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Symptoms » Rapid heart beat » Book Sections
 

Heart Murmurs (Asymptomatic)

  • Normal murmursare due to turbulence of normal blood flow.
  • A normal murmur does not result insymptoms. Cardiovascular exam, chest radiograph, and ECG are normal.Other terms used to signify a normal murmur are benign, insignificant,or innocent.
  • Pathologic murmurs are due to organicheart disease. Can be distinguished from normal murmurs by theirintensity, quality, duration, location of maximal intensity on chestwall, and transmission. Pathologic murmurs are usually associatedwith other abnormal findings on cardiovascular exam, chest radiograph,ECG, and echocardiogram.

    • Principal Causes of Heart Murmurs (Asymptomatic)

    1. Normalmurmurs
      1. Systolicejection murmurs
        1. Vibratory systolic murmur
        2. Pulmonary systolic murmur (pulmonarytrunk)
        3. Physiologic peripheral pulmonary systolicmurmur (pulmonary branches)
        4. Supraclavicular or brachiocephalicmurmur
      2. Continuous murmurs
        1. Venoushum
    2. Pathologic murmurs
      1. Systolicmurmurs
        1. Maximalintensity at the upper right sternal border
          1. Valvaraortic stenosis
        2. Maximal intensity at the upper leftsternal border
          1. Valvar pulmonic stenosis
          2. Atrial septal defects
          3. Mild-to-moderate coarctation of theaorta
          4. Small patent ductus arteriosus
        3. Maximal intensity at the lower leftsternal border
          1. Ventricular septal defect
          2. Tricuspid incompetence
        4. Maximal intensity at the apex
          1. Mitralincompetence
          2. Mitral valve prolapse
      2. Diastolic murmurs
        1. Maximalintensity at the upper right sternal border
          1. Aorticvalve incompetence
        2. Maximal intensity at the upper leftsternal border
          1. Pulmonic valve incompetence
        3. Maximal intensity at the lower leftsternal border
          1. Atrial septal defects
          2. Tricuspid stenosis
          3. Moderate-to-severe tricuspid incompetence
        4. Maximal intensity at the apex
          1. Mitralstenosis
          2. Moderate-to-severe mitral incompetence
          3. Moderate left-to-right shunt lesions
      3. Continuous murmurs
        1. Maximalintensity at the upper left sternal border
          1. Moderate patent ductus arteriosus
        2. Maximal intensity at the left mid sternalborder
          1. Aorticpulmonary window
        3. Maximal intensity with variable location
          1. Coronaryarteriovenous fistula
          2. Systemic arteriovenous fistula

    Clinical Features and Diagnosis

    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.

    • References

    1. Garson A Jr, et al., eds. The scienceand practice of pediatric cardiology, 2nd ed. Baltimore: Williams & Wilkins,1998.
    2. Perloff JK. The clinical recognition of congenitalheart disease, 4th ed. Philadelphia: WB Saunders, 1994.
    3. Rudolph AM. Congenital heart disease. Chicago: YearBook Medical, 1974.
    4. Rudolph AM, ed. Rudolph's pediatrics, 20thed. Stamford, CT: Appleton & Lange, 1996.
    5. Zuberbuhler JR. Clinical diagnosis in pediatric cardiology.Edinburgh, Scotland: Churchill Livingstone, 1981.
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    Book Source Details

    • Book Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    • Author(s): Paul S. Bellet
    • Year of Publication: 2006
    • Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2006 Lippincott Williams & Wilkins.

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    Copyright Details: The Diagnostic Approach to Symptoms and Signs in Pediatrics, Copyright © 2008 Williams & Wilkins.

    More About Causes of Rapid heart beat



    More About This Book:
    Title: The Diagnostic Approach to Symptoms and Signs in Pediatrics
    Authors: Paul S. Bellet
    Publisher: Lippincott Williams & Wilkins
    Copyright: 2006
    ISBN: 0-78172-899-1

     » Next page: Murmurs (Nursing: Interpreting Signs and Symptoms)

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