HEART MURMURS: INNOCENT OR GUILTY?

HEART MURMURS: INNOCENT OR GUILTY? William A. Lutin, MD, PhD Section of Pediatric Cardiology Georgia Regents University Augusta, GA (wlutin@gru.edu) DISCLOSURES I have no relevant financial relationships with the manufacturers(s) of any commercial products(s) and/or provider of commercial services discussed in this CME activity. I do not plan to discuss the investigational use of any medication or medical device. I DO plan to discuss the use of the physician s brain. 1

HEART MURMUR CHD!!! Murmur: 50/100 CHD: 1/100 2

LUTIN S 4 P s OF HEART DISEASE Physiology of lesion (P,V) +Physics of flow and sound +Physician s Brain =Proper diagnosis Strong s Law: Diagnosis +Natural History +Risks/Benefits + Family & Patient s Life = Best Treatment PRINCIPLE OF TONE Laminar Relative Number Musical Vibratory Turbulent Relative Number Thrill Harsh Velocity of Blood (Frequency of Vibration) 3

PRINCIPLE OF RESONANCE Guilty Innocent Intensity 1 0 10% Cardiac Output (L/min) PRINCIPLE OF LOCATION AND RADIATION Sounds are generally loudest directly over the structure making the noise. Sound radiates well parallel to flow. Sound radiates poorly perpendicular to flow. A knowledge of the flow physiology of a given heart lesion and the surface anatomy of the heart allow the prediction of cardiac murmurs and their radiation 4

SOUND LOUDEST OVER LESION, RADIATES PARALELL TO FLOW CARDIAC HISTORY Prenatal history: risk factors and teratogens Early growth and development- motor milestones Feeding pattern (for infants) Time and clinical setting when murmur was first noted (ARF, fever) Activity and exercise tolerance - children self-limit Respiratory symptoms (esp. wheezing, recurrent problems) Orthopnea, dy spnea, diaphoresis, cyanosis Palpitations, chest pain, syncope (less specific) Family history of CHD, syndromology, sudden death 5

NON CARDIAC PHYSICAL EXAM OF THE CHILD WITH A MURMUR Overall appearance of the child - well or ill Vital signs, including HR and RR, 4 extremity blood pressures Growth and development Pulses (simultaneous radial and femoral), HEENT: Be a good dysmorphologist Feel suprasternal notch for thrill, examine neck veins Respiratory pattern and exam Hepatomegaly, sidedness of liver, character of liver edge DYSMORPHOLOGY AND CHD CHD > 1/100 6

Association of CHD with Dysmorphology Syndrome Genetics % CHD Common Lesions (Trisomy 21) 50 A/V canal, VSD Trisomy 18 99 VSD, polyvalvular disease Trisomy 13 80 PDA, VSD Turner (45 XO) 20-40 Aortic coarctation Marfan AD 90+ Aortic ectasia, MVP Noonan AD 50 Pulmonic stenosis, SAD WHAT S WRONG HERE? A B 7

C/V EXAM: THE HEART Inspection Palpation (Percussion) Auscultation Exultation CARDIAC EXAM Inspection: Precordial prominence, PMI Palpation: LV and RV impulses, thrills (LLSB, LUSB, URSB). Precordial hyperactivity is important clue Auscultation: Locations of S1, S2. S2 splitting. Assess P2. Clicks. Location, effect of respiratory cycle Murmurs: Timing, quality, location, radiation, variation with respiratory cycle and posture 8

INSPECTION AND PALPATION: ALWAYS FEEL THE HEART! SSN RVO, PA RVI LVI AUSCULTATION Approach to the patient is key. 9

DESCRIBING A HEART MURMUR Timing and duration Character Intensity Location of maximal loudness Radiation Physiologic behavior (e.g. maneuvers) GRADING HEART MURMURS I II III IV V VI (VII Barely audible Easily heard Moderately loud Loud, with a thrill Heard with edge of stethoscope applied to chest wall Heard with stethoscope off chest Heard by MCG MS2 s) 10

SEM HSM DSM EDDM MDM Cont. Normal, ASD, AS, PS,Coarct VSD, MR, TR VSD AI, PI MS, (VSD, ASD) PDA, AVM, surgical shunts Timing Systolic Murmurs S1 S2 Ejection Pansystolic 11

SURFACE AUSCULTATORY ANATOMY OF THE HEART PATIENTS WITH INNOCENT HEART MURMURS Adventitial exam must be totally normal: Normal 4 ext. pulses, no radial-femoral pulse delay, no cyanosis, normal growth parameters and vital signs, normal respiratory pattern. Normal precordial activity (extremely important). Normal heart sounds (location of maximal loudness, amplitude, splitting) 12

TYPES OF INNOCENT HEART MURMURS Still's murmur Pulmonary outflow murmur Cervical venous hum Carotid bruit Peripheral pulmonic stenosis CHARACTERISTICS OF INNOCENT HEART MURMURS Ejection (definition), isovolumic contraction period, short duration, early peaking. No diastolic component. Character: Vibratory (definition) or musical ( plucked string quality). Location: max usually LLSB, occ. LUSB Frequency: low (definition). Radiation: along LSB, not to back 13

