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A 45-Year-Old with Asymptomatic Heart Murmur
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A 45-Year-Old with Asymptomatic Heart Murmur
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2022-02-28T00:00:00.0000000
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Language: EN.
Segment:0 .
[intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to today's episode, which is about a 45-year-old with an asymptomatic heart murmur.
DR. WIENER: Okay, Cathy, well, today in clinic, you're seeing a 45-year-old, previously healthy man who comes in for a new patient physical examination. This is his first time coming to a doctor for over 20 years. On examination, his vital signs are normal and the only finding that is notable, is that you auscultate a grade 2/6 diastolic murmur along his left sternal border.
DR. HANDY: A grade 2 murmur, really? I'm impressed that the physician heard the diastolic murmur. There are studies of accuracy in cardiac auscultation that suggest residents may miss almost 60% of cardiac murmurs, so good pickup.
DR. WIENER: Well, let's talk about what grade 2 means. Can you briefly review how to grade murmurs?
DR. HANDY: Yeah, so the grading refers to the Levine scale that was introduced back in the 1930s, but it's really stood the test of time. So, grade 1 is barely audible, grade 2 is audible with a stethoscope, grade 3 is louder than grade 2, or easily audible, but doesn't have a palpable thrill, grade 4 is loud with a palpable thrill, and grades 5 and 6 are even louder to the point of being heard with the stethoscope off the chest, but diastolic murmurs only go to grade 4.
DR. WIENER: Okay, so there's some subjectivity, but at least, we're all speaking the same language. In this case, we're presuming that because it was said to be grade 2, that it's a faint murmur and like you said, nice pickup by the examiner.
DR. HANDY: Yeah, and you only make the correct diagnosis 25% of the time in patients with a murmur. There are a lot of studies out there on this topic and all suggest that we can do better, but keep going with the case.
DR. WIENER: Okay, so the patient is asymptomatic. He denies any chest pain, dyspnea, edema or any syncopal or pre-syncopal episodes. He's been well for the past 20 years. Examination, as I mentioned, reveals no other abnormalities, but specifically, his carotid pulses are normal, his PMI or his point of maximal impulse on cardiac palpation is in the normal place below the nipple, his lung fields are clear, his extremities have no edema whatsoever.
DR. WIENER: You go on and get an ECG and a chest X-ray, both of those are normal. So, the question is going to ask you, which of the following is the next best step for evaluation of this murmur? And the options are A. cardiac computed tomography; B. cardiac MRI; C. carotid ultrasound; D. echocardiogram; or E. no further workup is required.
DR. HANDY: All right, well, here are the three things that you want to consider, that I would say are the key components to deciding whether or not you pursue further evaluation when you hear a heart murmur. So, one is the type of murmur, two is the patient's age, and then, three, you need to consider the history of the patient. The majority of heart murmurs are midsystolic and soft, so, grades 1 to 2 out of 6, and when such a murmur occurs in an asymptomatic child or a young adult without other evidence of heart disease on examination, and if they have a normal EKG, it's usually benign and no additional evaluation is required.
DR. HANDY: When further evaluation is needed, the next step is typically an echocardiogram with Doppler imaging, and this is indicated if a patient has a grade 3 or greater systolic murmur. And in fact, echocardiogram is indicated for all diastolic or continuous murmurs that you hear.
DR. WIENER: Okay, so the answer is in this case D. echocardiography.
DR. HANDY: Correct and the other ones wouldn't be necessary but since it is a diastolic murmur, you would want to do further workup.
DR. WIENER: Great. One of the innovations for season three of Harrison's Podclass is that we're going to have some of the editors from the Harrison's Internal Medicine textbook be guests on our podclass to discuss some of our interesting cases. We're starting off with Dr. Joseph Loscalzo. Dr. Loscalzo is the chairman of the Department of Medicine and is the physician in chief at the Brigham and Women's Hospital in Boston. He is a renowned physician scientist, vascular biologist, and cardiologist. So welcome, Dr. Loscalzo.
DR. LOSCALZO: Thank you. Thanks very much for having me. I appreciate the opportunity to be here with you both.
