Accuracy of the initial evaluation of heart murmurs in neonates: do we need an echocardiogram?

Anxiety levels in parents of asymptomatic neonates and young infants referred for echocardiography

INTRODUCTION

Previous studies in children with innocent murmurs have shown that parental concern is common.

METHODS

We assessed the anxiety levels among parents of asymptomatic neonates or infants up-to 6 weeks referred for cardiologic consultation because of a heart murmur. A six-item short-form of the state scale of the Spielberger State-Trait Anxiety Inventory (STAI) was completed by the parents before and after consultation.

RESULTS

The average STAI score decreased from 14.42 ± 4.54 on arrival to 9.69 ± 4.26 after the consultation (p < 0.001). Overall, the parents felt more calm, less tense, less upset, more relaxed, more content and less worried after the consultation (p < 0.001). Multivariable linear regression analysis showed that the STAI score prior to consultation was related to infants age (coefficient β = - 0.172; P = 0.046) and STAI score post consultation was related to the final diagnosis (β = 0.312; P < 0.001).

CONCLUSION

In conclusion, parents of asymptomatic neonates and young infants with a murmur exhibit moderate levels of anxiety which can be ameliorated after consultation. Parental education in the field is of paramount importance and the role of both paediatric cardiologists as well as primary care physicians is crucial and decisive.

Birth prevalence and late diagnosis of critical congenital heart disease: A population-based study from a middle-income country

Aims:

There are limited data regarding critical congenital heart disease (CCHD) from middle-income countries (MIC). This study aims to determine the birth prevalence, rate of late diagnosis, and influence of timing of diagnosis on the outcome of CCHD.

Setting and Design:

Retrospective observational cohort study in the State of Johor, Malaysia.

Subjects and Methods:

All infants born between January 2006 and December 2015 with a diagnosis of CCHD, defined as infants with duct-dependent lesions or cyanotic heart disease who may die without early intervention. The late diagnosis was defined as a diagnosis of CCHD after 3 days of age.

Results:

Congenital heart disease was diagnosed in 3557 of 531,904 live-born infants and were critical in 668 (18.7%). Of 668, 347 (52%) had duct-dependent pulmonary circulation. The birth prevalence of CCHD was 1.26 (95% confidence interval: 1.16–1.35) per 1000 live births, with no significant increase over time. The median age of diagnosis was 4 days (Q1 1, Q3 26), with 61 (9.1%) detected prenatally, and 342 (51.2%) detected late. The highest rate of late diagnosis was observed in coarctation of the aorta with a rate of 74%. Trend analysis shows a statistically significant reduction of late diagnosis and a significant increase in prenatal detection. However, Cox regression analysis shows the timing of diagnosis does not affect the outcome of CCHD.

Conclusions:

Due to limited resources in the MIC, the late diagnosis of CCHD is high but does not affect the outcome. Nevertheless, the timing of diagnosis has improved over time.

Evaluation and diagnostic approach for heart murmurs in children

Heart murmurs are common in children. Most of them are innocent murmurs with normal heart anatomy and function, and only a few are pathologic murmurs with congenital heart anomaly or abnormal heart function. However, a heart murmur may be the sole symptom of serious heart disease. Therefore, careful evaluation of heart murmurs for distinguishing pathologic murmurs from innocent murmurs is important. Heart murmurs are described by their intensity, timing in the cardiac cycle, location, transmission, and quality. Murmurs, such as a holosystolic or diastolic murmur, of grade 3 or higher intensity, harsh quality, an abnormal S2, a systolic click, or increased intensity when the patient stands are more likely to be pathologic murmurs. Innocent murmurs are more likely to be systolic murmurs, with soft sounds, short duration, low pitch, and varying intensity with phases of respiration and posture (disappears with standing). Not only auscultation but also physical examination findings are important to evaluate heart murmurs. The gold standard test for the evaluation of any potentially pathologic murmur is echocardiography. For the appropriate use of echocardiography, close physical examination, including auscultation, is essential and requires considerable practice.

Congenital heart disease diagnosed with echocardiogram in newborns with asymptomatic cardiac murmurs: a systematic review

BACKGROUND

More than 50% of newborns with congenital heart disease (CHD) are unrecognized at birth; however, the use of echocardiogram (Echo) for diagnosing CHD in newborns with asymptomatic, non-syndromic cardiac murmurs (ANCM), has not been systematically reviewed yet. We aimed to identify the incidence of CHD diagnosed with Echo and systematically review whether Echo should be recommended in this patient group.

