Search

An asymptomatic child with a murmur can be challenging practice management conundrum. Some providers refer all patients with a "new" murmur to a cardiologist, likely resulting in excessive resource utilization and parental anxiety. This study examines whether the prevalence of significant cardiac pathology differs in asymptomatic patients aged 2 to 18 years who were referred for a murmur that was "new" versus those referred for a murmur that was known to exist and followed conservatively during the previous 2 years. Of 473 patients meeting inclusion criteria, 33/473 (7.0%) were diagnosed with cardiac pathology, with 21/357 (5.9%) occurring among "new" murmur referrals and 12/116 (10.3%) occurring among "known" murmur referrals. Notably, 34/357 (9.5%) patients referred for a "new" murmur had no murmur present when assessed by the cardiologist. This study suggests that asymptomatic children with a "new" murmur may be conservatively managed. This may lessen health care resource utilization rates and overall parental anxiety.

Innocent heart murmurs are quite common in children and adolescents. These murmurs are physiologic in nature and are not associated with any structural heart disease. Not only does the idea of having a child with a murmur bring unnecessary unrest to families, but the child also often goes through numerous tests that could be avoided. It is critical to obtain a detailed history and perform a thorough physical examination to diagnose these innocent murmurs. This article reviews the different types of innocent murmurs, their characteristics, how they can be differentiated on the physical examination, and most importantly, how they can be differentiated from pathologic murmurs, which require referral to a pediatric cardiologist and additional testing. [Pediatr Ann. 2016;45(8):e306-e309.]., (Copyright 2016, SLACK Incorporated.)

Introduction: Hospitalists are frequently consulted on postoperative patients with hypotension. Postoperative hypotension is common and can be due to variety of causes. Systolic anterior motion of the mitral valve leading to left ventricular outflow tract obstruction is a rare cause of postoperative hypotension and can occur without prior structural heart disease. A high index of suspicion can lead to early recognition of this unique condition., Case Presentation: A 90-year-old Caucasian woman with no known structural heart abnormality was admitted to the intensive care unit with hypotension after a left hip arthroplasty revision. A transthoracic echocardiogram revealed systolic anterior motion of the mitral valve and dynamic left ventricular outflow tract obstruction as the likely cause of her hypotension. Our patient was treated with fluid resuscitation and phenylephrine with improvement in blood pressure. A repeat echocardiogram on postoperative day 5 showed resolution of the left ventricular outflow tract obstruction. Intraoperative vasodilatation and volume loss that caused underfilling of the left ventricle likely led to dynamic outflow tract obstruction in our patient., Conclusions: Hospitalists should be aware of systolic anterior motion of the mitral valve as a rare peri-operative complication in patients with or without underlying cardiac pathology as it is treated differently than other causes of peri-operative hypotension. Clinical suspicion, early recognition, and prompt treatment can improve clinical outcomes in these patients.

Background: Investigation and management of neonatal heart murmurs varies widely and is dependent on local resources. In order to standardise the management of heart murmurs in our hospital a guideline (based on clinical examination with selective cardiology review) was introduced., Aims: To establish adherence to and safety of the guideline; to review workload implications and to define the causes of neonatal heart murmurs in our population., Methods: Patients were prospectively identified over a 2-year period (August 2006 to July 2008). Case notes were reviewed and examination findings, investigations, follow up and diagnosis recorded., Results: 89 babies were identified. The guideline was generally well adhered to. In total 51 (57%) of babies were referred for cardiology assessment. In 40 babies this assessment included an echocardiogram. 30 babies (34%) had an underlying cardiac malformation: 25 were identified before discharge home. 15/30 (50%) of the babies with a cardiac malformation remain under cardiology follow up at the age of 1 year. No baby discharged from follow up without cardiology review subsequently presented with a cardiac problem., Conclusion: A significant minority of babies with a heart murmur have an underlying cardiac malformation. Our guideline appears to ensure the timely identification of these babies and rationalises our use of specialist services.

Heart murmurs are common in healthy infants, children, and adolescents. Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease. Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. Physical examination should focus on vital signs; age-appropriate exercise capacity; respiratory or gastrointestinal manifestations of congestive heart failure; and a thorough cardiovascular examination, including features of the murmur, assessment of peripheral perfusion, and auscultation over the heart valves. Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Electrocardiography and chest radiography rarely assist in the diagnosis. Referral to a pediatric cardiologist is recommended for patients with any other abnormal physical examination findings, a history of conditions that increase the likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified by the family physician. Echocardiography provides a definitive diagnosis and is recommended for evaluation of any potentially pathologic murmur, and for evaluation of neonatal heart murmurs because these are more likely to be manifestations of structural heart disease.

