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Diagnosis of Mitral-valve prolapse

Diagnostic Test list for Mitral-valve prolapse:

The list of medical tests mentioned in various sources as used in the diagnosis of Mitral-valve prolapse includes:

Mitral-valve prolapse Diagnosis: Book Excerpts

Tests and diagnosis discussion for Mitral-valve prolapse:

Sometimes, once a physician has heard the characteristic sounds of MVP through a stethoscope, other tests may be ordered. Echocardiography is a common and painless test that uses very high frequency sound waves. The sound waves travel through the layers of the skin and muscle to produce an image of the heart that can be seen on a screen. In this sense, it is similar to radar or sonar imaging.

Initially, "M-mode" echocardiography was used. This technology provides a single-plane view of the mitral valve and often resulted in overdiagnosis of MVP in the 1970s and 1980s. A study from National Heart, Lung, and Blood Institute's (NHLBI) Framingham Heart Study, reported in the July 1, 1999 issue of The New England Journal of Medicine, indicated that MVP is less common and less serious than previously thought.

The investigators used standard echocardiography equipment along with new, more accurate criteria that minimize false positive and false negative diagnoses. Whereas earlier estimates put the number of people with MVP at 5 to 35 percent of the population, the new NHLBI study showed the number is closer to 2 percent. In addition, MVP has long been thought to be more prevalent in women than men but the new study reported the condition appears with similar frequency in both men and women.

In light of this new information, NHLBI suggests that people who were diagnosed with MVP since the 1970s might discuss their current health status with their health care provider to determine if a new diagnostic test is warranted. (Source: excerpt from Facts About Mitral-Valve Prolapse: NHLBI)

Diagnosis of Mitral-valve prolapse: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Mitral-valve prolapse:

Diagnostic Tests for Mitral-valve prolapse: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Mitral-valve prolapse.


CARDIAC MURMURS: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Could the murmur be extracardiac in origin? Extracardiac murmurs include the pericardial friction rub and cardiorespiratory murmurs.
  2. Is the murmur continuous? A continuous murmur is most often due to a patent ductus arteriosus or combined valvular stenosis and insufficiency. However, arteriovenous aneurysms and ruptured aneurysm of the sinus of Valsalva must also be considered.
  3. Is the murmur systolic or diastolic? Diastolic murmurs include aortic regurgitation and mitral stenosis and are always organic. Many systolic murmurs are functional in nature.
  4. Is there associated cardiomegaly? An enlarged heart associated with the murmur makes it more likely that it is pathologic. One would consider mitral regurgitation, aortic regurgitation, and aortic stenosis and various forms of congenital heart disease.
  5. Is there hepatomegaly? Hepatomegaly associated with the murmur would make one think of congestive heart failure or tricuspid regurgitation and tricuspid stenosis.
  6. Is there associated fever? Cardiac murmurs occurring with fever suggest acute rheumatic fever and subacute bacterial endocarditis.
  7. Is there dyspnea? Dyspnea associated with a cardiac murmur suggests congestive heart failure.
  8. Is there chest pain? If there is chest pain associated with a cardiac murmur, one must consider pericarditis and myocardial infarction.
  9. Is there an enlarged thyroid or intention tremor? These findings suggest hyperthyroidism.
  10. Is there cyanosis or clubbing? These findings suggest congenital heart disease.