METHODS

The methodology utilized in this systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Using the MEDLINE, EMBASE, Web of Science, and Cochrane Library databases, we performed a systematic review of publications reporting CHD diagnosed with Echo in newborns with cardiac murmurs. The quality of the included studies was evaluated using the Study Quality Assessment Tools developed by the National Institutes of Health.

RESULTS

Of the 630 studies screened, six cohort studies, four cross-sectional studies, and two case reports were included in this review. The incidence of cardiac murmurs ranged from 0.6-8.6%. Among the 1928 newborns with ANCM, 719 (37.3%) were diagnosed with Echo as having CHD, and ventricular septal defect was the most common congenital malformation. More than 50% of the newborns showed moderate CHD necessitating outpatient cardiology follow-up, and 2.5% had severe CHD requiring immediate interventions, such as cardiac catheterization and heart surgery.

CONCLUSIONS

In this systematic review, a high incidence of CHD in newborns with ANCM was detected using Echo. This indicates that the use of Echo for diagnosing CHD in healthy newborns with cardiac murmurs could be helpful in earlier detection of CHD, thereby improving clinical outcomes for newborns with severe CHD.

Accuracy of cardiac auscultation in detection of neonatal congenital heart disease by general paediatricians

BACKGROUND

Challenges remain in the judgement of pathological murmurs in newborns at maternity hospitals, and there are still many simple major CHD patients in developing countries who are not diagnosed in a timely fashion. This study aimed to evaluate the accuracy of cardiac auscultation on neonatal CHD by general paediatricians.

METHODS

We conducted a prospective study at three hospitals. All asymptomatic newborns underwent auscultation, pulse oximetry monitoring, and echocardiography. Major CHD was classified and confirmed through follow-up. We evaluated the accuracy of various degrees of murmurs for detecting major CHD to determine the most appropriate standards and time of auscultation.

RESULTS

A total of 6750 newborns were included. The median age of auscultation was 43 hours. Cardiac murmurs were identified in 6.6% of newborns. For all CHD, 44.4% had varying degrees of murmurs. A murmur of grade ≥2 used as a reference standard for major CHD had a sensitivity of 89.58%. The false positive rate of murmurs of grade ≥2 for detecting major CHD was significantly negatively related to auscultation time, with 84.4% of false positives requiring follow-up for non-major CHD cardiac issues. Auscultation after 27 hours of life could reduce the false positive rate of major CHD from 2.7 to 0.9%.

CONCLUSIONS

With appropriate training, maternity hospital's paediatricians can detect major CHD with high detection rates with an acceptable false positive rate.

Cardiac Murmurs in Children: A Challenge For The Primary Care Physician

Congenital heart disease is present in almost 1% of live births and despite current progress in prenatal screening a significant percentage has delayed diagnosis or remain undiagnosed. A cardiac murmur may be the first or unique clinical sign of congenital heart disease in childhood, however, less than 1% of auscultated murmurs are of an organic cause. Distinguishing between an innocent and a pathologic murmur can be challenging and the experience of the examiner is crucial for identifying the distinctive properties of an innocent murmur. Timely diagnosis of underlying cardiovascular pathology is of great significance so that prompt management is provided and morbidity or mortality are restricted. Of similar importance is the avoidance of unnecessary anxiety for the parents and unreasonable referrals to Paediatric Cardiologists. Indications for referral include a medical history suggestive of a cardiac abnormality, such as the presence of relevant symptoms, the identification of abnormal findings on clinical examination, auscultatory findings suggestive of an organic murmur, and very young patient age. ECG and a chest X-ray are not usually part of the diagnostic approach of a child with a cardiac murmur, as they do not increase the success rate of diagnosing heart disease, as compared to a detailed medical history accompanied by a thorough physical examination. In conclusion, the recognition of suspicious distinctive features of cardiac murmurs is crucial and requires skills based on sufficient training and experience.

Heart murmurs and echocardiography findings in the normal newborn nursery

OBJECTIVE

To determine the clinical findings and management implications of echocardiograms performed on infants with murmurs in the nursery.

DESIGN

Retrospective cohort study conducted from January 2008 through December 2015. Patients in the study were followed by chart review for up to 5 years. In addition, a survey of nursery providers was conducted in February 2016.

SETTING

A single community hospital associated with a university.

PATIENTS

All 26 573 infants who received care in the normal newborn nursery were eligible for inclusion in the study. Infants with echocardiograms were analyzed. The survey was sent by e-mail to all 135 physicians who work in the nursery.

OUTCOME MEASURES

The primary outcomes include the specific findings on echocardiogram and whether the findings required an acute change in management, outpatient follow up, or were incidental findings. The primary survey question was how physicians would manage an otherwise asymptomatic newborn with a heart murmur.

