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{{Heart murmur}}


==Overview==
==Overview==
Cardiac auscultation is a cost-efficient and relatively sensitive test that should always be performed among all neonatal live births. Additionally, screening for heart murmurs is also recommended among school-children and athletes. While murmurs among neonates are always an indication for further investigation, triage of older children and adolescents according to murmur characteristics is required before referral to a pediatric cardiologist.
[[Cardiac auscultation]] is a cost-efficient and relatively sensitive test that should always be performed among all [[neonatal]] live births. Additionally, screening for heart murmurs is also recommended among school-children and athletes. While murmurs among [[neonates]] are always an indication for further investigation, triage of older children and adolescents according to murmur characteristics is required before referral to a [[Cardiologist|pediatric cardiologist]].


==Screening==
==Screening==
===Neonates===
Because congenital heart diseases occurs at a rate of 50-75 per 1000 live births, screening by physical examination, including a detailed cardiovascular examination and cardiac auscultation is recommended in all neonates. Heart murmurs may be present in approximately 1% of newborns, 31-86% of which have cardiac disease. (15876611, 11005364, 10325811). Referral should be made in all cases of murmur auscultation among neonates due to high prevalence of congenital heart disease in this age group. Sensitivity and specificity of pathological murmur detection among neonates is considered higher than other subjects, ranging from 80-95% and from 25-92%, respectively.(18692204, 16391989)
===Pediatrics===
Innocent heart murmurs are the most common cause of referral to pediatric cardiologists. The risk of pathological murmurs increases with positive family history of cardiac disease, maternal comorbidities during pregnancy, in-utero exposure to medications and alcohol, history of Kawasaki disease or rheumatic fever, and genetic disorders.( 22010618) During screening, murmurs of mitral insufficiency are considered the most common pathological heart murmurs auscultated in childhood, corresponding to approximately half of pathological murmurs in this age group.( 14153942) Early detection by screening techniques has been well-validated as an adequate technique to assess for heart diseases in children.
Although referral to cardiologists should be performed in virtually all cases of incidental auscultation of murmurs in infants, the diagnosis of innocent murmurs in children and adolescents may be made if 4 criteria are met: No other abnormal physical exam finding, negative review of systems, history negative for risks of structural heart disease, characteristic features of innocent murmurs are met. When all criteria are met in this patient age group, no further work-up is indicated.
          Normal  0          false  false  false    EN-US  JA  X-NONE
Features of innocent heart murmurs (20488808) (7 S):
· Sensitive to change in position and respiration
· Short duration, not holosystolic
· Single, with no association to gallop or clicks
· Small, limited to one region and does not radiate
· Soft, low amplitude
· Sweet, not harsh
· Systolic
Several physical examination red flags must be noted that might increase the possibility of a murmur to be pathological (14979389, 8673213, 15275986):
· Holosystolic or diastolic murmur
· Grade 3 of higher murmur
· Harsh quality murmur
· Abnormal S2
· Peak intensity at upper left sternal border


