Cardiac Murmurs in Children: A Challenge For The Primary Care Physician

Author(s): Eirini Kostopoulou*, Gabriel Dimitriou, Ageliki Karatza

Journal Name: Current Pediatric Reviews

Volume 15 , Issue 3 , 2019

Become EABM
Become Reviewer

Graphical Abstract:


Abstract:

Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause.

Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination.

In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.

Keywords: Cardiac murmurs, congenital heart disease, innocent murmurs, organic murmurs, transthoracic echocardiography, auscultatory, Cardiovascular malformations.

[1]
Hoffman JI, Kaplan S. The incidence of congenital heart disease. J Am Coll Cardiol 2002; 39(12): 1890-900.
[http://dx.doi.org/10.1016/S0735-1097(02)01886-7] [PMID: 12084585]
[2]
Knoester H, Sol JJ, Ramsodit P, Kuipers IM, Clur SA, Bos AP. Cardiac function in pediatric septic shock survivors. Arch Pediatr Adolesc Med 2008; 162(12): 1164-8.
[http://dx.doi.org/10.1001/archpedi.162.12.1164] [PMID: 19047544]
[3]
Peterson C, Ailes E, Riehle-Colarusso T, et al. Late detection of critical congenital heart disease among US infants: estimation of the potential impact of proposed universal screening using pulse oximetry. JAMA Pediatr 2014; 168(4): 361-70.
[http://dx.doi.org/10.1001/jamapediatrics.2013.4779] [PMID: 24493342]
[4]
Liberman RF, Getz KD, Lin AE, et al. Delayed diagnosis of critical congenital heart defects: trends and associated factors. Pediatrics 2014; 134(2): e373-81.
[http://dx.doi.org/10.1542/peds.2013-3949] [PMID: 25070301]
[5]
Meberg A. Critical heart defects--the diagnostic challenge. Acta Paediatr 2008; 97(11): 1480-3.
[http://dx.doi.org/10.1111/j.1651-2227.2008.00975.x] [PMID: 18671689]
[6]
Giuffre RM, Walker I, Vaillancourt S, Gupta S. Opening Pandora’s box: parental anxiety and the assessment of childhood murmurs. Can J Cardiol 2002; 18(4): 406-14.
[PMID: 11992134]
[7]
Geggel RL. Conditions leading to pediatric cardiology consultation in a tertiary academic hospital. Pediatrics 2004; 114(4): e409-17.
[http://dx.doi.org/10.1542/peds.2003-0898-L] [PMID: 15466065]
[8]
Pelech AN. The physiology of cardiac auscultation. Pediatr Clin North Am 2004; 51(6): 1515-35. [vii-viii.
[http://dx.doi.org/10.1016/j.pcl.2004.08.004] [PMID: 15561171]
[9]
Newburger JW, Rosenthal A, Williams RG, Fellows K, Miettinen OS. Noninvasive tests in the initial evaluation of heart murmurs in children. N Engl J Med 1983; 308(2): 61-4.
[http://dx.doi.org/10.1056/NEJM198301133080201] [PMID: 6847937]
[10]
McCrindle BW, Shaffer KM, Kan JS, Zahka KG, Rowe SA, Kidd L. Factors prompting referral for cardiology evaluation of heart murmurs in children. Arch Pediatr Adolesc Med 1995; 149(11): 1277-9.
[http://dx.doi.org/10.1001/archpedi.1995.02170240095018] [PMID: 7581765]
[11]
Sackey AH. Prevalence and diagnostic accuracy of heart disease in children with asymptomatic murmurs. Cardiol Young 2016; 26(3): 446-50.
[http://dx.doi.org/10.1017/S1047951115000396] [PMID: 25828377]
[12]
Smythe JF, Teixeira OHP, Vlad P, Demers PP, Feldman W. Initial evaluation of heart murmurs: are laboratory tests necessary? Pediatrics 1990; 86(4): 497-500.
[PMID: 2216611]
[13]
Bårdsen T, Sørbye MH, Trønnes H, Greve G, Berg A. Parental anxiety related to referral of childhood heart murmur; an observational/interventional study. BMC Pediatr 2015; 15: 193.
[http://dx.doi.org/10.1186/s12887-015-0507-4] [PMID: 26590070]
[14]
Bronzetti G, Corzani A. The Seven “S” Murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila) 2010; 49(7): 713.
[http://dx.doi.org/10.1177/0009922810365101] [PMID: 20488808]
[15]
McCrindle BW, Shaffer KM, Kan JS, Zahka KG, Rowe SA, Kidd L. Cardinal clinical signs in the differentiation of heart murmurs in children. Arch Pediatr Adolesc Med 1996; 150(2): 169-74.
[http://dx.doi.org/10.1001/archpedi.1996.02170270051007] [PMID: 8556121]
[16]
McConnell ME, Adkins SB III, Hannon DW. Heart murmurs in pediatric patients: when do you refer? Am Fam Physician 1999; 60(2): 558-65.
[PMID: 10465230]
[17]
Christensen DD, Vincent RN, Campbell RM. Presentation of atrial septal defect in the pediatric population. Pediatr Cardiol 2005; 26(6): 812-4.
[http://dx.doi.org/10.1007/s00246-005-0969-5] [PMID: 16235001]
[18]
Maroto E, Fouron JC, Aké E, et al. Closure of the ductus arteriosus: determinant factor in the appearance of transient peripheral pulmonary stenosis of the neonate. J Pediatr 1991; 119(6): 955-9.
