THE SYSTOLIC MURMUR*

Transcription

1 THE SYSTOLIC MURMUR* By J. S. BLUMENTHAL, M.D., Minneapolis, Minnesota THE systolic murmur is not an uncommon finding in routine examinations. Reid and Fahr have reported an incidence of as high as 20 and 35 per cent in normal youthful patients. The pendulum of opinion regarding the importance of these systolic murmurs has swung over a wide arc in the last century, from the extreme importance first attached to any murmur heard through the stethoscope to the view that murmurs were of no importance at all, and recently back again to viewing the systolic murmur with extreme suspicion. Mackenzie, 1 in his long continued follow-up studies, states that he has seen many individuals, with very loud rasping systolic murmurs for 30 years and with a rheumatic fever history, who never suffered from heart failure; and he states " where there are functional murmurs, the leak, if this be present causing them, is slight and never such as to embarrass the auricles in their work apart from cases where there is grave damage done to the heart muscle.,, He also says "the estimation of the sign of functional murmurs is not based on the murmur itself but on the functional efficiency of the heart and on the presence or absence of other signs of cardiac afifections (size, rate, and rhythm)." From this point of view, there have been published recently many papers giving great importance to the systolic murmur. Thus Levine 2 claims " systolic murmurs do occur, but are not common in normal individuals " and, after classifying these murmurs according to loudness from class one to class six, states " the loud ones are always associated with some form of cardiovascular disease." He includes, in a series of 1000 cases, all systolic murmurs even if complicated by conditions which would, as Blumgart 3 pointed out, cause a murmur because of the increase of the velocity of the blood stream, such as a severe anemia, hypertension, and hyperthyroidism. On the other hand, R. C. Cabot 4 pointed out that without other signs of cardiac disease the systolic murmurs are of no importance as evidence of valve lesions and claims " a diagnosis of mitral regurgitation without stenosis is never justified." Other investigators D ' 6 ' 7 ' 8 have reported varying views with reference to the importance attached to this condition. A very confusing factor is the reliance to be placed on insurance statistics, which have led most insurance companies to conclude that there is no such thing as a functional murmur and on that basis to rate up heavily or reject for life insurance an applicant with a murmur. F. H. McCrudden, 9 in a recent article, states that there is a definite decrease in life expectancy with apical systolic murmurs. In a recent review of 2,100,000 insurance * Received for publication July 25, From the Department of Medicine of the University of Minnesota. 637

2 638 J. S. BLUMENTHAL cases from 1909 to 1927 inclusive, the conclusion is reached that there is a tremendous increase in the mortality rate of all cases with a systolic murmur except those in which the murmur is at the pulmonic area, soft, inconstant, and not transmitted. Fineberg and Steuer 10 analyzed 100 cases presenting a systolic apical murmur which they had observed over a period of years. They concluded that in youngsters with a systolic murmur and a history of rheumatic fever or chorea there is a 50 per cent chance for the development of mitral stenosis, aortic regurgitation or both, that mitral stenosis or aortic regurgitation appeared on the average three to four years after the first observation, and that in only eight instances did the murmur disappear. Recently, however, the same authors reported the observation for over 10 years of 35 of the original 100 patients without the discovery of any new cases of mitral stenosis or aortic regurgitation. In the series of cases we are now reporting we have taken only those in whom there is no associated disease which might have caused the murmur and only those in whom careful physical examination, vital capacity, electrocardiographic, orthodiagraphic, and laboratory studies convinced us that the heart was normal in spite of the presence of a systolic murmur. In this series were also included those cases with a history of rheumatic fever or chorea. In concluding that there was a systolic murmur present, we defined the systolic murmur, as did Freeman and Levine, 11 as a " distinct bruit that is heard definitely following the first sound and extending appreciably into systole." We did not group them according to loudness, but in this series there were murmurs of varying intensity. In other words, this is a study of the pure systolic murmur as such and as evidence of an embarrassing valve lesion. Approximately 23 per cent of the cases referred to the Cardiac Clinic for cardiac examination were called normal and about 25 per cent of these normal cases had a systolic murmur. We were not interested in the significance of this systolic murmur as regards pathologic lesions of other organs. We have studied a group of 100 cases (not consecutive) with systolic murmurs over a period of from four to 16 years, ranging in age from 12 to 71 years. In the first 100 consecutive cases, we were able to get a return of 72 and were unable to trace the remaining 28. Of these 28 whom we could not trace, the Minnesota State Board of Health reports that'there have been five deaths with two dying of pneumonia, one postoperatively, one of ruptured appendix, and one of melanotic carcinoma. Of the 100 cases (not consecutive), 28 had a definite history of from one to three attacks of rheumatic fever or chorea occurring from three to 27 years before the first examination by us. A great majority of them had been restricted in activity before coming to the clinic and many had been given cardiac medications. The average follow-up period was about seven years. The murmur was located at the apex in 44 cases and at the base or sternum in the remainder. Electrocardiograms were taken on all cases and were negative. Every case also had an orthodiagram and esophagogram.