RESULTS

Four hundred ninety-nine infants had echocardiograms, and over the study period the utilization of echocardiography increased from 1.02% to 2.56% (P < .001) of all infants. Three hundred fifty-four babies had echocardiography performed because of a heart murmur. One hundred sixty-three (46.0%) of these echocardiograms were normal and 160 (45.2%) had findings that did not require additional care. Twenty-three neonates (6.5%) had echocardiographic findings that necessitated outpatient follow-up and 8 neonates (2.3%) required neonatal intensive care due to the findings on their echocardiogram. In total, 14 infants (4%) would go on to require heart surgery or interventional cardiac catheterization. 63/135 (47%) physicians completed the survey, with wide variations in the management of newborns with heart murmurs.

CONCLUSIONS

The use of echocardiography in the normal newborn nursery has increased with time despite improved prenatal detection of heart disease and the use of pulse oximetry screening, and identifies significant heart disease in a small but important number of infants.

Novel algorithm to screen for heart murmurs using computer-aided auscultation in neonates: a prospective single center pilot observational study

BACKGROUND

Automated detection of heart murmurs with computer-aided auscultation is not yet in clinical routine use. Aim of this study was to test sensitivity and specificity of a novel prototype algorithm in automated detection of heart murmurs from digitally recorded phonocardiograms in neonates admitted at the Neonatal Intensive Care Unit.

METHODS

In a prospective pilot observational study from November 2012 to December 2013 auscultations by pediatricians and computer aided auscultation were performed within 12 hours of neonatal echocardiography. Echocardiography was defined as pathological when resulting in any clinical consequences or causing murmur. Phonocardiograms and auscultation were defined as pathological if a murmur was detected. Phonocardiograms were analyzed offline with a novel algorithm prototype (CSD Labs, Graz, Austria) for detection of murmurs in neonates in a first run and with an optimized algorithm in a second run and were compared with echocardiography. Sensitivity and specificity of auscultation by pediatrician and computer aided auscultation were analyzed.

RESULTS

Thirty-six neonates (gestational age: 36±3 weeks) were included. Twenty-three (64%) neonates had pathological or murmur causing findings in echocardiography (positive echocardiography). Sensitivity and specificity of auscultation by pediatrician were 17% and 100%, respectively. In comparison to auscultation by pediatrician sensitivity of first run and second run were significantly higher with 70% and 83%, respectively. Specificity of first run and second run were 77% and 85%, respectively.

CONCLUSIONS

Phonocardiogram analysis using the novel algorithm prototype had a higher sensitivity than auscultation by pediatrician in detecting positive echocardiography findings in neonates.

Pulse Oximetry and Auscultation for Congenital Heart Disease Detection

OBJECTIVES

Pulse oximetry (POX) has been confirmed as a specific screening modality for critical congenital heart disease (CCHD), with moderate sensitivity. However, POX is not able to detect most serious and critical cardiac lesions (major congenital heart disease [CHD]) without hypoxemia. In this study, we investigated the accuracy and feasibility of the addition of cardiac auscultation to POX as a screening method for asymptomatic major CHD.

METHODS

A multicenter prospective observational screening study was conducted at 15 hospitals in Shanghai between July 1, 2012, and December 31, 2014. Newborns with either an abnormal POX or cardiac auscultation were defined as screen positive. All screen-positive newborns underwent further echocardiography. False-negative results were identified by clinical follow-up, parents' feedback, and telephone review. We assessed the accuracy of POX plus cardiac auscultation for the detection of major CHD.

RESULTS

CHD screening was completed in all 15 hospitals, with a screening rate of 94.0% to 99.8%. In total, 167 190 consecutive asymptomatic newborn infants were screened, of which 203 had major CHD (44 critical and 159 serious). The sensitivity of POX plus cardiac auscultation was 95.5% (95% confidence interval 84.9%-98.7%) for CCHD and 92.1% (95% confidence interval 87.7%-95.1%) for major CHD. The false-positive rate was 1.2% for detecting CCHD and 1.1% for detecting major CHD.

CONCLUSIONS

In our current study, we show that using POX plus cardiac auscultation significantly improved the detection rate of major CHD in the early neonatal stage, with high sensitivity and a reasonable false-positive rate. It provides strong evidence and a reliable method for neonatal CHD screening.

Is pre-discharge echocardiography indicated for asymptomatic neonates with a heart murmur? A retrospective analysis

OBJECTIVE

The purpose of this study was to determine whether a murmur detected on routine pre-discharge examination of asymptomatic newborn children in the first 48 hours of life warrants further investigation with echocardiography.

