How to Manage a Heart Murmur?
In the management of pathology of the heart, the diagnosis drives the treatment. For this reason, the diagnostic advantages of careful auscultation of the heart lead to both increased accuracy of diagnosis but also prevent missteps in protocol that can impact morbidity and mortality.
Confirmation of Diagnosis as Part of the Treatment Protocol
Once a provisional diagnosis is made based on abnormal heart sounds, confirmation usually relies on functional assessment as it is related to the diagnosis. Since many heart murmurs indicate disease, it is first important to differentiate the pathologic from the normal physiological (“flow”) murmurs. This requires adjunctive diagnostics:
- Examiner experience and expertise
- Electrocardiography (ECG): Used to correlate the sounds produced as murmurs with the electrical conduction sequence of the heart rate and rhythm.
- Chest X-ray: Identifies enlargement of the heart/ventricle(s) consistent with heart failure and valvular disease; it can also diagnose fluid shifts in the pulmonary system, such as pulmonary edema, lung congestion, and pleural effusions.
- Echocardiography: Cardiac ultrasonography can render visual information of structure (B mode ultrasound) and flow dynamics (functional flow via Doppler technology). The B mode is also useful in valve disease and in identifying the “vegetations” of endocarditis. The structural information gleaned from imaging can be used to assign physiologic relevance to the murmurs that are heard.
Therapy for Conditions Associated with Heart Murmurs
Therapy depends on the specific abnormality. Flow disturbances across the heart valves and through the chambers of the heart are treated according to site, severity of symptoms, and risks of morbidity and mortality. Stenosis, damage, or deterioration of a heart valve if mild and asymptomatic can be followed conservatively, but symptomatic patients can benefit from antiarrhythmics when indicated, anticoagulation therapy if there are thrombogenic conditions, and surgical repair (“commissurotomy”) or replacement (prosthetic valves). The decision for each of these is based on whether the mortality rate is lower for expectant therapy (mere observation) or for the specific invasive intervention.