Heart murmur: Difference between revisions

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A [[systematic review]] by the [http://jama.ama-assn.org/cgi/collection/rational_clinical_exam Rational Clinical Examination] addresses the diagnosis of systolic murmurs.<ref name="pmid9032164">{{cite journal |author=Etchells E, Bell C, Robb K |title=Does this patient have an abnormal systolic murmur? |journal=JAMA : the Journal of the American Medical Association |volume=277 |issue=7 |pages=564–71 |year=1997 |month=February |pmid=9032164 |doi= |url= |issn=}} [http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=linkout&SEARCH=9032164.ui Full text at OVID]</ref>
A [[systematic review]] by the [http://jama.ama-assn.org/cgi/collection/rational_clinical_exam Rational Clinical Examination] addresses the diagnosis of systolic murmurs.<ref name="pmid9032164">{{cite journal |author=Etchells E, Bell C, Robb K |title=Does this patient have an abnormal systolic murmur? |journal=JAMA : the Journal of the American Medical Association |volume=277 |issue=7 |pages=564–71 |year=1997 |month=February |pmid=9032164 |doi= |url= |issn=}} [http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=linkout&SEARCH=9032164.ui Full text at OVID]</ref>


====Aortic stenosis====
====Aortic valve stenosis====
A [[clinical prediction rule]] may help detecting moderate to severe [[aortic valve stenosis]] (defined as a valve area of 1.2 cm<sup>2</sup>or less, or a peak instantaneous gradient of 25 mm Hg or greater):<ref name="pmid9798818">{{cite journal |author=Etchells E, Glenns V, Shadowitz S, Bell C, Siu S |title=A bedside clinical prediction rule for detecting moderate or severe aortic stenosis |journal=Journal of general internal medicine : official journal of the Society for Research and Education in Primary Care Internal Medicine |volume=13 |issue=10 |pages=699–704 |year=1998 |month=October |pmid=9798818 |pmc=1500900 |doi= |url=http://www.blackwell-synergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0884-8734&date=1998&volume=13&issue=10&spage=699 |issn=}} [http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=citizendium&pubmedid=9798818 PubMed Central]</ref>
{{main|Aortic valve stenosis}}
* If the murmur does not radiate to the right neck, moderate aortic stenosis was very unlikely
* If the murmur has at least three of the following signs, moderate stenosis was likely:
** slow carotid artery upstroke (other studies suggest more than 200 msec is abnormal<ref name="pmid7236464">{{cite journal |author=Flohr KH, Weir EK, Chesler E |title=Diagnosis of aortic stenosis in older age groups using external carotid pulse recording and phonocardiography |journal=British heart journal |volume=45 |issue=5 |pages=577–82 |year=1981 |month=May |pmid=7236464 |pmc=482567 |doi= |url=http://heart.bmj.com/cgi/pmidlookup?view=long&pmid=7236464 |issn=}}</ref>)
** reduced carotid artery volume
** murmur loudest at the second right intercostal space
** reduced intensity of the second heart sound


===Diastolic murmurs===
===Diastolic murmurs===

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In medicine, heart murmurs are the "heart sounds caused by vibrations resulting from the flow of blood through the heart. Heart murmurs can be examined by heart auscultation, and analyzed by their intensity (6 grades), duration, timing (systolic, diastolic, or continuous), location, transmission, and quality (musical, vibratory, blowing, etc)."[1]


Prevalence of common valve abnormalities[2][3]
Valve Severity Prevalence
Males Females
Mitral[2] > mild 13% 9%
Tricuspid[2] > mild 19 19
Aortic[2] > mild 15 18
Aortic stenosis[3] Valve velocity > 2.0 m/s 2 1
Aortic sclerosis[3]   33 25


The location of the heart below the thoracic wall.

A diagram of the cardiac cycle is available and helps understand where to listen for different heart murmurs.[4]

Classification

Systolic murmurs

A systematic review by the Rational Clinical Examination addresses the diagnosis of systolic murmurs.[5]

Aortic valve stenosis

For more information, see: Aortic valve stenosis.


Diastolic murmurs

Indications for echocardiography

Indications for echocardiography have been formulated by clinical practice guidelines of the American College of Cardiology and the American Heart Association:[6] Class I recommendations

  1. "Echocardiography is recommended for asymptomatic patients with diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks or murmurs that radiate to the neck or back."
  2. "Echocardiography is recommended for patients with heart murmurs and symptoms or signs of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditis, or other clinical evidence of structural heart disease."
  3. "Echocardiography is recommended for asymptomatic patients who have grade 3 or louder midpeaking systolic murmurs."

Class IIa recommendations

  1. "Echocardiography can be useful for the evaluation of asymptomatic patients with murmurs associated with other abnormal cardiac physical findings or murmurs associated with an abnormal ECG or chest X-ray."
  2. "Echocardiography can be useful for patients whose symptoms and/or signs are likely noncardiac in origin but in whom a cardiac basis cannot be excluded by standard evaluation."

Class III recommendations

  1. "Echocardiography is not recommended for patients who have a grade 2 or softer midsystolic murmur identified as innocent or functional."

Auscultation

Murmurs may be graded by their loudness:[7]

  • Grade I - not heard immediately
  • Grade II - heard immediately
  • Grade III - hear immediately, but louder
  • Grade IV - associated with palpable thrill
  • Grade V - may be heard with stethoscope partially off the chest
  • Grade VI - may be heard with stethoscope off the chest

References

  1. ↑ Anonymous (2024), Heart murmur (English). Medical Subject Headings. U.S. National Library of Medicine.
  2. ↑ 2.0 2.1 2.2 2.3 Singh JP, Evans JC, Levy D, et al (March 1999). "Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study)". The American journal of cardiology 83 (6): 897–902. PMID 10190406. [e]
  3. ↑ 3.0 3.1 3.2 Otto CM, Lind BK, Kitzman DW, Gersh BJ, Siscovick DS (July 1999). "Association of aortic-valve sclerosis with cardiovascular mortality and morbidity in the elderly". The New England journal of medicine 341 (3): 142–7. PMID 10403851. [e]
  4. ↑ (1990) “The First Heart Sound”, Walker HK, Hall WD, Hurst JW: Clinical methods: the history, physical, and laboratory examinations (in English), 3rd. London: Butterworths. LCC RC71 .C63. ISBN 0-409-90077-X. “See image of cardiac cycle at http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=cm&partid=333&rendertype=figure&id=A684”  Library of Congress
  5. ↑ Etchells E, Bell C, Robb K (February 1997). "Does this patient have an abnormal systolic murmur?". JAMA : the Journal of the American Medical Association 277 (7): 564–71. PMID 9032164. [e] Full text at OVID
  6. ↑ Bonow RO, Carabello BA, Kanu C, de Leon AC Jr, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC Jr, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B.ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.Circulation. 2006 Aug 1;114(5):e84-231. PMID 16880336 (see page 462 for indications for replacement)
  7. ↑ McGee, Steven R. (2007). “Heart Murmurs: General Principles”, Evidence-Based Physical Diagnosis. Philadelphia: Saunders, 456. ISBN 1-4160-2898-6. 

Bibliography

See also

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