3 THE SYSTOLIC MURMUR 639 Bardeen, 12 checking the relation between heart volume, transverse diameter and area, found that their interrelation was sufficiently constant to justify the use of transverse diameter and area as indicative of heart volume. In determining the heart size in this series the measurements of the heart were limited for practical purposes to the transverse because, as pointed out, measurement of area frequently involves, besides the experimental error in obtaining heart outline, a further error in measuring it. Variations in the position of the heart were corrected by correlation with body height, weight, and age, and by comparison with the predicted transverse normal as obtained by the formula of Hodges and Eyster, 9 which can predict that diameter with an error of less than five mm. (the transverse diameter of the heart = X age X weight X height). Assuming that after a follow-up period of this length of time, the heart, if embarrassed by a valve defect of any consequence, should certainly show some signs of cardiac disease besides the systolic murmur and an increase in heart size of measurable degree, the findings of the last examination were compared with those of the first. In these 100 cases we found, after an average period of seven years, 96 showing no significant changes in electrocardiograms, orthodiagram, vital capacity, esophagogram, or physical findings. The standard deviation in these 96 cases seen in a large cardiac clinic in the orthodiagram studies was only 5.4 mm. An increase beyond the predicted transverse normal, as determined by the formula of Hodges and Eyster, 9 as well as any marked increase in this diameter beyond the first measurement, was considered abnormal. It bespeaks the extreme accuracy of carefully done orthodiagraphy that no more care was taken in the fluoroscopic examination of this group of patients than of those routinely examined in the cardiac clinic. After this follow-up period of seven years, we have the following four cases who, at the last examination, had developed definite heart abnormalities besides the systolic murmur and now showed definite cardiac findings. CASE REPORTS Case 1. This woman was first seen in 1933, was 20 years old, 5 ft. 5% in. tall, and weighed 114 lbs. Family history was negative. She gave no cardiac symptoms, but there was a history of chorea at the age of 11. The only cardiac rinding was a systolic murmur at the base, moderately loud, not transmitted, and not affected by breathing or exercise. No diastolic murmur was heard. Vital capacity, electrocardiogram, and esophagogram were normal. Orthodiagram showed the heart to be normal in shape with a transverse measurement of 9.7 centimeters. When examined in 1938 this patient still had no symptoms. The systolic murmur was then heard at the apex and was transmitted to the axilla. There was still no diastolic murmur. Vital capacity was still normal but electrocardiogram now showed a tendency to right preponderance and the heart had increased 3.1 centimeters in transverse diameter to 12.8 centimeters. The transverse thoracic measurement was 21.8 centimeters. The esophagogram was still negative. We now consider this a case of possible pure mitral regurgitation. Case 2. This case is that of a young girl aged 15, 5 ft. 6 in. tall, weight 115 lbs., who was first seen in 1932 with no cardiac symptoms, a negative family history, and a

