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.[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 other subjects, ranging from 80-95% and from 25-92%, respectively.[4][5]
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.[6] 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.[7] 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.
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Several physical examination red flags must be noted that might increase the possibility of a murmur to be pathological[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
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.[7]
Athletes
According to the 36th Bethesda Conference in 2005[12], 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.[13]
References
- ↑ Bansal M, Jain H (2005). "Cardiac murmur in neonates". Indian Pediatr. 42 (4): 397–8. PMID 15876611.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Frank JE, Jacobe KM (2011). "Evaluation and management of heart murmurs in children". Am Fam Physician. 84 (7): 793–800. PMID 22010618.
- ↑ 7.0 7.1 NALMAN RA, BARROW JG (1964). "HEART DISEASE SCREENING IN SCHOOL CHILDREN. A COMPARISON BETWEEN CLINICAL SCREENING AND HEART-SOUND SCREENING". Circulation. 29: 708–12. PMID 14153942.
- ↑ 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.
- ↑ Poddar B, Basu S (2004). "Approach to a child with a heart murmur". Indian J Pediatr. 71 (1): 63–6. PMID 14979389.
- ↑ Sissman NJ (1996). "Cardinal clinical signs in the differentiation of heart murmurs in children". Arch Pediatr Adolesc Med. 150 (7): 771. PMID 8673213.
- ↑ 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.
- ↑ 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.
- ↑ Maron BJ, Thompson PD, Puffer JC, McGrew CA, Strong WB, Douglas PS; et al. (1996). "Cardiovascular preparticipation screening of competitive athletes. A statement for health professionals from the Sudden Death Committee (clinical cardiology) and Congenital Cardiac Defects Committee (cardiovascular disease in the young), American Heart Association". Circulation. 94 (4): 850–6. PMID 8772711.