Heart murmur screening

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yazan Daaboul, Serge Korjian ,Nuha Al-Howthi, MD[2]

Cardiac auscultation is a cost-efficient and relatively sensitive test that should always be performed among all neonatal live births. Additionally, screening for heart murmurs is also recommended among school-children and athletes. While murmurs among neonates are always an indication for further investigation, triage of older children and adolescents according to murmur characteristics is required before referral to a pediatric cardiologist.

• Screening of the heart murmurs by physical examination, including cardiovascular examination and cardiac auscultation is recommended in all neonates, because congenital heart disease occurs at a rate of 50-75 per 1000 live births.^[1][2][3]
• Referral should be made in all cases of murmur auscultation among neonates due to high prevalence of congenital heart disease in this age group.
• Sensitivity and specificity of pathological murmur detection among neonates is considered higher than in older age groups.^[4][5]
• Innocent heart murmurs are the most common cause of referral to pediatric cardiologists.
• The risk of pathological murmurs increases with positive family history of cardiac disease, maternal comorbidities during pregnancy, in-utero exposure to medications and alcohol, history of Kawasaki disease or rheumatic fever, and genetic disorders.^[6]
• During screening, the most common pathological heart murmurs auscultated in childhood is the murmur of mitral insufficiency, and corresponding to half of pathological murmurs in this age group.^[7]
• Screening techniques has been well-validated as an adequate technique to assess for heart diseases in children.
• No further work-up is indicated if the diagnosis of innocent murmurs in children and adolescents made by these 4 criteria:
  • No other abnormal physical exam finding
  • Negative review of systems
  • History negative for risks of structural heart disease.
  • Characteristic features of innocent murmurs are met.
• The 7S of Innocent Heart Murmurs. ^[8]
  • Sensitive to change in position and respiration
  • Short duration, not holosystolic.
  • Single, with no association to gallop or clicks
  • Small, limited to one region and does not radiate
  • Soft, low amplitude
  • Sweet, not harsh
  • Systolic.
• Features of Pathological Murmurs^[9][10][11]
  • Holosystolic or diastolic murmur
  • Grade 3 of higher murmur
  • Harsh quality murmur
  • Abnormal S2
  • Peak intensity at upper left sternal border
  • Presence of systolic click
  • Increased intensity in standing position

• According to the 36th Bethesda Conference in 2005^[12], all athletes must undergo pre-participation screening, including a cardiovascular history and physical examination to quality for competitions, in both supine and standing positions to investigate for signs of left ventricular outflow tract obstruction.^[13]
• The 2007 American Heart Association (AHA) currently recommends that a standardized history and physical examination, including assessment for heart murmurs, is performed every 2 years for all high school and college students engaged in sports.^[13]
• Other athletic groups of different ages do not currently have defined guidelines, but according to AHA, the recommendations of high-school and college athletes may also apply to other age groups.^[13]

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