DR. HANDY: Welcome, Dr. Loscalzo to our podclass. So, we wanted to get your thoughts on this case of a 45-year-old with an asymptomatic grade 2 diastolic murmur that was picked up on physical exam. As part of the question we determined that the next best step in the management was an echocardiogram. Can you teach us a little bit about what you would look for on an echocardiogram for this patient and more broadly, your approach to diastolic heart murmurs?
DR. LOSCALZO: Sure, Cathy, I'd be delighted. Let's step back for a second and think about diastolic murmurs in general first, then talk about the echo, if I may. So, this patient has a 2 presumably out of 4 diastolic murmur which defines it as soft. And if that murmur was identified by a non-cardiologist in particular, it's likely indicative of real pathology. So, diastolic murmurs almost always require evaluation of some sort.
DR. LOSCALZO: On physical examination to begin with, one would want to focus on whether or not the pulse pressure is widened, seek signs of heart failure, including an S3, and determine the timing and qualities of the murmur. Is it early diastolic or mid-diastolic? Is it blowing, especially when sitting up, leaning forward, at end expiration, decrescendo as well, or is it a rumble that occurs in mid-cycle? Does the murmur increase with inspiration?
DR. LOSCALZO: These are all the kinds of features of the exam that I would focus on in order to sort out precisely what kind of lesion I think it is. And the electrocardiogram and to a certain extent, the chest X-ray can help in this regard as well. So in this case, the patient was sent for a transthoracic echocardiogram and given the likelihood that this patient of middle age, that he's likely to have an aortic lesion, but we don't know that from any other features of the exam.
DR. LOSCALZO: In patients who do have aortic regurgitation or are suspected of having it, the important features to focus on, on the echocardiogram, include the integrity of the aortic valve leaflets, the number of leaflets, Doppler detection of aortic regurgitation, the dimensions of the aortic root, the presence or absence of dissection, and vegetations on the leaflets as well. And I would point out that inter-observer precision in detecting aortic regurgitation is really moderate.
DR. LOSCALZO: Inter-observer agreement is greater among cardiologists, about 94%, than non-cardiologists, about 78%. about 94%, than non-cardiologists, about 78%. And the last point I'll make about assessing patients for the presence of aortic regurgitation, is that among those suspected of having aortic regurgitation who are referred for cardiac catheterization, the positive likelihood ratio is quite high, between four and nine, while the negative likelihood ratio is quite low, between 0.1 and 0.2. So, if the patient gets to that stage, in which a cardiac catheterization seems indicated, it's highly likely, based on prior evaluation by physical examination and echocardiography, that the diagnosis will be confirmed and the hemodynamics defined more precisely.
DR. WIENER: Joe, I'm glad you mentioned your accuracy comment and put in a plug for cardiologists, but what are your thoughts on the cardiac physical examination in 2021, particularly with the growth of bedside ultrasound amongst primary care doctors and residents, and what is the role of the stethoscope as we move forward?
DR. LOSCALZO: That's a wonderful question, Charlie, and it really does speak to some of the sort of natural sociological phenomena associated with the uptake of new technologies. So, remember that Laennec invented the stethoscope in 1816, and at that time, it met with skepticism by physicians of the day, just as-
DR. WIENER: Including me, by the way, because I was skeptical. [all doctors chuckle]
DR. LOSCALZO: -just as bedside ultrasound, or any other new technology for that matter, has in some quarters among cardiologists today. By and large though, the uptake has been increasing, especially among our trainees, and to get to the point, I think you're intimating about cardiologists having better ears, Kobal and colleagues in 2006 published a really interesting paper, in which they looked at point of care ultrasound by first year medical students and showed that the medical students using point of care ultrasound outperformed the bedside cardiac examination by Board certified cardiologists 75% to 49% respectively.
DR. LOSCALZO: by Board certified cardiologists 75% to 49% respectively. So it continues, based on studies like Kobal's and others more recently, it continues to gain momentum as an important part of the bedside evaluation.
DR. WIENER: Do you think that this should be a part of all general internal medicine residency training programs as we move forward?
DR. LOSCALZO: Absolutely. I think, you know, it's already been taken up to that degree among emergency medicine programs as you know, and it's being taken up increasingly among internal medicine programs and I support that completely. Now, I would say one thing before we, sort of, toss out the physical exam, one of the critical issues about the weaknesses in the physical exam is the quality of the teacher.