DISTINGUISHING INNOCENT FROM PATHOLOGICAL MURMURS Presence of variation with posture, respiration. Usually abolishable. No clicks or other ectopic sounds. Absence of high frequency components (never "harsh"). No diastolic murmur COMPARISON OF INNOCENT AND PATHOLOGIC MURMURS Characteristic Quality Duration Location Pitch Radiation Click, S3 or S4 Timing Functional Pathological Vibratory Harsher Short Variable Variable Variable Low Variable Not to backwith flow No Variable Systolic Variable 14

FACTORS WHICH INCREASE THE INTENSITY OF HEART MURMURS Fever Anemia Hyperthyroidism Exercise Drugs, agitation, pain BDC AND HEART MURMURS 2 / VI 0 / VI 15

OTHER HELPFUL HINTS FOR INNOCENT VS GUILTY Serial exams, especially if initially febrile If a murmur comes and goes, it's probably innocent If a murmur can be abolished or is very decreased by standing, it's likely innocent Presence of cardiac symptoms should make us much more concerned Be more cautious in young infants AN ECHO DOES NOT REPLACE A GOOD PHYSICAL EXAM!!!!! EFFECTS OF MANEUVERS ON HEART MURMURS Maneuver Innocent MVP / IHSS AS,PS VSD Standing Inspiration Exercise Valsalva or 16

CONGENITAL HEART DISEASE: THE BIG HITTERS Ventricular Septal Defect Atrial Septal Defect Mitral valve prolapse Patent Ductus Arteriosus Coarctation of the aorta Pulmonic Stenosis Aortic Stenosis 17

PATTERNS OF MAXIMAL LOUDNESS OF HEART MURMURS AND ECTOPIC SOUNDS Sounds are generally loudest directly over the structure making the noise Sound radiates parallel to flow A knowledge of the flow physiology of a given heart lesion and the surface anatomy of the heart allow the prediction of cardiac murmurs and their radiation Abnormal location of maximal loudness of the second heart sound is important NORMAL CARDIAC PHYSIOLOGY 20/10 13 3 72 100/60 73 5 76 20/4 100/8 18

Structures Comprising the Normal Cardiac Silhouette Asymptomatic 3 y.o. 19

ASD PHYSIOLOGY *Volume Overloaded 20/10 14 3 20/6 94 * 88 * * 90 3 100/60 75 100/7 (Q p /Q s 2.4:1) ASD Murmur Diagram SEM (LUSB) MDM (LLSB) 20

10 wk. old with tachypnea, poor feeding VSD PHYSIOLOGY 95/10 40 88 90 88 95/55 68 * * 12 3 95/6 92 * 95/14 (Q p /Q s 2.4:1) 21

VSD Murmur Diagram HSM (LLSB) MDM (Apex) S1 S2 PATENT DUCTUS 22

PDA PHYSIOLOGY (Q p /Q s 2.4:1) 88 50/10 23 88 92 * * 12 120/40 70 3 *Volume Overloaded PVR = 2.0 Wood Units 50/6 * 100/14 PDA Murmur Diagram S1 S2 S1 23

FINDINGS IN PDA Often asymptomatic, well grown Bounding pulses Wide pulse pressure S2 may be difficult to hear because of murmur Continuous "machinery-like" murmur 2nd LICS, radiating to back May have click, may have thrill in the SSN In newborn, diastolic component is absent, in most patients MODERATE PULMONIC STENOSIS 20/10 13 10 72 100/60 73 5 76 60/8 100/8 24

Moderate Valvar Pulmonic Stenosis click SEM (LUSB) S1 S2 S1 SO, NOW, WHAT'S THIS? 5 y.o. boy with a fever and sore throat for two days. Apetite and activity decreased, but fair. Sibling had GABS pharyngitis last week. Evanescent rash noted, now gone. No arthralgia. Exam: T 103.2 F, HR 100, RR 20. Mildly irritable 5 y.o. in NAD. Normal pulses. No rash. HEENT: Pharynx injected. Tonsilomegaly with pus. Neck: Tender, large cervical nodes. Cardiac: Normal S1, S2. LOUD 3/6 SEM, LLSB, no radiation. Abd.: Liver at RCM. LABS: ASO 1:200, slide strep +, WBC 12 K, 5% bands, Hgb 10.2. ECG: "Nonspecific T wave changes. T- waves inverted in V1- suggest clinical correlation". 25

ACME ECHO INC. Pediatric Echocardiogram Report The left ventricle is mildly dilated and hypercontractile. There is a small patent foramen ovale, with left to right shunt. Mild mitral and tricuspid regurgitation are noted. There is mild pulmonary insufficiency. The great vessels are normally related. The interventricular septum is intact.» I.M. Rich, M.D. Cost of evaluation : $2700.00 Well... WHAT'S THE DIAGNOSIS? 26

How to Reach Bill Lutin, MD William A. Lutin MD, PhD Section of Pediatric Cardiology Georgia Regents University Augusta, GA 30912 wlutin@gru.edu Billlutin@gmail.com 27