Evaluation of heart murmurs in children: cost-effectiveness and practical implications

OBJECTIVE

To assess the cost-effectiveness of various strategies to evaluate heart murmurs in children.

METHODS

We modeled 6 strategies to follow the initial examination by the pediatrician: (1) refer suspected pathologic murmurs to a cardiologist, (2) obtain a chest radiograph (CXR) and electrocardiogram (ECG) and refer suspected pathologic murmurs to a cardiologist, (3) refer suspected pathologic murmurs for an echocardiogram (ECHO), (4) obtain a CXR and ECG and refer suspected pathologic murmurs for an ECHO, (5) refer all patients with murmurs to a cardiologist, or (6) refer all patients with murmurs for an ECHO.

RESULTS

The least effective was strategy 1, which detects 82% of pathologic murmurs at $72 per patient evaluated. Strategy 5 detects 95% of pathologic murmurs at $38,000 per additional case detected over strategy 1. The most effective, strategy 6, detects 100% of pathologic murmurs at $158,000 per additional case detected over strategy 5. Strategies 2, 3, and 4 were not cost-effective. The results were sensitive to the costs of cardiology referral and ECHO.

CONCLUSIONS

Adding a CXR and ECG to the pediatrician's evaluation, or selectively referring directly to ECHO increases costs with little gain in accuracy. Given the current cost constraints present in health care, whether the optimal strategy involves referring to a cardiologist or obtaining an ECHO for all patients with murmurs depends on how much society should allocate to diagnose pathologic murmurs.

Echocardiographic yield in children when innocent murmur seems likely but doubts linger

The objective of our study was to determine the incidence and nature of heart disease found among children with murmurs clinically ambiguous to an expert examiner. The study was a prospective, blinded evaluation of accuracy of the expert examination using echocardiography as the diagnostic standard. The setting of the study was a pediatric cardiology outpatient department. The study comprised 903 outpatients with heart murmur under 21 years old without prior echocardiography or pediatric cardiology consultation. The intervention was echocardiography as clinically indicated for evaluation of heart murmur of uncertain cause. The outcome measure were a comparison of clinical diagnoses with echocardiographic results. In this clinical population, the presence of heart disease correlated with young age at presentation and with the expert examiner's level of suspicion of heart disease. However, 16 of 187 cases in which specific pathology was unsuspected had disease, and 6 of these 16 have had catheter or surgical intervention. Fourteen of the 16 unsuspected had objective indications for echocardiography and the other 2 were examined to allay anxiety. When evaluating very young outpatients with innocent-sounding murmur or older outpatients with innocent-sounding murmur and disconcerting symptoms, signs, or laboratory results, pediatric cardiologists should have a low threshold for echocardiography. Older outpatients with innocent-sounding murmur seldom have heart disease when anxiety is the only indication for echocardiography.

Prevalence of murmurs consistent with aortic stenosis among boxer dogs in Norway and Sweden

The prevalence and severity of cardiac murmurs consistent with subclinical or clinically detectable aortic stenosis among purebred boxer dogs in Norway and Sweden were evaluated. Two hundred and thirty-one boxers, randomly selected or investigated at dog shows, were examined by phonocardiography by two veterinarians and classified on the basis of the characteristics of their murmurs into categories 0 to 4. No murmur was detected in 23 per cent of the dogs, murmurs classified as category 1 were diagnosed in 25 per cent of the dogs, as category 2 in 46 per cent, as category 3 in 7 per cent cent, and two dogs had category 4 murmurs. In 55 per cent of the dogs, primarily those with very soft murmurs, there was some variation in the intensity of the murmur from beat to beat. The prevalence of cardiac murmurs among Norwegian and Swedish boxers was high and similar to the prevalence reported in Great Britain.

Prevalence and clinical importance of heart murmurs in racehorses

OBJECTIVE

To determine the prevalence of various types of heart murmurs in Thoroughbred racehorses and assess their association with performance by echocardiography and review of the horses' race records for the preceding 2 years.

DESIGN

Clinical and retrospective study.

ANIMALS

846 Thoroughbred racehorses.

PROCEDURE

Cardiac auscultations were performed by 3 individuals; for 30 horses, Doppler echocardiographic examinations were also performed. Statistical analyses of race records for 753 horses were performed to assess association of heart murmurs with performance.

