2. ………………..…………………………………………………………………………………………………………………………………….. Pediatric Murmurs Jessica Bowman, MD

3. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

4. ………………..…………………………………………………………………………………………………………………………………….. Epidemiology 70-80% of children will have murmur at some point during childhood Only about 1% of children have a structural heart defect

5. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

6. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

7. ………………..…………………………………………………………………………………………………………………………………….. Murmur - definition 1. A half suppressed or muttered complaint 2. A low indistinct but often continuous sound 3. A soft or gentle utterance 4. An atypical sound of the heart indicating a functional or structural abnormality Therefore, murmur = SOUND OR NOISE… nothing is necessarily opening, closing, blocking or leaking … but, it may be …

8. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

9. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

10. ………………..…………………………………………………………………………………………………………………………………….. Timing When during the cardiac cycle does the murmur occur? Systole Systolic Ejection Holosystolic s1s2 s1s2

11. ………………..…………………………………………………………………………………………………………………………………….. Timing Diastolic s1s2 Continuous s1s2

12. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

13. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

14. Location Aortic areaPulmonic area Mitral area Tricuspid area

15. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

16. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

17. 1 2 3 4 5 6 1 2 3 4 5 6 Faint, Heard immediately Easily heard, Intermediate intensity Loud, Palpable thrill Louder, Edge of stethoscope LOUDEST, Stethoscope off chest + Thrill - Thrill Intensity Grade Faint, with concentration Graph

18. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

19. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

20. ………………..…………………………………………………………………………………………………………………………………….. Quality Describe the “frequency”  Depends on pressure gradient  Low-pitched murmurs best heard with a bell  High-pitched murmurs are best heard with a diaphragm Quality  Musical or harmonic?  vibratory  Noisy or dissonant?  rough, non-vibratory

21. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

22. ………………..…………………………………………………………………………………………………………………………………….. Describing Heart Murmurs 1.Timing 2.Location 3.Intensity 4.Quality 5.Positional changes

23. ………………..…………………………………………………………………………………………………………………………………….. Positional Changes Sitting to standing Standing to squatting Valsalva Handgrip Leaning forward Supine

24. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

25. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

26. Innocent murmurs 1.Still’s murmur 2.Pulmonary flow murmur 3.Venous hum 4.Peripheral pulmonary stenosis 5.Supraclavicular or carotid bruit More Common Less Common McCrindle, BW, et al. Cardinal Clinical Signs in the Differentiation of Heart Murmurs in Children. Arch Pediatr Adolesc Med. 1996;150:169-174.

27. Distribution by Age Neonate123456789101112131415161718 PPS Still’s Murmur Venous Hum Pulmonary Flow Murmur Supraclavicular or Carotid Bruit Park MK. The Pediatric Cardiology Handbook. 3 rd ed. Mosby. Philadelphia: 2003. Emmanouilides GC et al, ed. Clinical Synopsis of Moss and Adams’ Heart Disease in Infants, Children, and Adolescents. Williams & Wilkins. Baltimore: 1998.

28. Location 4 1 3 2 55 Venous hum 1

29. Venous Hum

30. Timing/DurationContinuous Intensity1-3/6 LocationRight Infraclavicular ConfigurationCrescendo/Decrescendo PitchLow Quality“Whining”, “Roaring”, “Hum” S1 S2 A2 P2 S1 S2 A2 P2

31. 2 2 4 1 3 55 Pulmonary Flow Murmur Venous hum Image

32. Pulmonary Flow Murmur From: www.merck.com/mmhe/ print/resources/cp1/cp1f.htmlwww.merck.com/mmhe/ print/resources/cp1/cp1f.html

33. Pulmonary Flow Murmur Timing/DurationEarly to Mid-Systolic Intensity1-3/6 LocationLeft USB ConfigurationCrescendo/Decrescendo PitchLow Quality“Rough”, “Dissonant” S1 S2 A2 P2 S1 S2 A2 P2