DIAGNOSTIC WORKUP

If the murmur is believed to be organic, the most cost-effective approach would be to consult a cardiologist at the outset. If the astute clinician wishes to pursue the diagnostic workup on his own, it is suggested that a CBC, sedimentation rate, chemistry panel, VDRL test, and thyroid profile should be done for the initial blood work. In addition, a chest x-ray including obliques, congestive heart failure, phonocardiograms, and EKG should be performed. These findings may provide a diagnosis. If there is fever, a streptozyme test, antistreptolysin-O (ASO) titer, and serial blood culture should be performed. If congestive heart failure is suspected, venous pressure and circulation time should be determined. Pulmonary function studies are also helpful. Echocardiography will be extremely helpful in diagnosing the various forms of valvular disease and will also help in identifying a pericardial effusion, congestive heart failure, or the various cardiomyopathies. Cardiac catheterization and angiography and angiocardiography will identify the various congenital heart lesions and valvular disease. These studies, however, are most important when surgery is being considered.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Murmurs - Diastolic: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Aortic insufficiency
    –Decrescendo murmur heard best at the right second intercostal space
  • Austin Flint murmur
    –Late diastolic rumble of severe aortic regurgitation
    –A result of aortic regurgitation so severe that it causes diastolic mitral regurgitation
  • Mitral stenosis
    –Opening snap with mid-diastolic rumble, especially in the left lateral decubitus position
  • Pulmonary insufficiency
    –Accentuated P2 and decrescendo murmur at the left second/third intercostal spaces
  • Tricuspid stenosis
    –Mid-diastolic rumble at the left sternal border
    –Increases with inspiration
  • Cervical venous hum (disappears upon pressure to the jugular vein)
  • Hepatic venous hum (disappears with epigastric pressure)
  • Mammary souffle (in pregnancy; disappears on compressing breast)
  • PDA (continuous machinery sound)
  • Coronary or pulmonary arteriovenous fistula
  • Coarctation of the aorta
  • ASD with left-to-right shunt
  • Atrial myxoma (“tumor plop”)
  • Pericardial knock (constrictive pericarditis)
  • Bronchial collaterals (congenital heart disease)
  • Anomalous pulmonary venous drainage with left-to-right shunt
  • Pulmonary artery branch stenosis
  • Carey-Coombs murmur (mid-diastolic murmur that occurs in acute rheumatic fever)

Workup and Diagnosis

  • Complete history and physical examination, including cardiac maneuvers
  • ECG
  • Echocardiogram
  • Consider chest X-ray
  • Laboratory studies may include CBC, electrolytes, glucose, BUN/creatinine, TSH, liver function tests, pulse oximetry, and/or arterial blood gas
  • Consider cardiology consult

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Murmurs - Systolic: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Innocent systolic murmur
    –Heard at left sternal border
    –Increased when supine
    –May be caused by increased flow states (e.g., anemia, hypovolemia, fever)
  • Still's murmur
  • Mitral valve prolapse
    –Midsystolic click with late systolic murmur that shifts with maneuvers
  • Aortic stenosis
    –Right side at second intercostal space
    –Radiates to carotid arteries
  • Aortic sclerosis
    –Right side at second intercostal space
    –Midsystole
  • Hyperthyroidism
  • Cervical venous hum
    –Disappears with jugular vein pressure
  • Hepatic venous hum
    –Disappears with epigastric pressure
  • Mammary souffle
    –Occurs in pregnancy
    –Disappears upon compression of breast
  • Bicuspid aortic valve
    –Right side at second intercostal space
    –Little radiation
    –Possible early diastolic aortic murmur
    –Opening sound of aortic valve heard in early systole (systolic ejection click)
  • Mitral insufficiency
    –Holosystolic murmur heard best in the left lateral decubitus position
    –S1 is usually diminished in intensity
  • Tricuspid insufficiency
    –Holosystolic murmur at second/third intercostal spaces
  • Endocarditis
    –Abrupt onset of new murmur
  • Peripheral pulmonary artery stenosis
  • Atrial or ventricular septal defect
  • Ventricular septal defect
  • Patent ductus arteriosus (continuous machinery sound, second left intercostal space)
  • Coarctation of the aorta
  • Left ventricular outflow tract obstruction
  • Pulmonary artery stenosis
  • Prosthetic valve noises
  • Pericardial friction rubs
  • Papillary muscle dysfunction
  • Pulmonic outflow obstruction
  • Coronary/pulmonary arteriovenous fistula

Workup and Diagnosis

  • History and physical examination
    –Family history of sudden cardiac death
    –Past medical history of heart disease, murmurs, or rheumatic fever
    –Evaluation for jugular venous distention, carotid upstroke, and/or bruits
    –Heart, lung, and abdominal examinations
    –Peripheral pulses and evaluation for peripheral edema
  • ECG
  • Chest X-ray
  • Echocardiogram
  • Laboratory studies may include CBC, electrolytes, BUN/creatinine, glucose, and TSH
  • Consider cardiac enzymes
  • Consider blood cultures
  • Consider cardiology referral

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

MURMURS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

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.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Murmurs: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 406.) Use the bell of your stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs.

Next, obtain a patient history. Ask if the murmur is a new discovery or if it has been known since birth or childhood. Find out if the patient has experienced associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient’s medical history, noting especially an incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.

Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Murmurs: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 517.) Use the bell of your stethoscope for low-pitched murmurs; the diaphragm for high-pitched murmurs.