RESULTS

Heart murmurs were detected by cardiac auscultation in 686 of 846 (81.1%) horses. Systolic murmurs over the heart base were most common; 365 (43.1%) horses had systolic murmurs that were loudest over the pulmonary valve area, and 232 (27.4%) horses had systolic murmurs that were loudest over the aortic valve area. Systolic murmurs over the tricuspid valve area were detected in 241 (28.5%) horses, whereas systolic murmurs over the mitral valve area were detected in only 32 (3.8%) horses. Diastolic murmurs were much less common than systolic murmurs. Review of race records did not reveal a significant association between murmurs and performance.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that heart murmurs are a common finding in racehorses; most of these heart murmurs do not appear to be clinically important.

Effect of age and training on murmurs of atrioventricular valvular regurgitation in young thoroughbreds

Cardiac auscultation was carried out on 111 Thoroughbred horses age 2-5 years to test the hypothesis that athletic training might influence the development of atrioventricular (AV) valve regurgitation in young Thoroughbreds. Murmurs of valvular regurgitation were identified and graded on a 1-6 scale. There were 2 sources of auscultation data: 1) 55 2-year-old horses that were examined by auscultation before training commenced and 9 months later when at race fitness; 2) 56 horses age 2-5 years that were examined on one occasion only (25 2-year-olds, 23 3-year-olds, five 4-year-olds and five 5-year olds). All horses in the second data set were in full training and racing regularly at the time of the examination. To conclude the study, 35 horses were selected randomly from both groups of horses and examined with colour-flow Doppler echocardiography. The aim of the final part of the study was to check specificity and sensitivity of auscultation for detection of AV valve murmurs and therefore validate the auscultation findings. Prior to training, the prevalence in 2-year-old racehorses of murmurs of mitral regurgitation and tricuspid regurgitation was 7.3% (4/55) and 12.7% (7/55), respectively. After training, the prevalence proportions increased to 21.8% (12/55) and 25.5% (14/55). After training, one horse developed a murmur characteristic of aortic regurgitation. The differences in murmur prevalence were statistically significant for mitral and tricuspid regurgitation (paired t test results: mitral regurgitation, P = 0.019; tricuspid regurgitation, P = 0.007), as were the differences in mean murmur grade (P = 0.018 and P = 0.0006, respectively). There were no significant effects of age on the prevalence of valvular regurgitation in 56 horses examined at race fitness. Auscultation was a specific (specificity 100%) and reasonably sensitive method for detection of murmurs of mitral and tricuspid regurgitation (mitral regurgitation: positive predictive value 100%, negative predictive value 84%, tricuspid regurgitation: positive predictive value 100%, negative predictive value 65%). These data suggest that the prevalence and grade of murmurs of mitral and tricuspid valvular regurgitation increase in 2-year-old Thoroughbreds after 9 months of athletic training. Whereas the effects of age and growth on the prevalence of murmurs cannot be ruled out from these data, this study suggests that there is an influence of athletic training on the development of atrioventricular valvular regurgitation in flat-racing Thoroughbreds.

Cardiologic evaluation of children with suspected heart disease: experience of a public outpatient clinic in Brazil

CONTEXT

During initial evaluation of children on an outpatient basis, the index of suspected heart disease may be high, particularly if we consider that innocent murmur occurs in about 50% of the pediatric population. This is the most common cause of referral to the pediatric cardiologist.

OBJECTIVE

To report on the experience of a public outpatient clinic in the southeastern region of Brazil.

DESIGN

Retrospective analysis of all patients submitted to cardiologic evaluation within a 39 month period.

SETTING

Public pediatric cardiology outpatient clinic.

PARTICIPANTS

2675 consecutive children aged</=15 years referred from the local and regional basic health units due to suspected heart disease.

MAIN MEASUREMENTS

Reason for referral, diagnostic investigation, final diagnosis based on the reason for referral, therapeutic procedures.

RESULTS

The main reasons for referral were: murmur (70%), precordial pain (9%), suspicion of arrhythmia (9%) and breathlessness (5%). Of the total number, 695 cases (26%) did not complete the investigation and were not included in the analysis. A final diagnosis was obtained based on the reason for referral and the main conclusions were: l) a high incidence of normality was found: murmur (83%), pain (98%), arrhythmia (97%) and breathless (94%); 2) heart disease was unlikely, based on other referral reasons; 3) 14% of the children were considered abnormal and 1% needed therapeutical procedures.

