Nikhil K Chanani MD Murmurs: Do you hear what I hear? When does
it matter?
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2 Audience Poll You are examining a 5 day old and find either:
A) a 2/6 systolic murmur in an otherwise asymptomatic child B) a
saturation of 89% in an otherwise asymptomatic child with no
murmurs C) poor pulses and mottled skin in a distressed infant with
no murmurs Which is least likely to have hemodynamically
significant cardiac disease?
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3 Background Up to 2/3 of children will have a murmur heard at
some point in their childhood Incidence of congenital heart disease
is 8/1000 This means less than 2% of all murmurs are associated
with congenital heart disease As many as 80% of heart lesions are
missed during initial neonatal exam* * Emslie et al, Examination
for cardiac malformations at six weeks of age. Arch. Dis. Child
Fetal Neonatal ed. 1999; 80: F46.
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4 A cardiac murmur is the sound of turbulent blood flow. A
murmur does not necessarily indicate heart disease. The clinician
should emphasize this fact to the patients family. A murmur is
merely one part of a complete cardiovascular assessment. History,
vital signs, physical diagnosis, diagnostic testing
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5 Auscultation S1: closing of mitral & tricuspid valves
Normally single heard best at apex or LLSB Split S1 uncommon
Conduction delay: RBBB, LBBB Valvular problem, ex: Ebsteins
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6 Auscultation S2: closing of aortic & pulmonary valves
Physiologic splitting, varies with respiration Heard best at LUSB
Physiologic demo Abnormal S2 Widely split Narrowly split Single S2
Paradoxically split Abnormal intensity
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7 Auscultation S3: rapid ventricular filling Occurs soon after
S2 Best heard at the apex or LLSB May be normal in older children
(not infants!) Dilated ventricles large shunts dilated
cardiomyopathy myocarditis
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8 Auscultation S4: increased atrial pressure against stiff
ventricle Best heard at the apex Never normal in children
Immediately prior to S1 Indicates poor ventricular compliance HTN,
decreased ventricular compliance HCM
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9 Auscultation Clicks Ejection click Sounds like split S1, but
heard at base Dysplastic semilunar valve, dilated great artery
Midsystolic click Heard at apex in MVP Opening snap Early
diastolic, at apex in mitral stenosis Friction Rub Pericarditis,
effusion
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10 Physical exam - Murmurs Sound created by turbulant bloodflow
through heart and great vessels Murmurs grade/intensity Timing
Location Radiation Shape Quality frequency/pitch
12 Murmurs Diastolic Murmurs: between S2 & S1 Early:
decrescendo AI and PI Mid/Late: low pitched, may start with S3 AV
valve stenosis or increased flow Continuous Murmurs: continue
through S2 AP or AV connections: PDA, AVM, shunts Combination
systolic and diastolic To-fro murmurs: AS and AI, PS and PI Venous
hum
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13 Grading Murmurs Without thrill Grade 1: very faint, barely
audible Grade 2: soft but easily heard Grade 3: intermediate
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14 Grading Murmurs (cont.) With thrill Grade 4: loud, with a
palpable vibration (thrill) Grade 5: very loud, audible with edge
of stethoscope on chest Grade 6: very loud, audible with
stethoscope just off chest Diastolic murmurs are graded from
1-4
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15 Systolic Murmurs A systolic murmur generally represents
forward flow through the aortic or pulmonary valve backward flow
through the mitral or tricuspid valve flow through the VSD innocent
(Stills) murmur through the LV cavity innocent flow murmurs through
aortic and pulmonary valves with anemia, bradycardia, fever or
hyperthyroidism
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16 Diastolic Murmurs A diastolic murmur generally represents
forward flow through the mitral or tricuspid valve backward flow
through the aortic or pulmonary valve innocent flow murmurs across
mitral or tricuspid valve with anemia, bradycardia, fever, or
hyperthyroidism
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17 Continuous Murmurs Venous hums Patent ductus arteriosus
Collateral vessels Coronary arterial fistulae or any arteriovenous
fistula Surgical systemic arterial to pulmonary arterial shunts
Aorticopulmonary windows
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18 Innocent Murmurs The following is a list of innocent murmurs
and their characteristics in children and adolescents:
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19 Innocent Murmurs (cont.) Stills murmur Most common,
vibratory, musical in nature; LLSB-apex; louder supine; murmur
decreases with Valsalva strain; R/O VSD, MR, sub-AS
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20 Innocent Murmurs (cont.) Supraclavicular arterial bruit
Above clavicles; murmur is low intensity and in early systole;
possible associated thrill; R/O AS, PS, VSD, coarctation
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21 Innocent Murmurs (cont.) Venous hum Continuous;
gravity-dependent; due to turbulent subclavian, innominate vein and
SVC flow; murmur disappears when patient supine; R/O anemia,
hyperthyroidism, cerebral AVM
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22 Innocent Murmurs (cont.) Peripheral pulmonary stenosis
(newborn) Base, axillae, back bilaterally; relative PA hypoplasia
and bracing; murmur persists until three to six months; R/O ASD,
PDA, TOF
31 Pathologic Murmurs (cont.) Loud murmur in delivery
room/nursery: outflow tract stenosis; AV valve insufficiency Every
baby has a large PDA after delivery. This should not, however,
cause an audible murmur.
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32 Summary Listen in all areas for heart murmurs. First in
systole and then in diastole. Concentrate on dissection. After much
practice, this should become automatic. From Listening to Heart
Murmurs in Infants and Children by Jerome Liebman, MD