Heart murmur screening
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
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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
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
· Increased intensity in standing position
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)
Athletes
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)