Skip to main content

Main menu

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers

User menu

  • My alerts

Search

  • Advanced search
Annals of Family Medicine
  • My alerts
Annals of Family Medicine

Advanced Search

  • Home
  • Content
    • Current Issue
    • Online First
    • Multimedia
    • Collections
    • Past Issues
    • Articles by Subject
    • Articles by Type
    • Supplements
    • The Issue in Brief (Plain Language Summaries)
    • Call for Papers
  • Info for
    • Authors
    • Reviewers
    • Media
    • Job Seekers
  • About
    • Annals of Family Medicine
    • Editorial Staff & Boards
    • Sponsoring Organizations
    • Copyrights & Permissions
    • Announcements
  • Engage
    • Engage
    • e-Letters (Comments)
    • Subscribe
    • RSS
    • Email Alerts
    • Journal Club
  • Contact
    • Feedback
    • Contact Us
  • Careers
  • Follow annalsfm on Twitter
  • Visit annalsfm on Facebook
Research ArticleOriginal ResearchA

Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children

Bruno Lefort, Elodie Cheyssac, Nathalie Soulé, Jacques Poinsot, Marie-Catherine Vaillant, Alaeddin Nassimi and Alain Chantepie
The Annals of Family Medicine November 2017, 15 (6) 523-528; DOI: https://doi.org/10.1370/afm.2105
Bruno Lefort
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
2University François Rabelais, Tours, France
3INSERM UMR 1069 - Nutrition, Croissance et Cancer, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: lefort81@gmail.com
Elodie Cheyssac
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nathalie Soulé
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jacques Poinsot
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Marie-Catherine Vaillant
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alaeddin Nassimi
4University Hospital Centre of Poitiers, Poitiers, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Alain Chantepie
1Children Hospital Gatien de Clocheville, University Hospital Centre of Tours, Tours, France
2University François Rabelais, Tours, France
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF
Loading

Article Figures & Data

Tables

  • Additional Files
    • View popup
    Table 1

    Clinical and Echocardiographic Characteristics of the 30 Children With Abnormal Findings on an Echocardiogram

    PatientSexAge, yMurmur While StandingReduction of Intensity While StandingLocationRadiationTimingSymptomsCardiac Disease
    Patient 1M12NoNALow to middle left sternal borderNoSystolicNoMuscular VSD
    Patient 2F13NoNALeft upper sternal borderNoSystolicNoASD OS
    Patient 3M7YesNoLeft upper sternal borderNoSystolicYesASD OS
    Patient 4F10YesNoApexYesSystolicNoMitral regurgitation
    Patient 5F6YesNoApexNoSystolicNoMitral regurgitation
    Patient 6F5YesYesLeft upper sternal borderNoSystolicNoASD OS
    Patient 7F10YesYesLow to middle left sternal borderNoSystolicYesMitral regurgitation
    Patient 8F13YesYesLow to middle left sternal borderNoSystolicNoMitral regurgitation
    Patient 9F5YesNoLow to middle left sternal borderYesSystolicNoAortic stenosis
    Patient 10F5YesYesLeft upper sternal borderNoSystolicNoASD OS
    Patient 11F8YesNoLeft upper sternal borderNoSystolicNoASD OP
    Patient 12F13YesYesLeft upper sternal borderNoSystolicNoPulmonary stenosis
    Patient 13F5YesNoApexNoSystolicNoMitral regurgitation
    Patient 14F6YesYesLow to middle left sternal borderNoSystolicNoCoronary-to–pulmonary artery fistula
    Patient 15M9YesNoLow to middle left sternal borderNoSystolicNoPerimembranous VSD
    Patient 16M2YesNoLow to middle left sternal borderNoSystolicYesMuscular VSD
    Patient 17M4YesNoLow to middle left sternal borderNoSystolicNoMuscular VSD
    Patient 18M9YesYesLow to middle left sternal borderYesSystolicYesMuscular VSD, ASD OS
    Patient 19M4YesYesLow to middle left sternal borderNoSystolicYesMuscular VSD
    Patient 20M12YesYesLow to middle left sternal borderYesSystolicNoTricuspid regurgitation
    Patient 21M6YesNoLow to middle left sternal borderNoSystolicNoMitral regurgitation
    Patient 22M2YesYesLow to middle left sternal borderYesSystolicNoCoarctation of aorta
    Patient 23M6YesNoRight upper sternal borderYesSystolicNoMitral regurgitation
    Patient 24M10YesNoRight upper sternal borderYesSystolicNoAortic stenosis
    Patient 25M3YesNoLeft upper sternal borderYesSystolicNoASD OS
    Patient 26M5YesYesRight upper sternal borderYesSystolicNoAortic stenosis
    Patient 27M2YesNoLeft upper sternal borderNoSystolicYesASD OP
    Patient 28M13YesYesLeft upper sternal borderNoSystolicNoASD OP
    Patient 29M4YesNoLeft upper sternal borderNoSystolicYesASD OS
    Patient 30F2YesYesUnder left clavicleYesContinuousNoPDA
    • ASD =atrial septal defect; F=female; M=male; NA=not applicable; OP=ostium primum; OS=ostium secundum; PDA=patent ductus arteriosus; VSD = ventricular septal defect.

