Srinivas Merugu, MD
What is the value of physical examination, particularly sorting murmurs into topographic patterns, for diagnosis of pathologic murmurs in adult inpatients?
Mostly blinded comparison of physical examination with transthoracic echocardiography (echo). A blinded cardiologist interpreted all echos. Except for 14 patients, the author conducting the physical examination did not have clinical knowledge of the patients or their echo results.
Seattle Veterans Affairs Medical Center, Washington, USA.
A convenience sample of 376 inpatients (mean age 69 y, 98% men based on 409 patients examined) who had echos. 7% of echos were ordered to diagnose unexplained murmurs, 59% to assess structural heart disease, and 16% to follow up on known valvular disease. Patients with diastolic murmurs were excluded.
With the patient in supine position, the investigator assessed vital signs; arterial, venous, and precordial pulsations; and auscultated the anterior chest from apex to clavicles for heart sounds and murmurs. Findings of systolic murmurs were characterized using onomatopoeia (naming by vocal imitation of the sound), intensity, and sorting into 6 predetermined topographic patterns (see Figure 1, page 916 of the original article, for details on patterns).
The prevalences of any systolic murmur, aortic stenosis (AS) (peak aortic velocity ≥ 2.5 m/s on echo), mitral regurgitation (MR), and tricuspid regurgitation (TR) were 59%, 19%, 20%, and 17%, respectively. The “broad apical-base murmur pattern” detected AS, the “left lower sternal murmur” pattern detected TR, and the “broad apical murmur” pattern detected MR (Table). Absence of a murmur tended to rule out only AS (Table). Murmur radiation, heart sounds, and carotid upstroke also aided diagnosis (Table).
Classification of murmur auscultation into precordial patterns and select additional physical examination findings were useful for diagnosing systolic murmurs in adult inpatients.
Physical examination findings for diagnosing systolic murmurs in adults*
*Diagnostic terms defined in Glossary.
†Regurgitation, moderate or worse.
Srinivas Merugu. Physical examination and classification of murmur findings into patterns improved diagnosis of systolic murmurs in adult inpatients. Ann Intern Med. 2011;154:JC3–12. doi: 10.7326/0003-4819-154-6-201103150-02012
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Published: Ann Intern Med. 2011;154(6):JC3-12.
Cardiology, Hospital Medicine.
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