Heart murmur screening

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

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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 of the heart murmurs by physical examination, including cardiovascular examination and cardiac auscultation is recommended in all neonates, because congenital heart disease occurs at a rate of 50-75 per 1000 live births.[1][2][3]
  • 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 in older age groups.[4][5]
  • 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.[6]
  • During screening, the most common pathological heart murmurs auscultated in childhood is the murmur of mitral insufficiency, and corresponding to half of pathological murmurs in this age group.[7]
  • Screening techniques has been well-validated as an adequate technique to assess for heart diseases in children.
  • No further work-up is indicated if the diagnosis of innocent murmurs in children and adolescents made by these 4 criteria:
    • 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.
  • The 7S of Innocent Heart Murmurs. [8]
    • 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.
  • Features of Pathological Murmurs[9][10][11]
    • 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
  • According to the 36th Bethesda Conference in 2005[12], all athletes must undergo pre-participation screening, including a cardiovascular history and physical examination to quality for competitions, in both supine and standing positions to investigate for signs of left ventricular outflow tract obstruction.[13]
  • The 2007 American Heart Association (AHA) currently recommends that a standardized history and physical examination, including assessment for heart murmurs, is performed every 2 years for all high school and college students engaged in sports.[13]
  • Other athletic groups of different ages do not currently have defined guidelines, but according to AHA, the recommendations of high-school and college athletes may also apply to other age groups.[13]


  1. Bansal M, Jain H (2005). "Cardiac murmur in neonates". Indian Pediatr. 42 (4): 397–8. PMID 15876611.
  2. Rein AJ, Omokhodion SI, Nir A (2000). "Significance of a cardiac murmur as the sole clinical sign in the newborn". Clin Pediatr (Phila). 39 (9): 511–20. PMID 11005364.
  3. Ainsworth S, Wyllie JP, Wren C (1999). "Prevalence and clinical significance of cardiac murmurs in neonates". Arch Dis Child Fetal Neonatal Ed. 80 (1): F43–5. PMC 1720873. PMID 10325811.
  4. Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ (2009). "Can cardiologists distinguish innocent from pathologic murmurs in neonates?". J Pediatr. 154 (1): 50–54.e1. doi:10.1016/j.jpeds.2008.06.017. PMID 18692204.
  5. Azhar AS, Habib HS (2006). "Accuracy of the initial evaluation of heart murmurs in neonates: do we need an echocardiogram?". Pediatr Cardiol. 27 (2): 234–7. doi:10.1007/s00246-005-1122-1. PMID 16391989.
  6. Frank JE, Jacobe KM (2011). "Evaluation and management of heart murmurs in children". Am Fam Physician. 84 (7): 793–800. PMID 22010618.
  8. Bronzetti G, Corzani A (2010). "The Seven "S" Murmurs: an alliteration about innocent murmurs in cardiac auscultation". Clin Pediatr (Phila). 49 (7): 713. doi:10.1177/0009922810365101. PMID 20488808.
  9. Poddar B, Basu S (2004). "Approach to a child with a heart murmur". Indian J Pediatr. 71 (1): 63–6. PMID 14979389.
  10. Sissman NJ (1996). "Cardinal clinical signs in the differentiation of heart murmurs in children". Arch Pediatr Adolesc Med. 150 (7): 771. PMID 8673213.
  11. Frommelt MA (2004). "Differential diagnosis and approach to a heart murmur in term infants". Pediatr Clin North Am. 51 (4): 1023–32, x. doi:10.1016/j.pcl.2004.03.003. PMID 15275986.
  12. Maron BJ, Douglas PS, Graham TP, Nishimura RA, Thompson PD (2005). "Task Force 1: preparticipation screening and diagnosis of cardiovascular disease in athletes". J Am Coll Cardiol. 45 (8): 1322–6. doi:10.1016/j.jacc.2005.02.007. PMID 15837281.
  13. 13.0 13.1 13.2 Maron BJ, Thompson PD, Ackerman MJ, Balady G, Berger S, Cohen D; et al. (2007). "Recommendations and considerations related to preparticipation screening for cardiovascular abnormalities in competitive athletes: 2007 update: a scientific statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation". Circulation. 115 (12): 1643–455. doi:10.1161/CIRCULATIONAHA.107.181423. PMID 17353433.

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