Next, obtain a patient history. Ask if the murmur is a new discovery, or if it has been known since birth or childhood. Find out if the patient has experienced any associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. (See Differential diagnosis: Murmurs, pages 518 and 519.) Explore the patient’s medical history, noting especially any incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.

Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Heart Murmur, Diastolic: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Symptoms. Many patients with diastolic murmurs will not present with specific complaints; rather, the murmurs will be found in the course of a routine medical examination. With symptomatic lesions, the patient may experience dyspnea, chest pain, or palpitations. Pulmonary regurgitation (PR) is usually asymptomatic except in its most severe forms. More specific symptoms include chest or neck pounding in aortic regurgitation (AR); hemoptysis, embolism, or hoarseness (left recurrent laryngeal nerve compression from the left atrium) in mitral stenosis (MS); failure to thrive or frequent respiratory infections with congenital MS; edema in tricuspid stenosis (TS); and fever, anemia, weight loss, embolism, digital clubbing, arthralgias, syncope, rash, and Raynaud’s phenomenon with an atrial myxoma (1).

 B. Past medical history. Does the patient have a history of rheumatic fever (RF)? RF is the most common cause of all diastolic murmurs (mitral → aortic → tricuspid → pulmonic) (2). Of patients with mitral stenosis, 50% will have a history of rheumatic fever (3).

1. Endocarditis. Vegetations can lead to either AR/PR or MS/TS.

2. Pulmonary hypertension with PR is classically associated with the Graham Steell murmur, heard in the left third interspace near the sternum and propagated down the sternum.

3. Connective tissue and collagen vascular diseases predispose to aortic root dilatation and AR.

4. Congenital heart malformations can be associated with multiple valvular lesions, left ventricular (LV) outflow tract abnormalities, or shunts (with resultant volume overload).

5. Atrial myxoma is a rare cause of variable AV valve obstruction.

6. Syphilis can cause aortitis and AR.

Physical examination (PE)

A. Table 7.3 lists characteristic PE findings of diastolic murmurs.

B. Fine points of the physical examination

1. Is the murmur of AR louder at the right sternal border? If so, consider aortic root dilation. Remember, whereas the duration of the chronic AR murmur is directly proportional to the severity of the regurgitation, the duration of the acute AR murmur may not predict its severity (3).

2. Is the murmur of MS shorter, or does it extend closer to S2? The length of this murmur, not its intensity, is directly proportional to the severity of the stenosis (3). In addition, the murmur may not be audible with increased heart rates because of shortening of diastole.

 3. Does the murmur of MS vary from examination to examination? If so, and especially if it is introduced by a “plop” sound, consider atrial myxoma.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Heart Murmur, Systolic: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. General issues in the history. The history can provide important clues as to whether the murmur is clinically significant. Any history of rheumatic fever, previously known valvular disease, congenital heart disease, or intravenous drug abuse would be important to ascertain.

Murmurs of early adulthood suggest congenital or rheumatic disease, whereas murmurs with onset later in life are consistent with degenerative valvular changes.

 B. Patient symptoms. Patients should be asked about shortness of breath, dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Patients with these symptoms warrant an expedited evaluation because these symptoms suggest cardiac decompensation. Advanced aortic stenosis specifically is associated with chest pain, syncope, and heart failure, although a gradient across the valve can exist for years prior to symptom onset. Chest discomfort is often present in advanced disease, but sudden death occurs in 15% of patients with no previous symptoms (1).

 C. Association of a murmur with a specific disease. Recent myocardial infarction endocarditis could cause papillary muscle dysfunction resulting in mitral or tricuspid regurgitation. Mitral regurgitation can be seen in connective tissue disease, coronary artery disease, and congenital disease, but is commonly associated with conditions leading to left ventricular dilatation such as congestive heart failure (CHF) (Chapter 7.5). Endocarditis, myocardial infarction, trauma, prolapse, or congenital heart disease usually precede tricuspid regurgitation. Mitral valve prolapse, which is clinically characterized by palpitations, fatigue, and chest pain, is often associated with anxiety. Hypertrophic cardiomyopathy can be seen in patients with a family history and usually presents between the ages of 20 and 40 years. Presenting symptoms include dyspnea on exertion, chest pain, palpitations, or syncope. It is an important cause of sudden death in athletes. A history of anemia, thyroid disease, or fever should also be elicited from patients being evaluated for
a systolic murmur as each of these conditions can cause a murmur from increased flow.

