What is the recommended evaluation and treatment for a patient with heart murmurs, specifically S1, S2, A1, and A2, without clear symptoms of heart disease?

From the Guidelines

For patients with heart murmurs (S1, S2, A1, A2) without clear symptoms of heart disease, a thorough evaluation with echocardiography is recommended to determine the cause and severity of the murmur, as outlined in the ACC/AHA 2008 guidelines 1. The evaluation should start with a comprehensive physical examination, focusing on cardiac auscultation to characterize the murmur's timing, location, radiation, intensity, and quality.

• This should be followed by an electrocardiogram (ECG) and chest X-ray as baseline studies.
• An echocardiogram is essential to visualize cardiac structures and assess the murmur's cause and severity, as it can define the primary lesion, hemodynamics, coexisting abnormalities, and detect secondary lesions 1.
• For some patients, additional testing may include stress testing, Holter monitoring, or cardiac MRI depending on initial findings.
• If the evaluation reveals the murmur is innocent or physiologic, no treatment is needed, only regular follow-up.
• For pathological murmurs, treatment depends on the underlying cause - valvular disease may require medication like beta-blockers, ACE inhibitors, or diuretics, while severe cases might need surgical intervention, as recommended by the ACC/AHA guidelines 1. The approach is justified by the need to distinguish between benign murmurs (which are common and require no intervention) and pathological ones that may indicate underlying cardiac conditions requiring specific treatment, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.
• The use of echocardiography is particularly important in asymptomatic patients with diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks, or murmurs that radiate to the neck or back, as recommended by the ACC/AHA guidelines 1.

From the Research

Evaluation of Heart Murmurs

• The evaluation of heart murmurs, including S1, S2, A1, and A2, typically involves a thorough cardiac physical examination to identify patients who require further evaluation and management 2.
• Diastolic murmurs are often indicative of underlying valvular pathology and require further investigation, typically with echocardiography 2.
• The proper examination of patients with systolic murmurs is fundamental to cost-effective care, and echocardiography is the gold standard for diagnosis and severity grading of valvular heart disease 3.

Treatment of Heart Murmurs

• Patients with progressive valvular heart disease should be followed annually by cardiology, and imaging should be performed based on the severity of valvular dysfunction 3.
• Surgery or intervention is recommended only when symptoms dictate or when changes in left ventricular function occur, and should be performed after discussion by a heart team, including cardiologists and cardiac surgeons 3.
• The presence and character of a cardiac murmur in adolescents may not be associated with structural heart disease that confers risk of sudden cardiac death, and ECG evaluation is recommended in all patients with a cardiac murmur found during preparticipation screening to increase detection of hypertrophic cardiomyopathy 4.

Diagnostic Tools

• Echocardiography is a crucial diagnostic tool for evaluating heart murmurs and valvular heart disease, and can help identify structural heart disease and guide treatment decisions 2, 3, 5.
• Point-of-care ultrasound can also facilitate the diagnosis of heart failure and other conditions that may be associated with heart murmurs, by assessing for B-lines, cardiac function, and inferior vena cava size 6.
• The correlation between murmurs by auscultation and severity of heart valve disease by echocardiography is often poor, and a careful auscultation of the heart prior to the echocardiogram is mandatory to predict the echocardiographic findings and their interpretation in view of the clinical information 5.