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Published on: November 28, 2018
Etiology and diagnosis of systolic murmurs in adults
1Primary and Specialty Medical Care, Department of Veterans Affairs Medical Center, Seattle, Wash, USA. steven.mcgee@med.va.gov
Insights
Bedside physical examination has limitations but also unappreciated value in diagnosing systolic murmurs. A simple classification system for murmurs aids in diagnosis, complementing echocardiography findings.
Area of Science:
- Cardiology
- Diagnostic Medicine
- Medical Imaging
Background:
- The diagnostic utility of bedside cardiovascular examination for systolic murmurs is uncertain in the modern era.
- Echocardiography's role in elucidating murmur origins requires further investigation.
Purpose of the Study:
- To assess the diagnostic accuracy of physical examination for systolic murmurs.
- To explore the correlation between echocardiographic findings and physical examination in identifying cardiac pathologies.
- To determine the modern value of bedside cardiovascular diagnosis.
Main Methods:
- A study involving 376 inpatients compared physical examination findings with transthoracic echocardiography results.
- The research investigated associations between echocardiographic variables and systolic murmurs.
- Diagnostic accuracy of physical examination for pathological murmurs was evaluated.
Main Results:
- Four echocardiographic variables (peak aortic velocity, mitral regurgitation severity, mitral valve E-point velocity, absence of pericardial effusion) predict systolic murmurs.
- Murmur distribution on the chest wall, particularly relative to the 3rd left parasternal space, is a key diagnostic landmark.
- Specific murmur patterns ("apical-base", "broad apical", "left lower sternal") correlate with aortic velocity, mitral regurgitation, and tricuspid regurgitation, respectively.
Conclusions:
- Physical examination for systolic murmurs has both limitations and significant, though often unappreciated, diagnostic value.
- A simplified system categorizing murmurs into six patterns using onomatopoeia enhances diagnostic capabilities.
- While some classic physical findings have diminished accuracy, a structured approach to physical examination remains valuable.
Background:
It is unknown whether echocardiography can provide insights into the origin of systolic murmurs and the modern value of bedside cardiovascular diagnosis.
Methods:
The author examined 376 inpatients and compared their physical findings to transthoracic echocardiography, exploring the associations between echocardiography and systolic murmurs and investigating the diagnostic accuracy of physical examination for pathologic murmurs.
Results:
Four echocardiographic variables predict the presence of systolic murmurs: peak aortic velocity (P <.001); mitral regurgitation severity (P <.001); mitral valve E-point velocity (P=.09); and absence of pericardial effusion (P=.09). When diagnosing murmurs, the most helpful finding is its distribution on the chest wall with respect to the 3(rd) left parasternal space, a landmark that distinguishes murmurs into 6 patterns. The "apical-base" pattern indicates increased aortic velocity (likelihood ratio [LR] 9.7; 95% confidence interval [CI]; 6.7-14): a delayed carotid upstroke (LR 6.8; 95% CI; 4.0-11.5); absent S2 (LR 12.7; 95% CI; 5.3-30.4); and humming quality to the murmur (LR 8.5; 95% CI; 4.3-16.5) further increase the probability of aortic valve disease. The "broad apical" murmur pattern suggests significant mitral regurgitation (LR 6.8; 95% CI; 3.9-11.9); and the "left lower sternal" murmur pattern indicates significant tricuspid regurgitation (LR 8.4; 95% CI; 3.5-20.3): additional bedside observations refine these diagnoses. Nonetheless, this study shows that some classic physical findings are no longer accurate, that physical examination cannot reliably distinguish severe aortic stenosis from less severe stenosis, and that classic physical findings, despite having proven value, are absent in many patients with significant cardiac lesions.
Conclusions:
In the diagnosis of systolic murmurs, physical examination has limitations but also unappreciated value. A simple system using onomatopoeia and classifying systolic murmurs into 1 of 6 patterns is diagnostically helpful.
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