Cardiovascular Medicine Book

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Pediatric Murmur

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  1. See Also
    1. Congenital Heart Disease
    2. Heart Murmur
    3. Systolic Murmur
    4. Diastolic Murmur
  2. Epidemiology
    1. Overall Murmur Prevelance: 50% of all children
    2. Innocent murmurs more common than pathologic 10:1
    3. Age of murmur onset related to pathology
      1. Murmur onset at 24 hours of life: 8% pathologic
      2. Murmur onset at 6 months of life: 14% pathologic
      3. Murmur onset at 12 months of life: 2% pathologic
  3. Etiologies: Innocent Murmurs
    1. Still's Murmur (Aortic Vibratory Systolic)
      1. Most common innocent murmur
    2. Venous Hum of late infancy and early childhood
      1. Second most common innocent murmur
    3. Septal hypertrophy due to myocardial fat deposition
      1. Resolves over six months
    4. Pulmonary Flow Murmur
    5. Neonatal Pulmonary branch murmur
    6. Physiologic PPS
    7. Supraclavicular Murmur
  4. Etiologies: Pathologic Murmurs
    1. Ventricular Septal Defect (VSD) 38%
    2. Atrial Septal Defect (ASD) 18%
    3. Pulmonary Valve Stenosis 13%
    4. Pulmonary Artery Stenosis 7%
    5. Aortic Valve Stenosis 4%
    6. Patent Ductus Arteriosus (PDA) 4%
    7. Mitral Valve Prolapse 4%
    8. Others 4%
  5. Signs: Innocent Murmur accentuation maneuvers
    1. Sitting forward
    2. Exercise or increased Heart Rate
    3. Fever
    4. Anxiety, Restlessness, or crying
  6. Signs: Pathologic Murmur
    1. Evidence of Failure to Thrive
    2. Lethargy
    3. Cyanosis
    4. Shortness of Breath
    5. Parasternal heave or thrill
    6. Murmur radiates to back or neck
    7. Auscultation (6 Cardinal signs of pathology)
      1. Harsh murmur
      2. Pansystolic murmur
      3. Murmur Grade III or more
      4. Murmur at high Left sternal border
      5. Early or Midsystolic click or murmur
      6. Abnormal S2 Heart Sounds
  7. Management: Pathologic murmur suspected
    1. Newborn to eight weeks
      1. See Congenital Heart Disease for evaluation
    2. Pediatric Cardiology Referral
      1. Do not create preconceived notions of evaluation
      2. Not every pediatric murmur will need Echocardiogram
  8. Management: Innocent Murmur suspected
    1. Trust skilled clinical evaluation
    2. Study of clinical exam by pediatric cardiolgists
      1. Exam is as accurate as Echocardiogram
      2. Exam is more accurate than Electrocardiogram
      3. Test Sensitivity: 96%
      4. Test Specificity: 95%
      5. Positive Predictive Value: 88%
      6. Negative Predictive Value: 98%
    3. Reference
      1. McCrindle (1996) :

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