Management of Elderly Patients with Newly Discovered Heart Murmurs

Introduction to Murmur Assessment

The American College of Cardiology recommends that all elderly patients with newly discovered heart murmurs require echocardiography unless the murmur is clearly innocent (grade 1-2 midsystolic at left sternal border with normal S2 splitting, no symptoms, and normal ECG/chest X-ray if obtained) 1, 2, 3

Any diastolic murmur regardless of intensity is virtually always pathologic, according to the American College of Cardiology 1, 3, 4
All continuous murmurs suggest shunt lesions, as stated by the American College of Cardiology 1, 3, 4
Holosystolic or late systolic murmurs indicate mitral regurgitation or ventricular septal defect, as per the American College of Cardiology 1, 3, 4
Grade 3/6 or louder systolic murmurs have a higher likelihood of organic heart disease, according to the American Heart Association 5, 3, 4
Murmurs radiating to neck or back suggest aortic stenosis or coarctation, as stated by the American College of Cardiology 1, 3
Murmurs with ejection clicks indicate bicuspid aortic valve or pulmonic stenosis, according to the American College of Cardiology 1, 3

Syncope suggests severe aortic stenosis or hypertrophic cardiomyopathy, as per the American College of Cardiology 2, 6, 4
Angina pectoris indicates hemodynamically significant valve disease, according to the American College of Cardiology 2, 6, 4
Heart failure symptoms (dyspnea, orthopnea, edema) suggest decompensated valve disease, as stated by the American College of Cardiology 2, 6, 4
History of thromboembolism raises concern for atrial fibrillation from valve disease or endocarditis, according to the American College of Cardiology 1, 2, 4

Single or paradoxically split S2 may indicate severe aortic stenosis, as per the American Heart Association 5, 6
Widely split S2 suggests right ventricular volume overload, according to the American College of Cardiology 3
Parvus et tardus carotid pulse is a sign of severe aortic stenosis, although it may be absent in elderly patients due to vascular aging, as stated by the American College of Cardiology 2, 5, 6

The American College of Cardiology states that many elderly patients have grade 1-2 midsystolic murmurs from aortic sclerosis, but echocardiography is frequently necessary to distinguish this from true aortic stenosis 1, 2
Classic signs of severe aortic stenosis may be absent in elderly patients, including a normal carotid upstroke, a soft or apically radiating murmur, and the only reliable physical finding to exclude severe aortic stenosis is a normally split S2, as per the American Heart Association 2, 5, 6

The American College of Cardiology recommends performing careful auscultation with dynamic maneuvers (Valsalva, standing/squatting, handgrip) 2, 6, 3
Assessing for symptoms (syncope, angina, heart failure, thromboembolism) is crucial, as stated by the American College of Cardiology 2, 6, 4
Examining carotid pulses, S2 splitting, and other cardiac findings is necessary, according to the American College of Cardiology 2, 5, 6
Obtaining ECG and chest X-ray if readily available is recommended, but should not delay echocardiography, as per the American College of Cardiology 1, 2, 4
Ordering echocardiography for any concerning features is appropriate, as stated by the American College of Cardiology 1, 3, 4