Heart Murmurs

Introduction

Heart murmurs are heard commonly in infants, children, and adolescents. Approximately 50% to 70% of individuals seen for school or sports preparticipation examinations have a heart murmur. Indeed, a murmur is heard in most children at one or more of their examinations. Because most murmurs are innocent (ie, normal), it is important to differentiate those that are a manifestation of cardiac disease. Unfortunately, skills of physical diagnosis seem to be waning, as they are replaced by “advances” in medical technology. This so-called “hyposkillia” should not go unlamented because it has occurred among the caregiving community at great expense, not only in terms of economic cost, but also at a cost to the excellent physician-patient relationship that is established when the history and physical examination are performed well. (1)

This review focuses on the evaluation of cardiac murmurs within the context of a comprehensive history and physical examination, paying particular attention to the cardiovascular examination. The cardiovascular history should include notations regarding gestation, family history, neonatal status, growth and development, and feeding patterns for infants. For older children, the history should include the presence of palpitations, chest pain, lightheadedness or syncope, and activity level, remembering that the range of activity in healthy children is great and that children who have congenital heart defects generally have not experienced a decline in their exercise tolerance. Positive findings in any of these areas should increase suspicion that a murmur might be pathologic.

Cardiac Examination

The cardiac examination includes observation (Table 1), palpation (Table 2), and auscultation. Although observation of all patients precedes palpation and auscultation, whether to palpate or auscultate depends on the particular child being examined. Pediatric examinations frequently are not sequential, but rather proceed based on random opportunities offered by an often reluctant child.