CONCLUSIONS

The establishment of a pediatric cardiology outpatient clinic within the public health service in the region seems to be justifiable, due to the high current demand. The low global incidence of heart disease, with a high prevalence of children with innocent murmur, discloses the need for a specific training program in cardiology for pediatricians.

Prevalence of infective endocarditis in patients with systemic lupus erythematosus

BACKGROUND

Compared with the general population, patients with systemic lupus erythematosus, or SLE, have an increased prevalence of functionally impaired cardiac valves due to the presence of Libman-Sacks lesions. These lesions may place patients with SLE at risk of developing infective endocarditis, or IE.

METHODS

The authors performed a retrospective chart review to determine the association between SLE with valvulopathy and IE. They reviewed the records of 361 patients from two health care facilities who had the diagnostic code of SLE.

RESULTS

Of the 275 records that met the 1982 revised American Rheumatism Association criteria for SLE, 51 (18.5 percent) were for patients who had a clinically detectable heart murmur that resulted in echocardiography being performed. Nine (3.3 percent) of the 275 patients had a clinically significant valvular abnormality, three (1.1 percent) had a potentially significant valvular abnormality, and one (0.4 percent) had a history of IE that was diagnosed two years before her diagnosis of SLE was made.

CONCLUSIONS

The findings suggest that 18.5 percent of this cohort of patients with SLE had a clinically detectable heart murmur that would require further investigation to determine its significance. Furthermore, between 3.3 and 4.4 percent of the study population had cardiac valve abnormalities that potentially required antibiotic prophylaxis before certain dental procedures. However, the authors identified no cases that demonstrated an association between IE and diagnosed SLE.

CLINICAL IMPLICATIONS

Dentists should query their patients with SLE about their cardiac status and consult with the patient's physician if the cardiac status is unknown. Patients with confirmed valvular abnormalities should receive antibiotic prophylaxis for designated bacteremia-producing dental procedures.

Prevalence and clinical significance of cardiac murmurs in neonates

AIM

To determine the prevalence and clinical significance of murmurs detected during routine neonatal examination.

METHODS

In a two year prospective study, 7204 newborn babies underwent routine examination by senior house officers. All those with murmurs underwent echocardiographic examination. All babies presenting later in infancy were also identified, to ascertain the total prevalence of congenital heart disease in infancy.

RESULTS

Murmurs were detected in 46 babies (0.6%) of whom 25 had a cardiac malformation. The most common diagnosis was a ventricular septal defect, although four babies had asymptomatic left heart outflow obstruction. A further 32 infants from the same birth cohort had a normal neonatal examination but were found to have a cardiac malformation before 12 months of age.

CONCLUSIONS

The neonatal examination detects only 44% of cardiac malformations which present in infancy. If a murmur is heard there is a 54% chance of there being an underlying cardiac malformation. Parents and professionals should be aware that a normal neonatal examination does not preclude a clinically significant cardiac malformation. The detection of a murmur should prompt early referral to a paediatric cardiologist for diagnosis or appropriate reassurance.

A retrospective study of canine dilated cardiomyopathy (189 cases)

The case records of 189 dogs (including 38 breeds) with congestive heart failure caused by dilated cardiomyopathy were studied retrospectively. Airedale terriers, boxers, Doberman pinschers, English cocker spaniels, Newfoundlands, St. Bernards, and standard poodles were over-represented. German shepherd dogs were under-represented. A male predominance was observed. Systolic murmurs were detected in 25% of the cases. Atrial fibrillation was the most common arrhythmia. Mild hyperglycemia and mild-to-moderate hypercholesterolemia were found in 38% and 33% of cases, respectively. Histopathological changes consisted of attenuated wavy fibers and interstitial fibrosis.

The significance of basal systolic murmurs in the elderly

Aortic stenosis is common in the elderly. Basal systolic murmurs are also common. We studied 512 patients over the age of 65 years to ascertain the prevalence of basal systolic murmurs and by using echocardiography on those with basal murmurs to determine the prevalence of significant aortic stenosis. 29% (148) of patients had basal systolic murmurs. 81 (55%) patients of this group had echocardiography carried out and 21 (25.9%) had a gradient across the aortic valve of 30 mmHg or more.

Relationship between parental cardiac status in Cavalier King Charles spaniels and prevalence and severity of chronic valvular disease in offspring

OBJECTIVE

To study the relationship between parental cardiac status in Cavalier King Charles Spaniels and development of chronic valvular disease (CVD) in offspring.