Physical examination

A. Technique. Auscultate the heart with the bell to best detect lower frequencies and the heart sounds (S1-S4). The quality of the murmur is best heard with the diaphragm. Inspiration increases the audibility of right ventricular sounds.

 B. Murmur characteristics. Table 7.4 presents a summary of the characteristics of different causes of systolic murmurs (2,3). Etchell et al. (3) have prepared a comprehensive review on the usefulness of specific physical examination findings in the diagnosis of systolic murmurs.

» READ BOOK EXCERPT ONLINE »

Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Diastolic Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Aortic regurgitation

❑ Pulmonic regurgitation

❑ Mitral stenosis

❑ Tricuspid stenosis

❑ Atrial septal defect

❑ Left anterior descending artery stenosis

❑ Atrial myxoma

Diagnostic Approach

A diastolic murmur is always abnormal. An early diastolic murmur, caused by aortic or pulmonic regurgitation, is high-pitched and decrescendo. The duration of the murmur is an index of severity. A mid-diastolic murmur suggests mitral or tricuspid stenosis.

The murmur of mitral stenosis decreases or does not change with inspiration whereas the murmur of tricuspid stenosis increases.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Systolic Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Systolic ejection murmur

❑ Mitral regurgitation

❑ Mitral valve prolapse

❑ Aortic stenosis

❑ Aortic valve sclerosis

❑ Hypertrophic obstructive cardiomyopathy

❑ Atrial septal defect

❑ Pulmonic stenosis

❑ Tricuspid regurgitation

❑ Ventricular septal defect

❑ Aortic coarctation

Diagnostic Approach

The intensity of the murmur is proportional to the degree of stenosis until flow decreases markedly. Intensity can be expressed semiquantitatively, from grade 1/6, heard only with concentration, to grade 4/6, a loud murmur associated with a palpable thrill, to grade 6/6 with a thrill and murmur heard with the stethoscope off the chest. The duration of the murmur is proportional to the pressure differential between the two chambers.

An early systolic murmur, decrescendo at the apex, occurs in acute, severe mitral regurgitation (MR) with papillary muscle rupture, endocarditis, ruptured chordae tendineae, or blunt chest trauma. A midsystolic murmur is typical of aortic stenosis (AS). It can also be found with hypertrophic obstructive cardiomyopathy (HOC) and with hyperdynamic states. A late systolic murmur is usually heard with mitral valve prolapse (MVP) in association with a midsystolic click. A holosystolic murmur can be produced by severe MR or tricuspid regurgitation (TR), or by a ventricular septal defect (VSD), when the pressure differential between chambers persists throughout systole. Holosystolic murmurs are almost never innocent.

Handgrip decreases AS and HOC murmurs but increases MR, aortic regurgitation (AR), VSD, and mitral stenosis (MS). Transient arterial occlusion by a blood pressure cuff 20 mm above systolic increases left-sided murmurs. Valsalva decreases most murmurs (decreased right and left ventricular filling), except HOC and MVP, which increase.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Continuous Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Aortic stenosis/aortic insufficiency

❑ Pericardial friction rub

❑ Pulmonary arteriovenous fistula

❑ Venous hum

❑ Mammary souffle

❑ Aortic coarctation

❑ Mediastinal air dissection

❑ Patent ductus arteriosis

❑ Ruptured sinus of Valsalva

❑ Coronary artery fistula

Diagnostic Approach

Continuous murmurs begin in systole and extend into diastole without interruption. The murmur results from blood flow from a higher pressure chamber or vessel to a lower pressure system, with the gradient maintained during both systole and diastole, for example with aortopulmonary and arteriovenous connections.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Murmurs: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain a patient history. Ask if the murmur is a new discovery, or if it has been known since birth or childhood. Find out if the patient has experienced any associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient’s medical history, noting especially any incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.

Physical examination

If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs.) Use the bell of your stethoscope for low-pitched murmurs; the diaphragm for high-pitched murmurs.

Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient’s liver tender or palpable? Does he have peripheral edema?

» READ BOOK EXCERPT ONLINE »

Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

Murmurs: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs.) Use the bell of your stethoscope for low-pitched murmurs; the diaphragm for high-pitched murmurs.

