CARDINAL CLINICAL SIGNS IN THE DIFFERENTIATION OF HEART MURMURS IN CHILDREN

Objective: To determine the diagnostic accuracy of clinical assessment of heart murmurs in children and specific clinical features that are predictive of cardiac disease. Design: Concurrent case series with pre test-posttest assessment. Setting: Pediatric cardiology outpatient cli nic. Participants: Five full-time academic pediatric cardiologists. Me asures: For each of 222 consecutive patients who were seen for first-t ime evaluation of a heart murmur, the clinical findings and diagnostic impressions were recorded after clinical assessment. The results of e lectrocardiograms and echocardiograms were then reviewed, and changes in diagnostic impressions were recorded and compared with the original impressions. Results: The prevalence of cardiac disease was 33%. Clin ical assessment differentiated those patients with pathologic murmurs with a sensitivity of 92%, specificity of 94%, positive predictive val ue of 88%, and negative predictive value of 96%. If diagnostic uncerta inty was considered an indication for echocardiography, then sensitivi ty and specificity increased to 97% and 98%, respectively. Missed dise ase included only trivial or minor lesions. Clinical features that wer e independently predictive of the presence of disease included murmurs that were pansystolic (odds ratio [OR], 54.0), grade 3 or more in int ensity (OR, 4.84), heard best at the left upper sternal border (OR, 4. 24) and harsh in quality (OR, 2.37), and the presence of an abnormal s econd heart sound (OR, 4.09) and an early or midsystolic click (OR, 8. 35). Conclusions: Clinical assessment by a pediatric cardiologist is s ufficient to distinguish pathologic from innocent heart murmurs. A gen eric approach by using specific clinical features that are independent ly associated with disease may have some practical utility to noncardi ologists.