1. Pediatric cardiology JFK pediatric core curriculum
MGH Center for Global Health
Pediatric Global Health Leadership Fellowship
Credits:
Brett Nelson, MD, MPH

2. Discussion Cardiac evaluation Auscultation
Distinguishing pathologic from innocent murmurs
Common innocent pediatric murmurs
Further work-up of a concerning murmur

3. Initial cardiac evaluation
History: poor feeding, diaphoresis, FTT, family hx
Vital signs: height, weight, HR, RR
Inspection: dysmorphism, cyanosis, clubbing
Palpation: presence and quality of distal pulses; precordium for PMI and thrills; liver
Auscultation
(further cardiac evaluation to follow…)

4. Auscultation Rate & regularity Heart sounds Murmurs… Clicks Rub
Focus particularly on intensity and quality of S2 and for presence of extra heart sounds (S3, S4)
Murmurs…
Clicks
Abnormal valvular sounds (e.g. ejection clicks in early systole, MVP in mid/late systole)
Rub
Associated with pericarditis; scratchy sound best heard at apex (may diminish if pericardial effusion becomes large)

5. Auscultation

6. Heart sounds S1: closing of the AV valves
mitral then tricuspid
S2: closing of the semilunar valves
aortic then pulmonary
S3: ventricular overload
“TEN-NE-see”: S1, S2, s3
<40yrs, pregnancy, MR/TR, CHF
S4: decreased LV compliance
“ken-TUCK-Y”: s4, S1, S2
more likely than S3 to be pathologic (HTN, CAD, cardiomyopathy), although can be normal (athletes)

8. Murmurs Secondary to turbulent blood flow Assess: Intensity / loudness
Timing (systolic, diastolic, continuous)
Location of maximal intensity
Transmission / radiation
Quality (high-pitched, blowing, vibratory, harsh, soft)

9. Murmurs: grading of intensity
I barely audible
II soft, but easily audible
III moderately loud without thrill; roughly as loud as S1/S2
IV loud with a thrill
V audible with stethoscope barely on chest
VI audible with stethoscope off chest

10. Murmurs: timing

11. Maneuvers to dynamically evaluate murmurs
Inspiration typically increases murmurs originating from the right heart
Negative pressure temporarily increases venous return
Expiration typically increases murmurs originating from the left heart
Less LV restriction due to lower RV volumes
Increasing overall venous return (supine, squatting, leg-raise) can accentuate flow-type murmurs
Can also delay MVP click due to “tighter” chordae tendinae
Standing increases the murmur of hypertrophic cardiomyopathy (HOCM/IHSS)
Decreased venous return  smaller LV volume  closer apposition of LV walls

12. Distinguishing pathologic from innocent murmurs

13. Innocent murmurs
The prevalence of innocent murmurs in infants is as high as 60%
Versus: the incidence of congenital heart defect is 6 in 1000 (0.6%)
Innocent murmurs are usually…
early systolic
Grade I or II
poorly transmitted
Not associated with other findings

14. Pathologic murmurs (1) Murmurs that are… Loud (Grade III+) Diastolic
Abnormal heart sounds (e.g. S3/S4 gallop)
Long in duration
Systolic and associated with clicks
Louder upon standing

15. Pathologic murmurs (2) Murmurs that are associated with…
Abnormal or absent pulses
Unequal blood pressures
Cyanosis
Symptoms (e.g. syncope, chest pain)
Abnormal EKG / CXR
Syndromes, dysmorphism, other birth defects (e.g. CHARGE syndrome, DiGeorge, trisomy 21)

16. Common innocent murmurs

17. Still’s murmur
Most common innocent murmur, usually found between the ages of 3 and 6
Thought to be due to turbulence in LV outflow or to vibration of fibrous tissue bands crossing LV lumen
Typically grade II-III, midsystolic, LLSB, and classically described as “vibratory”
Decreases with standing
Increases with fever, exercise, anemia

18. Pulmonary flow murmur Accounts for 15% of all innocent murmurs
Heard in infants and school-aged children
Due to turbulent flow at the origin of the right and left pulmonary arteries
Grade I-III, midsystolic ejection, heard at the ULSB, higher pitched than a Still’s murmur
Like Still’s, increases with fever, exercise, and anemia

19. Peripheral pulmonary stenosis (PPS) of the newborn
Due to the physiologic relative stenosis of the right and left pulmonary arteries
Usually disappears by 1 year of age
Grade I-II, midsystolic ejection, heard at the ULSB with radiation to the axillae and back

20. Venous hum Seen in preschool-aged children
Due to turbulence in the jugular venous system
Continuous supraclavicular murmur heard throughout the cardiac cycle (usually right side > left side)
Disappears when the patient is supine, when the head is rotated, or with manual compression of the neck veins

21. Supraclavicular arterial bruit
Due to turbulence in the major brachiocephalic arteries as these vessels arise from the aorta
High-pitched, systolic ejection murmur heard best in the right supraclavicular fossa
Decreases with raising of the chin, throwing back the shoulders, or firm pressure on the subclavian artery
Increases with slight pressure on the subclavian artery

22. Further cardiac evaluation (as available)
Four-extremity blood pressures
Pre- and post-ductal pulse oximetry
O2 saturation <93% in the lower extremities is abnormal
Clinical cyanosis is not seen until saturation <88%
EKG
CXR
Cardiology referral and echocardiogram (definitive test)

23. Resources
** Online audio of heart sounds and murmurs **
Patel J. “Evaluation of Pediatric Murmurs.” San Antonio, TX.
McConnell ME, Adkins SB, Hannon DW. “Heart murmurs in pediatric patients: when do you refer?” American Family Physician. November
How to distinguish between innocent and pathologic murmurs in childhood. Pediatric Clinics of North America. 1984
Park MK. Pediatric Cardiology For Practitioners.
Bricker T. The Science and Practice of Pediatric Cardiology.
Allen H. Moss & Adams: Heart Disease in Infants and Children.