Article Figures & Data
Tables
- 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.
- 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) - 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.
Additional Files
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§ionid=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§ionid=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§ionid=61357497. Accessed Oct 13, 2017.
- Fagan TJ. Letter: Nomogram for Bayes theorem. N Engl J Med. 1975;293(5):257.