Next, obtain a patient history. Ask if the murmur is a new discovery or if it has been known since birth or childhood. Find out if the patient has experienced any associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient’s medical history, noting especially any incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Heart Murmurs (Asymptomatic): Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

Normal Murmurs

Systolic Ejection Murmurs

  • Normal systolicejection murmurs are grade III or less.
  • They begin after S1 following the isovolumiccontraction period and end before S2.
  • They vary from cycle to cycle withrespiration or change in position.
  • Intensity increases with fever, anxiety,or exercise.
  • Although heard with maximum intensityat specific locations on the chest wall, they are louder in supineposition.

    • Vibratory Systolic Murmur

  • Commonlyheard in childhood and less often in infancy.
  • Usually grade II/VI but canrange from grade I to III.
  • Heard with maximum intensity at lowerleft sternal border or between this area and apex.
  • Has distinctive vibratory quality.

    • Pulmonary Systolic Murmur

  • Frequentlyheard in childhood and adolescence.
  • Maximum intensity is in second intercostalspace at upper left sternal border.
  • Usual intensity is grade II/VIwith range from grade I to III.
  • Higher in pitch than vibratory systolicejection murmur.
  • Also heard in straight back syndrome,which is characterized by absence of normal thoracic kyphosis andnarrow anterior-posterior diameter of chest. RV and pulmonary arterylie against sternum, and murmur is easily heard. Straight back syndromealso may be associated with mitral valve prolapse.

    • Physiologic Peripheral Pulmonary Systolic Murmur

  • May be heardin neonates, especially in preterm infants.
  • Intensity is usually grade I–II/VI.
  • Heard equally well in right and leftanterior chest, axillae, and back.
  • Usually disappears by 3–6mos of age.

    • Supraclavicular or Brachiocephalic Murmur

  • May be heardin childhood or adolescence.
  • Usually grade II or III/VI.
  • Maximum intensity is always above medialaspect of clavicles in supraclavicular fossa but may be heard belowclavicles.
  • Usually louder on right side.
  • Shoulder maneuvers are useful in distinguishingit from other murmurs. When physician is listening for murmur, childshould sit with shoulders relaxed and arms in front of chest. Murmurdiminishes or disappears when shoulders are hyperextended with elbowsbrought behind back.

    • Continuous Murmurs

    Venous Hum

  • Commonlyheard in sitting position.
  • Grade II–IV/VI continuousmurmur with maximal intensity in supraclavicular fossa, just lateralto sternocleidomastoid muscle with transmission below clavicles.
  • Usually more prominent on right side.
  • Diminishes or disappears with compressionof ipsilateral jugular vein, head/neck turning or positioning,or with lying down.

    • Pathologic Murmurs

  • Can be systolic,diastolic, or continuous.
  • Intensity is usually grade III or more,but can be grade I or II if lesion is mild.
  • Duration is usually longer than thatof normal murmur.
  • Heard with maximum intensity at specificlocations on chest wall.

    • Systolic Murmurs

    Maximal Intensity at Upper Right Sternal Border

    Valvar Aortic Stenosis

  • Most commontype of LV outflow tract obstruction.
  • Produces grade II–IV/VIharsh systolic ejection murmur that is heard with maximum intensityat upper right sternal border.
  • Aortic ejection click also can be heardalong left sternal border and at apex.
  • Prominent apical impulse is palpable.
  • Chest radiography shows normal to mildlyenlarged heart, normal pulmonary vascular markings, and mild dilatationof ascending aorta.
  • ECG is normal or shows LV hypertrophy.
  • 2-D echocardiography shows abnormalvalve. Doppler methods demonstrate abnormal flow pattern.

    • Maximal Intensity at Upper Left Sternal Border

    Valvar Pulmonic Stenosis

  • Associatedwith prominent RV impulse over lower sternum, normal S2, and systolic ejectionclick (louder on expiration) along left sternal border.
  • Grade II–IV/VI harshsystolic ejection murmur transmits to neck and back.
  • In infants, click may be absent withmild stenosis.
  • Chest radiograph shows normal heartsize, normal pulmonary vascular markings, and dilated main pulmonaryartery segment.
  • ECG is normal or shows RV hypertrophy.
  • 2-D echocardiography shows abnormalvalve. Doppler methods demonstrate abnormal flow pattern.