    • View popup
    Table 2

    Comparison of Clinical and Echocardiographic Characteristics Between Children With Pathologic and Physiologic Murmurs (N = 194)

    CharacteristicPathologic Murmur (n=30)Physiologic Murmur (n=164)P Value
    Age, y7.4 ± 3.86.2 ± 3.3.07
    Sex, % (No.)
     Male57 (17)64 (105).53
     Female43 (13)36 (59)
    Symptoms, % (No.)1.00
     Yes20 (6)9 (14)<.001
     No80 (24)91 (150)
    Murmur present in standing position, % (No.)
     Yes93 (28)40 (66)<.001
     No7 (2)60 (98)
    Murmur intensity decreased in standing position, % (No.)
     Yes43 (12)80 (53)<.001
     No57 (16)20 (13)
    Murmur timing, % (No.)
     Systolic97 (29)100 (164).16
     Diastolic0 (0)0 (0)
     Continuous3 (1)0 (0)
    Murmur location, % (No.)
     Right upper sternal border13 (4)6 (9).76
     Left upper sternal border7 (11)10 (16)<.001
     Low to middle left sternal border33 (10)82 (126)<.001
     Apex13 (4)2 (3)<.01
     Under left clavicle4 (1)0 (0).16
    Murmur radiation, % (No.)
     Yes33 (10)15 (25)<.05
     No67 (20)85 (139)
    • View popup
    Table 3

    Diagnostic Performance of Clinical Characteristics for Excluding a Pathologic Murmur

    CharacteristicPPV, % (95% CI)Specificity, % (95% CI)Sensitivity, % (95% CI)
    Disappearance on standing98 (93–100)93 (78–99)60 (52–67)
    Conventionally used characteristics
     Low to middle left sternal border location93 (87–96)67 (47–83)82 (75–88)
     Diminution or disappearance on standing91 (86–95)53 (34–72)90 (85–94)
     No radiation87 (81–92)33 (17–53)85 (78–90)
     No symptoms86 (80–91)20 (7–39)91 (86–95)
     Systolic timing85 (79–90)3 (0–17)100 (98–100)
    • PPV=positive predictive value.

Additional Files

  • Tables
  • The Article in Brief

    Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathological Heart Murmur in Children

    Bruno Lefort , and colleagues

    Background Although heart murmur in children is usually harmless (referred to as innocent murmur), in a small number of cases it is symptomatic of cardiac disease (referred to as pathological murmur). This study tests whether the disappearance of heart murmur upon standing can rule out a pathological murmur.

