Still's murmur

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Recording of an innocent Still's murmur in a toddler

Still's murmur (also known as vibratory murmur) is a common type of benign or "innocent" functional heart murmur that is not associated with any sort of cardiac disorder or any other medical condition. [1] It can occur at any age although it is most common among children two to seven years of age and it is rare in adulthood. [2]

Contents

Still's murmur was initially described by Dr. George Frederic Still, England's first professor of childhood medicine at the Great Ormond Street Hospital for Children. In his pediatric textbook Common Disorders and Diseases of Childhood (published 1909) Dr. Still noted:

“I should like to draw attention to a particular bruit which has somewhat of a musical character, but is neither of sinister omen nor does it indicate endocarditis of any sort. …its characteristic feature is a twangy sound, very like that made by twanging a piece of tense string... Whenever may be its origin, I think it is clearly functional, that is to say, not due to any organic disease of the heart either congenital or acquired.” [3]


Signs and symptoms

Still's murmur is detected via auscultation with a stethoscope. It has a peculiar "musical", "resonant" or "vibratory" quality that is quite unique. [1] [2] It is generally most easily heard at the left middle or lower sternal border and the right upper sternal border, often with radiation to the carotid arteries, although other locations are common. The murmur is usually louder in the supine position and may only be audible in the supine position.[ citation needed ]

The Still's murmur can be differentiated from pathological murmurs by this musical quality and lack of extra snaps or clicks in the heart sounds.

Because the Still's murmur has never been associated with any sort of cardiac disorder, it has no associated symptoms. [1] [2]

Causes

Heart murmurs are sounds generated by blood flowing through the structures of the heart. The location of the Still's murmur on examination suggests resonation of blood in the left ventricular outflow tract and aorta, and this is supported by studies that have shown that the murmur is more intense over the aortic valve than the pulmonary valve. [4] There has been conjecture that the vibratory or musical quality of the murmur is caused by vibration of “false chordae” of the left ventricle, which are a common finding in normal individuals, but no relationship between the two has been proven. [5] There is some evidence that a smaller aorta with higher peak flow velocities are associated with Still's murmur, [6] [7] [8] which certainly fits in well with the concept that the murmur is a musical phenomenon.[ citation needed ]

Diagnosis

Positioning for stethoscope to best hear Still's Murmur Stills murmur auscultation location.png
Positioning for stethoscope to best hear Still's Murmur

Still's murmur is diagnosed in the course of a physical examination of the patient, usually using a stethoscope. The murmur has a vibratory quality that can be detected as a regular frequency on phonocardiography, [9] although this type of testing is now rarely used. Additional testing including electrocardiography (ECG or EKG) or echocardiography may be helpful in ruling out other conditions, particularly if the physical examination is not completely characteristic of Still's murmur. When additional testing is done in the setting of Still's murmur the results are normal, since Still's murmur is not associated with any sort of cardiovascular pathology.[ citation needed ]

Treatment

Still's murmur does not represent any sort of disorder and does not present a health risk, so no treatment is necessary. [1] [2]

Epidemiology

Still's murmurs may occur in as many as a third of all children. This type of murmur occurs most often in children two to seven years of age, but can occur in younger or older children. In most cases, the innocent Still's murmur is present on and off during childhood and resolves on its own by young adulthood. [2]

Prognosis

The Still's murmur is a harmless finding that does not suggest any medical disorder. In most cases, Still's murmur disappears around adolescence without medical intervention. [2]

However, families are often anxious when told their child has a heart murmur. Parents of children diagnosed with Still's murmur may experience significantly greater anxiety than the children themselves. In a study conducted on the families impacted by Still's murmur, the parents were worried about a variety of issues. Their concerns included: the need for medicine (49%), facing sports restrictions (41%), the need for heart surgery (29%), other offspring also having Still's murmur (20%), and early death (13%). Mothers worried that they did something during pregnancy that caused the murmur (19%). Even after being reassured by the child's physician, 17% of parents were still anxious. After hearing from a cardiologist that the children would be fine, only 7% of the parents were still nervous. [10]

Related Research Articles

<span class="mw-page-title-main">Stethoscope</span> Medical device for auscultation

The stethoscope is a medical device for auscultation, or listening to internal sounds of an animal or human body. It typically has a small disc-shaped resonator that is placed against the skin, and one or two tubes connected to two earpieces. A stethoscope can be used to listen to the sounds made by the heart, lungs or intestines, as well as blood flow in arteries and veins. In combination with a manual sphygmomanometer, it is commonly used when measuring blood pressure.

<span class="mw-page-title-main">Heart sounds</span> Noise generated by the beating heart

Heart sounds are the noises generated by the beating heart and the resultant flow of blood through it. Specifically, the sounds reflect the turbulence created when the heart valves snap shut. In cardiac auscultation, an examiner may use a stethoscope to listen for these unique and distinct sounds that provide important auditory data regarding the condition of the heart.

