Transcript Innocent Murmurs in Children - Pediatric Associates of Newnan

Innocent Murmurs
in Children
Georgeann Wang, MS3
Murmurs in Children
 Heart murmurs are one of the most
common physical findings in any practice
that cares for children
 50-60% of children have a heart murmur
 Over 90% of heart murmurs are normal
and require no further evaluation/referral
 termed “innocent,” “functional,” “benign,” or
“physiologic”
Evaluation of Murmur
 Timing – where during cardiac cycle? –
systolic, diastolic, or continuous
 Type – holosystolic, ejection/crescendodecrescendo, early, late
 Quality – harsh, blowing, vibratory
 Intensity – grades I-VI
Innocent Murmurs
 Not solely diastolic! (systolic or
continuous)
 Not associated with a thrill! (grades I-III)
 Not associated with a click!
Grading Murmurs
Grade
Description
I
Barely audible
II
Easily audible
III
Very audible without a thrill
IV
With thrill – stethoscope fully on chest
V
With thrill – stethoscope halfway off
chest
With thrill – stethoscope off chest
VI
Grading Murmurs –
A New Approach
Grade
Description
I
Less in intensity to heart sounds
II
Equal in intensity to heart sounds
III
IV
Greater in intensity to heart sounds,
without thrill
With thrill, stethoscope fully on chest
V
With thrill, stethoscope halfway off
VI
With thrill, stethoscope off chest
Logic-based Pneumonic
 Innocent murmurs
occur at sites with
disproportionatesized connections
 Smaller vessel
connecting to larger
vessel
 Or larger vessel
branching into
smaller vessels
1. Venous Hum
 Connection between
jugular, subclavian,
and innominate veins
to SVC
Venous Hum
 Most common continuous murmur in
children
 Most often in ages 2-8 y/o (toddlers to
school-age)
 Low frequency, continuous murmur often
louder in diastole
 Best heard below the right clavicle
Venous Hum
 Increased: in sitting or standing position
 Decreased: in supine position, with
compression of neck veins (directly or
with changes in head position)
 Compressing neck veins or turning head to
the right will diminish murmur
 Diminishes completely in supine position
Venous Hum – differential
diagnosis
 PDA – loud, continuous machinery
murmur with systolic prominence
 best heard on left 2nd interspace and
radiates to back
 not changed with position or neck vein
occlusion
 AV fistula – not changed with position or
occlusion of neck veins
2. Pulmonary Flow Murmur
 Connection of right
ventricle with main
pulmonary artery
Pulmonary Flow Murmur
 May be heard in wide range from schoolage children to adolescents and young
adults
 Low intensity systolic ejection murmur
 Best heard at LUSB (2nd or 3rd
interspace)
Pulmonary Flow Murmur
 Increased: high output states (fever,
illness, anemia, etc), with expiration
 Decreased: standing position, with
inspiration
Pulmonary Flow Murmur
 Is exaggerated by any condition that
brings the RVOT closer to the anterior
chest wall
 eg. pectus excavatum, kyphoscoliosis
Pulmonary Flow Murmur –
differential diagnosis
 ASD – “relative” pulmonic stenosis
murmur (due to increased blood volume
in right heart)
 accompanied by a widely split S2, middiastolic flow murmur, right ventricular heave
 Pulmonic stenosis – louder, harsher
sounding murmur
 can be associated with a thrill or ejection
click
3. Physiologic Peripheral
Pulmonary Stenosis (PPS)
 Connection of main
pulmonary artery to
right and left
pulmonary artery
branches
Physiologic PPS
 Most often in neonates and infants from birth to
6 mos of age
 Soft, low-pitched systolic ejection murmur (can
extend slightly past S2)
 “blowing” in quality, sounds like breath sounds
(can briefly occlude nares)
 Best heard at left infraclavicular area with
radiation to bilateral axillae and back
Physiologic PPS
 Increased in: high output states (fever,
illness, anemia, etc), viral URI, RAD
exacerbations
PPS – differential diagnosis
 Pulmonic stenosis – louder, harsher
murmur, associated with ejection click or
thrill
 VSD – no radiation to axillae
 PDA – machinery like, lower pitch
 Pathologic PPS – longer duration, higher
pitch, older children
4. Still’s Murmur
 Connection of left
ventricle with aorta
Still’s Murmur
 Most common innocent murmur in
children
 Reported to be present in up to 75-85%
of children
 Most often in ages 2-6 y/o, but can be
from birth to adolescence
Still’s Murmur
 Low-pitched II/VI early systolic ejection
