What is the appropriate evaluation and management of a patient with an ejection systolic murmur?

Evaluation and Management of Ejection Systolic Murmur

In asymptomatic patients with a grade 1-2 ejection systolic murmur and an otherwise normal cardiac examination, extensive workup is not necessary; however, echocardiography should be performed for any grade ≥3 murmur, any diastolic component, or when clinical features suggest pathology. 1

Initial Clinical Assessment

Characterize the Murmur Through Dynamic Auscultation

Timing and configuration are critical - ejection systolic murmurs are crescendo-decrescendo, starting after S1 when ventricular pressure opens the semilunar valve, peaking mid-systole, and ending before S2 1. This distinguishes them from holosystolic murmurs (mitral regurgitation, ventricular septal defect) that extend from S1 to S2 1.

Perform bedside maneuvers to differentiate causes:

• Inspiration: Right-sided murmurs (pulmonic stenosis, tricuspid regurgitation) increase with inspiration due to increased venous return (100% sensitivity, 88% specificity) 2, 3
• Valsalva maneuver: Most murmurs decrease, but hypertrophic cardiomyopathy increases (65% sensitivity, 96% specificity) 1, 3
• Standing from squatting: Hypertrophic cardiomyopathy and mitral valve prolapse increase (95% sensitivity, 84% specificity for HCM) 1, 3
• Handgrip exercise: Mitral regurgitation and ventricular septal defect increase (68% sensitivity, 92% specificity), while aortic stenosis decreases 1, 3

Assess Associated Physical Findings

Critical findings that mandate echocardiography:

• Abnormal S2 splitting: Fixed splitting suggests atrial septal defect; soft or absent A2 indicates severe aortic stenosis 1, 4
• Systolic ejection sounds: Heard during both inspiration and expiration suggests bicuspid aortic valve; heard only during expiration in pulmonic area indicates pulmonic stenosis 1
• Left ventricular dilatation on palpation: Suggests significant volume overload from regurgitant lesions 1

Indications for Echocardiography

Echocardiography is mandatory for:

• All diastolic murmurs - these virtually always represent pathology 1
• Grade ≥3 midsystolic murmurs - cannot reliably distinguish benign from pathologic aortic stenosis by examination alone 1
• All holosystolic or late systolic murmurs - indicate regurgitant lesions requiring evaluation 1
• Any systolic murmur with symptoms - including heart failure, syncope, myocardial ischemia, or signs of endocarditis 1
• Murmurs with abnormal S2, ejection sounds, or other cardiac findings 1

Echocardiography is also indicated for grade 1-2 murmurs when:

• Patient has cardiovascular symptoms (dyspnea, chest pain, syncope) 1
• Signs of endocarditis, thromboembolism, or heart failure are present 1
• Dynamic auscultation suggests specific pathology (HCM, mitral valve prolapse) 1

When Echocardiography Can Be Deferred

Characteristics of innocent murmurs that do not require imaging in asymptomatic patients:

• Grade 1-2 intensity at left sternal border 1
• Systolic ejection pattern (crescendo-decrescendo) 1
• Normal S2 intensity and physiologic splitting 1
• No other abnormal cardiac sounds 1
• No murmur augmentation with Valsalva or standing 1
• No evidence of ventricular hypertrophy or dilatation 1

These innocent murmurs are especially common in high-output states including pregnancy, thyrotoxicosis, anemia, and arteriovenous fistula 1.

Common Pitfalls to Avoid

Physical examination has significant limitations - even experienced cardiologists miss combined valvular lesions (45% missed combined aortic and mitral disease) and aortic regurgitation (79% missed) 5. The sensitivity for detecting intraventricular pressure gradients is only 18% 5.

Aortic stenosis severity can be misjudged when left ventricular ejection fraction is severely reduced, as the murmur may be softer than expected despite severe stenosis 5. A normally split S2 reliably excludes severe aortic stenosis 4.

Trivial physiologic regurgitation detected on echocardiography occurs in many normal patients without murmurs and should not drive clinical decisions in asymptomatic patients with isolated soft murmurs 1.

Do not rely on a single maneuver - use a combination of bedside techniques to determine murmur etiology, as no single maneuver is 100% accurate 3.