

inaudible frequency ranges. This innovative

device enabled the visualization of quan-

titative results, ensuring precise data inter-

pretation during remote auscultations, while

mitigating potential disruptions arising from

ﬂuctuations in sound quality.

The use of digital stethoscopes has the

potential to signiﬁcantly enhance the de-

tection of murmurs through the conversion

of acoustic sounds into electronic signals,

which can then be ampliﬁed, ﬁltered, and

digitalized. This technology, when combined

with advanced analysis software, has the

potential to transform auscultation into a

more objective and quantitative tool for cli-

nical heart evaluation. This innovation has

the potential to enhance the assessment

of innocent murmurs, mitigate the variabili-

ty resulting from human acoustic limitations,

and improve the teaching of cardiac aus-

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and technology experts, and establishing

strict regulatory frameworks. The urgency

of transitioning from conventional methods

to advanced, technology-driven approa-

ches is crucial in ensuring improved cardiac

care for pediatric patients. However, only

the future will determine whether the bi-

naural stethoscope will become a relic of

the past, like its predecessor, the monaural

stethoscope, or will remain a relevant and

valuable clinical diagnostic tool.

Author contributions:

Conceptualization: MTI. Investigation: MTI,

NI. Resources: MTI. Writing – Original Draft:

MTI, NI. Writing – Review & Editing: MTI, NI.

Visualization: MTI, NI. Supervision: MTI. Pro-

ject administration: MTI.

Disclaimer: None.

Funding: None.

Conﬂict of interest: None.

Ethical statement: No ethical approval

was required as this study did not involve

human participants or laboratory animals.

Data availability: Data sharing is not

applicable to this article as no new data

were created or analyzed in this study.

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Para referenciar aplique esta cita:

Ijaz MT, Ijaz N. Más allá de los estetoscopios: avances en la precisión diagnóstica en cardiología pediátrica

Una revisión narrativa. REV-SEP [Internet]. 26 de agosto de 2024 [citado 13 de enero de 2025];25(2):46-53.

Disponible en: https://rev-sep.ec/index.php/johs/article/view/235

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