Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children

Abstract

PURPOSEThe distinction between physiologic (innocent) and pathologic (organic) heart murmurs is not always easy in routine practice, leading too often to unnecessary cardiology referrals and expensive investigations. We aimed to test the hypothesis that the complete disappearance of murmur on standing can exclude cardiac disease in children.METHODS From January 2014 to January 2015, we prospectively included 194 consecutive children aged 2 to 18 years who were referred for heart murmur evaluation to pediatric cardiologists at 2 French medical centers. Heart murmur characteristics while supine and then while standing were recorded, and an echocardiogram was performed.RESULTS Overall, 30 (15%) of the 194 children had a pathologic heart murmur as determined by an abnormal echocardiogram. Among the 100 children (51%) who had a murmur that was present while they were supine but completely disappeared when they stood up, only 2 had a pathologic murmur, and just 1 of them needed further evaluation. Complete disappearance of the heart murmur on standing therefore excluded a pathologic murmur with a high positive predictive value of 98% and specificity of 93%, albeit with a lower sensitivity of 60%.CONCLUSIONS Disappearance of a heart murmur on standing is a reliable clinical tool for ruling out pathologic heart murmurs in children aged 2 years and older. This basic clinical assessment would avoid many unnecessary referrals to cardiologists. 2017;15:523-528. https://doi.org/10.1370/afm.2105. Ann Fam Med INTRODUCTIONH eart murmur is a clinical finding currently affecting about 65% to 80% of schoolchildren 1,2 and one of the most common reasons for referral to cardiologists. Most murmurs are physiologic (innocent) 3 and result from the normal pattern of blood flow through the cardiac cavities and vessels. In a few cases, however, the murmur may be the single symptom of cardiac disease, even if most congenital heart diseases are diagnosed before birth or during the first year of life. 1Differences between physiologic and pathologic murmurs are well known, 4-9 but primary care physicians in family medicine or pediatricians too frequently refer their patients to pediatric cardiologists because they fear missing a heart disease diagnosis, resulting in unneeded parental anxiety, time consumption, and expensive evaluations. 10,11 Several clinical features of the murmur such as intensity, timing, quality and pitch, and the presence of a click are subjective and require extensive training for use to distinguish between physiologic and pathologic murmur. A simple, objective, and robust clinical test to exclude cardiac disease in apparently healthy children could prevent many unnecessary referrals.McLaren et al 12 reported that the prevalence of physiologic heart murmur in schoolchildren was 65% when they were in a supine position, whereas it was only 15% when they were standing. To our knowledge, however, no study has demonstrated that the disappearance of murmur 524on standing can allow clinicians to rule out a murmur ...

Classification of heart sounds associated with murmur for diagnosis of cardiac valve disorders

“…Traditional auscultation technique using stethoscope requires intensive training and experience of the physician for proper diagnosis of cardiac valve disorder. In contemporary that, the storage of records for future references is not possible with conventional auscultation (5). This is the driving force of this study to move forward automatic auscultation using electronic stethoscopes.…”

Classification of Heart Sounds Associated With Murmur For Diagnosis of Cardiac Valve Disorders

“…Conventional auscultation using acoustic stethoscope requires extensive training and experience of the physician for proper diagnosis. Moreover, the storage of records for follow-ups and future references is also not possible with conventional auscultation (5). This is the driving force for this study in order to move towards automatic auscultation using electronic stethoscopes.…”

A ausculta cardíaca é eficaz para o diagnóstico de sopros em crianças? - revisão de literatura científica / Is heart auscultation effective for the diagnosis of chips in children? - scientific literature review

“…Dentro deste contexto, a distinção entre sopros cardíacos fisiológicos (inocentes) e patológicos (orgânicos) nem sempre é fácil na prática rotineira, levando muitas vezes a encaminhamentos desnecessários para cardiologia e investigações dispendiosas. [1][2][3] Sopros cardíacos são comuns em crianças e adolescentes. Embora a maioria seja inocente, um sopro cardíaco isolado em crianças assintomáticas pode ser o único achado que indica doença cardíaca grave.…”

“…A distinção entre um sopro inocente do coração e um sopro cardíaco patológico nem sempre é fácil para os médicos da atenção primária porque a maioria deles tem pouca experiência com a ausculta em busca de malformação cardíaca congênita. [2][3][4][5] A ecocardiografia fornece um diagnóstico definitivo de doença cardíaca, mas não é necessária em caso de sopro inocente. Encaminhamentos inadequados para o cardiologista pediátrico levam a exames inúteis e dispendiosos, resultando em sobrecarga de trabalho para os especialistas.…”