DESIGN

Historical cohort.

ANIMALS

54 female and 53 male Cavalier King Charles Spaniel offspring.

PROCEDURE

7 sires, selected on the basis of their liability to develop CVD, were screened for clinical signs of CVD and assigned to 1 of 3 groups (late, intermediate, and early onset of CVD). The mates of these sires (30 dams) were selected and classified likewise, and 107 offspring produced in 1988 from matings between these parents were screened for clinical signs of CVD at a mean age of 5.3 +/- 0.3 years.

RESULTS

55% of the offspring were free from clinical signs of CVD, whereas 45% had cardiac murmurs of low or moderate intensity. The proportion of offspring with heart murmurs and the intensity of murmurs were significantly greater with increased parental classification. More males than females had developed murmurs, and murmurs of moderate intensity also were more prevalent in males. Results of multiple-regression analysis indicated that mean parental classification and sex had significant effects on proportion of offspring with murmurs and their intensity. Additionally, age affected disease prevalence and severity, despite the narrow range in age of offspring examined.

CLINICAL IMPLICATIONS

Parental CVD status is an important factor influencing the probability of heart murmurs and their intensity in offspring. The results of this study indicate that CVD development is a polygenic threshold trait and that sex of the offspring influences threshold levels.

Value of the cardiovascular physical examination for detecting valvular heart disease in asymptomatic subjects

To determine the accuracy of the cardiovascular physical examination for the diagnosis of asymptomatic valvular heart disease (VHD), we prospectively studied 143 subjects, 68 apparent normal subjects and 75 patients with diseases known to produce VHD. All subjects underwent a complete physical examination with dynamic cardiac auscultation by a physician blinded to clinical data and compared with the results of transesophageal color Doppler echocardiography (TEE). By TEE, 33 subjects (23%), and by physical examination, 25 subjects (17%) had at least 1 form of VHD. Despite a high frequency of mild valve abnormalities and a 31% prevalence of functional murmurs, the physical examination showed a sensitivity of 70%, a specificity of 98% (confidence interval = 0.51 to 0.84, and 0.94 to 0.99, respectively), and a positive and negative predictive value of 92% for the diagnosis of VHD. Only 2 of the 10 patients with VHD by TEE, but not by physical examination, had clinically important VHD. We conclude that the physical examination is a sensitive and highly specific method of screening for VHD in subjects without cardiac symptoms. Therefore, its use should be encouraged rather than the routine application of echocardiography.

Potential recruits referred for cardiac opinion review of 100 consecutive cases--a waste of time or an investment?

Eighty seven of 100 consecutive recruits referred for cardiac assessment of fitness to serve had heart murmurs. Seven of these were rejected as having significant cardiac disease. One with a diagnosis of hypertrophic cardiomyopathy would have been placed at considerable risk had he been exposed to the physical stress of military training. The remaining 6 rejected had conditions which could have been worsened by the stress of military training and/or required intensive cardiac follow-up. These included 3 individuals with aortic regurgitation, 1 with atrial septal defect, 1 with ventricular septal defect combined with a small atrial septal defect and 1 with post rheumatic fever mitral regurgitation. Thirteen patients we assessed because of other cardiac problems including repaired congenital heart disease and hypertension. The rejection rate in this group was high at 10 out of 13. The majority of those referred (83/100) were found to be fit for military service. Five of these required advice on antibiotic prophylaxis but the majority had totally unrestricted service. Although most recruits who present with cardiac "problems" will be fit for service, important and potentially fatal conditions can be detected. Therefore vigilance must be high amongst examining doctors and suspect individuals referred for appropriate assessment.

Physiological valvular regurgitation in clinically normal young racehorses: prevalence and two-dimensional colour flow Doppler echocardiographic characteristics

Colour flow Doppler echocardiographic examinations were performed on 15 horses; 10 Thoroughbreds and 5 Standardbreds; 9 mares, 5 geldings and 1 stallion; mean +/- s.d. 3.4 +/- 1.1 years. Cardiac murmurs were audible in 12 horses (80%), but these had characteristics consistent with functional murmurs in all horses. A standardised two-dimensional (2-D) and M-mode echocardiographic examination was unremarkable in all horses except that aortic valve prolapse was identified in 3 horses, tricuspid valve prolapse in 2 horses and mitral valve prolapse was present in one horse. Colour flow Doppler echocardiography revealed laminar antegrade flow in most sites but variance was noted in the right ventricular outflow tract in some horses. Small regurgitant jets associated with the aortic valve were seen in 12 horses (80%), with the tricuspid valve in 7 horses (46%), with the pulmonary valve in 4 horses (26%) and the mitral valve in 4 horses (26%). It was concluded that with colour flow Doppler echocardiography, as in other species, small regurgitant jets could be detected in many normal horses.

