[Diagnosis of a systolic murmur among young asymptomatic patient: An assessment of professional practices for the expertise in military medicine]

The finding of a systolic heart murmur is common in medical military practice. Albeit often benign among young healthy adults, it can reveal a valvular or a cardiac disease, which could worsen during workout or expose to risk of a sudden death. This study aims to evaluate the diagnostic efficiency of the military general practitioner when discovering a systolic murmur among young asymptomatic patients.

MATERIALS AND METHODS

During one year, this study involved all the general practitioners of the medical military centres of Brittany and the cardiologists of the military hospital in Brest. It prospectively enrolled a cohort of all military asymptomatic patients under 40, without any underlying known heart condition. Military general practitioners listed, thanks to an anonymous form, the main features of the systolic murmur and of the ECG and proposed an auscultatory diagnosis: innocent or organic murmur. Then cardiologists did the same and finally performed a transthoracic echocardiography giving the diagnosis.

RESULTS

Fifty-eight patients were referred, 5 not meeting the inclusion criteria. Of the 53 patients included, military general practitioners found 46 innocent murmurs and 7 organic ones. Cardiologists found 51 innocent murmurs and 2 organic. Transthoracic echocardiography just took on one organic murmur (linked with a bicuspid aortic valve), spotted by the specialist, though judged innocent by the general practitioner.

DISCUSSION

Most of innocent murmurs diagnosed by general practitioners (45/46) were confirmed. Regarding the seven organic murmurs, the main selected criteria (intensity over 3, orthostatic persistence, diffuse irradiation) are mostly in accordance with the literature, proving right medical instincts. Authors propose a practical management of systolic murmurs among asymptomatic young patients.

CONCLUSION

Military general practitioners seem to master symptoms of organic murmur. This assessment argues for a promotion of a holistic clinical examination, which will help not only to rationalize the use of transthoracic echocardiography in economic terms but also to value the medical expertise.

[Echographic diagnosis of systolic murmur among 280 young French militaries. Implications for the expertise in military medicine]

Clinically discovering a systolic murmur is frequent among the young military population. When this murmur does not sound benign, a transthoracic echocardiography (TTE) is made to detect any cardiopathy, which could cause sudden cardiac death. The aim of this study was to evaluate the interest of systematic TTE in the assessment of any cardiac systolic murmur (CSM) among militaries.

METHODS

We ran a retrospective monocentric study in the "Clermont-Tonnerre" military hospital in Brest. We included all patients sent for TEE, aged 15 to 30 years old, from the 1st January 2010 until the 31st July 2013.

RESULTS

Two hundred and eighty TTES assessing CSM were performed. We found 28/280 (10%) echocardiographic abnormalities: 13 were bicuspid aortic valves (4.6%), 6 were ventricular septal defects (2.15%), 3 were atrial septal defects (1.07%), 4 were mild mitral regurgitations (1.43%), one mild pulmonary stenosis (0.35%) and one aortic stenosis (0.35%). No hypertrophic cardiomyopathy was found. Concerning military expertise, 11 (3.92%) patients among these 28 with abnormal TEE were considered unfit for work or "fit for work with limitations".

CONCLUSION

Assessing a cardiac systolic murmur with TEE lead to the diagnosis of a cardiomyopathy in 10% of the case. This study enhances the importance of systematic TEE when a CSM is detected in the young military, in order to determine if those soldiers can still fulfill their military duty.