4- Paediatric Cardiology - heart murmurs (2/2)

Question 1

innocent murmurs

Answer 1

common benign murmus occur in 1/3rd of children at some point during childhood

Question 2

causes of innocent murmurs

Answer 2

• Stills murmur
• Venous hum
• acute infective illness

Question 3

features of innocent murmurs

Answer 3

6 S’s
- soft
- systolic (all diastolic murmurs are pathological)
- sensitive (change with position/respiration)
- short
- single
- small (localised and non-radiating)

Question 4

management of innocent murmurs

Answer 4

Innocent murmurs can be made more prominent when children have a febrile illness. If a murmur like this is discovered when a child has a febrile illness, the best option is to review the child in a few weeks. This will allow assessment of the murmur to see if it has resolved with the infection, in keeping with an innocent murmur.

If the murmur persists, then further investigation (e.g. echocardiogram) could be considered.

Question 5

atrial septal defect murmur

Answer 5

• Mid-systolic, crescendo-decrescendo murmurs
• Loudest at the upper left sternal border
• Fixed split second heart sound
  -> Can be normal with inspiration, however a fixed split second heart sound means the split does not change with inspiration and expiration
  -> Doesn’t vary with respiration

Question 6

ventricular septal defect

Answer 6

• Pan-systolic murmurs
• Heard most prominently on the left lower sternal border in the 3rd and 4th intercostal space
• Systolic thrill on palpation

Question 7

patent ductus arteriosus

Answer 7

• May not cause any abnormal heart sounds
• Continuous crescendo-decrescendo “machinery” murmur that may continue during second heart sound making it hard to hear

Question 8

aortic stenosis

Answer 8

• Ejection systolic murmur- aortic area (second intercostal space, right sternal border)
• Crescendo-decrescendo character and radiates to the carotids
  –>Palpable thrill
  –> Slow rising pulse and narrow pulse pressure

Question 9

coarctation of the aorta

Answer 9

• Systolic murmur heard below the left clavicle and below the scapular
• Left ventricular heave due to left ventricular hypertrophy

Question 10

tetralogy of fallot

Answer 10

• Arises due to pulmonary stenosis
• Ejection systolic murmurs loudest over pulmonary area (second intercostal space, left sternal border)

Question 11

transposition of the great arteries

Answer 11

murmurs are not typically present unless a small VSD or pulmonic stenosis exists

Question 12

tricuspid atresia

Answer 12

holosystolic murmur that may have a crescendo and decrescendo

Question 13

atrioventricular septal defect

Answer 13

mid-diastolic rumbling murmur, audible along the lower left sternal border.

Question 14

pan-systolic murmurs

Answer 14

To differentiate depends on where they are heard loudest
* Mitral regurgitation heard at the mitral area (fifth intercostal space, mid-clavicular line)
* Tricuspid regurgitation heard at the tricuspid area (fifth intercostal space, left sternal border)
* Ventricular septal defect heard at the left lower sternal border

Question 15

ejection-systolic murmurs

Answer 15

To differentiate depends on where they are heard loudest
* Aortic stenosis heard at the aortic area (second intercostal space, right sternal border)
* Pulmonary stenosis heard at the pulmonary area (second intercostal space, left sternal border)
* Hypertrophic obstructive cardiomyopathy heart at the fourth intercostal space on the left sternal border

Question 16

diastolic murmurs

Answer 16

• aortic and pulmonary regurgitation (early diastolic),
• mitral or tricuspid stenosis (mid-late diastolic).

Question 17

grading of heart murmurs

Answer 17

Gr= grad
Th= thrills
St- stethoscope