Long-term outcome of patients with rheumatic fever receiving benzathine penicillin G prophylaxis every three weeks versus every four weeks

OBJECTIVE

To compare the efficacy of injections of 1.2 million units of benzathine penicillin G given every 3 weeks versus every 4 weeks for secondary prevention of rheumatic fever, based on the long-term outcome of patients receiving such prophylaxis.

METHODS

A total of 249 consecutive patients with rheumatic fever, randomly assigned to either a 3-week or a 4-week regimen, were examined every 3 to 6 months, and followed for 794 and 775 patient-years, respectively.

RESULTS

Compliance with each regimen was comparable: 83 (66.9%) of 124 patients in the 3-week group versus 92 (73.6%) of 125 patients in the 4-week group stayed in the program (p > 0.05). Streptococcal infections occurred less frequently in those receiving the 3-week regimen: 7.5 versus 12.6 per 100 patient-years (p < 0.01). Prophylaxis failed in 2 patients receiving the 3-week regimen and in 10 receiving the 4-week regimen (0.25 and 1.29 per 100 patient-years respectively; p = 0.015). Serum penicillin levels were adequate (> or = 0.02 micrograms/ml) in 100 (56%) of 179 samples obtained 21 days after penicillin injection in the 3-week regimen, and in 51 (33%) of 155 samples obtained 28 days after injection in the 4-week regimen (p < 0.01). Of 71 patients with mitral regurgitation in the 3-week regimen, 47 (66%) no longer had the murmur; of 87 patients in the 4-week regimen, 40 (46%) no longer had the murmur (p < 0.05).

CONCLUSIONS

This 12-year controlled study indicates that the outcome of patients with rheumatic fever is better with a 3-week than with a 4-week penicillin prophylaxis regimen. Greater emphasis and more widespread use of the 3-week regimen should be recommended.

The vibratory innocent heart murmur in schoolchildren: difference in auscultatory findings between school medical officers and a pediatric cardiologist

In 810 schoolchildren heart auscultation was performed by both a school medical officer (SMO) and a pediatric cardiologist (PC). The prevalence for a grade 1, 2, or 3 vibratory innocent heart murmur (VIHM), a grade 2 or 3 VIHM, and a grade 3 VIHM heard by the PC was 41%, 13%, and 1%, respectively. The SMO noted such murmurs in 26%, 9%, and 1%, respectively. In 30% of the cases in which the PC had noted a grade 2 or 3 VIHM, the SMO agreed; in 30% of such cases the SMO did not hear any heart murmur. If the PC heard a grade 2 or 3 VIHM phonocardiography was performed in a case-control study in which the controls did not have a heart murmur (94 pairs). In four children with a grade 2 or 3 VIHM no heart murmur could be registered and in three other children the murmur did not have the typical diamond shape. In contrast, in three children without a heart murmur at school a VIHM was seen on the phonocardiogram. In 26 children with a phonocardiographically proven grade 2 or 3 VIHM the SMO did not hear any heart murmur. One child with a grade 3 VIHM (both by the PC and SMO) had a minor subvalvular aortic stenosis. There is quite a difference in auscultatory detection of a venous hum: 9% (PC) and 2% (SMO). The prevalence of the pulmonary ejection murmur is identical at 4%. The carotid bruit is heard in 4% (PC) and 2% (SMO).(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic mitral valve disease in cavalier King Charles spaniels: 95 cases (1987-1991)

Systolic heart murmurs caused by chronic mitral valve disease are particularly common in Cavalier King Charles Spaniels (CKCS) in Great Britain. To determine if American-bred CKCS have a similar high prevalence of chronic valve disease, results of stethoscopic examinations on 394 CKCS were analyzed. Left apical systolic heart murmurs were found in 22% of the dogs. The prevalence ranged from 9% in dogs < 1 year old to 100% in those > or = 10 years old; prevalence was 56% in dogs > or = 4 years old. Differences were not found in prevalence between sexes and among various coat colors. Reexamination of 79 dogs after 1 year revealed an incidence of new murmurs of 21%. Comparison of ages at initial examination in 128 referral hospital cases with chronic mitral valve disease revealed a mean age of 6.25 years in 17 CKCS, in contrast to a mean age of 12 years in other breeds. Echocardiographic and necropsy findings indicated that ruptured chordae tendineae and mitral valve prolapse are major components in the chronic valve disease process in CKCS.

