Evaluation of a Newly Detected Cardiac Murmur in a Child

Indications for Echocardiography

• The American College of Cardiology recommends immediate echocardiography for any diastolic murmur, as it is always pathologic, in children with a newly detected cardiac murmur 1, 2, 3
• The American College of Cardiology suggests that continuous murmurs, which may indicate patent ductus arteriosus or shunt lesions, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Holosystolic/pansystolic murmurs, which may indicate mitral regurgitation or ventricular septal defect, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Late systolic murmurs, which may suggest mitral valve prolapse, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Grade 3 or louder systolic murmurs, which have a higher likelihood of organic heart disease, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Murmurs with ejection clicks, which may indicate bicuspid aortic valve or pulmonary stenosis, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Murmurs radiating to the neck or back, which may suggest aortic stenosis or coarctation, require immediate echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• The American College of Cardiology recommends echocardiography for any symptoms, such as syncope, chest pain, dyspnea, exercise intolerance, or signs of heart failure, in children with a newly detected cardiac murmur 1, 2, 3
• Abnormal cardiac physical findings, such as abnormal S2, S3 or S4 gallop, displaced apical impulse, or abnormal peripheral pulses, require echocardiography in children with a newly detected cardiac murmur 1, 2, 3
• Abnormal ECG findings, such as ventricular hypertrophy, atrial enlargement, or conduction abnormalities, require echocardiography in children with a newly detected cardiac murmur 1, 2, 4
• Abnormal chest X-ray findings, such as cardiomegaly or abnormal pulmonary vascularity, require echocardiography in children with a newly detected cardiac murmur 1, 2, 4

Echocardiography in Asymptomatic Children

• The American College of Cardiology does not recommend routine echocardiography for asymptomatic children with isolated grade 2 or softer midsystolic murmurs at the left sternal border and completely normal physical examination findings 1, 2

Role of ECG and Chest X-Ray

• Routine ECG and chest radiography are not recommended for asymptomatic children with isolated grade 2 or softer midsystolic murmurs at the left sternal border, as they rarely change management and add unnecessary cost 1, 2, 4
• However, if ECG or chest X-ray have already been obtained and show abnormalities, echocardiography is recommended 1, 2