DOES THIS PATIENT HAVE AN ABNORMAL SYSTOLIC-MURMUR

Our objective was to review the available evidence of the precision an d accuracy of the clinical examination for abnormal systolic murmurs. We conducted a MEDLINE search, manually reviewed all reference lists,a nd contacted authors of published studies. Each study was independentl y reviewed by 2 observers and graded for methodologic quality. We foun d that most studies were conducted using cardiologist examiners. In th e clinical setting, the reliability of detecting systolic murmurs was fair (kappa, 0.30-0.48). The most useful findings for ruling in aortic stenosis are a slow rate of rise of the carotid pulse (positive likel ihood ratio, 2.8-130), mid to late peak intensity of the murmur (posit ive likelihood ratio, 8.0-101), and decreased intensity of the second heart sound (positive likelihood ratio, 3.1-50). The most useful findi ng for ruling out aortic stenosis is the absence of murmur radiation t o the right carotid artery (negative likelihood ratio, 0.05-0.10). Sma ller, lower-quality studies indicate that cardiologists can accurately rule in and rule out mitral regurgitation, tricuspid regurgitation, h ypertrophic cardiomyopathy, and echocardiographic mitral valve prolaps e. We conclude that the clinical examination by cardiologists is accur ate for detecting various causes of abnormal systolic murmurs. Studies of the clinical examination by noncardiologists are needed.