4 640 J. S. BLUMENTHAL negative history of rheumatic fever. The only rinding was a systolic murmur at the apex, constant but not transmitted. There was no diastolic murmur heard. The vital capacity was normal. The electrocardiogram showed a tendency to left preponderance but was otherwise negative. The orthodiagram revealed a normal shaped heart though with a slight fullness of the conus area which is sometimes seen in a drop type of heart. The esophagogram was negative. The transverse diameter was 11.9 centimeters. When seen again, in 1934, the findings were the same and there were no cardiac symptoms. The electrocardiogram, however, now showed a tendency to right preponderance, and the orthodiagram revealed a transverse heart diameter of 12.6 centimeters. The patient was seen again in 1938 and had shown a further increase of the transverse diameter to 13.3 centimeters, with a transverse thoracic measurement of 23 centimeters or a total increase in six years of 1.4 centimeters. The esophagogram has been negative at all times and no diastolic murmur has ever been heard. We now believe this to be a case of possible mitral regurgitation. Case 3. This patient was a man aged 25, 5 ft. 8% in. tall, weight 173 lbs., first seen in He had a negative family history, but gave a history of rheumatic fever at the age of 18. The only cardiac finding, when he was first seen, was a systolic murmur at the base, not constant and not transmitted. Electrocardiogram, vital capacity, orthodiagram, and esophagogram were normal. The transverse diameter of the heart was 12.5 centimeters and the transverse thoracic diameter 25.5 centimeters. Five years after this examination this patient had another attack of rheumatic fever. When reexamined in 1938, this man had developed not only a systolic murmur at the apex but a typical mitral-diastolic murmur. He still had no cardiac symptoms. His vital capacity was still normal, but his esophagogram was now positive to the right and to the posterior. The transverse diameter of the heart had increased 1.4 centimeters to 13.9 centimeters. He had a definite conus bulge with a typical mitral shaped heart. We believe that the last attack of rheumatic fever, in 1936, damaged the mitral valves. Case 4. The fourth patient was a woman aged 41, 5 ft. 3% in. tall, weight 153 lbs., first seen in She gave a negative family history, negative history of rheumatic fever, and had no cardiac symptoms. The only cardiac finding was a loud constant systolic murmur at pulmonic area. Vital capacity was normal, as were orthodiagram and electrocardiogram. The orthodiagram revealed a normal shaped heart with a transverse diameter of centimeters with a transverse thoracic diameter of 24 centimeters. When this patient was examined in 1938 she still had no cardiac complaints. The vital capacity was still normal and the systolic murmur was the same, but on orthodiagram the transverse diameter of the heart was definitely increased by 1.4 centimeters to 13.1 centimeters. Electrocardiogram now showed a flat T 2 and a negative T 3. Her blood pressure had remained 130 mm. Hg systolic and 86 mm. diastolic. We now believe that this patient has developed coronary disease. It would be reasonable to assume that, even with a rheumatic history, if these cases showing systolic murmurs had a valve lesion which would afifect their heart efficiency to any appreciable degree, some finding other than the heart murmur should be elicited in the period of time covered. Beyond the cases stated this was not true. In one case coronary disease developed; and we believe only two cases really had a mitral insufficiency at the time of first diagnosis, as the heart in the other case was probably damaged by a later attack of rheumatic fever. It is also interesting to note that the hearts which later showed cardiac findings other than the systolic murmur were followed for a period of six and one-fourth years and showed very marked increases in heart size whereas the others did not. It is important

5 THE SYSTOLIC MURMUR 641 to note that of the four cases reviewed which developed demonstrable heart lesions in addition to the murmur only two had a history of rheumatic fever; and that these cases which did not develop definite signs of cardiac pathologic lesions did not have a history of rheumatic fever within a period of at least three years prior to the first examination or thereafter. The only case in which a diastolic murmur could be heard at the second examination was one in which the patient had had a new attack of rheumatic fever two years before the last examination. CONCLUSION We did not try to diagnose conditions in organs other than the heart by the systolic murmur, but in spite of the fact that these cases of systolic murmur were not consecutive, we believe a vast majority of them were normal hearts as far as functional capacity is concerned and that "if we find in a heart of normal size and rhythm a systolic murmur with absence of any sign that would indicate that it is definitely organic in origin and with a good functioning organ, then we may conclude that the heart is perfectly normal. If there be evidence of weakness or other signs of abnormal conditions present, then the opinion should be based on these other signs and not the murmur." BIBLIOGRAPHY 1. MACKENZIE, JAMES : Diseases of the heart, 1913, Oxford Med. Publications, page LEVINE, SAMUEL A.: Significance of the systolic murmur, Jr. Am. Med. Assoc, 1933, ci, BLUMGART, H. L.: Velocity of blood flow in health and disease, Medicine, 1931, x, CABOT, R. C.: Facts on the heart, 1926, W. B. Saunders Co., Philadelphia, page WHITE, P. D.: in CECIL, R. L.: Textbook of medicine, 2nd ed., 1930, W. B. Saunders Co., Philadelphia, page HERRICK, J. B.: In defense of the stethoscope, ANN. INT. MED., 1930, iv, LEE, R. I.: The physical examination of apparently healthy individuals, Boston Med. and Surg. Jr., 1923, clxxxviii, THAYER, W. S.: Reflections on the interpretation of the systolic cardiac murmurs, Am. Jr. Med. Sci., 1925, clxix, MCCRUDDEN, F. H.: Heart murmurs and insurance, New England Jr., Med., 1931, cciv, FINEBERG, M. H., and STEUER, L. G.: Apical systolic murmurs, Am. Heart Jr., 1932, vii, FREEMAN, A. R., and LEVINE, S. A.: Significance of the systolic murmur, ANN. INT. MED., 1933, vi, BARDEEN, C. R.: Determination of the size of the heart of men by the x-ray, Am. Jr. Anat., 1918, xxiii, 423.