PEDIATRIC HEART MURMURS. Manish Bansal, MD Clinical Assistant Professor Division of Pediatric Cardiology University of Iowa

Transcription

1 PEDIATRIC HEART MURMURS Manish Bansal, MD Clinical Assistant Professor Division of Pediatric Cardiology University of Iowa

2 Murmur murmur. (n.d.). Dictionary.com Unabridged. Retrieved March 9, 2018 from Dictionary.com website

3 Murmur Sound or noises made by blood Caused by abnormal flow patterns Abnormalities of the heart valves Holes within the heart Abnormal communications between blood vessels or between blood vessels and the heart. Often innocent and result from the normal patterns of blood flow through the heart and vessels

4 Incidence and prevalence Revealed in over 50% of children and adolescents, with a peak incidence between 8 to 12 years CHD /1000 live births CHD may occur in presence of absence of heart murmur 6 cases per 1000 were moderate or severe Pediatr Cardiol Nov-Dec; 15(6):282-7

5 History

6 History Feeding difficulties appr 1/3 with CHD Acute heart Failure Dyspnea (74%) Nausea and vomiting (60%) Fatigue (56%) Cough (40%) Exercise intolerance age appropriate history Ability to play and the duration and vigor of feeding Ability to participate in team sports with that of peers

7 History Chest pain is rarely a symptom of cardiac disease in children Chest pain or syncope prompted consultation in approximately 10 percent of children; only 11 percent of those with chest pain and 5 percent of those with syncope had cardiac disease. Pediatrics. 2004;114(4):e409-e417

8 History

9 Physical Examination Vitals compared with age appropriate norms. Focused examination of respiratory, cardiovascular and GI system. General appearance, activity level, color and respiratory effort Neck: prominent vessels, abnormal pulsations and bruits. Chest: abnormalities of sternum, abnormal cardiac impulse or thrills.

10 Physical examination Lungs Abnormal breath sounds Abdomen Liver location, enlargement or ascites Pulse: rate, rhythm, volume, character and capillary refill time

11 Examination of heart

12 Properties of a Murmur Timing - systolic vs diastolic Duration-length in systole or diastole Location where in the heart they may originate Quality or pitch how they sound. This is important in differentiating normal flow murmurs from the abnormal. Intensity or loudness does not necessarily define the severity, but changes in intensity may help determine the type of murmur being heard. Presence of an extra sound called a click

13 Grading

14 My grading Grade 1: I can hear it (very faint) Grade 2: resident can hear it easily (easily heard) Grade 3: Medical student can hear it (can t miss it!!) Grade 4: Thrill Grade 5: Stethoscope half of the chest Grade 6: Stethoscope over the chest barely touching

15 Murmur (frequency or pitch)

16 Red flags (odds ratio OR) for pathologic murmur Holosystolic murmur (OR = 54) Grade 3 or higher (OR = 4.8) Harsh quality (OR = 2.4) An abnormal S2 (OR = 4.1) Maximal intensity at the upper left sternal border (OR = 4.2) Systolic click (OR = 8.3), Diastolic murmur, or increased murmur intensity with standing

17 Innocent murmurs May be heard in virtually anyone Most often heard in childhood. AKA Functional murmur Flow murmur Benign murmur Normal murmur Non pathologic murmur In organic murmur

18 Innocent murmurs (seven S s) Sensitive (changes with child s position or with respiration) Short duration (not holosystolic) Single (no associated clicks or gallops) Small (murmur limited to a small area and non radiating) Soft (low amplitude) Sweet (not harsh sounding) Systolic (occurs during and is limited to systole)

19 Still murmur Still murmur Grade 1 to 3 Early systolic murmur Low to medium pitch with a vibratory or musical quality Best heard at lower left sternal border Loudest when patient is supine and decreases when patient stands Infancy to adolescence, often 2 to 6 years Can sound like Ventricular septal defect or hypertrophic cardiomyopathy