· Presence of systolic click
*Screening of the heart murmurs by physical examination, including cardiovascular examination and cardiac auscultation is recommended in all neonates, because [[congenital heart disease]] occurs at a rate of 50-75 per 1000 live births.<ref name="pmid15876611">{{cite journal| author=Bansal M, Jain H| title=Cardiac murmur in neonates. | journal=Indian Pediatr | year= 2005 | volume= 42 | issue= 4 | pages= 397-8 | pmid=15876611 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15876611 }} </ref><ref name="pmid11005364">{{cite journal| author=Rein AJ, Omokhodion SI, Nir A| title=Significance of a cardiac murmur as the sole clinical sign in the newborn. | journal=Clin Pediatr (Phila) | year= 2000 | volume= 39 | issue= 9 | pages= 511-20 | pmid=11005364 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11005364 }} </ref><ref name="pmid10325811">{{cite journal| author=Ainsworth S, Wyllie JP, Wren C| title=Prevalence and clinical significance of cardiac murmurs in neonates. | journal=Arch Dis Child Fetal Neonatal Ed | year= 1999 | volume= 80 | issue= 1 | pages= F43-5 | pmid=10325811 | doi= | pmc=PMC1720873 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10325811 }} </ref>
*Referral should be made in all cases of murmur auscultation among neonates due to high prevalence of [[congenital heart disease]] in this age group.
*Sensitivity and specificity of pathological murmur detection among neonates is considered higher than in older age groups.<ref name="pmid18692204">{{cite journal| author=Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ| title=Can cardiologists distinguish innocent from pathologic murmurs in neonates? | journal=J Pediatr | year= 2009 | volume= 154 | issue= 1 | pages= 50-54.e1 | pmid=18692204 | doi=10.1016/j.jpeds.2008.06.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18692204 }} </ref><ref name="pmid16391989">{{cite journal| author=Azhar AS, Habib HS| title=Accuracy of the initial evaluation of heart murmurs in neonates: do we need an echocardiogram? | journal=Pediatr Cardiol | year= 2006 | volume= 27 | issue= 2 | pages= 234-7 | pmid=16391989 | doi=10.1007/s00246-005-1122-1 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16391989 }} </ref>
*[[Innocent murmur|Innocent heart murmurs]] are the most common cause of referral to [[Cardiologist|pediatric cardiologists]].
*The risk of pathological murmurs increases with positive family history of [[Heart disease|cardiac disease]], maternal comorbidities during [[pregnancy]], in-utero exposure to medications and [[Alcohol, Drug Abuse, and Mental Health Services Block Grant|alcohol,]] history of [[Kawasaki disease]] or [[rheumatic fever]], and [[Genetic disorder|genetic disorders]].<ref name="pmid22010618">{{cite journal| author=Frank JE, Jacobe KM| title=Evaluation and management of heart murmurs in children. | journal=Am Fam Physician | year= 2011 | volume= 84 | issue= 7 | pages= 793-800 | pmid=22010618 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22010618 }} </ref>
*During screening, the most common pathological [[Heart murmur|heart murmurs]] auscultated in childhood is the murmur of [[Mitral regurgitation|mitral insufficiency]], and corresponding to half of pathological murmurs in this age group.<ref name="pmid14153942">{{cite journal| author=NALMAN RA, BARROW JG| title=HEART DISEASE SCREENING IN SCHOOL CHILDREN. A COMPARISON BETWEEN CLINICAL SCREENING AND HEART-SOUND SCREENING. | journal=Circulation | year= 1964 | volume= 29 | issue= | pages= 708-12 | pmid=14153942 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14153942 }} </ref>
*Screening techniques has been well-validated as an adequate technique to assess for heart diseases in children.
*No further work-up is indicated if the diagnosis of innocent murmurs in children and adolescents made by these 4 criteria:
**No other abnormal physical exam finding
**Negative review of systems
**History negative for risks of structural heart disease.
**Characteristic features of innocent murmurs are met.
*The 7S of Innocent Heart Murmurs. <ref name="pmid20488808">{{cite journal| author=Bronzetti G, Corzani A| title=The Seven "S" Murmurs: an alliteration about innocent murmurs in cardiac auscultation. | journal=Clin Pediatr (Phila) | year= 2010 | volume= 49 | issue= 7 | pages= 713| pmid=20488808 | doi=10.1177/0009922810365101 | pmc= |url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20488808 }} </ref>
**'''Sensitive''' to change in position and respiration
**'''Short duration''', not holosystolic.
**'''Single''', with no association to gallop or clicks
**'''Small''', limited to one region and does not radiate
**'''Soft''', low amplitude
**'''Sweet''', not harsh
**'''Systolic.'''
*Features of Pathological Murmurs<ref name="pmid14979389">{{cite journal| author=Poddar B, Basu S| title=Approach to a child with a heart murmur. | journal=Indian J Pediatr | year= 2004 | volume= 71 | issue= 1 | pages= 63-6 | pmid=14979389 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14979389 }} </ref><ref name="pmid8673213">{{cite journal| author=Sissman NJ| title=Cardinal clinical signs in the differentiation of heart murmurs in children. | journal=Arch Pediatr Adolesc Med | year= 1996 | volume= 150 | issue= 7 | pages= 771 | pmid=8673213 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8673213 }} </ref><ref name="pmid15275986">{{cite journal| author=Frommelt MA| title=Differential diagnosis and approach to a heart murmur in term infants. | journal=Pediatr Clin North Am | year= 2004 | volume= 51 | issue= 4 | pages= 1023-32, x | pmid=15275986 | doi=10.1016/j.pcl.2004.03.003 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15275986 }} </ref>
**Holosystolic or diastolic murmur
**Grade 3 of higher murmur
**Harsh quality murmur
**Abnormal S2
**Peak intensity at upper left sternal border
**Presence of systolic click
**Increased intensity in standing position


