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. After 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.
V—Vascular suggests myocardial infarction, ball–valve thrombi,
mural thrombus, and congestive heart failure (CHF). Hypertensive
cardiovascular disease may lead to cardiac dilatation and murmurs.
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.
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.
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.
I—Intoxication reminds one that there may be no murmur in
alcoholic myocardiopathy until failure develops, but it is a condition to
consider nevertheless.
C—Congenital heart disease is a well-known cause of murmurs.
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.
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.
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.
Approach to the Diagnosis
A chest x-ray with anterior oblique films during a barium swallow along
with an electrocardiogram (ECG), sedimentation rate, 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
antistreptolysin-O (ASO) titer, and a C-reactive protein (CRP) test should
be done. An antinuclear antibody (ANA) test, ECG, 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.
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- 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.
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