LETTERS TO THE EDITOR Mitral Annulus Calcificatioa Is It Benign? To the Editor:-Mitral annulus calcification (MAC) i s generally believed to be a benign degenerative process that exists in the elderly. However, 33%of the patients with MAC have been reported to have valvular insufficiency of hemodynamic importance,*and congestiveheart failure and death of cardiac causes are more common than age- and sex-matched subjects without MAC.' One-hundred forty-six geriatric patients were referred for echocardiographic evaluation of positive auscultatory findings during the years 1980-1985. The patients consisted of 41 males and 105 females with a mean age of 75.7 years. The echocardiographic findings were: deformity of the aortic valve (60%),mitral valve disease (19%),combined mitral and aortic valvular disease (3.4%), obstructive cardiomyopathy (8%), and dilated cardiomyopathy (7.5%).The group of 87 patients with deformed aortic valve showed insignificant aortic stenosis on Doppler echocardiography. They were divided into two subgroups, 34 patients (39%)with echocardiographically diagnosed MAC (group I) and 53 patients (61%)without MAC (Group 11). The groups did not differ in mean age (77.2 and76.6 years; or gender (82% and 68% females). Table 1 shows trends for higher incidence of coronary heart disease and atrial fibrilation and mortality and significantly more congestive heart failure ( p < 0.021) in patients with MAC. Five patients with MAC had acquired mitral stenosis; all sufferedfrom congestive heart failure, and two died. Doppler echocardiographydisclosed mitral regurgitation in all patients with MAC, ranging from minimal to moderate in degree. Labovitz et al' found by Doppler studies that 33% of the patients with MAC had valvular insufficiency of hemodynarnic importance. Nair et a12 reported a higher inadence of sudden and non-sudden cardiac deaths in patients with MAC, compared with control subjects. This was attributed to higher frequencies of rhythm and conduction disturbance, mitral and aortic valvular dysfunction, and congestive heart failure. Our patients showed a less significant difference, probably because Nair et a1 studied a younger group of patients than we did and compared them with a control group of normal subjects rather than ones with aortic sclerosis. We believe that the pathogenesis of MAC in younger patients differs from that in elderly patients and that the pathogenesis of MAC is probably multifactorial. MAC may occur in younger patients with significant calcium-phosphoTABLE 1. SUMMARY OF FOLLOW-UP DATA IN 87 PATIENTS WITH DEFORMED AORTIC VALVE Patients Patients without with MAC MAC (Group (Group D IU No. % No. 9% Cerebrovascular events Atrial fibrillation Coronary heart disease Congestive heart failure Total cardiac deaths * P c 0.021. IAGS 40:0000-0000,1992 0 1992 by the American Geriatrics Society

4 9 19 27 5

12 26 56 79* 15

7 9 26 31 6

13 17 49 49 11

rusmetabolic abnormalities,chronic renal disease, or diseases of abnormal collagen In the geriatric age group there is higher incidence of coronary heart disease, and it is reasonable to suspect that MAC in them is a result of atheroscler~sis.~ Long-term follow up studies are needed to compare the etiology, progression, and occurrence of complications of MAC in younger and older patients. Mosm ALGOM,MD ZALMAN&BIB, MD BKNIHALOT,MD JACK MADJAR,MD ZWISCHLEiW~MD

The Heart Institute Assof Harofeh Medical Center Zerifin,k a e l REFERENCES .1 Labovitz AJ, Nelson JG, Windhorst DM et al. Frequency of mitrd valve dysfunction from mitral annular calaum as detected by Doppler echocardiography. Am J Cardiol1985;55133-137. 2. Nair CK, Thomson W, Ryschon E et al. Long-term follow-up of patients with echocardiographicaliydetected mitral annular calaum and comparison with age and sex matched control subjects. Am J Cardiol 1989;63: 465-670. 3. Nestico PF,Depace NL, Morganroth J et al. Mitral annular calcification: clinical, pathophysiology, and echocardiographicreview. Am Heart J 1984; 107989-996. 4. Nestico PF, DePace NL, Kotler MN et al. Calcium-phosphorusrnetabokn in dialysis patients with and without mitral annular calcium. Am J Cardiol 1983;51:497-500. 5. Roberts W C The senile cardiac calafications)mdrome.Am J Cardioll986; 58572-974.

Teaching Physical Diagnosis in the Nursing Home To the Editor:-I commend Dr.Mayo-Smith for pointing out the advantages of teaching physical diagnosis in a Nusing Home Care Unit (NHCU)as illustrated in his recent article, Teaching Physical Diagnosis in the Nursing Home: A Prospective, Controlled Trial."' However, I have some m a tions. Nursing home residents tend to have very busy, activityoriented, schedules, especiallyduring medical students' usual working hours of 8:OO am to 5 0 0 pm. They also tend to be more ambulatory than hospital patients. Students were assigned 2 hours of time with each patient at both the settings for history and physical exam, followed by a 1-hour session with an attending preceptor. In this setting patients' 'ready accessibility"and 'available time" are misconceptions. Teaching institutions are based in acute-care facilities, and the pattern of history and physical exam revolves around the chief complaint. It is a major mistake for preceptors to spoonfeed medical students by selecting appropriate patients with acceptable chief complaints. T h i s defeats the very purpose of trying to teach the skills of assessing patients by a multifaceted approach, as opposed to a chief-complaint-guidedapproach. Despite the emphasis of Dr. Mayo-Smith on nursing homes as excellent alternative sites for teaching physical diagnosis, there seems to be an inherent dislike by medical students for internal medicine in general, and for geriatric medicine in particular. This causes a low score on overall quality of experience by medical students in nursing home settings even though there are fewer interruptions and peaceful sur, rounding.

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