DR. LOSCALZO: I'm always disturbed by those studies that suggest that the physical examination has, you know, a poor predictive accuracy of some sort or another, but it really depends upon who taught the examiner how to perform the exam and I'm sure that you've seen differences by generation in this regard as well. So, you're only as good as your best teacher, when it comes to using the physical examination.
DR. LOSCALZO: There's no absolute gold standard, as there might be if you're doing point of care ultrasound. So I want to put a pitch in for improving the quality of teaching the physical examination because coupling the physical examination with observations made by these technologies, like ultrasound, is absolutely the best way to make management decisions for our patients.
DR. HANDY: And I think too, one of the things you highlighted is that one of the most important parts is being at the bedside and there are a lot of things that, I think, pull us away, but all of these new technologies still are best at the bedside.
DR. LOSCALZO: Oh, I absolutely agree with that. I mean, I think that's another feature of the stethoscope, it really connects us physically and, if you will, emotionally to our patients. While it may have its limitations, it's really critical for patient-physician connection. It's a symbol of our profession and perhaps even a talisman in some cases among ill patients. So, I don't think we should toss it out in any significant way until we improve the quality of care in other ways that would enhance the physician-patient relationship to the same degree.
DR. HANDY: Thank you so much for that. Any other final thoughts or pearls for us today?
DR. LOSCALZO: I think I touched on all the points I wanted to make, but I guess I would say one other feature of the physical examination for aortic regurgitation that I didn't mention that most American-trained physicians may not realize, is that the best way to listen for a diastolic decrescendo murmur of AR is not just having the patient sit up, lean forward and end-expire, but also placing one's hands behind one's head, that also enhances the proximity of the aortic root to the chest wall and improves the pickup.
DR. WIENER: Great. Dr. Loscalzo, thank you so much for joining us today and we look forward to your wisdom on future cases of Harrison's Podclass.
DR. LOSCALZO: Thank you.
DR. HANDY: And if you want to learn more about this topic, you can check out Harrison's chapter on heart murmurs. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.
Segment:0 .
[intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener, and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to today's episode, which is about a 45-year-old with an asymptomatic heart murmur.
DR. WIENER: Okay, Cathy, well, today in clinic, you're seeing a 45-year-old, previously healthy man who comes in for a new patient physical examination. This is his first time coming to a doctor for over 20 years. On examination, his vital signs are normal and the only finding that is notable, is that you auscultate a grade 2/6 diastolic murmur along his left sternal border.
DR. HANDY: A grade 2 murmur, really? I'm impressed that the physician heard the diastolic murmur. There are studies of accuracy in cardiac auscultation that suggest residents may miss almost 60% of cardiac murmurs, so good pickup.
DR. WIENER: Well, let's talk about what grade 2 means. Can you briefly review how to grade murmurs?
DR. HANDY: Yeah, so the grading refers to the Levine scale that was introduced back in the 1930s, but it's really stood the test of time. So, grade 1 is barely audible, grade 2 is audible with a stethoscope, grade 3 is louder than grade 2, or easily audible, but doesn't have a palpable thrill, grade 4 is loud with a palpable thrill, and grades 5 and 6 are even louder to the point of being heard with the stethoscope off the chest, but diastolic murmurs only go to grade 4.
DR. WIENER: Okay, so there's some subjectivity, but at least, we're all speaking the same language. In this case, we're presuming that because it was said to be grade 2, that it's a faint murmur and like you said, nice pickup by the examiner.
DR. HANDY: Yeah, and you only make the correct diagnosis 25% of the time in patients with a murmur. There are a lot of studies out there on this topic and all suggest that we can do better, but keep going with the case.
DR. WIENER: Okay, so the patient is asymptomatic. He denies any chest pain, dyspnea, edema or any syncopal or pre-syncopal episodes. He's been well for the past 20 years. Examination, as I mentioned, reveals no other abnormalities, but specifically, his carotid pulses are normal, his PMI or his point of maximal impulse on cardiac palpation is in the normal place below the nipple, his lung fields are clear, his extremities have no edema whatsoever.