20 Aortic Flow murmur Systolic ejection murmur best heard over the aortic valve Older childhood into adulthood Usually result of increased flow velocity from the larger stroke volume passing through relatively narrow LVOT and aortic valve annulus Pediatr Cardiol 27:19 24, 2006

21 Mammary artery soufflé High-pitched systolic murmur that can extend into diastole Best heard along the anterior chest wall over the breast Rare in adolescence Arteriovenous anastomoses or patent ductus arteriosus

22 Pulmonary flow murmur Grade 2 or 3 Crescendo-decrescendo Early- to mid-systolic murmur peaking in mid-systole Best heard at the left sternal border between the second and third intercostal spaces Characterized by a rough, dissonant quality Loudest when patient is supine and decreases when patient is upright and holding breath Heard in all ages Can be confused with Atrial septal defect or pulmonary valve stenosis

23 Supraclavicular/ brachiocephalic systolic murmur Brief, low-pitched, crescendo-decrescendo murmur heard in the first two-thirds of systole Best heard above clavicles Radiates to neck Diminishes when patient hyperextends shoulders Childhood to young adulthood D/D Bicuspid/stenotic aortic valve, pulmonary valve stenosis, or coarctation of the aorta

24 Venous hum Grade 1 to 6 continuous murmur Accentuated in diastole Whining, roaring, or whirring quality Best heard over low anterior neck, lateral to the sternocleidomastoid Louder on right Resolves or changes when patient is supine 3 to 8 years D/D Cervical arteriovenous fistulas or patent ductus arteriosus

25 Distribution of normal murmurs Acta Informatica Medica. 2016;24(2):94-98

26 Causes of pathologic murmur Acta Informatica Medica. 2016;24(2):94-98

27 Common Pathologic heart murmurs Lesion Prevalence amongst children with CHD (%) Clinical features VSD Small defects: usually asymptomatic Medium or large defects: CHF, symptoms of bronchial obstruction, frequent respiratory infections Murmur characteristic Small: loud holosystolic murmur at LLSB Medium and large defects: prominent left ventricular impulses; thrill at LLSB; split or loud single S2; SEM to holosystolic murmur at LLSB without radiation; may also hear a grade 1 or 2 mid-diastolic rumble ASD 8-13 Usually asymptomatic 2 or 3 SEM best heard at ULSB; wide split fixed S2; may have a grade 1 or 2 diastolic flow rumble at LLSB

28 Common Pathologic heart murmurs Lesion Prevalence amongst children with CHD (%) Clinical features PDA 6-11 May be asymptomatic; can cause easy fatigue, CHF, and respiratory symptoms Tetralogy of Fallot 10 Depends on the severity of PS Murmur characteristic Continuous murmur normal S1; S2 may be buried in the murmur; thrill or hyperdynamic left ventricular impulse may be present Central cyanosis; clubbing ; grade 3 or 4 long systolic ejection murmur heard at ULSB; increased S1; single S2 Pulmonary stenosis Usually asymptomatic Systolic ejection murmur (grade 2 to 5); at ULSB radiating to infraclavicular regions, axillae, and back; normal or loud S1; variable S2; systolic ejection click

29 Common Pathologic heart murmurs Lesion Prevalence amongst children with CHD (%) Clinical features Coarctation of Aorta Newborns and infants: CHF Older children: hypertension, leg pain Aortic stenosis 5-6 Usually asymptomatic Moderate to severe: chest pain with exertion, dyspnea Murmur characteristic SEM at back, decreased femoral pulses. BP lower in legs than arms SEM at RUSB radiating to carotids TGA 5 Variable presentation Cyanosis. Murmur may be absent TAPVR 2-3 Onset of CHF at 4-6 weeks Grade 2-3 systolic ejection murmur at ULSB; grade 1 or 2 mid-diastolic flow rumble at LLSB; wide split fixed S2 HLHS Rare May be asymptomatic at birth but cyanosis and CHG develop within first 2 weeks Hyperdynamic precordium; single S2; nonspecific grade 1 or 2 systolic ejection murmur along left sternal border

