Heart murmurs recorded by a Electronic stethoscope and e-mailed for remote assessment
ORIGINAL ARTICLE
  - L B Dahl, P Hasvold, E Arild, T Hasvold

Correspondence to: Dr L B Dahl, Department of Pediatrics, University

Background: ¹è°æ
Heart murmurs are common in children, and they are often referred to a specialist for examination. A clinically innocent murmur does not need further investigation. The referral area of the University Hospital is large and sparsely populated. A new service for remote auscultation (telemedicine) of heart murmurs in children was established where heart sounds and short texts were sent as an attachment to e-mails.
½ÉÀå ÀâÀ½Àº ¾ÆÀ̵鿡°Ô¼­ º¸ÅëÀÌ°í, ±×µéÀº °¡²û Àü¹®ÀǵéÀÇ ¿¬±¸¿¡ ÂüÁ¶µÇ±âµµ ÇÑ´Ù. ÀÓ»óÀûÀ¸·Î ±ú²ýÇÑ ½ÉÀâÀ½Àº ´õ ÀÌ»óÀÇ Á¶»ç¸¦ ÇÊ¿ä·Î ÇÏÁö ¾Ê´Â´Ù. ´ëÇÐ º´¿øÀÇ ÁøÂû Áö¿ªÀº ±¤¹üÀ§ÇÏ°Ô ¶³¾îÁ® ÀÖ´Ù. ½ÉÀå¼Ò¸®¿Í ªÀº ´Ü¹®ÀÇ À̸ÞÀÏ¿¡ ÷ºÎµÇ¾î º¸³»Áø °÷¿¡ ½ÉÀ庴 ¾î¸°À̸¦ À§ÇÑ ¿ø°ÝÁø·á ¼­ºñ½º°¡ ¼³¸³µÇ¾ú´Ù.

Aim: ¸ñÀû
To assess the clinical quality of this method.
ÀÌ·¯ÇÑ ¹æ¹ýÀÇ ÀÓ»ó Ç°ÁúÀ» Æò°¡ÇÏ´Â °Í.

Methods: ¹æ¹ý
Heart sounds from 47 patients with no murmur (n = 7), with innocent murmurs (n = 20), or
with pathological murmurs (n = 20) were recorded using a sensor based stethoscope and e-mailed to a remote computer. The sounds were repeated, giving 100 cases that were randomly distributed on a compact disc. Four cardiologists assessed and categorised the cases as having ¡°No murmur¡±, ¡°Innocent murmur¡±, or ¡°Pathological murmur¡±, recorded the assessment time per case, their degree of certainty, and whether they recommended referral.
47¸íÀÇ È¯ÀÚ °¡¿îµ¥ ¹®Á¦¾ø´Â murmur (n = 20)¿Í ¿ÏÀüÈ÷ ½ÉÀâÀ½ÀÌ ¾ø´Â »ç¶÷ (n = 7)ÀÌ ÀÖ°í, º´¸®ÇÐÀû ÀâÀ½(n=20)Àº ÀüÀÚûÁø½Ã½ºÅÛ¿¡ ÀÇÇØ ³ìÀ½½ÃÅ°°í, ±×´ÙÀ½ ¿ø°ÝÁö ÄÄÇ»ÅÍ¿¡ Àü¼ÛÀ» Çß´Ù.  ±× ¼Ò¸®µéÀº ÄÞÆÑÆ® µð½ºÅ© »ó¿¡¼­ ·£´ýÇÏ°Ô ºÐ¹èµÈ 100°¡Áö °æ¿ì¸¦ Áָ鼭 µÇÇ®ÀÌ µÇ¾ú´Ù. 4¸íÀÇ ½ÉÀåÀü¹®ÀÇ µéÀº ÀÌ·¯ÇÑ ÄÉÀ̽ºµéÀ» Æò°¡ÇÏ°í ºÐ·ùÇÏ°í, ¡°No murmur¡±,¡°Innocent murmur¡±¶Ç´Â¡°Pathological murmur¡±·Î, ÀÌ·± Çüź°·Î ºÐ·ù ½Ã°£À» ±â·ÏÇϸ鼭, È®½ÇÇÑ µî±ÞÀ» ¸Å±â°í, ¶Ç Á¶È¸¸¦ ÃßõÇϱ⵵ Çß´Ù.

Results: °á°ú
On average, 2.1 minutes were spent on each case. The mean sensitivity and specificity were 89.7% and 98.2% respectively, and the inter-observer and intra-observer variabilities were low (kappa 0.81 and 0.87), respectively. A total of 93.4% of cases with a pathological murmur and 12.6% of cases with an innocent murmur were recommended for referral.
Æò±ÕÀ¸·Î, 2.1ºÐ Á¤µµ°¡ °¢ °æ¿ì¸¦ ºÐ·ùÇϴµ¥ ¾²¿©Á³´Ù. Æò±Õ sensitivy¿Í specificity´Â °¢°¢ 89.7%¿Í 98.2%¿´´Ù. ±×¸®°í ³»ºÎ ¾÷Àú¹ö¿Í ¿ÜºÎ ¾÷Àú¹ö °¡º¯¼ºÀº °¢ÀÚ ³·¾Ò´Ù(kappa 0.81°ú 0.87). ÇÕ°è 93.4%ÀÇ º´¸®ÇÐÀû murmur¿Í 12.6%ÀÇ ¹®Á¦¾ø´Â ½ÉÀâÀ½°ú ´õºÒ¾î Á¶È¸¿ëÀ¸·Î ÃßõµÇ¾ú´Ù.

Conclusion: °á·Ð
Telemedical referral of patients with heart murmurs for remote assessment by a cardiologist is safe and saves time. Skilled auscultation is adequate to detect patients with innocent murmurs.
½ÉÀåÀü¹®ÀÇ¿¡ ÀÇÇÑ ¿ø°Ý ÆÇ´ÜÀ» À§ÇÑ ½ÉÀâÀ½°ú ´õºÒ¾î ȯÀÚÀÇ TelemedicalÇÑ Á¶È¸´Â ¾ÈÀüÇÏ°í, ½Ã°£À» Àý¾àÇÑ´Ù. ¼÷·ÃµÈ ½ÉÀåûÃë¹ýÀº ¹®Á¦¾ø´Â ½ÉÀâÀ½°ú ÇÔ²² ȯÀÚ¸¦ ¹ß°ßÇϱâ À§Çؼ­ ÀûÀýÇÏ´Ù.

Heart murmurs are common in children, and may be heard through infancy to adolescence. Most are innocent - that is, not associated with anatomical or physiological abnormalities. It has been estimated that up to 80% of schoolchildren may have heart murmurs under certain circumstances, but less than 1% have confirmed organic heart disease, the majority being diagnosed during infancy.
½ÉÀå ÀâÀ½Àº ¾ÆÀ̵鿡°Ô¼± ÀϹÝÀûÀÌ°í, ¿µ¾Æ±â¿¡¼­ »çÃá±â±îÁö ³»³» µé¸±Áöµµ ¸ð¸¥´Ù. ´ëºÎºÐÀº ¹®Á¦°¡ ¾ø´Ù – ±×°ÍÀº ÇغÎÇÐÀ̰ųª »ý¸®ÇÐÀÇ ÀÌ»ó°ú °ü·ÃµÇÁö ¾Ê´Â´Ù. ÃÖ°í 80%ÀÇ ¾Æµ¿ÀÌ ½ÉÀå ÀâÀ½À» ¾î¶² °æ¿ì¿¡´Â °¡Áö°í ÀÖÀ»Áöµµ ¸ð¸¥´Ù. ±×·¯³ª À¯±âÀûÀÎ ½ÉÀ庴(¿µ¾Æ±â µ¿¾È Áø´ÜÇÏ°í ÀÖ´Â ´ë´Ù¼ö)À» 1%º¸´Ù ´õ È®ÀÎÇÏÁö ¾Ê¾ÒÀ»Áöµµ ¸ð¸¥´Ù ¶ó°í ÃßÁ¤Çß´Ù.

Evaluation of a heart murmur represents one of the most common reasons for referral to a pediatric cardiologist.
½ÉÀå ÀâÀ½ÀÇ Æò°¡´Â ¼Ò¾Æ ½ÉÀå Àü¹®ÀÇ¿¡°Ô Á¶È¸Çϱâ À§ÇÑ °¡Àå º¸ÆíÀûÀÎ ÀÌÀ¯ °¡¿îµ¥ ÇϳªÀÓÀ» Ç¥ÇöÇÑ´Ù.

Studies have shown that following clinical examination by a pediatric cardiologist, the diagnosis of a murmur as innocent or pathological, is correct with a specificity of 95% and a sensitivity of 96%.  Further procedures, such as chest radiography, electrocardiography, and echocardiography, are thus unlikely to alter a clinical diagnosis of an innocent murmur made by a pediatric cardiologist, based on auscultation.
¿¬±¸´Â ¼Ò¾Æ½ÉÀå Àü¹®ÀÇ¿¡ ÀÇÇÑ ÀÓ»ó ½ÃÇè¿¡ µû¸§À» º¸¿©ÁÖ¾ú´Ù. º´ÀÌ Àְųª ¾ø´Â ½ÉÀâÀ½À» ºÐ¼®ÇÏ´Â °ÍÀº 96%ÀÇ ¹Î°¨µµ¿Í 95%ÀÇ ºÐ·ùµµ¿¡ ÀÇÇØ Á¤È®ÇÏ´Ù.  ±× ÀÌ»óÀÇ °úÁ¤(¿¹ÄÁ´ë °¡½¿ ¹æ»ç¼± ÃÔ¿µ, ECG¿Í ÃÊÀ½ÆÄ Áø´Ü)Àº ÀÌ¿Í °°ÀÌ ¼Ò¾Æ½ÉÀå Àü¹®ÀÇ¿¡ ÀÇÇØ ¸¸µé¾îÁø ¹®Á¦¾ø´Â ÀâÀ½µîÀÇ ÀÓ»ó Áø´ÜÀ» ¹Ù²Ü °Í °°Áö ¾Ê°í, ÀÌ´Â ¼Ò¸®¸¦ ±âÁØÀ¸·Î ÇÑ´Ù.

Parents and referring physicians often expect a number of investigations to alleviate their concern, or to confirmor refute their suspicions.
ºÎ¸ðµé°ú Ãßõ ÀÇ»ç´Â °¡²û ±×µéÀÇ °ü½ÉÀ» ´ú¾îÁÙ ¸¹Àº Á¶»ç¸¦ ±â´ëÇϰųª, ½ÂÀÎÇÏ´Â »ç¶÷¿¡°Ô ±×µéÀÇ Àǽɿ¡ ´ëÇØ ¹Ý¹ÚÇÑ´Ù.

In some circumstances there may even be a financial incentive for the cardiologist to perform echocardiography. Expensive investigations are therefore sometimes performed without any evident medical reason.
¾à°£ÀÇ ¾î¶² ȯ°æµéÀº ½ÉÃÊÀ½ÆÄ Áø·á¸¦ ¼öÇàÇÏ´Â ½ÉÀåÀü¹®ÀǸ¦ À§ÇÑ ÀçÁ¤ÀûÀÎ º¸»óÀÌ µÉÁöµµ ¸ð¸¥´Ù. ±×·¯¹Ç·Î ¶§¶§·Î °ªºñ½Ñ Á¶»çµéÀÌ ¾î¶°ÇÑ Áõ¸íµÈ ÀÇÇÐÀû ÀÌÀ¯°¡ ¾øÀÌ ¼öÇàµÇ±âµµ Çß´Ù.  

The University Hospital in Tromso is a teaching hospital in north Norway. The coverage area of the hospital is sparsely populated with vast distances and a severe climate. Most of the doctors recruited to the small rural communities are young and inexperienced in assessing heart murmurs in children.
TromsoÀÇ ´ëÇÐ º´¿øÀº ³ë¸£¿þÀÌ ºÏÂÊ¿¡ ÀÖ´Â ±³À° º´¿øÀÌ´Ù. º´¿øÀÇ Ä¿¹ö¸®Áö ¿¡¾î¸®¾î´Â ¹æ´ëÇÑ °Å¸®¿Í ½É°¢ÇÑ ±âÈÄ¿Í ÇÔ²² µå¹®µå¹® ¶³¾îÁ® ÀÖ´Ù. ÀÛÀº ½Ã°ñÀÇ Ä¿¹Â´ÏƼ¿¡ µé¿©Áö´Â ´ëºÎºÐÀÇ ÀÇ»ç´Â Àþ°í ¾ÆÀ̵鿡°Ô¼­ ½ÉÀå ÀâÀ½À» Æò°¡ÇÏ´Â °Í¿¡¼­ ¹Ì¼÷ÇÏ´Ù.

