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Murmur, Systolic: Edward Etchells, MD, discusses the clinical examination for systolic murmurs.
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Murmur, Systolic: Edward Etchells, MD, discusses the clinical examination for systolic murmurs.
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>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure of speaking with Dr. Edward Etchells about systolic murmurs, a common condition and a topic discussed in Chapter 33 of The Rational Clinical Examination. Dr. Etchells, why don't you introduce yourself to our listeners? >> Hi Joan, thanks for inviting me to speak with you today. My name is Edward Etchells. I'm a staff physician in the Division of General Internal Medicine, at Sunnybrook Health Sciences Center an affiliated teaching hospital with the University of Toronto.
>> Dr. Etchells, what are systolic murmurs, and in what population should systolic murmurs be considered? >> Joan, systolic murmurs are sounds caused during systole by turbulent blood flow, through cardiac structures. They're clinically important because systolic murmurs can occur in any patient at any age. They can be heard in normal, healthy people, but they can also be a sign of clinically important structural cardiac disease. They can also be a sign of other important medical conditions, such as anemia, or thyrotoxicosis, that cause pathologically increased flow through normal cardiac structures.
>> How accurate are cardiologists and emergency physicians at distinguishing abnormal from innocent murmurs? >> So, there are many studies showing that cardiologists are very accurate at both ruling in, and ruling out, clinically important valvular heart disease even though cardiologists are probably faced with far more difficult cases than we would face in primary or secondary practice. I think that's a good demonstration of the principle that practice makes perfect. There is a single study of Emergency Room physicians that also showed very good accuracy.
>> Please describe the steps in the physical examination for assessing systolic murmurs? >> Sure. So, Joan, first, I want to emphasize that it's really important for clinicians to think about the non-auscultatory examination. So, it's not just the listening to the heart with the stethoscope. So, I can't over-emphasize how important it is to look at the JVP, the jugular venous pressure, examine the precordium, and examine the carotid artery pulsation. Once you've decided you're ready to get to the auscultatory or listening part of the exam, take a few moments to be prepared.
So, first, the environment is crucial. It is very difficult to hear heart murmurs in a loud environment. A simple step that I always take is I simply close the door and ask people to not talk while I'm listening to the heart. Next is make sure your equipment is in good working order. I can't tell you how many residents I've seen who have broken or cracked ear tips, which would make it virtually impossible to hear subtle findings, and last, perhaps not for the young people, but for older people like myself, make sure your ears are working, particularly, make sure you don't have a problem with ear wax.
Those are simple steps easily overlooked, worth definitely attending to. Then you are ready to listen, so here are the key steps. First, make sure you know when systole is. The simplest way to do that is to palpate the patient's carotid artery while you're listening to the heart. And the beginning of systole is the first heart sound, which is synchronous with the upstroke of the carotid artery. Next, if the patient is breathing loudly, you may need to take steps to control the breathing, so you can hear what you need to hear.
So one trick is just to ask the patient to take a big breath in, then breathe out, then stop breathing. And, as a clinician, you should stop breathing at the same time you tell the patient to stop breathing, so that you don't forget to tell them to take a breath. That way you can hear things very nicely in between breaths, and you have a few seconds to focus your attention on systole. If you hear any systolic murmur, the next useful step is to decide if there is an audible gap between the end of the murmur and hearing the second heart sound.
If there is an audible gap, this would put you in the category of an ejection type murmur. Then, the last thing I always tell students is, once you've heard the murmur, and done your best to characterize it, forget about it. It's so easy to get overwhelmed or over-excited that you actually heard something. It's actually equally important, or more important to decide what is going on other than the murmur. Focus your attention next on the heart sounds, particularly the intensity of the second heart sound. Look for extra sounds, S4 and S3s.
In particular, spend time listening for diastolic murmurs, because if you hear a diastolic murmur, it completely changes the nature of the case, and mandates an echocardiogram. Finally, you can decide whether you want to do any dynamic maneuvers to decide what happens to the murmur during these maneuvers. A simple maneuver is simply to have the patient go from lying to standing, and the clinician's job is to decide whether the murmur intensity changes as the patient moves from the lying to standing position.
>> What factors determine the precision of the clinical examination for systolic murmurs? >> Joan, I think attention to the steps I just outlined above is critical. A lot of people simply don't take time to make the environment optimal to hear murmurs, and they don't take time to clearly listen to all of the accompanying findings that I outlined above. I also think that there are some simple rules for converting observations into interpretations that can improve precision. For example, if a murmur is not heard immediately, but can be heard with focused attention, that is a grade 1 murmur.