METHODS

We conducted a retrospective review of all echocardiography studies of neonates born at Jordan University Hospital between August, 2007 and June, 2014. Findings on physical examination as well as the indication of the echocardiographic studies were reviewed. We included asymptomatic neonates for whom echocardiographic studies were carried out due to the sole indication of a heart murmur on routine pre-discharge neonatal physical examination.

RESULTS

Of 309 asymptomatic newborns with murmurs on pre-discharge examination, echocardiography revealed 68 (22%) cases of CHD, with 18 (6%) designated as significant heart disease with anticipated intervention during infancy or childhood. The most common abnormality was ventricular septal defect occurring in 36 cases. Critical heart diseases detected included hypoplastic left heart syndrome in two and aortic valve stenosis in four newborns.

CONCLUSIONS

Although most asymptomatic neonates with heart murmurs have normal hearts, a small percentage may have significant heart disease. The decision to refer an asymptomatic newborn with a murmur for echocardiography before discharge from the hospital remains controversial and must be supported by other evidence such as murmur characteristics and local trends in parental compliance with follow-up well-baby visits.

The importance of heart murmur in the neonatal period and justification of echocardiographic review

Introduction:

Heart murmurs can be functional (innocent) and pathological (organic). Although it is not considered a major sign of heart disease, it may be a sign of a serious heart defect. In most cases the noise is initiation for cardiac treatment. Is it possible to differentiate on the basis of auscultation innocent from pathological heart murmur? In this article we present the results of ultrasonography of newborns with positive auscultation finding of the heart in the neonatal and early infancy period.

Goal:

To determine the role of murmurs in the heart detected by routine clinical examination in the neonatal period and early infancy, and to establish the legitimacy of cardiology consultation and ultrasound of the heart.

Methods:

A retrospective review of medical records in the period from January 1 to December 31, 2011 at the Maternity ward of Cantonal Hospital in Bihac 1899 children was born. In 32 neonates was registered a heart murmur, in the period from birth up to 6 weeks of life. All children with positive auscultation finding of the heart were examined echocardiography by ultrasound ALOCA 2000, multifrequency probe from 3.5 to 5 MHz, and used M-mode, 2-D, continuous, pulsed and color Doppler.

Results:

Of the 32 examined children regular echocardiographic findings had two children (6.25%), aberrant bunch of left ventricle 11 (34.37%), patent foramen ovale 5 (15.62%), atrial septal defect 3 children (9.37%), ventricular septal defect 8 children (25%), cyanogen anomaly 2 children (6.25%), stenosis of the pulmonary artery 1 child (3.12%). We see that 14 children (43.75%) had a structural abnormality of the heart that requires further treatment and monitoring.

Conclusion:

Echocardiography is necessary to set up or refute the diagnosis of structural heart defect in children with positive auscultation finding in the neonatal period.

Management of asymptomatic cardiac murmurs in term neonates

Approximately 2 % of newborn infants are noted to have cardiac murmur on routine postnatal examination. Our aim was to look at current evidence and practice in the management of asymptomatic cardiac murmur in term neonates. We performed a systematic literature review and a telephone survey of all neonatal units in the United Kingdom (UK). The systematic review of the literature did not support the routine practice of four-limb blood pressure (BP), chest X-ray (CXR), and electrocardiogram (ECG) in the assessment of asymptomatic cardiac murmur in term neonates. The survey had participation from 132 (68 %) of 193 neonatal units in the UK. In an asymptomatic term neonate with cardiac murmur, 124 (94 %) units perform pulse oximetry, 100 units (76 %) measure four-limb BP, 36 units (27 %) perform a CXR, and 52 units (39 %) perform an ECG. Eight-six units (65 %) have availability of in-house echocardiography services provided mainly by paediatricians with cardiology interest in special care units and neonatologists in neonatal intensive care units. Currently there is wide variation in practice in the management of asymptomatic cardiac murmur in term neonates. There is no evidence to support the routine use of four-limb BP, CXR, and ECG in the assessment of asymptomatic cardiac murmur in term neonates. Based on the evidence available, both structured clinical examination (including determining presence and quality of bilateral femoral pulses) and universal use of pulse oximetry are most important in identifying CHD in asymptomatic term neonates with cardiac murmur before discharge home.

Benefits of predischarge echocardiography service for postnatal heart murmurs

AIM

To review the findings and outcomes of predischarge echocardiography service for postnatal heart murmurs provided by neonatologists.