[http://dx.doi.org/10.1016/S0022-3476(05)83055-0] [PMID: 1960617]
[19]
Kiyomatsu Y. Transient heart murmur in the late neonatal period: its origin and relation to the transition from fetal to neonatal circulation. Kurume Med J 2001; 48(1): 31-5.
[http://dx.doi.org/10.2739/kurumemedj.48.31] [PMID: 11402617]
[20]
Slavotinek A, Ali M. Recognizable syndromes in the newborn period. Clin Perinatol 2015; 42(2): 263-80. [viii.
[http://dx.doi.org/10.1016/j.clp.2015.02.003] [PMID: 26042904]
[21]
Adams DJ, Clark DA. Common genetic and epigenetic syndromes. Pediatr Clin North Am 2015; 62(2): 411-26.
[http://dx.doi.org/10.1016/j.pcl.2014.11.005] [PMID: 25836705]
[22]
Wren C, Richmond S, Donaldson L. Presentation of congenital heart disease in infancy: implications for routine examination Arch Dis Fetal Neonatal Ed 1999; 80: 49-53.
[23]
Gregory J, Emslie A, Wyllie J, Wren C. Examination for cardiac malformations at six weeks of age. Arch Dis Child Fetal Neonatal Ed 1999; 80(1): F46-8.
[http://dx.doi.org/10.1136/fn.80.1.F46] [PMID: 10325812]
[24]
Ainsworth S, Wyllie JP, Wren C. Prevalence and clinical significance of cardiac murmurs in neonates. Arch Dis Child Fetal Neonatal Ed 1999; 80(1): F43-5.
[http://dx.doi.org/10.1136/fn.80.1.F43] [PMID: 10325811]
[25]
Taksande A. Neonatal heart murmur: is it useful for the diagnosis of congenital heart diseases? World J Pediatr 2014; 10(1): 91.
[http://dx.doi.org/10.1007/s12519-014-0463-3] [PMID: 24464675]
[26]
Hurwitz RA, Caldwell RL. Should pediatric echocardiography be performed in adult laboratories? Pediatrics 1998; 102(2)e15
[http://dx.doi.org/10.1542/peds.102.2.e15] [PMID: 9685460]
[27]
Paediatrics: A core text with self-assessment, 2006 Attard-Montalto S, Saha V Churchill Livingstone; 2 edition, January 20 2006
[28]
Felner JM. The Second Heart SoundClinical Methods: The history. Physical, and Laboratory Examination 3rd ed 1990.
[29]
Rosenzweig EB, Feinstein JA, Humpl T, Ivy DD. Pulmonary arterial hypertension in children: Diagnostic work-up and challenges. Prog Pediatr Cardiol 2009; 27(1): 4-11.
[http://dx.doi.org/10.1016/j.ppedcard.2009.09.003] [PMID: 21691442]
[30]
Bull MJ. Health supervision for children with Down syndrome. Pediatrics 2011; 128(2): 393-406.
[http://dx.doi.org/10.1542/peds.2011-1605] [PMID: 21788214]
[31]
Hoffman JI. Congenital heart disease: incidence and inheritance. Pediatr Clin North Am 1990; 37(1): 25-43.
[http://dx.doi.org/10.1016/S0031-3955(16)36830-4] [PMID: 2408002]
[32]
Frank JE, Jacobe KM. Evaluation and management of heart murmurs in children. Am Fam Physician 2011; 84(7): 793-800.
[PMID: 22010618]
[33]
Abdullah NL, Quek SC, Seto KY, Teo LL. Clinics in diagnostic imaging (160). Levocardia with abdominal situs inversus. Singapore Med J 2015; 56(4): 198-201.
[http://dx.doi.org/10.11622/smedj.2015059] [PMID: 25917470]
[34]
Koo S, Yung TC, Lun KS, Chau AKT, Cheung YF. Cardiovascular symptoms and signs in evaluating cardiac murmurs in children. Pediatr Int 2008; 50(2): 145-9.
[http://dx.doi.org/10.1111/j.1442-200X.2008.02560.x] [PMID: 18353047]
[35]
Mackie AS, Jutras LC, Dancea AB, Rohlicek CV, Platt R, Béland MJ. Can cardiologists distinguish innocent from pathologic murmurs in neonates? J Pediatr 2009; 154(1): 50-54.e1.
[http://dx.doi.org/10.1016/j.jpeds.2008.06.017] [PMID: 18692204]
[36]
Azhar AS, Habib HS. Accuracy of the initial evaluation of heart murmurs in neonates: do we need an echocardiogram? Pediatr Cardiol 2006; 27(2): 234-7.
[http://dx.doi.org/10.1007/s00246-005-1122-1] [PMID: 16391989]
[37]
Bakr AF, Habib HS. Combining pulse oximetry and clinical examination in screening for congenital heart disease. Pediatr Cardiol 2005; 26(6): 832-5.
[http://dx.doi.org/10.1007/s00246-005-0981-9] [PMID: 16088415]
[38]
Kemper AR, Mahle WT, Martin GR, et al. Strategies for implementing screening for critical congenital heart disease. Pediatrics 2011; 128(5): e1259-67.
[http://dx.doi.org/10.1542/peds.2011-1317] [PMID: 21987707]
[39]
Ebell MH, Siwek J, Weiss BD, et al. Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician 2004; 69(3): 548-56.
[http://dx.doi.org/10.3122/jabfm.17.1.59] [PMID: 14971837]


open access plus

Rights & PermissionsPrintExport Cite as

Article Details

VOLUME: 15
ISSUE: 3
Year: 2019
Page: [131 - 138]
Pages: 8
DOI: 10.2174/1573396315666190321105536

Article Metrics

PDF: 33
HTML: 8
EPUB: 1
PRC: 1