>> What is the reference standard test for determining the cause of a systolic murmur? >> Joan, I think the reference standard is the conventional transthoracic echocardiogram. This is the best, most practical, least-invasive way of detecting clinically important structural heart disease. Obviously, a cardiac MRI or cardiac catheterization would be equally useful, but these are less widely available, or more invasive respectively. >> What are the potential next steps, if a clinician detects a systolic murmur in a patient? >> So, as you recall, the critical distinguishing questions are, is this a normal, healthy person with a so-called innocent systolic murmur?
Is this a sign of structural cardiac disease? Or does this patient have an important, non-cardiac medical condition, like anemia, that is causing pathologically increased flow through normal cardiac structures? So, the first step is to decide whether you're dealing with a healthy person with an innocent murmur. And this is what cardiologists are very good at. There are certain things that really point towards an innocent murmur. So, first of all, the patient should have no red-flag symptoms such as exertional syncope, or angina, or symptoms of heart failure.
Their non-auscultatory examination should be normal, including the precordium, the JVP, and the carotid artery pulsation. They should have normal first and second heart sounds. There should be no extra heart sounds. There absolutely cannot be a diastolic component to the murmur. And virtually all innocent murmurs will reduce in intensity or disappear when the patient stands up. So, these are the types of features that an expert clinician would look for to categorize the murmur accurately as innocent.
If you have these simple tests available, an innocent murmur should be associated with a normal electrocardiogram, and a normal chest x-ray. So, with the physical findings, supported benign or innocent flow murmur, you should still ask yourself, could this patient have a non-cardiac condition causing abnormally increased flow, such as anemia, or thyrotoxicosis? And that's outside of the scope of this discussion. If there is still residual concern after the physical exam that the murmur could represent structural cardiac disease, then get an echo.
>> Dr. Etchells, is there anything else you would like to tell our listeners about systolic murmurs? >> Yeah, I think that four more short messages. First, always listen to your patient's hearts. Second, always take time to document your findings. Third, ask colleagues to verify your findings if you're uncertain of them, and finally, relate your findings to the echocardiograms that you order. The best way to improve auscultatory skills is through practice and feedback. That's how cardiologists get such high accuracy, and it's within the scope of any clinician's practice to do so.
>> Thank you so much Dr. Etchells, for this useful overview of systolic murmurs. Additional information about this topic is available in chapter 33 of The Rational Clinical Examination. This has been Joan Stephenson of JAMA, talking with Dr. Edward Etchells, about systolic murmurs, for JAMAevidence.
Segment:0 .
>> I'm Joan Stephenson, Editor of JAMA's Medical News and Perspectives Section. Today, I have the pleasure of speaking with Dr. Edward Etchells about systolic murmurs, a common condition and a topic discussed in Chapter 33 of The Rational Clinical Examination. Dr. Etchells, why don't you introduce yourself to our listeners? >> Hi Joan, thanks for inviting me to speak with you today. My name is Edward Etchells. I'm a staff physician in the Division of General Internal Medicine, at Sunnybrook Health Sciences Center an affiliated teaching hospital with the University of Toronto.
>> Dr. Etchells, what are systolic murmurs, and in what population should systolic murmurs be considered? >> Joan, systolic murmurs are sounds caused during systole by turbulent blood flow, through cardiac structures. They're clinically important because systolic murmurs can occur in any patient at any age. They can be heard in normal, healthy people, but they can also be a sign of clinically important structural cardiac disease. They can also be a sign of other important medical conditions, such as anemia, or thyrotoxicosis, that cause pathologically increased flow through normal cardiac structures.
>> How accurate are cardiologists and emergency physicians at distinguishing abnormal from innocent murmurs? >> So, there are many studies showing that cardiologists are very accurate at both ruling in, and ruling out, clinically important valvular heart disease even though cardiologists are probably faced with far more difficult cases than we would face in primary or secondary practice. I think that's a good demonstration of the principle that practice makes perfect. There is a single study of Emergency Room physicians that also showed very good accuracy.
>> Please describe the steps in the physical examination for assessing systolic murmurs? >> Sure. So, Joan, first, I want to emphasize that it's really important for clinicians to think about the non-auscultatory examination. So, it's not just the listening to the heart with the stethoscope. So, I can't over-emphasize how important it is to look at the JVP, the jugular venous pressure, examine the precordium, and examine the carotid artery pulsation. Once you've decided you're ready to get to the auscultatory or listening part of the exam, take a few moments to be prepared.
So, first, the environment is crucial. It is very difficult to hear heart murmurs in a loud environment. A simple step that I always take is I simply close the door and ask people to not talk while I'm listening to the heart. Next is make sure your equipment is in good working order. I can't tell you how many residents I've seen who have broken or cracked ear tips, which would make it virtually impossible to hear subtle findings, and last, perhaps not for the young people, but for older people like myself, make sure your ears are working, particularly, make sure you don't have a problem with ear wax.