34. 4 1 3 2 55 Pulmonary flow murmur Venous hum Peripheral pulmonary stenosis 3 Image

35. Peripheral Pulmonary Stenosis

36. Timing/DurationMid-Systolic Intensity1-2/6 LocationLeft USB  lung fields ConfigurationCrescendo/Decrescendo PitchLow to Medium QualityVariable S1 S2 A2 P2 S1 S2 A2 P2

37. 4 1 3 2 55 Pulmonary flow murmur Still’s murmur 4 Venous hum Peripheral pulmonary stenosis Image

38. Still’s Murmur Vibration of pulmonary valve leaflets? Vibrations caused by shifting blood mass in contracting left ventricle? Physiologic narrowing of left ventricular outflow tract? Ventricular false tendons? Pelech AN. The physiology of cardiac auscultation. Pediatr Clin N Am. 2004;51:1515-35.

39. Still’s Murmur Timing/DurationEarly Systolic Intensity1-3/6 LocationApex, left LSB ConfigurationCrescendo/Decrescendo PitchLow to Medium Quality“Vibratory”, “Musical” S1 S2 A2 P2 S1 S2 A2 P2

40. 4 1 3 2 55 Pulmonary flow murmur Still’s murmur Venous hum Supraclavicular or carotid bruit 55 Peripheral pulmonary stenosis Image

41. Supraclavicular/Carotid Bruit

42. Timing/DurationEarly Systolic Intensity2-3/6 LocationAbove clavicles  neck ConfigurationCrescendo/Decrescendo PitchLow to Medium Quality“Blowing” S1 S2 A2 P2 S1 S2 A2 P2

43. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

44. ………………..…………………………………………………………………………………………………………………………………….. Objectives Learn to more precisely describe the different characteristics of a cardiac murmur Become familiar with the five most common innocent murmurs of childhood, including physiology, age of presentation, and auscultatory findings Recognize concerning clinical characteristics of potentially pathologic murmurs

45. Typically – no change with standing/positional changes ATRIAL SEPTAL DEFECT: systolic ejection murmur radiating to axilla & back fixed split second heart sound (S2) AORTIC VALVE/ PULMONARY VALVE STENOSIS: harsh, higher pitched, systolic ejection murmur systolic “click” AS – radiation RUSB carotids, suprasternal notch thrill PS – radiation to axilla and back Am I missing…

46. VENTRICULAR SEPTAL DEFECT: holosystolic murmur systolic regurgitant murmur (TR) harsh, higher pitched large VSDs may not have a loud murmur PATENT DUCTUS ARTERIOSUS: continuous murmur left upper sternal border, left infraclavicular area murmur does not decrease with head position changes Am I missing…

47. HYPERTROPHIC CARDIOMYOPATHY: systolic ejection murmur at left sternal border does NOT decrease in intensity with standing (innocent murmur should decrease with standing) may increase in intensity with standing may decrease in intensity with squatting Am I missing …

48. ………………..…………………………………………………………………………………………………………………………………….. Diastolic Murmur Pathologic, if present Timing with pulse Causes: - Aortic Valve regurgitation - Pulmonary valve regurgitation Am I missing…

49. History: Pregnancy and birth history Intermittent nature Normal growth and development Negative family history Physical Examination: Characteristic qualities of innocent murmur - practice Second heart sound: o “physiologic splitting” inspiration- splits… expiration- single o no increased intensity, pounding or loud No click, no thrill (grade IV/VI murmur) No suprasternal notch thrill Positional changes - supine and standing Innocent Murmurs What You Can Do

50. Greater than grade III/VI (thrill) Holosystolic Diastolic Harsh Click Pulse abnormality Failure to thrive Significant family history Murmurs - When to be concerned?

52. ………………..…………………………………………………………………………………………………………………………………….. Thank you Thank you for completing this module. If you have any questions or feedback, please contact me: Jessica.Bowman@nationwidechildrens.org

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