Heart murmur resident survival guide
Heart murmur Resident Survival Guide Microchapters |
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Overview |
Causes |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Nuha Al-Howthi, MD[2]
Synonyms and keywords: Approach to a heart murmur, Heart murmur diagnostic workup
Overview
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.
Causes
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
Common Causes
- Systolic murmur[1]
- 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
- Functional
- 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
- Roger's type (small and large)
- Mitral regurgitation:
- 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
- Ejection murmurs
- Diastolic murmur[2]
- Aortic regurgitation
- Pulmonary valve regurgitation
- Mitral rumble
- Obstruction to flow
- Mitral stenosis (rheumatic, congenital)
- Left atrial myxoma
- Cor triatriatum
- Localized pericardial constriction
- Increased flow
- Obstruction to flow
- Tricuspid rumble
- Obstruction to flow
- Tricuspid stenosis (rheumatic, Ebstein's anomaly, carcinoid)
- Right atrial myxoma
- Localized pericardial constriction
- Increased flow
- Obstruction to flow
- Continuous murmur [3]
- 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
- Precordial
- EXTRATHORACIC:
- Venous hum
- Cruveilhier-Baumgarten sindrom
- Severe arterial stenosis
- Extrathoracic arteriovenos fistulas
- THORACIC:
Diagnosis
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.[4] 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 | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Examine the patient: | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Early Systolic Murmur | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Strategy for evaluating heart murmurs
Abbreviations: ECG:electrocardiogram
Diastolic Murmur | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Midsystolic, grade 2 or less | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Asymptomatic and no associated findings | ❑ Symptomatic or other signs of cardiac diseases, ❑ If an ECG or X-ray has been obtained and is abnormal | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No further workup | No further workup | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Echocardiography | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Catheterization and angiography if appropriate | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Treatment
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 ❑ HOCM |
❑ Aortic regurgitation ❑ Mitral stenosis |
Do's
- 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'ts
- 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.
References
- ↑ 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.