    • Atrial Septal Defects

  • Includeostium secundum, ostium primum, and sinus venosus defects.
  • Physical exam is similar with all defects.
  • Prominent RV impulse, grade II–III/VIsystolic ejection murmur with maximum intensity at upper left sternalborder, usually wide fixed splitting of S2, and grade II–III/VImid-diastolic rumbling murmur with maximum intensity at lower leftsternal border.
  • In infants, splitting of S2 may benormal or wide and not fixed.
  • Systolic murmur signifies increasedblood flow across pulmonic valve, and diastolic murmur reflectsincreased flow across tricuspid valve.
  • Chest radiography shows mild cardiomegaly,increase in pulmonary vascular markings, and enlarged pulmonaryartery segment.
  • ECG shows RV hypertrophy. In ostiumprimum defect, frontal plane QRS axis often shows left axis deviation,which signifies conduction system displacement. P wave on ECG ismore horizontal with sinus venosus defect.
  • 2-D echocardiography visualizes defectsand can distinguish between them.

    • Mild-to-Moderate Coarctation of Aorta

  • BP in rightarm is significantly higher than that in legs with coarctation ofaorta.
  • Femoral pulses are diminished comparedwith brachial or radial pulses.
  • Prominent apical impulse.
  • Grade II–III/VI harshsystolic ejection murmur is commonly heard at upper left sternalborder and left back.
  • Grade II–III/VI high-pitchedcontinuous murmur may be heard over left side of spine along scapularedge.
  • Presence of aortic ejection click andsystolic ejection murmur at upper right sternal border usually signifiesbicuspid aortic valve, which is commonly associated with coarctationof aorta.
  • Chest radiograph shows normal or mildlyenlarged heart and normal pulmonary vasculature. Ascending aortamay be dilated. In older infants and children, indentation of descendingaorta just distal to aortic arch produces "3" sign.Erosion of bone by large intercostal arteries can produce notchingof lower margins of posterior ends of ribs 3–9.
  • In early infancy, ECG usually showsRV hypertrophy, whereas in children it may be normal or show mildLV hypertrophy.
  • 2-D echocardiography can often demonstratecoarctation. In older children, if coarctation is not well demonstratedby echocardiography, it may be visualized by MRI.

    • Small Patent Ductus Arteriosus

  • Common interm infants and very common in preterm infants, especially in thosewith birth weight <1,500 g.
  • Murmur is usually grade II–III/VIand is systolic or continuous. Systolic ejection sounds are occasionallyheard along left sternal border.
  • Chest radiography shows normal sizeor mildly enlarged heart with increased pulmonary vascular markings.
  • ECG is either normal or shows mildLV hypertrophy.

    • Maximal Intensity at Lower Left Sternal Border

    Normal vibratory ejection murmur must bedistinguished from 2 pathologic systolic murmurs that are heardwith maximum intensity at lower left sternal border: murmurs ofventricular septal defect and tricuspid incompetence.

    Ventricular Septal Defect

  • Murmur ofsmall VSD may be heard as early as 1–3 days of age as pulmonaryvascular resistance decreases and left-to-right shunt develops.
  • Palpation reveals normal-sized or mildlyenlarged heart.
  • Intensity and splitting of S2 are normal.
  • Murmur is grade II–IV/VIand is heard throughout systole. It is harsh in quality with maximalintensity at lower left sternal border.
  • If defect begins to close with time,duration of murmur is less.
  • No diastolic murmur is heard at apexunless pulmonary:systemic flow ratio is ≥2:1.
  • Chest radiograph shows normal or mildlyenlarged heart, and increased pulmonary vascular markings.
  • ECG is normal or shows mild LV hypertrophy.
  • 2-D echocardiography may not visualizesmall defects.

    • Tricuspid Incompetence

  • Murmur ishigh pitched, usually grade II–III/VI, and heardthroughout systole with maximal intensity at lower left sternalborder.
  • May be heard in asymptomatic lesions(isolated mild congenital tricuspid incompetence, atrioventricularcanal defects, Ebstein anomaly) or in symptomatic ones (atrioventricularcanal defects, Ebstein anomaly, pulmonary atresia with intact septum,endocarditis, perinatal asphyxia).

    • Maximal Intensity at Apex

    Mitral Incompetence

  • Murmur ishigh pitched, usually grade II–IV/VI, and heardthroughout systole at apex with transmission to left axilla andback.
  • Heart is normal sized or mildly enlarged.
  • Chest radiograph and ECG are usuallynormal.
  • Causes include congenital defects ofmitral valve, atrioventricular canal defects, anomalous left coronaryartery from pulmonary artery, hypertrophic cardiomyopathy, Marfansyndrome, and Hurler syndrome.
  • Symptomatic causes include these lesionsas well as acute rheumatic fever, myocarditis, endocarditis, endocardialfibroelastosis, and perinatal asphyxia.

