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[The incidental heart sound. Study of clinical diagnostic certainty and possible causes]
U Mellies1, F Hentrich, B Hofelich
1Abteilung für pädiatrische Kardiologie, Zentrum für Kinder- u. Jugendmedizin, Universitäts-GHS-Essen.
Insights
Echocardiography is useful for diagnosing innocent heart murmurs in children, though clinical examination is highly sensitive. Echocardiography confirmed or changed diagnoses in 3% of cases, highlighting its role in pediatric cardiology.
Area of Science:
- Pediatric Cardiology
- Diagnostic Imaging
- Echocardiography
Background:
- The diagnosis of an innocent heart murmur relies on the absence of heart disease indicators.
- Clinical examination, including auscultation, and electrocardiography are initial diagnostic tools.
- Echocardiography is a key imaging modality for evaluating pediatric cardiac conditions.
Purpose of the Study:
- To assess the utility of echocardiography in diagnosing innocent heart murmurs in children.
- To compare echocardiographic findings with clinical examination results for murmur diagnosis.
- To identify potential correlations between echocardiographic findings and murmur characteristics.
Main Methods:
- Two hundred children (121 male, 79 female) with suspected innocent murmurs underwent clinical evaluation and echocardiography.
- Children were included only if two independent pediatricians found no signs of heart disease prior to echocardiography.
- Sensitivity, specificity, and positive predictive value of clinical examination were calculated and compared to echocardiography.
Main Results:
- Of 200 children, 194 (97%) had innocent murmurs, and 6 (3%) had diagnosed heart disease.
- Clinical examination sensitivity was 92-99%, with 50-60% specificity; diagnoses were altered in 6 cases post-echocardiography.
- Left ventricular bands were found in 26.5% of children and correlated with musical murmurs (77%).
Conclusions:
- Echocardiography is a valuable tool for confirming innocent heart murmurs and refining diagnoses in pediatric patients.
- While clinical assessment is highly sensitive, echocardiography provides crucial diagnostic accuracy, especially in ambiguous cases.
- Specific echocardiographic findings like left ventricular bands may correlate with murmur characteristics but do not indicate disease.
Abstract:
The diagnosis "innocent murmur" is made when there is no evidence for a heart disease either by history nor by examination, auscultation, electrocardiogram or echocardiography. The purpose of the present study was to determine the usefulness of echocardiography for diagnosing of an innocent heart murmur and further to compare the findings of ultrasound with those of the clinical examination. Children were accepted for the study after clinical examination and evaluation of the electrocardiogram (but before echocardiography) only when two independent pediatricians did not realize any symptoms of a heart disease. A total number of 200 children were examined; 121 were male and 79 female. 194 children (97%) had an innocent murmur, six children (3%) a heart disease [atrial septum defect (3), bicuspid aortic valve (1), aortic stenosis (1) or pulmonary stenosis]. The sensitivity and positive predictive value of clinical examination and auscultation ranged from 92% to 99%, the specificity from 50% to 60%. In six cases the initial diagnosis had to be changed after echocardiography. Three times an innocent murmur was diagnosed as a heart disease and another three times a pathological murmur was regarded as innocent. Left ventricular bands were seen in 53 (26,5%) children and they significantly correlated with the musical heart murmur (77%). If there was no false tendon, the murmur was mostly an uncharacteristic one (74% (less than 0,001). The echocardiographic findings were not different of those children without a murmur or heart disease. The average peak velocity in the ascending aorta was 143,1 +/- 23,6 cm/s (87-215 cm/s), the shortening fraction 36,2 +/- 6,3%. We could not find a correlation between velocity, shortening fraction and aortic diameter.