Effective use of the consultant, laboratory testing, and echocardiography for the pediatric patient with heart murmur

Blood pressure and heart rate monitoring in children and adolescent with Still's vibratory murmur

BACKGROUND

Innocent heart murmur is common in healthy infants, children and adolescents. Although most cases are not pathologic, a murmur may be the manifestation of cardiovascular disease. It may also cause or be an indicator of blood pressure (BP) and heart rate (HR) changes.

OBJECTIVE

This study aimed to document changes in BP and HR in children with Still's vibratory murmur (SVM).

METHODS

This study included 226 children with SVM, and the control group included 138 healthy children that were age-, height- and weight-balanced. Patient files and our hospital registry system were retrospectively investigated for laboratory findings and electrocardiography and echocardiography results. In addition, we prospectively performed 24-h ambulatory BP monitoring in both groups.

RESULTS

There were no statistically significant differences in 24-h, daytime and nighttime systolic BP, 24-h and nighttime diastolic BP and nighttime HR between the patient and control groups (P = ns). However, daytime diastolic BP, mean HR and daytime HR were significantly higher in patient group (P = 0.009, 0.039 and 0007, respectively).

CONCLUSIONS

We believe that in the presence of a higher HR and a higher aortic diastolic BP, which may induce hemodynamic changes in the left ventricle, flow turbulence through the aortic valve may increase, increasing the probability of hearing a murmur. ambulatory BP monitoring could be useful to obtain a better picture of these parameters during the 24-h period.

The discerning ear: cardiac auscultation in the era of artificial intelligence and telemedicine

Heart murmur, a thoracic auscultatory finding of cardiovascular origin, is extremely common in childhood and can appear at any age from premature newborn to late adolescence. The objective of this review is to provide a modern examination and update of cardiac murmur auscultation in this new era of artificial intelligence (AI) and telemedicine. First, we provide a comprehensive review of the causes and differential diagnosis, clinical features, evaluation, and long-term management of paediatric heart murmurs. Next, we provide a brief history of computer-assisted auscultation and murmur analysis, along with insight into the engineering design of the digital stethoscope. We conclude with a discussion of the paradigm shifting impact of deep learning on murmur analysis, AI-assisted auscultation, and the implications of these technologies on telemedicine in paediatric cardiology. It is our hope that this article provides an updated perspective on the impact of AI on cardiac auscultation for the modern paediatric cardiologist.

Nonauscultatory clinical criteria are sensitive for cardiac pathology in low-risk paediatric heart murmurs

Background

Healthy children with likely innocent heart murmurs are frequently referred to cardiologists for reassurance. Existing guidelines that advise against these referrals are not consistently followed partly because they involve subjective auscultatory judgements with which many care providers are uncomfortable. Here, we investigate whether clinical criteria with no subjective auscultatory component are sensitive for cardiac pathology.

Methods

A retrospective chart review was performed of all new patients seen in our paediatric cardiology clinic for assessment of a murmur from January 1, 2016 through June 30, 2018. Patients were characterized as "low-risk" if they met all of the following criteria: asymptomatic; normal physical examination other than the murmur; no risk factors for congenital heart disease; and age over 12 months. The primary outcomes were the sensitivity for ruling out pathology and the negative predictive value of the proposed criteria.

Results

Of 915 total patients, 214 met the low-risk criteria. The sensitivity of our criteria for ruling out pathology was 97.2% (95% confidence interval 94.1% to 99.0%) and the negative predictive value was also 97.2% (95% confidence interval 94.0% to 98.7%). Six of the 214 low-risk patients had pathology (2.8%; 95% confidence interval 1.3% to 6.0%), none of which has required intervention since diagnosis. Each of these six children had a murmur that sounded pathological to the auscultating cardiologist.

Conclusions

Basic clinical criteria that do not require auscultation are highly sensitive for ruling out significant cardiac pathology in children over 12 months of age.

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.

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.

Cardiac risk factors and participation guidelines for youth sports

Accurate assessment of the cardiac system in pediatric and adolescent youth is important. The hemodynamic demands associated with exercise, training, and sport participation are usually positive and beneficial; however, when an underlying cardiac problem exists, it is imperative that such cardiac problems be identified. Safe sport-related cardiac participation guidelines should be provided for young athletes and their families and coaches. This chapter provides a physician perspective on the recognition and current cardiac management considerations for young athletes participating in both static and dynamic types of sports. The most recent guidelines for hypertension in youth are also provided.