title: Cardinal clinical signs in the differentiation of heart murmurs in children.
abstract: OBJECTIVE
  To determine the diagnostic accuracy of clinical assessment of heart murmurs in children and specific clinical features that are predictive of cardiac disease.
  
  
  METHODS
  Concurrent case series with pretest-posttest assessment.
  
  
  METHODS
  Pediatric cardiology outpatient clinic.
  
  
  METHODS
  Five full-time academic pediatric cardiologists.
  
  
  METHODS
  For each of 222 consecutive patients who were seen for first-time evaluation of a heart murmur, the clinical findings and diagnostic impressions were recorded after clinical assessment. The results of electrocardiograms and echocardiograms were then reviewed, and changes in diagnostic impressions were recorded and compared with the original impressions.
  
  
  RESULTS
  The prevalence of cardiac disease was 33%. Clinical assessment differentiated those patients with pathologic murmurs with a sensitivity of 92%, specificity of 94%, positive predictive value of 88%, and negative predictive value of 96%. If diagnostic uncertainty was considered an indication for echocardiography, then sensitivity and specificity increased to 97% and 98%, respectively. Missed disease included only trivial or minor lesions. Clinical features that were independently predictive of the presence of disease included murmurs that were pansystolic (odds ratio [OR], 54.0), grade 3 or more in intensity (OR, 4.84), heard best at the left upper sternal border (OR, 4.24) and harsh in quality (OR, 2.37), and the presence of an abnormal second heart sound (OR, 4.09) and an early or midsystolic click (OR, 8.35).
  
  
  CONCLUSIONS
  Clinical assessment by a pediatric cardiologist is sufficient to distinguish pathologic from innocent heart murmurs. A genetic approach by using specific clinical features that are independently associated with disease may have some practical utility to noncardiologists.
authors.affiliation: Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
authors.forename: B W
authors.initials: BW
authors.lastname: McCrindle
authors.forename: K M
authors.initials: KM
authors.lastname: Shaffer
authors.forename: J S
authors.initials: JS
authors.lastname: Kan
authors.forename: K G
authors.initials: KG
authors.lastname: Zahka
authors.forename: S A
authors.initials: SA
authors.lastname: Rowe
authors.forename: L
authors.initials: L
authors.lastname: Kidd
mesh_terms: D002648:Child; D002675:Child, Preschool; D003937:Diagnosis, Differential; D005260:Female; D006331:Heart Diseases / Q000150:complications / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000503:physiopathology; D006337:Heart Murmurs / Q000209:etiology*; D006801:Humans; D007223:Infant; D008297:Male; D011237:Predictive Value of Tests; D012017:Referral and Consultation; D012680:Sensitivity and Specificity; D014463:Ultrasonography