    • Mitral Valve Prolapse

  • Can occuras isolated defect or in association with ostium secundum atrialseptum defect, endocarditis, Hurler syndrome, Marfan syndrome, orEhlers-Danlos syndrome.
  • Usual finding is midsystolic nonejectionclick followed by late systolic murmur of mitral incompetence.
  • Murmur is heard best at apex, especiallyin standing position after squatting.
  • Chest radiograph is normal.
  • ECG may show inverted T waves in leadsII, III, and aVF as well as ST depression in left precordial leads.
  • Clinical diagnosis can be confirmedby M-mode or 2-D echocardiography.

    • Diastolic Murmurs

  • There havebeen some reports of normal diastolic murmurs occurring in infantsand children, but this is rare.
  • For this discussion, all diastolicmurmurs are considered pathologic. These murmurs usually indicate

  • Semilunarvalve incompetence (aortic or pulmonic valve)
  • Atrioventricular valve stenosis (mitralor tricuspid valve)
  • Severe mitral or tricuspid valve incompetence
  • Increased blood flow across the tricuspidvalve (atrial septal defect) or mitral valve (large ventricularseptal defect or patent ductus arteriosus)

    • Maximal Intensity at Upper Right Sternal Border

    Aortic Valve Incompetence

  • Can occuras isolated congenital lesion or in association with valvar aorticstenosis, discrete subaortic stenosis, ventricular septal defect,acute rheumatic fever, or endocarditis.
  • Diastolic murmur of aortic valve incompetenceis grade I–IV/VI and is characterized by its highpitched decrescendo sound. Heard with maximum intensity at upperright sternal border but is also heard along left midsternal border.Murmur begins with aortic closure, and the more severe the incompetence,the longer the murmur and the wider the pulse pressure. Usuallyis louder when patient is sitting up and leaning forward.
  • Apical impulse may be prominent, dependingon degree of incompetence.
  • Chest radiography shows normal or mildlyenlarged heart.
  • ECG is normal or shows LV hypertrophy.

    • Maximal Intensity at Upper Left Sternal Border

    Pulmonic Valve Incompetence

  • Producesmedium-pitched, grade I–IV/VI, diastolic decrescendomurmur, which begins with pulmonary closure and varies in durationdepending on severity of lesion.
  • Longer murmur signifies more severeincompetence.
  • Causes include congenital pulmonicvalve incompetence, idiopathic dilatation of pulmonary artery, valvarpulmonic stenosis, postsurgical repair (valvar pulmonary stenosis,tetralogy of Fallot), and endocarditis.

    • Maximal Intensity at Lower Left Sternal Border

    Atrial Septal Defects

    Diastolic flow rumble, usually grade I–III/VI,can be heard with maximal intensity at lower left sternal borderwith any type of ASD.

    Tricuspid Stenosis

  • Rare lesionthat can occur as isolated congenital lesion or in association withsevere valvar pulmonic stenosis, hypoplasia of right ventricle withpulmonary atresia, or chronic rheumatic heart disease.
  • Murmur is grade I–III/VIdiastolic rumble with presystolic accentuation, which may increasein intensity with inspiration. Opening snap also may be heard.

    • Moderate-to-Severe Tricuspid Incompetence

  • Grade I–III/VIdiastolic flow rumble of tricuspid incompetence reflects increasein blood flow across tricuspid valve during diastole.
  • Systolic murmur of tricuspid incompetencealso is heard at lower left sternal border.
  • Affected children are usually symptomatic.
  • See section Tricuspid Incompetence.

    • Maximal Intensity at Apex

    Mitral Stenosis

  • Murmur isgrade I–II/VI, diastolic, low-rumbling murmurwith presystolic accentuation and opening snap.
  • Heard with maximum intensity at apex.
  • May occur as isolated congenital defect,as part of Shone syndrome, or secondary to rheumatic fever.

    • Moderate-to-Severe Mitral Incompetence

  • Diastoliclow-pitched murmur heard with mitral incompetence reflects increasedantegrade blood flow across mitral valve.
  • Murmur varies in intensity and durationwith severity of incompetence and is heard with maximal intensityat apex.
  • Systolic murmur of mitral incompetenceis also heard at apex.