DR. WIENER: You go on and get an ECG and a chest X-ray, both of those are normal. So, the question is going to ask you, which of the following is the next best step for evaluation of this murmur? And the options are A. cardiac computed tomography; B. cardiac MRI; C. carotid ultrasound; D. echocardiogram; or E. no further workup is required.
DR. HANDY: All right, well, here are the three things that you want to consider, that I would say are the key components to deciding whether or not you pursue further evaluation when you hear a heart murmur. So, one is the type of murmur, two is the patient's age, and then, three, you need to consider the history of the patient. The majority of heart murmurs are midsystolic and soft, so, grades 1 to 2 out of 6, and when such a murmur occurs in an asymptomatic child or a young adult without other evidence of heart disease on examination, and if they have a normal EKG, it's usually benign and no additional evaluation is required.
DR. HANDY: When further evaluation is needed, the next step is typically an echocardiogram with Doppler imaging, and this is indicated if a patient has a grade 3 or greater systolic murmur. And in fact, echocardiogram is indicated for all diastolic or continuous murmurs that you hear.
DR. WIENER: Okay, so the answer is in this case D. echocardiography.
DR. HANDY: Correct and the other ones wouldn't be necessary but since it is a diastolic murmur, you would want to do further workup.
DR. WIENER: Great. One of the innovations for season three of Harrison's Podclass is that we're going to have some of the editors from the Harrison's Internal Medicine textbook be guests on our podclass to discuss some of our interesting cases. We're starting off with Dr. Joseph Loscalzo. Dr. Loscalzo is the chairman of the Department of Medicine and is the physician in chief at the Brigham and Women's Hospital in Boston. He is a renowned physician scientist, vascular biologist, and cardiologist. So welcome, Dr. Loscalzo.
DR. LOSCALZO: Thank you. Thanks very much for having me. I appreciate the opportunity to be here with you both.
DR. HANDY: Welcome, Dr. Loscalzo to our podclass. So, we wanted to get your thoughts on this case of a 45-year-old with an asymptomatic grade 2 diastolic murmur that was picked up on physical exam. As part of the question we determined that the next best step in the management was an echocardiogram. Can you teach us a little bit about what you would look for on an echocardiogram for this patient and more broadly, your approach to diastolic heart murmurs?
DR. LOSCALZO: Sure, Cathy, I'd be delighted. Let's step back for a second and think about diastolic murmurs in general first, then talk about the echo, if I may. So, this patient has a 2 presumably out of 4 diastolic murmur which defines it as soft. And if that murmur was identified by a non-cardiologist in particular, it's likely indicative of real pathology. So, diastolic murmurs almost always require evaluation of some sort.
DR. LOSCALZO: On physical examination to begin with, one would want to focus on whether or not the pulse pressure is widened, seek signs of heart failure, including an S3, and determine the timing and qualities of the murmur. Is it early diastolic or mid-diastolic? Is it blowing, especially when sitting up, leaning forward, at end expiration, decrescendo as well, or is it a rumble that occurs in mid-cycle? Does the murmur increase with inspiration?
DR. LOSCALZO: These are all the kinds of features of the exam that I would focus on in order to sort out precisely what kind of lesion I think it is. And the electrocardiogram and to a certain extent, the chest X-ray can help in this regard as well. So in this case, the patient was sent for a transthoracic echocardiogram and given the likelihood that this patient of middle age, that he's likely to have an aortic lesion, but we don't know that from any other features of the exam.
DR. LOSCALZO: In patients who do have aortic regurgitation or are suspected of having it, the important features to focus on, on the echocardiogram, include the integrity of the aortic valve leaflets, the number of leaflets, Doppler detection of aortic regurgitation, the dimensions of the aortic root, the presence or absence of dissection, and vegetations on the leaflets as well. And I would point out that inter-observer precision in detecting aortic regurgitation is really moderate.
