A Clinical Approach to Pediatric Heart Murmurs Authors

A Clinical Approach to Pediatric Heart Murmurs Author(s): Bianca CHAN 1, MBBS Suzanne GOH 2, MBBS Level: Basic Academic Affiliation: 1 KK Women's and Children's Hospital, Pediatric Resident Submitted: May 2012 2 Duke-NUS Graduate Medical School Singapore, Assistant Professor Version No: 1. 0 Editors’ Review:

2 Disclaimer/Liability • The information provided in the VAP is made available in good faith and is derived from sources believed to be reliable and accurate at the time of release. • The materials presented on the VAP may include links to external Internet sites. These external information sources are outside the control of Duke-NUS. The user of the Internet links is responsible for making his or her own decision about the accuracy, reliability and correctness of the information found. • In no event shall Duke-NUS be liable for any indirect, special, incidental, or consequential damages arising out of any use of reliance of any information contained in the VAP. Nor does Duke-NUS assume any responsibility for failure or delay in updating or removing the information contained in the VAP. • Moreover, information provided on the VAP does not constitute medical advice or treatment nor should it be considered as a replacement of the patient/physician relationship or a physician’s professional judgment. Duke-NUS expressly disclaims all liability for treatment, diagnosis, decisions and actions taken or not taken in reliance upon information contained in the VAP. This work is licensed under a Creative Commons Attribution-Non. Commercial-No. Derivs 3. 0 Unported License To view a copy of this license, visit [http: //creativecommons. org/licenses/by-nc-nd/3. 0/]

3 Financial Disclosures (past 3 years) “No Disclosures”

4 Outline • Innocent or Pathologic? • History • Physical Exam • Common causes of heart murmurs • Investigations • Management • Conclusion • Further reading

5 Innocent or Pathologic? Innocent Pathologic (no clinical significance) (may have cardiac symptoms) 1. Symptoms Asymptomatic Symptomatic 2. Timing Early Ejection Systolic • Diastolic (except venous hum) • Pansystolic (obscures S 1) 3. Character • Short, Soft • Vibrating, musical • No radiation, vary with posture and position • Sternal Edge • Long, Loud grade > 3/6 • High pitched, harsh • Radiation over precordium (VSD), back (PS, coarctation), neck (AS), axilla (MR) 4. Associated with No added Sounds/ thrill/ventricular lift Loud/fixed S 2 Precordial thrill

6 History - Key Features Symptoms Asymptomatic – small ASD, VSD Cyanosis – TGA, TOF Syncope – AS, PS Cardiac Failure (fatigue) – VSD, PDA Cardiogenic Shock (collapse)

7 History - Cardiac Failure Sx - Fatigue Infants • Poor feeding (fatigue) ─ smaller feeds/longer to finish ─ breathless on sucking/cyanosed ─ perspires when feeding • Failure to thrive • Wheezing/tachypnea/dyspnea • Cyanosis Older Child • Exercise intolerance (inability to keep up with peers, tires easily) • Exertional dyspnea / chest pain • Syncope

8 History Family History ─ Sudden death in young relatives ─ Siblings with congenital heart disease Birth History /Developmental Assessment ─ Tachypnea/cyanosis at birth ─ Maternal chronic disease/alcohol abuse ─ Developmental delay ─ Age at presentation

9 Physical Exam: Observation Cyanotic Tetralogy of Fallot http: //www. secretstodefeatingdisease. com/birth-defects-and-infertility-problems-solved/ http: //www. myhealthyfeeling. com/wp-content/uploads/2011/09/fetal-alcohol-syndrome-baby-300 x 224. jpg

10 Physical Exam: Observation Syndromic • Down Syndrome - Atrio-ventricular canal defect VSD, ASD • Marfan Syndrome - Mitral regurgitation Mitral Valve Prolapse http: //palmreadingperspectives. files. wordpress. com/2011/05/marfan-syndrome-hand-diagnosis. jpg http: //palmreadingperspectives. wordpress. com/2011/05/20/hands-signs-in-marfan-syndrome-thin-fingers-hand-shape-hypermobility/ http: //www. jbjs. org/data/Journals/JBJS/190/1868 fig 2. jpeg

11 Physical Exam: Observation • Respiratory Distress - Tachypnea Wheezing • Clubbing - Usually takes 1 -2 years to develop • Peripheral perfusion http: //www. tracheostomy. com/images/drawings/distress 2. gif