    What This Study Found A simple test--comparing children's heart murmur characteristics while standing versus lying flat on their back--reliably rules out pathological heart murmurs. Using an acoustic based, non-electronic stethoscope, researchers at two French universities noted heart sound characteristics of 194 consecutive children referred to pediatric cardiologists for heart murmur, first with patients in the supine (flat on their back) position, and then for at least one minute in the standing position. After observational data were collected, an echocardiogram was performed to assess the presence or absence of cardiac anomalies that could explain the murmur. Eight-five percent of children (n=164) referred to a cardiologist for heart murmur did not have a cardiac disease. Thirty children (15 percent) had an abnormal echocardiogram that explained the heart murmur. Of 100 children (51 percent) who had heart murmur while supine but not standing, two had an organic murmur and only one required follow-up. The disappearance of heart murmur while standing, therefore, excluded a pathological murmur with a high predictive positive value of 98 percent and a specificity of 93 percent, but with a poor sensitivity of 60 percent.

    Implications

    • In an era of highly technical medicine, the authors state, physical examination should remain the first step in diagnosis.
    • The authors conclude that the disappearance of heart murmur in children upon standing is a valuable clinical test to exclude a pathological cardiac murmur and avoid costly referral to a cardiologist.
  • Annals Journal Club

    Nov/Dec 2017: Auscultation While Standing


    The Annals of Family Medicine encourages readers to develop a learning community to improve health care and health through enhanced primary care. Participate by conducting a RADICAL journal club. RADICAL stands for Read, Ask, Discuss, Inquire, Collaborate, Act, and Learn. We encourage diverse participants to thinking critically about important issues affecting primary care and act on those discussions.1

    HOW IT WORKS

    In each issue, the Annals selects an article and provides discussion tips and questions. Take a RADICAL approach to these materials and post a summary of your conversation in our online discussion. (Open the article online and click on "TRACK Discussion/ Submit a comment.") Discussion questions and information are online at: http://www.AnnFamMed.org/site/AJC/.

    CURRENT SELECTION

    Lefort B, Cheyssac E, Soulé N, et al. Auscultation while standing: a basic and reliable method to rule out a pathological heart murmer in children. Ann Fam Med. 2017;15(6):523-528.

    Discussion Tips

    Evaluations of diagnostic tests are a critical, but under-appreciated, proportion of the medical literature. In clinical practice, appropriate use of high value diagnostic tests (eg, Lachman's test for ACL tear)2 and avoidance of low value tests (eg, Homan's sign for deep vein thrombosis,3 Tinel or Phalen signs for carpal tunnel in patients with symptoms)4 has the potential to improve the quality and value of medical care.

    Discussion Questions

    • What is a diagnostic test? Why do they matter? Are questions you ask patients diagnostic tests?
    • What question is asked by this study and why does it matter?
    • How does this study advance beyond previous research and clinical practice on this topic?
    • How strong is the study design for answering the question?
    • What are positive and negative predictive values? What are sensitivity and specificity? How are these statistics used to judge diagnostic tests?
    • What is a likelihood ratio and how is it calculated? Are you able to calculate likelihood ratios from this study? If so, does this diagnostic test have a strong impact on the probability of the diagnosis?
    • What is a Fagan's nomogram and how is it used?5
    • What are the main study findings?
    • To what degree could the findings be affected by:
      • How patients were selected or excluded?
      • How the main variables were measured?
      • Chance?
    • How comparable is the study sample to similar patients in your practice? How transportable are the findings?
    • What is spectrum bias? How could it apply to this study?
    • How might this study change your practice? Education? Research?
    • Are further studies on the topic warranted? If so, how would you design the study?
    • Could different diagnostic tests combine to further improve decision making in applicable clinical scenarios?