During the period between January 1999 and December 2000, 103 children with heart murmurs were referred to the outpatient clinic at the University Hospital, and the waiting time averaged 60 days. It was found that 99 (96%) of these children had an innocent murmur, in most cases diagnosed by clinical examination only.
1999³â 1¿ù°ú 2000³â 12¿ù »çÀÌÀÇ ±â°£ µ¿¾È, ½ÉÀâÀ½ÀÌ ÀÖ´Â 103¸íÀÇ ¾ÆÀ̵éÀÌ ´ëÇÐ º´¿øÀÇ ¿Ü·¡ Ŭ¸®´Ð¿¡ Áø·á¸¦ ¹Þ¾Ò°í, Æò±Õ 60ÀÏ Á¤µµ¸¦ ±â´Ù·È´Ù. ÀÌ ¾ÆÀ̵éÁßÀÇ 99¸í(96%)°¡ ÀÓ»ó½ÇÇè¿¡ ÀÇÇØ ´ëºÎºÐÀÌ ¾Ë·ÁÁø innocent murmur°¡ ÀÖ´Â °ÍÀ¸·Î ¹ß°ßµÇ¾ú´Ù.

We therefore suggested that utilising telemedicine by referring the children¡¯s heart sounds as sound files in an e-mail attachment, instead of referring the children, had the potential to eliminate waiting time, travel, and reduce cost associated with the assessment of cardiac murmurs in children in our area.
±×·¡¼­, ¿ì¸®´Â ±¦È÷ Áø·á¹Þ±â À§ÇØ ±â´Ù¸®°í, ¿©ÇàÇÏ°í (¶Ç ¿ì¸®Áö¿ªÀÇ ¾î¸°À̷μ­ ½ÉÀâÀ½ÀÇ Æò°¡¸¦ Çϴµ¥ °æºñ¸¦ ÁÙÀ̴µ¥ ¿°µÎ¿¡ µÐ) ±×·¯´Â °Íº¸´Ù, E-mail¿¡ ÷ºÎÇÑ Sound ÆÄÀÏ·Î ¾î¸°ÀÌ ½ÉÀå¼Ò¸®¸¦ ÂüÁ¶ÇÑ ¿ø°ÝÁø·á¸¦ ÀÌ¿ëÇ϶ó°í Á¦¾ÈÇß´Ù.

Before introducing this method as a routine, we wanted to evaluate its clinical quality.
Our hypothesis was that this could be safely performed both technically and clinically. To explore whether a heart murmur could be assessed accurately, we conducted simulated telemedicine consultations. The results of this evaluation are described.
ÀÌ°ÍÀº ÇϳªÀÇ ¹æ¹ýÀ¸·Î ¼Ò°³Çϱâ Àü¿¡ ¸ÕÀú ±× ÀÓ»ó Ç°ÁúÀ» Æò°¡ÇÏ°í ½Í¾ú´Ù.  
¿ì¸® °¡¼³Àº ÀÌ°ÍÀÌ ±â¼úÀûÀ¸·Î ±×¸®°í ÀÓ»óÀûÀ¸·Î ¾ÈÀüÇÏ°Ô ¼öÇàµÉ ¼ö ÀÖÀ» °ÍÀ̶ó´Â °ÍÀ̾ú´Ù. ½ÉÀå ÀâÀ½ÀÌ Á¤È®ÇÏ°Ô Æò°¡ ¹ÞÀ» ¼ö ÀÖÀ»Áö ¸ð¸¦ ŽÇèÀ» À§ÇØ, ¿ì¸®´Â ¸ðÀÇµÈ ¿ø°Ý ÀÇ·á »ó´ãÀ» ½Ç½ÃÇß´Ù. ÀÌ Æò°¡ÀÇ °á°ú´Â ±â¼úµÇ¾ú´Ù.

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