<span class="mw-page-title-main">Heart murmur</span> Medical condition

Heart murmurs are unique heart sounds produced when blood flows across a heart valve or blood vessel. This occurs when turbulent blood flow creates a sound loud enough to hear with a stethoscope. Turbulent blood flow is not smooth. The sound differs from normal heart sounds by their characteristics. For example, heart murmurs may have a distinct pitch, duration and timing. The major way health care providers examine the heart on physical exam is heart auscultation; another clinical technique is palpation, which can detect by touch when such turbulence causes the vibrations called cardiac thrill. A murmur is a sign found during the cardiac exam. Murmurs are of various types and are important in the detection of cardiac and valvular pathologies.

<span class="mw-page-title-main">Mitral valve prolapse</span> Medical condition

Mitral valve prolapse (MVP) is a valvular heart disease characterized by the displacement of an abnormally thickened mitral valve leaflet into the left atrium during systole. It is the primary form of myxomatous degeneration of the valve. There are various types of MVP, broadly classified as classic and nonclassic. In severe cases of classic MVP, complications include mitral regurgitation, infective endocarditis, congestive heart failure, and, in rare circumstances, cardiac arrest.

<span class="mw-page-title-main">Chest pain</span> Discomfort or pain in the chest as a medical symptom

Chest pain is pain or discomfort in the chest, typically the front of the chest. It may be described as sharp, dull, pressure, heaviness or squeezing. Associated symptoms may include pain in the shoulder, arm, upper abdomen, or jaw, along with nausea, sweating, or shortness of breath. It can be divided into heart-related and non-heart-related pain. Pain due to insufficient blood flow to the heart is also called angina pectoris. Those with diabetes or the elderly may have less clear symptoms.

<span class="mw-page-title-main">Auscultation</span> Listening to the internal sounds of the body, usually using a stethoscope

Auscultation is listening to the internal sounds of the body, usually using a stethoscope. Auscultation is performed for the purposes of examining the circulatory and respiratory systems, as well as the alimentary canal.

<span class="mw-page-title-main">Aortic regurgitation</span> Medical condition

Aortic regurgitation (AR), also known as aortic insufficiency (AI), is the leaking of the aortic valve of the heart that causes blood to flow in the reverse direction during ventricular diastole, from the aorta into the left ventricle. As a consequence, the cardiac muscle is forced to work harder than normal.

<span class="mw-page-title-main">Bicuspid aortic valve</span> Medical condition

Bicuspid aortic valve is a form of heart disease in which two of the leaflets of the aortic valve fuse during development in the womb resulting in a two-leaflet (bicuspid) valve instead of the normal three-leaflet (tricuspid) valve. BAV is the most common cause of heart disease present at birth and affects approximately 1.3% of adults. Normally, the mitral valve is the only bicuspid valve and this is situated between the heart's left atrium and left ventricle. Heart valves play a crucial role in ensuring the unidirectional flow of blood from the atrium to the ventricles, or from the ventricle to the aorta or pulmonary trunk. BAV is normally inherited.

<span class="mw-page-title-main">Ventricular septal defect</span> Medical condition

A ventricular septal defect (VSD) is a defect in the ventricular septum, the wall dividing the left and right ventricles of the heart. The extent of the opening may vary from pin size to complete absence of the ventricular septum, creating one common ventricle. The ventricular septum consists of an inferior muscular and superior membranous portion and is extensively innervated with conducting cardiomyocytes.

<span class="mw-page-title-main">Mitral regurgitation</span> Form of valvular heart disease

Mitral regurgitation(MR), also known as mitral insufficiency or mitral incompetence, is a form of valvular heart disease in which the mitral valve is insufficient and does not close properly when the heart pumps out blood. It is the abnormal leaking of blood backwards – regurgitation from the left ventricle, through the mitral valve, into the left atrium, when the left ventricle contracts. Mitral regurgitation is the most common form of valvular heart disease.

<span class="mw-page-title-main">Persistent truncus arteriosus</span> Medical condition

Persistent truncus arteriosus (PTA), often referred to simply as truncus arteriosus, is a rare form of congenital heart disease that presents at birth. In this condition, the embryological structure known as the truncus arteriosus fails to properly divide into the pulmonary trunk and aorta. This results in one arterial trunk arising from the heart and providing mixed blood to the coronary arteries, pulmonary arteries, and systemic circulation. For the International Classification of Diseases (ICD-11), the International Paediatric and Congenital Cardiac Code (IPCCC) was developed to standardize the nomenclature of congenital heart disease. Under this system, English is now the official language, and persistent truncus arteriosus should properly be termed common arterial trunk.

<span class="mw-page-title-main">Valvular heart disease</span> Disease in the valves of the heart

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

<span class="mw-page-title-main">Tricuspid regurgitation</span> Type of valvular heart disease

Tricuspid regurgitation (TR), also called tricuspid insufficiency, is a type of valvular heart disease in which the tricuspid valve of the heart, located between the right atrium and right ventricle, does not close completely when the right ventricle contracts (systole). TR allows the blood to flow backwards from the right ventricle to the right atrium, which increases the volume and pressure of the blood both in the right atrium and the right ventricle, which may increase central venous volume and pressure if the backward flow is sufficiently severe.