The morbidity of cardiac nondisease revisited. Is there lingering concern associated with an innocent murmur?

BACKGROUND

The phenomenon of cardiac nondisease was first reported in 1967 to call attention to the fact that some children were being restricted from their normal activities because their parents believed that they had a heart problem when, in fact, the child's heart was perfectly normal. This influential article and others have suggested that there may be significant morbidity in children who have been found to have innocent cardiac murmurs.

METHODS

Parents of 71 schoolchildren were interviewed 1 to 5 years after their child had been examined by a pediatric cardiologist. Parents were asked about the presence of a family history of heart disease, their recall of the diagnosis and recommendations made by the cardiologist, and their level of satisfaction with the visit to the cardiologist. Parents were extensively questioned for evidence of restriction of the child's activities and for the presence of a belief that their child's murmur was something to still be concerned about.

RESULTS

None of the parents reported restricting their child's activity, but 12 (17%) were still concerned about the murmur. A statistically significant relationship between parents reporting being less than "very satisfied" with the visit to the cardiologist and the presence of concern was found (P = .0006 by chi 2, Yates' correction). No other associations were noted.

CONCLUSION

The association with a lower degree of satisfaction suggests that communication issues are relevant to the presence of lingering parental concern. Because the parents of a child with an innocent murmur may consider him or her to be "vulnerable," primary care physicians should follow up with parents of children referred to pediatric cardiologists for evaluation of a murmur so that any potential misunderstandings can be clarified.

A survey of cardiac auscultatory findings in horses

Auscultation was used to examine 545 horses for cardiac murmurs and some arrhythmias. The most significant finding was the high prevalence of right-sided holosystolic or pansystolic plateau-type murmurs compatible with a diagnosis of tricuspid regurgitation in National Hunt racing Thoroughbreds of all ages (16.4%). This condition was found in 4.7% of flat-racing Thoroughbreds, 3.7% of non-racing Thoroughbreds and Thoroughbred crosses, and in none of the ponies examined. High prevalences of left-sided early systolic murmurs (53%), left-sided early diastolic murmurs (23%), right-sided early diastolic murmurs (22%) and second degree atrioventricular block (23%) were found in racehorses of both types.

Nonspecific systolic murmurs: an audit of the clinical value of echocardiography

AIM

To evaluate the clinical use of echocardiography in patients with nonspecific systolic murmurs.

METHODS

Analysis of request forms and echocardiogram reports in a consecutive series of scans done for patients with nonspecific systolic murmurs between 1984 and 1991.

RESULTS

Normal cardiac structure and function were found in: (1) 62% of 565 studies done for patients with nonspecific systolic murmurs; (2) 96% of 69 scans in patients with clinical diagnosis of a benign murmur and (3) 93% of 45 pregnant women with nonspecific systolic murmurs. No echocardiographic abnormalities were detected in 76% of studies done for patients aged between 1 and 50 yr. Congenital heart disease was found in 39% of patients with nonspecific systolic murmurs aged between 0 and 1 yr. Mitral regurgitation was found in 33% and aortic valve disease in 22% of nonspecific systolic murmurs patients aged over 60 yr.

CONCLUSIONS

Echocardiography rarely revealed significant abnormalities in the assessment of patients with nonspecific systolic murmurs aged between 1 and 50 yr, especially when the test was used to confirm the clinical suspicion that the heart was normal. Ultrasound scanning was useful in the assessment of nonspecific murmurs in patients aged 0-1 yr or over 50 yr, particularly those over 60 yr.

Cost assessment of the evaluation of heart murmurs in children

Echocardiography available directly to primary care physicians represents an alternative strategy to pediatric cardiology consultation for childhood heart murmur evaluation. A decision analysis model compared the costs of two diagnostic strategies: (1) echocardiography first, referral to the cardiologist if appropriate; and (2) cardiologist evaluates murmur, echocardiography if appropriate. The model incorporated probability of heart disease, frequency of cardiologist-ordered echocardiography, and echocardiography results established by review of 388 records of consecutive patients evaluated for murmurs in a pediatric cardiology clinic. Echocardiography-first strategy costs were $257 greater than referral-strategy costs. Referral-strategy advantages were not highly sensitive to changes in model assumptions. Pediatric cardiology consultation is the preferred approach provided (1) consultation costs are moderate, (2) echocardiography costs are moderate to high, and (3) the rate at which the cardiologist orders echocardiography for patients with innocent murmurs is low.