METHODS

We retrospectively reviewed all predischarge echocardiograms performed on babies from the postnatal wards (PNW) over the last 3 years. We evaluated the indications, median age, findings and outcome.

RESULTS

A total of 408 echocardiograms were performed on 350 babies on the PNW. The most common indication was presence of a murmur (58%). In babies with a heart murmur, 26% had a normal echocardiogram, 2% had major structural heart defects, 38% had minor structural heart defects and 34% had transient circulatory changes. 32% were discharged with no follow-up, 28% were followed up in the local cardiac clinic and 40% were referred to the cardiologist.

CONCLUSION

Predischarge echocardiography service for postnatal heart murmurs provided by neonatologists has the benefit of providing an early diagnosis, counselling of the parents and arranging appropriate follow-up. It helps to triage the referrals to the cardiologist. We felt that we were able to alleviate parental anxieties by providing a definitive diagnosis and written information prior to discharge from hospital. We strongly believe that this service should only be provided by those appropriately trained and skilled in echocardiography.

Accuracy of cardiac auscultation in asymptomatic neonates with heart murmurs: comparison between pediatric trainees and neonatologists

The aim of this study was to assess whether cardiac auscultation performed by pediatric trainees and neonatologists can reliably distinguish innocent from pathologic heart murmurs in asymptomatic neonates. From January 2008 to April 2009 the pediatric trainees of our institution were requested to refer all asymptomatic neonates with a murmur and classify the murmurs as "innocent," "pathologic," or "possibly pathologic." Prior to echocardiography, each neonate was evaluated by two experienced neonatologists. The echocardiographic studies of 169 neonates were analyzed. Abnormal cardiac anatomy was found in 55 neonates (32.6%). The overall ability of pediatric trainees in identifying congenital heart disease (CHD) was moderate [area under the curve (AUC) = 0.855] and significantly lower compared to neonatologists (AUC = 0.919, p = 0.007). However, at "lower" levels of clinical confidence (i.e., clinical diagnosis of possibly pathologic murmurs), pediatric trainees had good ability in excluding CHD (sensitivity 94.6%; negative likelihood ratio = 0.09). The ability of cardiac auscultation for diagnosing CHD in asymptomatic neonates is limited and dependent on the physician's experience and level of clinical confidence. Echocardiography should remain an option for all neonates with a possibly pathologic murmur.

Can cardiologists distinguish innocent from pathologic murmurs in neonates?

OBJECTIVES

To determine the sensitivity and specificity of the clinical assessment of murmurs in neonates, as performed by pediatric cardiologists, and to identify clinical features that predict the presence of congenital heart disease (CHD) in this population.

STUDY DESIGN

Neonates (n = 201) referred for outpatient evaluation of a heart murmur were enrolled consecutively. After a clinical evaluation, the cardiologist documented whether the murmur was "likely innocent" or "likely pathologic." The cardiologist repeated his/her assessment after an electrocardiogram. Echocardiography served as the gold standard.

RESULTS

The median age was 12 days (range, 2-31 days). CHD was present in 113 of 201 (56%). Clinical assessment alone identified patients with CHD with a sensitivity of 80.5% (95% CI, 73.2-87.8), specificity of 90.9% (95% CI, 84.9-96.9), positive predictive value of 91.9% (95% CI, 86.6-97.3), and negative predictive value of 78.4% (95% CI, 70.4-86.4). The addition of an electrocardiogram did not improve these test characteristics. Features that were predictive of CHD were murmur quality (P < .0001), location (P = .02), and timing (P = .04). No patients requiring catheter or surgical intervention were missed by clinical assessment.

CONCLUSIONS

The prevalence of CHD in this referral population was high. Clinical assessment detected all complex CHD, although some simple lesions were missed. Murmur quality, location, and timing were predictive of CHD.

Patent ductus arteriosus evaluation by serial echocardiography in preterm infants

BACKGROUND

Patent ductus arteriosus (PDA) is associated with morbidity and mortality in premature neonates.

METHODS

The effect of serial echocardiography performed by a neonatologist and early targeted medical PDA treatment was evaluated and compared to historical controls. One hundred ninety-two infants <1,500 g were included and 45 infants had a PDA.

RESULTS

Serial echocardiography allowed significantly earlier identification and treatment of PDA versus awaiting the evolution of clinical signs. Severe intraventricular haemorrhage and ventilator days were significantly decreased in the studied cohort following the introduction of echocardiography. In addition, hospital stay was also reduced in the non-PDA group and other outcomes were unchanged.

CONCLUSION

Serial echocardiography for PDA evaluation, performed by a neonatologist trained in echo, may reduce morbidity in preterm infant.