murmur
 Described as “vibratory,” “musical,”
“harmonic,” “twanging,” “groaning/moaning,”
“squeaky”
 Like the sound of a guitar string being plucked
 Best heard at LLSB/apex
Still’s Murmur
 Increased: supine position, fever, anemia
 Decreased: sitting or standing, with
valsalva
Still’s Murmur –
differential diagnosis
 VSD – different quality, harsh not musical
 LVOT obstruction – different quality
 HOCM – different quality
5. Supraclavicular
Systemic Bruit
 Connection of
brachiocephalic
vessels to aortic arch
Supraclavicular Systemic
Bruit
 Heard in children and young adults
 Harsh, medium to high-pitched, brief
early systolic ejection murmur
 Best heard in the carotids bilaterally with
some radiation to infraclavicular area
Supraclavicular Systemic
Bruit
 Decreased: with shoulders pulled back
(hyperextension)
 No change with position
Supraclavicular Systemic
Bruit – differential diagnosis
 Aortic stenosis/supraaortic stenosis –
louder in chest with radiation to carotids
ASD
 Most common misdiagnosed heart
murmur in children
 More often than not there is no murmur
heard with ASD
Auscultation of ASD
 3 auscultatory findings in ASD – all due to Lto-R shunting across defect  larger blood volume in
right heart
 1. widely split S2 – longer time to empty right
side of heart vs. left side
 2. pulmonary “stenosis” flow murmur – large
amount of blood exiting through RVOT
 3. mid-diastolic flow murmur – large amount
of flow across triscuspid valve
Red Flags! – Caution!
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Holosystolic murmur
Presence of a thrill (grade >III/VI)
Harsh quality
Presence of early/mid systolic click
Abnormal S2
Diastolic murmur
Increase in intensity with standing up
Beware!
 General appearance – dysmorphic features
 Constitutional – poor weight gain, diaphoresis,
cyanosis
 Respiratory symptoms – tachypnea, wheezing,
chronic cough, poor/difficulty feeding
 Cardiovascular symptoms – chest pain,
syncope/presyncope, tachycardia
 Abnormal tests – enlarged heart on CXR,
hypertrophy on EKG
Case 1
A 5 y/o Latin American boy presents for his
annual school physical. He has no significant
PMH and is very active. More recently he has
had fever and diarrhea. PE is normal with the
exception of this murmur heard at the LLSB
near the apex.
You tell mom that he has a benign murmur. She
asks you why no doctor has ever heard this
murmur before today. You say?
Case 1
He has a vibratory Still’s murmur that is just
now detected since he is sick with fever
(high output state increases intensity of
the murmur).
Case 2
 You are a medical student and you are
examining a 6 y/o Caucasian girl here for
routine check-up. She is previously healthy
and has no complaints. During PE, you listen
to her heart as she lies on the exam table. You
present her CV exam as normal to your
attending. He examines her as she sits on the
table and he hears this murmur just below her
right clavicle.
 You are very embarrassed for missing this
obvious murmur. What was your mistake?
Case 2
 She has a venous hum murmur that
diminishes completely in the supine
position. It is important to perform the
CV exam in both supine and upright
positions.
 Your attending is not upset and tells you
that you will not fail the cardiology
elective afterall. PHEW!
Case 3
 3 y/o AA girl is a new patient who has a
history of a heart murmur per mom.
Mom says her previous pediatrician told
her that the murmur was “harmless and
normal.” You take a listen and hear this
murmur at the LUSB.
 Do you refer her to a cardiologist? Why?
Why not?
Case 3
 She has a LUSB SEM associated with a
abnormally split second heart sound
which is indicative of an ASD.
References
 Sapin SO. Recognizing Normal Heart Murmurs: A Logic-based
Pneumonic. Pediatrics 1997; 99(4):616-618
 Biancaniello T. Innocent Murmurs. Circulation 2005; 111:e20-e22
 Poddar B, Basu S. Approach to a Child with a Heart Murmur.
Indian J Pediatr 2004; 71(1):63-66
 Brumund MR, Strong WB. Murmurs, Fainting, Chest Pain: Time
for a Cardiology Referral? Contemporary Pediatrics 2002;
http://www.contemporarypediatrics.com/contpeds/article/articleDet
ail.jsp?id=126596
 Keren R, Tereschuk M, Luan X. Evaluation of a Novel Method for
Grading Heart Murmur Intensity [abstract]. Arch Pediatr Adolesc
Med 2005; 159(4):329-34
 Moses S. http://www.fpnotebook.com/