Chronic valvular disease in the cavalier King Charles spaniel in Sweden

The prevalence of chronic valvular disease was studied in 494 cavalier King Charles spaniels with a mean (+/- sd) age of 3.0 +/- 2.7 years. Cardiac murmurs were detected in 65 (13.2 per cent) of the dogs. Among 61 cavalier King Charles spaniels with a mean age of 6.4 +/- 2.8 years, cardiac murmurs were detected in 32 (52 per cent). In both groups of dogs the prevalence of cardiac murmurs was low among dogs younger than three years (1.9 per cent) but increased with age (P < 0.001). The estimated ages at which 50 per cent of the dogs had developed murmurs were 7.5 and 6.2 years, respectively. When 39 of the 61 dogs were re-examined three years later, cardiac murmurs were detected in 28 (72 per cent), and the intensities of the murmurs had generally increased (P < 0.05). Nine (28 per cent) of the dogs which had previously had murmurs had been euthanased for signs of congestive heart failure whereas none of the dogs which had been free of murmurs had died from congestive heart failure. Animal insurance statistics from 1982 to 1990 (1983 excluded) for dogs less than 10 years old showed that claims for veterinary care or death or euthanasia were five times more common in the cavalier King Charles spaniel than in dachshunds (P < 0.001) and eight times more common than the mean for all other insured breeds (P < 0.001).

Dental care of patients susceptible to infective endocarditis

McGowan and Tuohy carried out a survey in Belfast in 1968 to identify patients with cardiac lesions susceptible to infective endocarditis. They also asked whether adequate precautions had been taken by the patients' medical and dental advisers in respect of antibiotic cover for dental surgical procedures. This survey has now been repeated in the Belfast and Glasgow Dental Schools. When compared with those of 1968, the results of these recent studies show that while more 'at risk' patients are receiving antibiotic cover for dental surgical procedures there is still room for improvement in the advice given to patients by medical and dental practitioners.

[The incidence and clinical significance of the echocardiographic finding of false chordae tendineae]

The presence of false tendons (FT) with M-mode and 2-D echocardiography in a consecutive series of 916 patients (520 men--396 women) with a wide age range (9-83 y) was investigated, and a possible correlation with heart systolic murmurs and/or heart arrhythmias evaluated. The problems that FT cause in differential diagnosis with other intraventricular structures were also considered. FT were observed in 53 subjects (5.8%), 30 men--23 women, and in an additional 51 cases (96%) in the left ventricular cavity. A clear prevalence of FT was observed during childhood and adolescence (26.1%), with the preferential location at the top of the ventricular chamber. No relevant correlation between FT and heart systolic murmurs and/or cardiac rhythm disorders was found. Although our results show that FT constitute an occasional finding, with no anatomic or functional relevance, they should always be held in due consideration in case of diagnostic uncertainty with other pathological structures, in particular intracavitary thrombi.

Assessment of phonocardiographical investigations among seafarers

A total of 763 seafarers were selected at random for the examinations. Their number represented 9.82% of the total employed. About 86.63% of them were examined. Another group examined were 202 college undergraduates--all the undergraduates of the second year of studies. The average age of seafarers was 41.14 +/- 8.84 years, and of undergraduates 22.54 +/- 1.29 years. A normal heart first sound was recorded in 95.41% of seafarers, normal second sound in 95.94%, and in 95.05% and 95.05% of the undergraduates, respectively. Normal third and fourth sounds were recorded jointly in 4.45% of seafarers and 0.99% of the undergraduates, whereas abnormal ones in 1.05% of seafarers and 0.99% of the undergraduates. Aortic ejection sound and systolic zone clicks were detected only in seafarers: in 0.79% and 1.31% of the subjects, respectively. Systolic zone murmurs were recorded in 4.19% of the seafarers, including those with heart defects (1.44%), therein mitral valve insufficiency (0.79%), mitral valve prolapse syndrome (0.39%) and aortal valve stenosis (0.26%). In all other cases the recorded heart murmurs in undergraduates and seafarers were considered functional (not pathological).