Heart murmur resident survival guide

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

Overview

This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• papillary muscle rupture complicating acute myocardial infarction (MI)
• rupture of chordae tendineae.
• infective endocarditis
• blunt chest wall trauma

Common Causes

• systolic murmur
  • Ejection murmurs
    • Functional
      • Still's murmur and its adult variant
      • Flow murmur emanating from the root of the pulmonary artery
      • Murmur associated with high cardiac output states
      • Flow murmurs associated with aortic or pulmonary valvular insufficiency
    • Organic
      • Valvular aortic stenosis
      • Aortic sclerosis
      • Discrete subvalvular aortic stenosis (web or tunnel)
      • Supravalvular aortic stenosis
      • Hypertrophic obstructive cardiomyopathy
      • Pulmonary valvular stenosis
      • Pulmonary infundibular stenosis
      • Atrial septal defect
      • Tetralogy of Fallot
  • Regurgitant murmurs
    • Functional: none
    • Organic:
      • Mitral regurgitation:
        • Rheumatic
        • Papillary muscle dysfunction
        • Mitral valve prolapse
        • Acute
      • Tricuspid regurgitation:
        • Chronic
        • Acute
      • Ventricular septal defect
        • Roger's type (small and large)
          • Without pulmonary hypertension
          • With pulmonary hypertension
        • Slitlike
    • Extracardiac sounds simulating systolic heart murmurs
      • Subclavian (supraclavicular/brachiocephalic) murmur
      • Internal mammary soufflé
      • Carotid artery bruits
      • Coarctation of the aorta
      • Murmurs emanating from a dilated aortic or pulmonary artery root
      • Patent ductus arteriosus with pulmonary hypertension
        
• diastolic murmur
  • Aortic regurgitation
  • Pulmonary valve regurgitation
  • Mitral rumble
    • Obstruction to flow
      • Mitral stenosis (rheumatic, congenital)
      • Left atrial myxoma
      • Cor triatriatum
      • Localized pericardial constriction
    • Increased flow
      • Mitral regurgitation
      • Ventricular septal defect
      • Patent ductus arteriousus
      • Complete heart block
  • Tricuspid rumble
    • Obstruction to flow
      • Tricuspid stenosis (rheumatic, Ebstein's anomoly, carinoid)
      • Right atrial myxoma
      • Localized pericardial constriction
    • Increased flow
      • Atrial septal defect
      • Tricuspid regurgitation
• continuous murmur
  • THORACIC:
    • Precordial
      • Patent ductus arteriosus
      • Coronary arteriovenous fistulas
      • Sinus of Valsalva aneurysm ruptured into right cavities
      • Atrial septal defect associated with abnormalities that cause increased pressure in the left atrium
      • Left coronary artery origin from pulmonary artery anomaly
      • Continuous murmur at intern mammary artery
    • Extra Precordial
      • Coarctation of the aorta
      • Pulmonary atresia
      • Pulmonary arteriovenous fistula
      • Truncus arteriosus
      • Anomalies of origin of the pulmonary artery
  • EXTRATHORACIC:
    • Venous hum
    • Cruveilhier-Baumgarten sindrom
    • Sever arterial stenosis
    • Extrathoracic arteriovenos fistulas

Diagnosis

Shown below is an algorithm summarizing the Strategy for evaluating heart murmurs according the the ACC/AHA Guidelines for the Management of Patients With ValvularHeart Disease.

Cardiac murmur

Systolic Murmur

Diastolic Murmur

Continuous Murmur

❑ Midsystolic, grade 2 or less

❑Early systolic, ❑ Midsystoilic grade 3 or more, ❑ Late systolic, ❑ Holosystolic murmur

❑ Venous hum ❑ Mammary souffle of pregnancy

Echocardiography Class I ❑ 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.(Level of Evidence: C) ❑ 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.(Level of Evidence: C) ❑ Echocardiography is recommended for asymptomatic patients who have grade 3 or louder mid peaking systolic murmurs.(Level of Evidence: C) Class IIa ❑ 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.(Level of Evidence: C) ❑ Echocardiography can be useful for patients whose symptoms and/or signs are likely non cardiac in origin but in whom a cardiac basis cannot be excluded by standard evaluation.(Level of Evidence: C) Class III ❑ Echocardiography is not recommended for patients who have a grade 2 or softer midsystolic murmur identified as innocent or functional by an experienced observer.(Level of Evidence: C)

Asymptomatic and no associated findings

❑ Symptomatic or other signs of cardiac diseases, ❑ If an ECG or X-ray has been obtained and is abnormal

catheterization and angiography if appropriate

No further workup

No further workup

Treatment

Shown below is an algorithm summarizing the treatment of [[disease name]] according the the [...] guidelines.

Do's

• The content in this section is in bullet points.

Don'ts

• The content in this section is in bullet points.

References

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