· Increased intensity in standing position
*According to the 36th Bethesda Conference in 2005<ref name="pmid15837281">{{cite journal| author=Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD| title=Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 8 | pages= 1322-6 | pmid=15837281 | doi=10.1016/j.jacc.2005.02.007 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15837281 }} </ref>, all athletes must undergo pre-participation screening, including a  cardiovascular history and physical examination to quality for competitions, in both supine and standing positions to investigate for signs of left ventricular outflow tract obstruction.<ref name="pmid17353433">{{cite journal| author=Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D et al.| title=Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation. | journal=Circulation | year= 2007 | volume= 115 | issue= 12 | pages= 1643-455 | pmid=17353433 | doi=10.1161/CIRCULATIONAHA.107.181423 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17353433  }} </ref>
*The 2007 American Heart Association (AHA) currently recommends that a standardized history and physical examination, including assessment for heart murmurs, is performed every 2 years for all high school and college students engaged in sports.<ref name="pmid17353433" />
*Other athletic groups of different ages do not currently have defined guidelines, but according to AHA, the recommendations of high-school and college athletes may also apply to other age groups.<ref name="pmid17353433" />


When comparing clinical auscultation of pediatric murmurs to recorded readings by trained cardiologists, the two techniques were not found to be different and were both able to detect approximately half of pediatric heart diseases among a group of 1382 school children.( 14153942)
<br />


===Athletes===
<br />
According to the 36th Bethesda Conference in 2005(15837281), all athletes must undergo pre-participation screening, including a thorough cardiovascular history and physical examination to quality for competitions. Murmurs among athletes may be suggestive of several diseases common in this age group, including hypertrophic obstructive cardiomyopathy. Heart murmurs in athletes must be thus assessed according to the American Heart Association (AHA) Consensus Panel Recommendations for Pre-participation Athletic Screening in both supine and standing positions to investigate for signs of left ventricular outflow tract obstruction(8772711)


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
{{WH}}
{{WS}}


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Latest revision as of 23:17, 21 January 2021


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, Serge Korjian ,Nuha Al-Howthi, MD[2]

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Overview

Cardiac auscultation is a cost-efficient and relatively sensitive test that should always be performed among all neonatal live births. Additionally, screening for heart murmurs is also recommended among school-children and athletes. While murmurs among neonates are always an indication for further investigation, triage of older children and adolescents according to murmur characteristics is required before referral to a pediatric cardiologist.

