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

doi:10.1370/afm.2105

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Table 1

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

Patient	Sex	Age, y	Murmur While Standing	Reduction of Intensity While Standing	Location	Radiation	Timing	Symptoms	Cardiac Disease
Patient 1	M	12	No	NA	Low to middle left sternal border	No	Systolic	No	Muscular VSD
Patient 2	F	13	No	NA	Left upper sternal border	No	Systolic	No	ASD OS
Patient 3	M	7	Yes	No	Left upper sternal border	No	Systolic	Yes	ASD OS
Patient 4	F	10	Yes	No	Apex	Yes	Systolic	No	Mitral regurgitation
Patient 5	F	6	Yes	No	Apex	No	Systolic	No	Mitral regurgitation
Patient 6	F	5	Yes	Yes	Left upper sternal border	No	Systolic	No	ASD OS
Patient 7	F	10	Yes	Yes	Low to middle left sternal border	No	Systolic	Yes	Mitral regurgitation
Patient 8	F	13	Yes	Yes	Low to middle left sternal border	No	Systolic	No	Mitral regurgitation
Patient 9	F	5	Yes	No	Low to middle left sternal border	Yes	Systolic	No	Aortic stenosis
Patient 10	F	5	Yes	Yes	Left upper sternal border	No	Systolic	No	ASD OS
Patient 11	F	8	Yes	No	Left upper sternal border	No	Systolic	No	ASD OP
Patient 12	F	13	Yes	Yes	Left upper sternal border	No	Systolic	No	Pulmonary stenosis
Patient 13	F	5	Yes	No	Apex	No	Systolic	No	Mitral regurgitation
Patient 14	F	6	Yes	Yes	Low to middle left sternal border	No	Systolic	No	Coronary-to–pulmonary artery fistula
Patient 15	M	9	Yes	No	Low to middle left sternal border	No	Systolic	No	Perimembranous VSD
Patient 16	M	2	Yes	No	Low to middle left sternal border	No	Systolic	Yes	Muscular VSD
Patient 17	M	4	Yes	No	Low to middle left sternal border	No	Systolic	No	Muscular VSD
Patient 18	M	9	Yes	Yes	Low to middle left sternal border	Yes	Systolic	Yes	Muscular VSD, ASD OS
Patient 19	M	4	Yes	Yes	Low to middle left sternal border	No	Systolic	Yes	Muscular VSD
Patient 20	M	12	Yes	Yes	Low to middle left sternal border	Yes	Systolic	No	Tricuspid regurgitation
Patient 21	M	6	Yes	No	Low to middle left sternal border	No	Systolic	No	Mitral regurgitation
Patient 22	M	2	Yes	Yes	Low to middle left sternal border	Yes	Systolic	No	Coarctation of aorta
Patient 23	M	6	Yes	No	Right upper sternal border	Yes	Systolic	No	Mitral regurgitation
Patient 24	M	10	Yes	No	Right upper sternal border	Yes	Systolic	No	Aortic stenosis
Patient 25	M	3	Yes	No	Left upper sternal border	Yes	Systolic	No	ASD OS
Patient 26	M	5	Yes	Yes	Right upper sternal border	Yes	Systolic	No	Aortic stenosis
Patient 27	M	2	Yes	No	Left upper sternal border	No	Systolic	Yes	ASD OP
Patient 28	M	13	Yes	Yes	Left upper sternal border	No	Systolic	No	ASD OP
Patient 29	M	4	Yes	No	Left upper sternal border	No	Systolic	Yes	ASD OS
Patient 30	F	2	Yes	Yes	Under left clavicle	Yes	Continuous	No	PDA

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.

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Table 2

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

Characteristic	Pathologic Murmur (n=30)	Physiologic Murmur (n=164)	P Value
Age, y	7.4 ± 3.8	6.2 ± 3.3	.07
Sex, % (No.)
Male	57 (17)	64 (105)	.53
Female	43 (13)	36 (59)
Symptoms, % (No.)			1.00
Yes	20 (6)	9 (14)	<.001
No	80 (24)	91 (150)
Murmur present in standing position, % (No.)
Yes	93 (28)	40 (66)	<.001
No	7 (2)	60 (98)
Murmur intensity decreased in standing position, % (No.)
Yes	43 (12)	80 (53)	<.001
No	57 (16)	20 (13)
Murmur timing, % (No.)
Systolic	97 (29)	100 (164)	.16
Diastolic	0 (0)	0 (0)
Continuous	3 (1)	0 (0)
Murmur location, % (No.)
Right upper sternal border	13 (4)	6 (9)	.76
Left upper sternal border	7 (11)	10 (16)	<.001
Low to middle left sternal border	33 (10)	82 (126)	<.001
Apex	13 (4)	2 (3)	<.01
Under left clavicle	4 (1)	0 (0)	.16
Murmur radiation, % (No.)
Yes	33 (10)	15 (25)	<.05
No	67 (20)	85 (139)

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Table 3

Diagnostic Performance of Clinical Characteristics for Excluding a Pathologic Murmur

Characteristic	PPV, % (95% CI)	Specificity, % (95% CI)	Sensitivity, % (95% CI)
Disappearance on standing	98 (93–100)	93 (78–99)	60 (52–67)
Conventionally used characteristics
Low to middle left sternal border location	93 (87–96)	67 (47–83)	82 (75–88)
Diminution or disappearance on standing	91 (86–95)	53 (34–72)	90 (85–94)
No radiation	87 (81–92)	33 (17–53)	85 (78–90)
No symptoms	86 (80–91)	20 (7–39)	91 (86–95)
Systolic timing	85 (79–90)	3 (0–17)	100 (98–100)

PPV=positive predictive value.

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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

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.
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.
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.
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.
Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293(5):257.