2010 - Physical examination and classification of murmur findings into patterns improved diagnosis of systolic murmurs in adult inpatients

Merugu, Srinivas
March 2011
ACP Journal Club;3/20/2011, Vol. 154 Issue 3, p11
Academic Journal
Question What is the value of physical examination, particularly sorting murmurs into topographic patterns, for diagnosis of pathologic murmurs in adult inpatients? Methods Design 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. Setting Seattle Veterans Affairs Medical Center, Washington, USA. Patients 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. Description of test 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). Diagnostic standard Transthoracic echo. Outcomes Likelihood ratios. Main results 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). Conclusion Classification of murmur auscultation into precordial patterns and select additional physical examination findings were useful for diagnosing systolic murmurs in adult inpatients.


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