Heart murmurs

Heart murmurs are the typical findings that accompany heart deseases. They can be caused either by the turbulent flow of the blood or by the tissue vibration. Although this sign is always disturbing, it doesn't always stands for the heart desease. If all other heart tests are normal, the heart murmur is considered as the "innocent". For the diagnosis it is contributive to define the type of the heart murmur - systolic, diastolic (in most cases pathological) or continuous. The heart murmur takes at least a quarter of the apprropriate fase of the cycle (systole or diastole).

Fase of the heart cycle
Determination is not possible in children because of the high heart rate.
 * Early (prosystolic, protodiastolic)
 * Middle (meso-)
 * Late (tele-)

Changes of the intensity

 * Without changes of the intensity
 * Crescendo
 * Decrescendo
 * Crescendo-decrescendo



Intensity of the murmurs

 * Levine grading scale:
 * 1/6 audible while listening very carefully with concentration
 * 2/6 the most quiet but audible without concentration
 * 3/6 readily audible but without thrill
 * 4/6 murmur with a thrill
 * 5/6 audible with only the rim of the stethoscope
 * 6/6 audible even if the stethoscope is removed from the chest

Frequency of the murmurs

 * Low frequency (the rumbling murmur)
 * Medium frequency (the harsh murmur)
 * High frequency (the blowing murmur)

The systolic murmur

 * Ejection murmur
 * appears while the blood flows through the narrowed valve, doesn't take the whole systole, begins after the first and ends before the second heart sound (crescendo-decrescendo).


 * Regurgitation murmur
 * appears in case of the valve insufficiency, is pansystolic, the volume of the murmur remains the same for the whole time.

In children cardiology these terms are not recommended because they're not typical and can stand for the other problems.

Innocent murmur
An innocent murmur is a sound that is caused by the virbrations of the heart walls during the blood flow through the ventricles and valves or through the heart's blood vessels. This murmur is not harmful, often occures in children and disappears before the adulthood. This phenomenon is relatively common. It appears in 80 % of the cases, an experienced paediatrician is able to recognize it easily. Innocent murmurs are systolic murmurs with short intensity, graded 1-2/6, with no propagation. In some cases it is appropriate to use echocardiography and electrocardiogram in order to exclude possible problems. These murmurs require no medicamentation and don't indicate heart disorders. Although they mostly occure in children and then disappear, they can also occure in adults.

Still's murmur
This type of murmur occures mostly in preschool-age children and toddlers. It's a vibratory low-frequency murmur that is audible close to the lower sternal border. It's brief and reminds a string twang.

Physiological eject murmur above the pulmonary trunk
Mostly occures in school-age children and adolescents. This murmur is expulsive and audible in second intercostal space close to the sternum. It can be mistaken with the findings in mild pulmonary trunk stenosis or the ventricular septal defect, that's why it's important to examine the second heart sound above the pulmonary trunk (without splittings or clicks).

The murmur of the physiological peripheral pulmonary stenosis
Is audible in the pericordium, axilla and on the back, often occures in newborns and infants, maximum 6 months old. It can be mistaken with the true peripheral pulmonary stenosis and mild coarctation of the aorta.

Whirling venous murmur
Most often occures in children from three to eight years old, is audible under the clavicles, especially on the right side. The murmur is quite, buzzing and continuous, can cause the suspicion of the patent ductus arteriosus. The most expressive sound is in standing and tilting the head back, on the contrary in lying on back or leaning the head forward (or pressing the jugular vein with a finger) the murmur disappears.

Indication for cardiac testing
Patient with murmurs should be sent for the cardiac testing if he


 * has other signs - cyanosis, decreased physical fitness, repetitive respiratory infections,
 * has low birth weight, insufficient weight gain during his growth and puberty or the chromosomal abnormalities,
 * has a loud murmur (3/6 and more) accompanied with a thrill or other phenomena, or the diastolic murmur,
 * has an abnormal EKG or RTG measures.