The ability of the NP to discern pediatric heart murmurs is critical for accurate assessment of etiology, appropriate diagnostic testing, and prudent referral when indicated. This review includes an overview of cardiac assessment, distinguishing features of innocent and pathologic murmurs, differential diagnosis of murmurs, and current referral recommendations.

Objective: To assess whether primary care physicians, via referrals or other mechanisms, are now providing proportionally less care for children with specific common diagnoses, thus driving greater demand for specialist services., Study Design: Secondary data analysis (1993-2001) from one of the largest commercial healthcare organizations in the United States. Evaluation and management (E/M) common procedural terminology (CPT) visit codes and International Classification of Diseases (ICD) codes pertaining to asthma, constipation, headache, and heart murmurs were selected. Visits were then assigned to the specialty of physician providing care. Significant differences between and among categories of physicians were tested using logistic regression., Results: Overall, pediatrician generalists and specialists provided a greater proportion of E/M visits to children in 2001 than in 1993, compared with nonpediatrician providers. However, although the absolute increase in the proportion of all E/M visits by children <18 years of age to pediatrician generalists was greater than that of pediatrician subspecialists (4.77% vs 0.69%; P <.0001), the relative increase was much smaller for the generalists (8.9% vs 19.7%; P <.0001). Findings were consistent for most of the specific diagnoses examined., Conclusions: The increases in both the proportion and number of visits made to specialists has not been accompanied by a decrease in visits to generalists.

A 19-year-old girl with coarctation of the aorta and patent ductus arteriosus underwent simultaneous treatment of native coarctation and closure of ductus arteriosus using a covered Cheatham-Platinum stent. This technique may be used as an alternative to other forms of interventional therapy or surgery for this combination of lesions in adolescents and adults., (Copyright 2003 Wiley-Liss, Inc.)

Background: Limited resources, managed care, and advances in technology have led to the suggestion that physicians other than cardiologists be further empowered to perform the initial cardiac evaluation in children with suspected heart disease. To study this strategy, we compared the management decisions of pediatricians with the recommendations of pediatric cardiologists who reviewed the records of the same patients., Methods: Sixty-nine patients aged <23 years with suspected heart disease were referred by pediatricians (n = 40) on the inpatient service at Boston Medical Center for either a cardiology consultation or echocardiography. Two pediatric cardiologists who were blinded to the management decisions and clinical outcomes later reviewed the patient records. Recommendations between the 2 pediatric cardiologist reviewers and the managing pediatricians were compared., Results: Pediatricians scheduled significantly fewer cardiology follow-up visits, instituted cardiac medications significantly less often, arranged significantly fewer family meetings to review cardiac findings, and ordered significantly fewer additional cardiac procedures than the pediatric cardiologists. This result was consistent regardless of whether the pediatrician's management decisions were made on the basis of the echocardiogram results only or on the recommendations of a cardiology consultant. The 2 pediatric cardiologist reviewers agreed more often with each other than either did with the managing pediatricians., Conclusions: Pediatricians have different management styles than pediatric cardiologists for patients with suspected cardiac disease. The effect of these differences on outcome is unknown, and further investigation is warranted.

History and Clinical Findings: A 19-year-old youth was hospitalised because of sudden onset of incomplete lid closure and drooping mouth on the left. He regularly walked through fields and woods; three weeks before admission he had noted swelling and reddening on his neck, which he thought was due to an insect bite. When 9 years old a functional heart murmur and 1 degree AV block (P-R interval 0.25s) had been found. Physical examination showed peripheral facial paresis and a 2/6 systolic murmur over the aortic area., Investigations: As Borreliosis (Lyme disease) was suspected, relevant laboratory tests were performed. These revealed specific IgM antibodies against Borrelia burgdorferi. Polymerase chain reaction demonstrated B. burgdorferi-specific DNA in cerebrospinal fluid and urine. The ECG showed 1 degree AV block (P-R interval 0.28s)., Treatment and Course: Ceftriaxone was administered at once (4 g, followed by 2 g daily intravenously for 14 days). The P-R interval increased to maximally 0.31 s and transient incomplete right bundle branch block developed on the second day. Long-term ECG monitoring also revealed ventricular arrhythmias (Lown IVb), but they gradually disappeared. The neurological signs regressed completely within five days of the start of treatment, while the P-R interval had returned to its initial value of 0.25 s 3 months later., Conclusion: The case makes clear that an ECG should be recorded in borreliosis even in the absence of cardiac symptoms. Hospitalisation with long-term monitoring becomes necessary if it is abnormal.