Screening

  • Screening of the heart murmurs by physical examination, including cardiovascular examination and cardiac auscultation is recommended in all neonates, because congenital heart disease occurs at a rate of 50-75 per 1000 live births.[1][2][3]
  • Referral should be made in all cases of murmur auscultation among neonates due to high prevalence of congenital heart disease in this age group.
  • Sensitivity and specificity of pathological murmur detection among neonates is considered higher than in older age groups.[4][5]
  • Innocent heart murmurs are the most common cause of referral to pediatric cardiologists.
  • The risk of pathological murmurs increases with positive family history of cardiac disease, maternal comorbidities during pregnancy, in-utero exposure to medications and alcohol, history of Kawasaki disease or rheumatic fever, and genetic disorders.[6]
  • During screening, the most common pathological heart murmurs auscultated in childhood is the murmur of mitral insufficiency, and corresponding to half of pathological murmurs in this age group.[7]
  • Screening techniques has been well-validated as an adequate technique to assess for heart diseases in children.
  • No further work-up is indicated if the diagnosis of innocent murmurs in children and adolescents made by these 4 criteria:
    • No other abnormal physical exam finding
    • Negative review of systems
    • History negative for risks of structural heart disease.
    • Characteristic features of innocent murmurs are met.
  • The 7S of Innocent Heart Murmurs. [8]
    • Sensitive to change in position and respiration
    • Short duration, not holosystolic.
    • Single, with no association to gallop or clicks
    • Small, limited to one region and does not radiate
    • Soft, low amplitude
    • Sweet, not harsh
    • Systolic.
  • Features of Pathological Murmurs[9][10][11]
    • Holosystolic or diastolic murmur
    • Grade 3 of higher murmur
    • Harsh quality murmur
    • Abnormal S2
    • Peak intensity at upper left sternal border
    • Presence of systolic click
    • Increased intensity in standing position
  • According to the 36th Bethesda Conference in 2005[12], all athletes must undergo pre-participation screening, including a cardiovascular history and physical examination to quality for competitions, in both supine and standing positions to investigate for signs of left ventricular outflow tract obstruction.[13]
  • The 2007 American Heart Association (AHA) currently recommends that a standardized history and physical examination, including assessment for heart murmurs, is performed every 2 years for all high school and college students engaged in sports.[13]
  • Other athletic groups of different ages do not currently have defined guidelines, but according to AHA, the recommendations of high-school and college athletes may also apply to other age groups.[13]



References

  1. ↑ Bansal M, Jain H (2005). "Cardiac murmur in neonates". Indian Pediatr. 42 (4): 397–8. PMID 15876611.
  2. ↑ Rein AJ, Omokhodion SI, Nir A (2000). "Significance of a cardiac murmur as the sole clinical sign in the newborn". Clin Pediatr (Phila). 39 (9): 511–20. PMID 11005364.
  3. ↑ Ainsworth S, Wyllie JP, Wren C (1999). "Prevalence and clinical significance of cardiac murmurs in neonates". Arch Dis Child Fetal Neonatal Ed. 80 (1): F43–5. PMC 1720873. PMID 10325811.
  4. ↑ Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ (2009). "Can cardiologists distinguish innocent from pathologic murmurs in neonates?". J Pediatr. 154 (1): 50–54.e1. doi:10.1016/j.jpeds.2008.06.017. PMID 18692204.
  5. ↑ Azhar AS, Habib HS (2006). "Accuracy of the initial evaluation of heart murmurs in neonates: do we need an echocardiogram?". Pediatr Cardiol. 27 (2): 234–7. doi:10.1007/s00246-005-1122-1. PMID 16391989.
  6. ↑ Frank JE, Jacobe KM (2011). "Evaluation and management of heart murmurs in children". Am Fam Physician. 84 (7): 793–800. PMID 22010618.
  7. ↑ NALMAN RA, BARROW JG (1964). "HEART DISEASE SCREENING IN SCHOOL CHILDREN. A COMPARISON BETWEEN CLINICAL SCREENING AND HEART-SOUND SCREENING". Circulation. 29: 708–12. PMID 14153942.
  8. ↑ Bronzetti G, Corzani A (2010). "The Seven "S" Murmurs: an alliteration about innocent murmurs in cardiac auscultation". Clin Pediatr (Phila). 49 (7): 713. doi:10.1177/0009922810365101. PMID 20488808.
  9. ↑ Poddar B, Basu S (2004). "Approach to a child with a heart murmur". Indian J Pediatr. 71 (1): 63–6. PMID 14979389.
  10. ↑ Sissman NJ (1996). "Cardinal clinical signs in the differentiation of heart murmurs in children". Arch Pediatr Adolesc Med. 150 (7): 771. PMID 8673213.
  11. ↑ Frommelt MA (2004). "Differential diagnosis and approach to a heart murmur in term infants". Pediatr Clin North Am. 51 (4): 1023–32, x. doi:10.1016/j.pcl.2004.03.003. PMID 15275986.
  12. ↑ Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD (2005). "Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes". J Am Coll Cardiol. 45 (8): 1322–6. doi:10.1016/j.jacc.2005.02.007. PMID 15837281.
  13. ↑ 13.0 13.1 13.2 Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D; et al. (2007). "Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation". Circulation. 115 (12): 1643–455. doi:10.1161/CIRCULATIONAHA.107.181423. PMID 17353433.

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