Those are simple steps easily overlooked, worth definitely attending to. Then you are ready to listen, so here are the key steps. First, make sure you know when systole is. The simplest way to do that is to palpate the patient's carotid artery while you're listening to the heart. And the beginning of systole is the first heart sound, which is synchronous with the upstroke of the carotid artery. Next, if the patient is breathing loudly, you may need to take steps to control the breathing, so you can hear what you need to hear.
So one trick is just to ask the patient to take a big breath in, then breathe out, then stop breathing. And, as a clinician, you should stop breathing at the same time you tell the patient to stop breathing, so that you don't forget to tell them to take a breath. That way you can hear things very nicely in between breaths, and you have a few seconds to focus your attention on systole. If you hear any systolic murmur, the next useful step is to decide if there is an audible gap between the end of the murmur and hearing the second heart sound.
If there is an audible gap, this would put you in the category of an ejection type murmur. Then, the last thing I always tell students is, once you've heard the murmur, and done your best to characterize it, forget about it. It's so easy to get overwhelmed or over-excited that you actually heard something. It's actually equally important, or more important to decide what is going on other than the murmur. Focus your attention next on the heart sounds, particularly the intensity of the second heart sound. Look for extra sounds, S4 and S3s.
In particular, spend time listening for diastolic murmurs, because if you hear a diastolic murmur, it completely changes the nature of the case, and mandates an echocardiogram. Finally, you can decide whether you want to do any dynamic maneuvers to decide what happens to the murmur during these maneuvers. A simple maneuver is simply to have the patient go from lying to standing, and the clinician's job is to decide whether the murmur intensity changes as the patient moves from the lying to standing position.
>> What factors determine the precision of the clinical examination for systolic murmurs? >> Joan, I think attention to the steps I just outlined above is critical. A lot of people simply don't take time to make the environment optimal to hear murmurs, and they don't take time to clearly listen to all of the accompanying findings that I outlined above. I also think that there are some simple rules for converting observations into interpretations that can improve precision. For example, if a murmur is not heard immediately, but can be heard with focused attention, that is a grade 1 murmur.
>> What is the reference standard test for determining the cause of a systolic murmur? >> Joan, I think the reference standard is the conventional transthoracic echocardiogram. This is the best, most practical, least-invasive way of detecting clinically important structural heart disease. Obviously, a cardiac MRI or cardiac catheterization would be equally useful, but these are less widely available, or more invasive respectively. >> What are the potential next steps, if a clinician detects a systolic murmur in a patient? >> So, as you recall, the critical distinguishing questions are, is this a normal, healthy person with a so-called innocent systolic murmur?
Is this a sign of structural cardiac disease? Or does this patient have an important, non-cardiac medical condition, like anemia, that is causing pathologically increased flow through normal cardiac structures? So, the first step is to decide whether you're dealing with a healthy person with an innocent murmur. And this is what cardiologists are very good at. There are certain things that really point towards an innocent murmur. So, first of all, the patient should have no red-flag symptoms such as exertional syncope, or angina, or symptoms of heart failure.
Their non-auscultatory examination should be normal, including the precordium, the JVP, and the carotid artery pulsation. They should have normal first and second heart sounds. There should be no extra heart sounds. There absolutely cannot be a diastolic component to the murmur. And virtually all innocent murmurs will reduce in intensity or disappear when the patient stands up. So, these are the types of features that an expert clinician would look for to categorize the murmur accurately as innocent.
If you have these simple tests available, an innocent murmur should be associated with a normal electrocardiogram, and a normal chest x-ray. So, with the physical findings, supported benign or innocent flow murmur, you should still ask yourself, could this patient have a non-cardiac condition causing abnormally increased flow, such as anemia, or thyrotoxicosis? And that's outside of the scope of this discussion. If there is still residual concern after the physical exam that the murmur could represent structural cardiac disease, then get an echo.
>> Dr. Etchells, is there anything else you would like to tell our listeners about systolic murmurs? >> Yeah, I think that four more short messages. First, always listen to your patient's hearts. Second, always take time to document your findings. Third, ask colleagues to verify your findings if you're uncertain of them, and finally, relate your findings to the echocardiograms that you order. The best way to improve auscultatory skills is through practice and feedback. That's how cardiologists get such high accuracy, and it's within the scope of any clinician's practice to do so.
>> Thank you so much Dr. Etchells, for this useful overview of systolic murmurs. Additional information about this topic is available in chapter 33 of The Rational Clinical Examination. This has been Joan Stephenson of JAMA, talking with Dr. Edward Etchells, about systolic murmurs, for JAMAevidence.
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