    References

    1. Stange KC, Miller WL, McLellan LA, et al. Annals Journal Club: It's time to get RADICAL. Ann Fam Med. 2006;4(3):196-197. http://annfammed.org/content/4/3/196.full.
    2. Knee ligaments and menisci. In: Simel DL, Rennie D. eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://jamaevidence.mhmedical.com/content.aspx?bookid=845&sectionid=61357572. Accessed Oct 17, 2017.
    3. Deep vein thrombosis. In: Simel DL, Rennie D. eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://jamaevidence.mhmedical.com/content.aspx?bookid=845&sectionid=61357505. Accessed Oct 13, 2017.
    4. Carpal tunnel syndrome. In: Simel DL, Rennie D. eds. The Rational Clinical Examination: Evidence-Based Clinical Diagnosis. New York, NY: McGraw-Hill; 2009. http://jamaevidence.mhmedical.com/content.aspx?bookid=845&sectionid=61357497. Accessed Oct 13, 2017.
    5. Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293(5):257.

PreviousNext
Back to top

In this issue

The Annals of Family Medicine: 15 (6)
The Annals of Family Medicine: 15 (6)
Vol. 15, Issue 6
November/December 2017
  • Table of Contents
  • Index by author
  • Back Matter (PDF)
  • Front Matter (PDF)
  • In Brief
Print
Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Email Article

Thank you for your interest in spreading the word on Annals of Family Medicine.

NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

Enter multiple addresses on separate lines or separate them with commas.
Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children
(Your Name) has sent you a message from Annals of Family Medicine
(Your Name) thought you would like to see the Annals of Family Medicine web site.
CAPTCHA
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
2 + 15 =
Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.
Citation Tools
Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children
Bruno Lefort, Elodie Cheyssac, Nathalie Soulé, Jacques Poinsot, Marie-Catherine Vaillant, Alaeddin Nassimi, Alain Chantepie
The Annals of Family Medicine Nov 2017, 15 (6) 523-528; DOI: 10.1370/afm.2105

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Get Permissions
Share
Auscultation While Standing: A Basic and Reliable Method to Rule Out a Pathologic Heart Murmur in Children
Bruno Lefort, Elodie Cheyssac, Nathalie Soulé, Jacques Poinsot, Marie-Catherine Vaillant, Alaeddin Nassimi, Alain Chantepie
The Annals of Family Medicine Nov 2017, 15 (6) 523-528; DOI: 10.1370/afm.2105
del.icio.us logo Digg logo Reddit logo Twitter logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Abstract
    • INTRODUCTION
    • METHODS
    • RESULTS
    • DISCUSSION
    • Footnotes
    • References
  • Figures & Data
  • Info & Metrics
  • eLetters
  • PDF

Related Articles

  • PubMed
  • Google Scholar

Cited By...

  • In This Issue: Tech, Touch, & Templates for Understanding and Improving Care
  • Google Scholar

More in this TOC Section

  • Primary Care Physicians’ and Patients’ Perspectives on Equity and Health Security of Infectious Disease Digital Surveillance
  • The Impact of Community Health Information Exchange Usage on Time to Reutilization of Hospital Services
  • Impact of Primary Care Attributes on Hospitalization During the COVID-19 Pandemic: A Nationwide Prospective Cohort Study in Japan
Show more Original Research

Similar Articles

Keywords

  • heart murmur
  • heart defects
  • congenital
  • children
  • auscultation
  • primary care
  • practice-based research

Content

  • Current Issue
  • Past Issues
  • Past Issues in Brief
  • Multimedia
  • Articles by Type
  • Articles by Subject
  • Multimedia
  • Supplements
  • Online First
  • Calls for Papers

Info for

  • Authors
  • Reviewers
  • Media
  • Job Seekers

Engage

  • E-mail Alerts
  • e-Letters (Comments)
  • RSS
  • Journal Club
  • Submit a Manuscript
  • Subscribe
  • Family Medicine Careers

About

  • About Us
  • Editorial Board & Staff
  • Sponsoring Organizations
  • Copyrights & Permissions
  • Contact Us
  • eLetter/Comments Policy

© 2023 Annals of Family Medicine