1. edwin francis

2. Warm Greetings from Kerala, India!

3. ………………..God’s own country

4. 4 Amrita Institute of Medical Sciences, Cochin, India

5. Agenda  definition  Functional murmur  Differentiating from pathological  When to worry/ When to refer ?  When to worry without murmur  How to counsel parents  Conclusion

6. definition  Murmur : auditory vibration resulting from turbulent blood flow within the cardiovascular system. Functional murmur :  are those not associated with any anatomic or physiologic abnormality.  Inorganic, normal, innocuous, benign or innocent.

7. Introduction  Reported prevalence of cardiac murmurs in healthy children varies 5 – 80 %.  < 1% of all murmurs in pediatric age group result from CHDs  Incidence of CHD is about 0.8 %  Challenge is to differentiate those normal from those which has underlying heart disease.

8. How to describe a murmur  Timing  Intensity  Location  Pitch  Radiation  Response to maneuvers

9. grading of murmur: Grade 1: barely audible Grade 2: faint, but heard immediately Grade 3: moderately loud Grade 4: with thrill Grade 5: with steth lightly on the chest Grade 6: with steth off the chest. Dr.Levine

10.  What is pathological ?  What is innocent ?

11. Functional murmur Innocent – better term  Characteristics: ( seven S’s ) 1) sensitive 2) short duration 3) single 4) small ( limited to a small area) 5) soft ( low amplitude) 6) sweet ( not harsh) 7) systolic

12. Innocent murmur  Common types : 1. Still’s murmur 2. Pulmonary flow murmur 3. Peripheral pulmonary arterial stenosis 4. Venous hum

13. Innocent murm… Stills murmur:  Commonest  Systolic, vibratory quality  Low frequency  Best heard between apex and left lower sternal border.  Better heard in supine  Originates from left ventricular outflow tract  Beyond infancy to adulthood

14. Innocent murm… Physiologic pulmonary systolic ejection murmur:  Best heard at II and III Lt intercostal space  Turbulence across RV outflow  High frequency  Increased in supine position  prominent in conditions increased C.O ( anxiety, fever, sick )

15. Innocent murm… Physiologic peripheral pulmonary stenosis:  Best heard at the base of the heart  Neonates and early infancy  Due to relative hypoplasia of branch pulmonary arteries.  Acute angle of branch PAs in newborn

16. Innocent murm… Venous hum:  Continuous murmur, best heard at right base.  Age 3 – 8 yrs  Due to the sharp angle of rt subclavian to innominate vein.  Loud in sitting position

17. When to worry Timing of murmur :  Diastolic, continous murmurs – patho  Most innocent murmurs – systolic Grade :  When it grade III or more  Suprasternal thrill : aortic stenosis, pulmonary stenosis, coarctation, PDA.

18. Postural variation :  Most innocent murmurs become less prominent on erect position.  Pathological murmurs ; no much change  Or become more prominent on standing position.

19. Hypertrophic Cardiomyopathy Mitral valve prolapse  Murmur – prominent in upright position.  Reduced preload, smaller ventricular volume

20. When to worry Other clinical features :  Evidence of cardiomegaly  Hyperdynamic precordium  Abnormal pulsations  Fetaures of heart failure

21. When to worry Other heart sounds..  Single second sound  Wide fixed splitting S2  Presence of ejection click  Loud S3 or S4  Pericardial rub.

22. Comparison  Systolic  Ejection  Soft or vibratory  Grade 1 – 2/6  Normal S1, S2  No extra sounds  Louder supine  No other evidence  Diastolic  Holosystolic  Harsh  Grade ≥ 3  Abnormal Splitting  Extra sounds  Louder with standing  Other evidence Innocent Pathological

23. Role of CXR, ECG

24. CXR, ECG..  Studied all articles from 1966 – 2001  ECG and CXR rarely adds value in the evaluation.

25. Role of ECG, CXR  5 yr old asymptomatic child.  Referred for RVH in ECG ! ( ecg was normal)  What is the abnormality  Scimitar syndrome

26.  7 yr old boy referred for a soft systolic murmur.  Echo showed a mild turbulence in RV outflow tract.  Mediatinal mass - lymphoma

27. Why can’t we do echo on all?  Not a viable option  expensive, waste of resources ( 2500USD/echo )  Unnecesary anxiety to parents  Echo may pick up insignifcant, normal variations.  When u do unnecessary, likely to miss

28. Counselling parents  Don’t scare them.  Murmurs – sounds or noises  Not synonymous with abnormality of heart  Parents should not be promised, children will outgrow the murmur.

29. 16 %, murmur grade 2 84 %, murmur grade 3 ( In this group majority had lesions with no functional significance) 81213 school children were screened Murmur detected - 2.7% Structural heart disease (SHD) – 0.2 % SHD Conclusion :Healthy school children with murmurs < grade 2 are least likely to have SHD.

30. Recent study  450 patients referred for paed.cardiac evaluation.  pathological murmur was reason for referral in 250 patients  Echo was done for all  Incidence of heart disease was only 10 % !!!  So in 90 % of cases the assessment of murmur was wrong !

31. When to worry without murmur  Acyanotic heart disease  5 month old  Failure to thrive  Soft diastolic murmur at apex (1-2/6)  Large VSD

32.  4 month old  Grade 1-2 soft diastolic murmur at tricuspid area  Saturation :89%  Total anomalous pulmonary venous drainage

33. When to worry without murmur  1 month old  Mild tachypnea  No murmur  Sat : 92%  Transposition of great arteries.

34. When to worry without murmur  LV dysfunction, myocarditis  Coarctation  Pulmonary AV fistulas  Pulmonary Hypertension

35. Cardiac Murmur Systolic murmur Diastolic murmur Continuous murmur Referral to Paed Cardiologist Early/mid systolic Grade II or less Midsystolic, Grade III or more Holosystolic Late systolic Asymptomatic No additional findings No work up required Symptomatic Additional findings

36. Conclusion  Do not rely on murmur alone to prove it guilty or innocent.  Thorough clinical evaluation (history,general evaluation) before interpreting murmur.  Do a complete cardiac examination  If found innocent, reassure parents. (murmur doesn’t mean hole )

37.  If in doubt, examine again or at a later date.( don’t jump into conclusions, unless it is urgent )  Many significant cardiac conditions may not have murmur.  CXR, ECG only has very minimal sensitivity.( don’t diagnose too much from it )

38. THANK YOU