12 Physical Exam: Palpation Abnormal Pulses − Weak volume – CHF, AS, COA − Radial-radial/femoral delay – COA − Bounding character – AR, PDA Precordial Activity − Prominent RV/LV? Displacement? − Thrills / Heaves − LVH, RVH Hepatomegaly − CHF

13 Physical Exam: Auscultation Heart Sounds - S 1, S 2 Added sounds, clicks Murmur: − − − − Timing, Character (systolic, diastolic, continuous) Length (short, long) Quality (vibratory, musical, blowing) Frequency (high, low) Loudness (Grade 1 -6) Location Radiation

14 Auscultation: Heart Sounds, Timing http: //2. bp. blogspot. com/_uiyskj. NZYt 8/TJW 2 u. Bf. P 2 I/AAAACHc/ef. Gjdp. XNqw. Q/s 1600/Mechanical+and+Electrical+Events+of+the+Cardiac+Cycle. jpg

15 Auscultation: Character, Intensity Grading Heart Murmur Intensity Grade Description Thrill 1 Very faint, not heard in all positions No 2 Soft, heard in all positions No 3 Easily heard, prominent No 4 Loud, with palpable thrill Yes 5 Loud, heard with edge of stethoscope partly off chest Yes 6 Very loud, heard with stethoscope 5 -10 mm off chest Yes

16 Auscultation: Location, Character 3. Upper Left Sternal Border PDA 4. Upper Right Sternal Border Venous Hum (innocent) - Blowing continuous murmur in systole and diastole - Heard below clavicles - Disappears on lying down/compression of jugular - Continuous, machinery-like - Active precordium - Widened pulse pressure ASD - Soft ESM, radiates to neck, - Preceded by ejection click - Asymptomatic or a/w dizziness on exertion, syncope - Soft systolic murmur - Wide fixed splitting of S 2 PS - Soft ESM, radiates to back -Preeded by ejection click, - a/w systolic thrill 2. Lower Left Sternal Border Still’s murmur (innocent) - Short systolic murmur - Vibratory/musical quality - Changes with position - Intensified by fever, exercise. 1. Apex MR - Pansystolic murmur - Radiates to axilla. VSD - Harsh, pansystolic murmur - Radiates all over chest - A/w cardiac failure, FTT TR - Pansystolic murmur http: //www. aafp. org/afp/1999/0801/afp 19990801 p 558 -f 2. gif MVP Co. A - Systolic murmur on left side - Radiates to the back - Absent/delayed femoral pulses - Late systolic murmur - Preceded by systolic click

17 Initial Investigations Chest X-ray ECG Cardiomegaly, boot-shaped heart, pulmonary vascular congestion Ventricular/atrial hypertrophy http: //www. bem. fi/book/19/19. htm http: //www. ebmedicine. net/topics. php? paction=show. Topic. Seg&topic_id=141&seg_id=2832

18 Other Investigations Echocardiography Cardiac Catheterization Cardiac structure, function, gradients across valves, shunt size and direction of flow Rarely required for diagnosis http: //cardiophile. org/wp-content/uploads/2009/09/TOF-with-right-to-left-shunt-across-VSD. jpg

19 Management Medical PDA: indomethacin, ibuprofen Congestive cardiac failure: diuretics, ACE inhibitors, etc Growth: Appropriate calories with fluid restriction if necessary Surgical May required staged repair Preliminary: BT shunt Definitive: Correction of structural abnormality

20 Conclusion • Cardiac murmurs in children may be innocent or pathological • Determine if the child is symptomatic or not • Murmur: Timing, Character, Quality, Frequency, Loudness, Location , Radiation • Definitive investigation: 2 D echocardiography • Management includes correcting the structural abnormality, but also the complications

21 References • Menashe V(2007) Heart Murmurs Pediatrics in Review 28(4), e 19 -22. • Silberbach M and Hannon D (2007) Presentation of Congenital Heart Disease in the Neonate and Young Infant Pediatrics in Review 28 (4) 123 -131 • Mcconnell ME, Adkins SB, Hannon DW (1999) Heart murmurs in Pediatric Patients: When do you refer? AFP 60(2): 558 -564 • Miall L, Rudolf M, Levene M (2003) Ch 43 Heart Murmurs. Pediatrics at a Glance pg 94 -95. • Phoon CK (1998) A Guide to Pediatric Cardiovascular Physical Examination.

Partners in Academic Medicine