Heart murmur resident survival guide
|Heart murmur Resident Survival Guide Microchapters|
Synonyms and keywords: Approach to a heart murmur, Heart murmur diagnostic workup
A Heart murmur is an abnormal heart sound produced as a result of turbulent blood flow, which is sufficient to produce audible noise, defined as a relatively prolonged series of auditory vibrations of varying intensity (loudness), frequency (pitch), quality, configuration, and duration. Murmurs could be systolic or diastolic or continuous murmur.
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated.
- Papillary muscle rupture complicating acute myocardial infarction
- Rupture of chordae tendineae.
- Infective endocarditis
- Blunt chest wall trauma
- Systolic murmur
- Ejection murmurs
- Regurgitant murmurs
- Functional: none
- Extracardiac sounds simulating systolic heart murmurs
- Ejection murmurs
- Diastolic murmur
- Aortic regurgitation
- Pulmonary valve regurgitation
- Mitral rumble
- Tricuspid rumble
- Continuous murmur 
- 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
- Venous hum
- Cruveilhier-Baumgarten sindrom
- Severe arterial stenosis
- Extrathoracic arteriovenos fistulas
Shown below is an algorithm summarizing the Approach to the Heart Murmurs according to ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease. Abbreviations: AR: Aortic regurgitation, AS:Aortic stenosis, COP:Cryptogenic organizing pneumonia , HOCM:Hypertrophic cardiomyopathy , JVP: Jugular venous pressure , MR:Mitral regurgitation , MVP: Mitral valve prolapse , PAH:Pulmonary hypertension , PR:Pulmonic regurgitation , PS:Pulmonary stenosis , TR: Tricuspid regurgitation , TS: Tricuspid stenosis , TTE:Echocardiography , VSD:Ventricular septal defect
Obtain a Detailed History
The history, and associated physical examination findings provide additional clues by which the significance of a heart murmur can be established
Accurate bedside identification of a heart murmur can inform decisions regarding the indications for noninvasive testing and the need for referral to a cardiovascular specialist.
❑ Address specific patient symptoms and complaints
❑ Obtain review of systems relevant to Cardiovascular system
❑ Chest pain / Angina
❑ Abdominal pain
❑ Peripheral edema
❑ Dyspnea on exertion
❑ Paroxysmal nocturnal dyspnea
Past Medical History
❑ History of previous medical diagnoses / past medical complaints / hospitalizations and surgeries
❑ Cardiovascular disease
❑ Bicuspid aortic valve
❑ Rheumatic fever
❑ History of diabetes mellitus
❑ Current prescribed medications
❑ Previous intake of medications and reason for discontinuation
❑ History of drug adverse effects
❑ Known drug allergies
❑ Known environmental/food allergies
❑ Family history of cardiovascular disease
❑ Overall living situation
❑ Diet (general)
❑ Smoking history
❑ Alcohol use
❑ Recreational drug use
❑ Sexual lifestyle & contraceptive methods
Examine the patient:
Rate, rhythm, and characteristics include contour and amplitude of the pulse like (Water hammer pulse in AR)
❑ Blood pressure
❑ Respiratory rate
Obtain the whole features of the murmur
❑ The accurate timing of heart murmurs is the first step in their identification.
❑ Duration and Character:
❑ Location and Radiation
❑ Interventions Used to Alter the Intensity of Cardiac Murmurs’’’
Early Systolic Murmur
❑ Chronic mitral regurgitation
❑ Hypertrophic cardiomyopathy (HOCM)
❑ Congenital pulmonic stenosis
❑ ASD with left-to-right intra-cardiac shunting
Late Systolic Murmurs
❑ late systolic murmur that is best heard at the left ventricular apex is usually due to MVP.
Early Diastolic Murmurs
❑ Large left atrial myxomas
❑ Severe, isolated TR and with large ASD and significant left-to-right shunting Other signs of an ASD are present including fixed splitting of S2 and a mid-systolic murmur at the mid- to upper left sternal border.
❑ Begin in systole, peak near the S2, and continue into all or part of diastole.
❑ If the continuous murmur heard at the upper left sternal border, mostly associated with a patent ductus arteriosus.
Strategy for evaluating heart murmurs
grade 2 or less
|Asymptomatic and no associated findings|
|No further workup||No further workup|
❑ Echocardiography is recommended for asymptomatic patients with diastolic murmurs, continuous murmurs, holosystolic murmurs,late systolic murmur, 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)
|Catheterization and angiography if appropriate|
The management of heart murmurs depend on the underlying cause. Click on each disease shown below to see a detail management for every cause of heart murmur.
Abbreviations: HOCM:Hypertrophic cardiomyopathy
|SYSTOLIC MURMUR||DIASTOLIC MURMUR|
|❑ Acute Mitral Regurgitation
❑ chronic Mitral Regurgitation
❑ Aortic stenosis
|❑ Aortic regurgitation|
❑ Mitral stenosis
- Order echocardiography 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 or murmurs and symptoms or signs of heart failure, myocardial ischemia/infarction, syncope,thromboembolism,infective endocarditis.
- Order Cardiac Catheterization if there is a discrepancy between the echocardiographic and clinical findings.
- Do Serial measurements over time, or reassessment with a different imaging technology (radionuclide ventriculography or cardiac magnetic resonance) to determine surgical recommendations for asymptomatic patients with MR or AR.
- Don't do Echocardiography for patients who have a grade 2 or softer midsystolic murmur identified as innocent or functional by an experienced observer.
- Don't re-place the cardiovascular examination by Echocardiography.
- Walker HK, Hall WD, Hurst JW (1990). "Clinical Methods: The History, Physical, and Laboratory Examinations". PMID 21250186.
- Walker HK, Hall WD, Hurst JW (1990). "Clinical Methods: The History, Physical, and Laboratory Examinations". PMID 21250187.
- Ginghină C, Năstase OA, Ghiorghiu I, Egher L (2012). "[[Continuous murmur]]—the auscultatory expression of a variety of pathological conditions". J Med Life. 5 (1): 39–46. PMC 3307079. PMID 22574086. URL–wikilink conflict (help)
- Bonow, Robert O.; Carabello, Blase A.; Chatterjee, Kanu; de Leon, Antonio C.; Faxon, David P.; Freed, Michael D.; Gaasch, William H.; Lytle, Bruce Whitney; Nishimura, Rick A.; O’Gara, Patrick T.; O’Rourke, Robert A.; Otto, Catherine M.; Shah, Pravin M.; Shanewise, Jack S. (2006). "ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease". Circulation. 114 (5). doi:10.1161/CIRCULATIONAHA.106.176857. ISSN 0009-7322.