MURMURS

MURMURS: Excerpt from Differential Diagnosis in Primary Care

The first consideration on hearing a heart murmur is to determine whether the murmur is functional or organic. Certainly, the low-grade systolic murmurs tend to be functional; if the murmur changes or disappears on position, inspiration, or exercise it is likely to be functional. A diastolic murmur, however, is invariably organic. Perhaps the most significant question to ask is, “Are the heart sounds normal?" This is a decisive factor in many cases. If the heart sounds are normal, organic disease is unlikely. Once the murmur is determined to be organic, one needs to have a working differential diagnosis in mind to proceed efficiently. VINDICATE provides a mnemonic for this purpose.

1. V—Vascular suggests myocardial infarction, ball–valve thrombi, mural thrombus, and CHF. Hypertensive cardiovascular disease may lead to cardiac dilatation and murmurs.
2. I—Inflammatory recalls acute and subacute bacterial endocarditis, viral myocarditis, and the myocarditis of trichinosis and Chagas disease. Syphilis is also a prominent cause of aortic insufficiency.
3. N—Neoplasm includes atrial myxomas, the most significant disorder to remember here, but leukemic infiltration of the heart and all the neoplasms associated with anemia might be considered.
4. D—Degenerative disease recalls atherosclerotic heart disease, muscular dystrophy, and Friedreich ataxia. Atherosclerotic heart disease should be emphasized because it frequently causes aortic murmurs. Medionecrosis may lead to murmurs when a dissecting aneurysm begins.
5. I—Intoxication reminds one that there may be no murmur in alcoholic myocardiopathy until failure develops, but it is a condition to consider nevertheless.
6. C—Congenital heart disease is a well-known cause of murmurs.
7. A—Autoimmune disease includes rheumatic fever, the best known of these disorders, although it is now a less frequent consideration in murmurs. Libman–Sacks mitral valvular disease occurs in lupus erythematosus.
8. T—Traumatic disorders recall a ventricular or aortic aneurysm and occasionally a coronary arteriovenous fistula or valvular insufficiency that may result from a stab wound.
9. E—Endocrinopathies indicate hyperthyroidism and hypothyroidism, particularly because the associated CHF may lead to cardiac dilatation and murmurs. Hyperthyroidism produces murmurs in some cases because of the rushing blood and rapid rate, causing many eddy currents.

MURMURS

Approach to the Diagnosis

A chest x-ray with anterior oblique films during a barium swallow along with an ECG, sedimentation rate, a blood serology thyroid profile, and CBC are basic in the workup of a murmur. If there is a fever or if there is recent onset of the murmur, blood cultures, an ASO titer and C-reactive protein (CRP) should be done. An ANA test, echocardiogram, and phonocardiogram are frequently done. Referral to a cardiologist is wise if the cause is obscure or if one is unable to spend the time for a careful workup. Angiocardiography and cardiac catheterization are the only sure ways to determine the location of the valvular disease, and, in many cases, the exact cause.

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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