30 Physiologic interventions Auscultatory events Valvar aortic stenosis HCM Mitral regurgitation Mitral valve prolapse Tricuspid regurgitation VSD Intervention and response Louder following a pause after a premature beat Louder on standing, Valsalva maneuver. Fainter with prompt squatting Louder on sudden squatting or with isometric handgrip Midsystolic click moves toward S1 and late systolic murmur Starts earlier on standing; click may occur earlier on Inspiration; murmur starts later and click moves toward S2during squatting Louder with inspiration Louder with isometric grip

31 Physiologic interventions Auscultatory events Aortic regurgitation Mitral stenosis Continuous murmurs - Patent ductus arteriosus Cervical venous hum Intervention and response Louder with sitting upright and leaning forward, sudden squatting, and isometric handgrip Louder with exercise, left lateral decubitus position, coughing Diastolic phase louder with isometric handgrip Disappears with direct compression of Jugular vein

32 Role of diagnostic testing CXR rarely assist with diagnosis in an asymptomatic patient. ECG is useful depending on clinical examination and symptoms

33 Cost effectiveness and practical implications J Pediatr 2002;141:504-11

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35 Is echocardiogram necessary

36 Is Echocardiogram necessary

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38 Indications for referral Innocent murmur Absence of abnormal physical findings (except for murmur) Negative review of symptoms Negative history Murmur with seven features of innocent murmur Not appropriate for newborns and infants younger than 1 year as there is higher rate of asymptomatic structural heart disease.

39 Neonatal Heart Murmurs Incidence per 1000 live birth Incidence of CHD per 1000 live births Bansal M, Jain H. Cardiac Murmur in Neonates. Indian Pediatrics 2005; 42:

40 Neonatal heart murmurs 1 percent of newborns have a heart murmur 31 to 86 percent of these infants have structural heart disease Referral to a pediatric cardiologist is recommended Sensitivity for detection of a pathologic heart murmur in newborns ranges from 80.5 to 94.9% among pediatric cardiologists, with specificity ranging from 25 to 92 percent

41 Key recommendations Clinical recommendation Structural heart disease is more likely when the murmur is holosystolic, diastolic, grade 3 or higher, or associated with a systolic click; when it increases in intensity with standing; or when it has a harsh quality. Chest radiography and electrocardiography rarely assist in the diagnosis of heart murmurs in children. Family physicians should consider referral to a pediatric cardiologist for newborns with a heart murmur, even if the child is asymptomatic, because of the higher prevalence of structural heart lesions in this population. Evidence Rating C B B Am Fam Physician. 2011;84(7):

42 References 1. Evaluation of heart murmurs in children: Cost-effectiveness and practical implications. Yi, Michael S. et al. The Journal of Pediatrics, Volume 141, Issue 4, Phoon, Colin. (2001). Estimation of pressure gradients by auscultation: An innovative and accurate physical examination technique. American heart journal Frank JE, Jacobe KM. Evaluation and Management of Heart Murmurs in Children. Am Fam Physician. 2011;84(7): Bansal M, Jain H. Cardiac Murmur in Neonates. Indian Pediatrics 2005; 42: Van Oort A, Le Blanc-Botden M, De Boo T, Van Der Werf T, Rohmer J, Daniëls O. The vibratory innocent heart murmur in schoolchildren: difference in auscultatory findings between school medical officers and a pediatric cardiologist.pediatr Cardiol Nov-Dec; 15(6): Begic Z, Dinarevic SM, Pesto S, Begic E, Dobraca A, Masic I. Evaluation of Diagnostic Methods in the Differentiation of Heart Murmurs in Children. Acta Informatica Medica. 2016;24(2): doi: /aim Advani, N., Menahem, S., & Wilkinson, J. (2000). The diagnosis of innocent murmurs in childhood. Cardiology in the Young, 10(4), doi: /s x 8. Geva, T, Hegash, J, Frand, M. Reappraisal of the approach to the child with heart murmur; is echocardiography mandatory? Int J Cardiol

43 Thanks Manish Bansal, MD Ph: