Approach to Evaluating Abnormal Heart Sounds
Initial Assessment of Heart Sounds
- A comprehensive echocardiogram with Doppler flow studies is the single most useful diagnostic test for evaluating abnormal heart sounds, as it can determine whether abnormalities of myocardium, heart valves, or pericardium are present and which chambers are involved, according to the American College of Cardiology 1
- Systolic murmurs occur between S1 and S2 heart sounds, as noted by the American College of Cardiology 2
- The American College of Cardiology recommends determining the precise timing within the cardiac cycle (systolic vs. diastolic) and noting the relationship to S1 and S2 heart sounds 3
Diagnostic Algorithm
- The American College of Cardiology recommends that diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, and systolic murmurs grade 3 or louder require immediate echocardiography 2
- Echocardiography is a Class I indication (strongly recommended) for diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, and murmurs associated with ejection clicks, according to the American College of Cardiology 3
- The American Heart Association recommends exercise testing when exercise limitation is a symptom but the contribution of heart disease is uncertain, as published in Circulation 5
- Cardiac catheterization with coronary angiography is recommended for patients with chest pain, as noted in Circulation 6
Special Considerations
- Innocent murmurs in adults are characterized by a grade 1-2 intensity at the left sternal border, systolic ejection pattern, normal S1 and S2, and no other abnormal sounds, according to the American College of Cardiology 2
- The American College of Cardiology recommends that children with cyanosis, respiratory distress, abnormal pulses, or cardiac murmur in neonates, loud or abnormal murmurs in infants or children, failure to thrive with abnormal cardiac findings, or syndromes associated with heart disease should undergo echocardiography 4