<span class="mw-page-title-main">Myocardial rupture</span> Medical condition

Myocardial rupture is a laceration of the ventricles or atria of the heart, of the interatrial or interventricular septum, or of the papillary muscles. It is most commonly seen as a serious sequela of an acute myocardial infarction.

Shone's syndrome is a rare congenital heart disease described by Shone in 1963. In the complete form, four left-sided defects are present:

Aortopulmonary septal defect is a rare congenital heart disorder accounting for only 0.1-0.3% of congenital heart defects worldwide. It is characterized by a communication between the aortic and pulmonary arteries, with preservation of two normal semilunar valves. It is the result of an incomplete separation of the aorticopulmonary trunk that normally occurs in early fetal development with formation of the spiral septum. Aortopulmonary septal defects occur in isolation in about half of cases, the remainder are associated with more complex heart abnormalities.

<span class="mw-page-title-main">Pacemaker syndrome</span> Medical condition

Pacemaker syndrome is a condition that represents the clinical consequences of suboptimal atrioventricular (AV) synchrony or AV dyssynchrony, regardless of the pacing mode, after pacemaker implantation. It is an iatrogenic disease—an adverse effect resulting from medical treatment—that is often underdiagnosed. In general, the symptoms of the syndrome are a combination of decreased cardiac output, loss of atrial contribution to ventricular filling, loss of total peripheral resistance response, and nonphysiologic pressure waves.

Heart valve repair is a cardiac surgery procedure, carried out to repair one or more faulty heart valves. In some valvular heart diseases repair where possible is preferable to valve replacement. A mechanical heart valve is a replacement valve that is not itself subject to repair.

Computer-aided auscultation (CAA), or computerized assisted auscultation, is a digital form of auscultation. It includes the recording, visualization, storage, analysis and sharing of digital recordings of heart or lung sounds. The recordings are obtained using an electronic stethoscope or similarly suitable recording device. Computer-aided auscultation is designed to assist health care professionals who perform auscultation as part of their diagnostic process. Commercial CAA products are usually classified as clinical decision support systems that support medical professionals in making a diagnosis. As such they are medical devices and require certification or approval from a competent authority.

Arnold Martin Katz was a medical doctor, professor of cardiology, medical researcher, and author of medical textbooks and research articles.

References

  1. 1 2 3 4 Newburger, Jane (2006). Nadas' Pediatric Cardiology 2nd Edition. Philadelphia: Elsevier. p. 358. ISBN   978-1-4160-2390-6.
  2. 1 2 3 4 5 6 Frank, Jennifer (2011). "Evaluation and Management of Heart Murmurs in Children" (PDF). American Family Physician. 84 (7): 793–800. PMID   22010618 . Retrieved 14 December 2020.
  3. ↑ Still, George Frederick (1909). Common Disorders and Diseases of Childhood. London: Hodder and Stoughton. pp.  434–435. ASIN   B006PCYAWQ.
  4. ↑ Stein, P.D.; Sabbah, H.N. (1977). "Aortic origin of innocent murmurs". Am. J. Cardiol. 39 (5): 665–671. doi:10.1016/s0002-9149(77)80126-4. PMID   67794.
  5. ↑ van Oort, A.; van Dam, I.; Heringa, A.; Alsters, J.; Hopman, J.; Daniëls, O. (1986). "The vibratory innocent heart murmur studied by echo-Doppler". Paediatr. Scand. 329: 103–7. doi:10.1111/j.1651-2227.1986.tb10394.x. PMID   3473896. S2CID   21206205.
  6. ↑ Klewer, S.E.; Donnerstein, R.L.; Goldberg, S.J. (1991). "Still's-like innocent murmur can be produced by increasing aortic velocity to a threshold value". Am. J. Cardiol. 68 (8): 810–2. doi:10.1016/0002-9149(91)90664-7. PMID   1892096.
  7. ↑ Schwartz, M.L.; Goldberg, S.J.; Wilson, N.; Allen, H.D.; Marz, G.R. (1986). "Relation of Still's murmur, small aortic diameter and high aortic velocity". Am. J. Cardiol. 57 (15): 1344–1348. doi:10.1016/0002-9149(86)90216-x. PMID   3717035.
  8. ↑ Donnerstein, R.L.; Thomsen, V.S. (1994). "Hemodynamic and anatomic factors affecting the frequency content of Still's innocent murmur". Am. J. Cardiol. 74 (5): 508–510. doi:10.1016/0002-9149(94)90917-2. PMID   8059739.
  9. ↑ Segal, BL (1964). The Theory and Practice of Auscultation. Philadelphia: F.A. Davis Company. p. 169. LCCN   63020195.
  10. ↑ Geggel RL, Horowitz LM, Brown EA, et al. (2002). "Parental anxiety associated with referral of a child to a pediatric cardiologist for evaluation of a Still's murmur". The Journal of Pediatrics. 140 (6): 747–52. doi:10.1067/mpd.2002.124379. PMID   12072881.
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