DR. LOSCALZO: Inter-observer agreement is greater among cardiologists, about 94%, than non-cardiologists, about 78%. about 94%, than non-cardiologists, about 78%. And the last point I'll make about assessing patients for the presence of aortic regurgitation, is that among those suspected of having aortic regurgitation who are referred for cardiac catheterization, the positive likelihood ratio is quite high, between four and nine, while the negative likelihood ratio is quite low, between 0.1 and 0.2. So, if the patient gets to that stage, in which a cardiac catheterization seems indicated, it's highly likely, based on prior evaluation by physical examination and echocardiography, that the diagnosis will be confirmed and the hemodynamics defined more precisely.
DR. WIENER: Joe, I'm glad you mentioned your accuracy comment and put in a plug for cardiologists, but what are your thoughts on the cardiac physical examination in 2021, particularly with the growth of bedside ultrasound amongst primary care doctors and residents, and what is the role of the stethoscope as we move forward?
DR. LOSCALZO: That's a wonderful question, Charlie, and it really does speak to some of the sort of natural sociological phenomena associated with the uptake of new technologies. So, remember that Laennec invented the stethoscope in 1816, and at that time, it met with skepticism by physicians of the day, just as-
DR. WIENER: Including me, by the way, because I was skeptical. [all doctors chuckle]
DR. LOSCALZO: -just as bedside ultrasound, or any other new technology for that matter, has in some quarters among cardiologists today. By and large though, the uptake has been increasing, especially among our trainees, and to get to the point, I think you're intimating about cardiologists having better ears, Kobal and colleagues in 2006 published a really interesting paper, in which they looked at point of care ultrasound by first year medical students and showed that the medical students using point of care ultrasound outperformed the bedside cardiac examination by Board certified cardiologists 75% to 49% respectively.
DR. LOSCALZO: by Board certified cardiologists 75% to 49% respectively. So it continues, based on studies like Kobal's and others more recently, it continues to gain momentum as an important part of the bedside evaluation.
DR. WIENER: Do you think that this should be a part of all general internal medicine residency training programs as we move forward?
DR. LOSCALZO: Absolutely. I think, you know, it's already been taken up to that degree among emergency medicine programs as you know, and it's being taken up increasingly among internal medicine programs and I support that completely. Now, I would say one thing before we, sort of, toss out the physical exam, one of the critical issues about the weaknesses in the physical exam is the quality of the teacher.
DR. LOSCALZO: I'm always disturbed by those studies that suggest that the physical examination has, you know, a poor predictive accuracy of some sort or another, but it really depends upon who taught the examiner how to perform the exam and I'm sure that you've seen differences by generation in this regard as well. So, you're only as good as your best teacher, when it comes to using the physical examination.
DR. LOSCALZO: There's no absolute gold standard, as there might be if you're doing point of care ultrasound. So I want to put a pitch in for improving the quality of teaching the physical examination because coupling the physical examination with observations made by these technologies, like ultrasound, is absolutely the best way to make management decisions for our patients.
DR. HANDY: And I think too, one of the things you highlighted is that one of the most important parts is being at the bedside and there are a lot of things that, I think, pull us away, but all of these new technologies still are best at the bedside.
DR. LOSCALZO: Oh, I absolutely agree with that. I mean, I think that's another feature of the stethoscope, it really connects us physically and, if you will, emotionally to our patients. While it may have its limitations, it's really critical for patient-physician connection. It's a symbol of our profession and perhaps even a talisman in some cases among ill patients. So, I don't think we should toss it out in any significant way until we improve the quality of care in other ways that would enhance the physician-patient relationship to the same degree.
DR. HANDY: Thank you so much for that. Any other final thoughts or pearls for us today?
DR. LOSCALZO: I think I touched on all the points I wanted to make, but I guess I would say one other feature of the physical examination for aortic regurgitation that I didn't mention that most American-trained physicians may not realize, is that the best way to listen for a diastolic decrescendo murmur of AR is not just having the patient sit up, lean forward and end-expire, but also placing one's hands behind one's head, that also enhances the proximity of the aortic root to the chest wall and improves the pickup.
DR. WIENER: Great. Dr. Loscalzo, thank you so much for joining us today and we look forward to your wisdom on future cases of Harrison's Podclass.
DR. LOSCALZO: Thank you.
DR. HANDY: And if you want to learn more about this topic, you can check out Harrison's chapter on heart murmurs. [outro music] [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine. Go to accessmedicine.com to learn more.
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