    • Moderate Left-to-Right Shunt Lesions

  • Lesions(e.g., VSD and patent ductus arteriosus) may produce moderate orlarge left-to-right shunts.
  • Grade I–III/VI low-pitcheddiastolic flow murmur can be heard at apex because of increased bloodflow across mitral valve in diastole.
  • Children with large left-to-right shuntsare in cardiac failure.

    • Continuous Murmurs

    Maximal Intensity at Upper Left Sternal Border

    Moderate Patent Ductus Arteriosus

  • Typicalmurmur of moderate-sized patent ductus arteriosus is continuousmachinery-like murmur, usually at least grade III/VI, withmaximum intensity at upper left sternal border, and transmissionalong left sternal border and in lung fields.
  • There is often increased LV impulse,wide but variable split of S2, and increased pulse pressure.
  • Chest radiograph shows mild cardiomegalyand increased pulmonary vascular markings.
  • ECG shows LV hypertrophy and occasionallyleft atrial enlargement.
  • 2-D echocardiography with Doppler methodsis confirmatory.

    • Maximal Intensity at Left Midsternal Border

    Aortic Pulmonary Window

  • There iscommunication between ascending aorta and main pulmonary artery.
  • Defect is usually large, which resultsin large amount of pulmonary blood flow.
  • Murmur is heard with maximum intensityat left midsternal border.
  • Primarily systolic with diastolic component.However, continuous murmur may be heard with rare small aortic pulmonarywindow.
  • Chest radiographic and ECG findingsare similar to those of patent ductus arteriosus.
  • 2-D echocardiography with Doppler methodsis diagnostic.

    • Maximal Intensity with Variable Location

    Coronary Arteriovenous Fistula

  • Communicationbetween coronary artery and heart, usually right atrium or pulmonaryartery.
  • Continuous murmur is usually heardover lower precordium, away from area where ductus is heard.
  • Cardiac catheterization and angiographyare usually necessary for definitive diagnosis.

    • Systemic Arteriovenous Fistula

  • This typeof connection within thorax can occur with communications betweensubclavian artery and innominate vein, between internal mammaryartery and vein, between bronchial arteries and branches of systemicazygous system, and between other chest wall vessels.
  • Continuous murmur is heard over areaof abnormal communication.
  • Cardiac catheterization and angiographyare necessary for definitive diagnosis.

    • Diagnostic Approach

  • To distinguisha normal from a pathologic murmur, physicians must rely on theirskill in physical exam of cardiovascular system; on their interpretationof chest radiograph, ECG, and 2-D echocardiogram; and on their knowledgeof the diagnostic possibilities that each murmur suggests.
  • In most cases, cardiovascular examat bedside can distinguish a normal from a pathologic murmur.

  • With a normalmurmur, no tests are needed. Physicians can reassure parents andexplain that the murmur is a normal phenomenon due to normal turbulenceof blood flow. They can also emphasize that the murmur is not indicativeof mild heart disease, nor is it of any importance whether it disappears.
  • With a pathologic murmur, precise diagnosismust be made because subsequent management depends on it. Diagnosisof pathologic murmurs is based on cardiovascular exam in conjunctionwith chest radiograph and ECG and sometimes 2-D echocardiogram.
  • Only rarely are cardiac catheterizationand angiography needed to clarify etiology of murmurs in asymptomaticchildren.
    • >

    » READ BOOK EXCERPT ONLINE »

    Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

    Murmurs: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you discover a murmur, try to determine its type through careful auscultation. (See Identifying common murmurs, page 398.) Use the bell of your stethoscope for low-pitched murmurs and the diaphragm for high-pitched murmurs.

    Next, obtain a patient history. Ask if the murmur is a new discovery or if it has been known since birth or childhood. Find out if the patient has experienced associated symptoms, particularly palpitations, dizziness, syncope, chest pain, dyspnea, and fatigue. Explore the patient's medical history, noting especially an incidence of rheumatic fever, recent dental work, heart disease, or heart surgery, particularly prosthetic valve replacement.

    Perform a systematic physical examination. Note especially the presence of cardiac arrhythmias, jugular vein distention, and such pulmonary signs and symptoms as dyspnea, orthopnea, and crackles. Is the patient's liver tender or palpable? Does he have peripheral edema?

    » READ BOOK EXCERPT ONLINE »

    Source: Nursing: Interpreting Signs and Symptoms, 2007

    MURMURS: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    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.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007


     » Next page: Signs of Mitral-valve prolapse

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