Etiology and diagnosis of systolic murmurs in adults.

Etiology and diagnosis of systolic murmurs in adults.

MedLine Citation:	PMID: 20920693 Owner: NLM Status: MEDLINE
Abstract/OtherAbstract:	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.

Authors:	Steven McGee
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Publication Detail:	Type: Journal Article; Research Support, U.S. Gov't, Non-P.H.S.
Journal Detail:	Title: The American journal of medicine Volume: 123 ISSN: 1555-7162 ISO Abbreviation: Am. J. Med. Publication Date: 2010 Oct
Date Detail:	Created Date: 2010-10-05 Completed Date: 2010-10-25 Revised Date: 2011-04-26
Medline Journal Info:	Nlm Unique ID: 0267200 Medline TA: Am J Med Country: United States
Other Details:	Languages: eng Pagination: 913-921.e1 Citation Subset: AIM; IM
Copyright Information:	Copyright © 2010. Published by Elsevier Inc.
Affiliation:	Primary and Specialty Medical Care, Department of Veterans Affairs Medical Center, Seattle, Wash, USA. steven.mcgee@med.va.gov
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MeSH Terms
Descriptor/Qualifier:	Adult Aged Aged, 80 and over Aortic Valve / physiopathology, ultrasonography Chi-Square Distribution Echocardiography Female Humans Likelihood Functions Logistic Models Male Middle Aged Mitral Valve / physiopathology, ultrasonography Mitral Valve Insufficiency / ultrasonography Pericardial Effusion / ultrasonography Physical Examination Systolic Murmurs / diagnosis*, etiology, physiopathology, ultrasonography Young Adult
Comments/Corrections
Comment In:	Ann Intern Med. 2011 Mar 15;154(6):JC3-12 [PMID: 21403063 ]

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