Pediatric Cardiology Review
Four heart sounds - ANS S1 - closure of AV valves (mitral and tricuspid)
S2 - closure of semilunar valves (aortic and pulmonic valves)
S3 (gallop) - rapid LV filling in early diastole after S2; can be normal in kids and should diminish when
the child goes from laying down to sitting
S4 - atrial contraction into a non-compliant ventricle (always pathologic)
Six grades of murmur intensity - ANS Grade 1 - very faint, may only be heard by an expert, not heard
in all positions, no thrill
Grade 2 - soft, heard in all positions, no thrill
Grade 3 - moderately loud, no thrill
Grade 4 - loud and associated with a palpable thrill
Grade 5 - very loud, with thrill, heard with the stethoscope partly off the chest
Grade 6 - loudest, with thrill, heard with the stethoscope entirely off the chest (just above the
precordium, not touching the skin)
Heart murmurs are common in the pediatric population, especially during illness. Up to 45% of
children have benign (innocent) murmurs at some time during childhood. These children have an
otherwise normal physical exam and growth. The murmurs are transient and resolve with age. What
is the typical grade of intensity of these murmurs? - ANS Soft and systolic - grade 1 and 2
Eleven characteristics of innocent murmurs (be familiar with) - ANS 1. Negative family history
2. Normal prenatal ultrasound
,3. Non-syndromic (no genetic abnormalities)
4. Age > 2 years
5. Asymptomatic
6. No gallops, clicks or rubs
7. Grade ≤ 2 intensity
8. Short systolic duration - not holosystolic and not diastolic
9. Minimal radiation
10. Musical or vibratory quality
11. Softer intensity when the patient is sitting and louder when supine
What is the most common innocent murmur of childhood? - ANS Stills murmur
- most common between 2-7 years
Four characteristics of a stills murmur - ANS 1. Grade 1-3/6 musical or vibratory
2. Early systolic
3. Heard best midway between the apex and the lower sternal border
4. Loudest when supine and diminishes when sitting up
, A __________ ________ is a common innocent murmur heard in children ages 2 and up. It is the
result of turbulence at the union of the jugular and subclavian veins. - ANS Venous hum
Five characteristics of a venous hum - ANS 1. Grade 1-2/6 continuous low to medium pitch musical
hum
2. Best heard in the right infraclavicular area
3. Accentuated in diastole and with inspiration
4. Best heard in the sitting position
5. Turning the child's neck, placing them supine, and compressing the jugular vein will obliterate the
hum
Fourteen features of pathologic murmurs - ANS 1. Positive family history of CHD
2. Abnormal prenatal US
3. Symptoms suggestive of heart disease
4. grade ≥3 in intensity
5. Maximum intensity at the left upper sternal border
6. Increased intensity with upright position
7. Diastolic murmur
8. Gallops, clicks or rubs
9. Abnormal vital signs
Four heart sounds - ANS S1 - closure of AV valves (mitral and tricuspid)
S2 - closure of semilunar valves (aortic and pulmonic valves)
S3 (gallop) - rapid LV filling in early diastole after S2; can be normal in kids and should diminish when
the child goes from laying down to sitting
S4 - atrial contraction into a non-compliant ventricle (always pathologic)
Six grades of murmur intensity - ANS Grade 1 - very faint, may only be heard by an expert, not heard
in all positions, no thrill
Grade 2 - soft, heard in all positions, no thrill
Grade 3 - moderately loud, no thrill
Grade 4 - loud and associated with a palpable thrill
Grade 5 - very loud, with thrill, heard with the stethoscope partly off the chest
Grade 6 - loudest, with thrill, heard with the stethoscope entirely off the chest (just above the
precordium, not touching the skin)
Heart murmurs are common in the pediatric population, especially during illness. Up to 45% of
children have benign (innocent) murmurs at some time during childhood. These children have an
otherwise normal physical exam and growth. The murmurs are transient and resolve with age. What
is the typical grade of intensity of these murmurs? - ANS Soft and systolic - grade 1 and 2
Eleven characteristics of innocent murmurs (be familiar with) - ANS 1. Negative family history
2. Normal prenatal ultrasound
,3. Non-syndromic (no genetic abnormalities)
4. Age > 2 years
5. Asymptomatic
6. No gallops, clicks or rubs
7. Grade ≤ 2 intensity
8. Short systolic duration - not holosystolic and not diastolic
9. Minimal radiation
10. Musical or vibratory quality
11. Softer intensity when the patient is sitting and louder when supine
What is the most common innocent murmur of childhood? - ANS Stills murmur
- most common between 2-7 years
Four characteristics of a stills murmur - ANS 1. Grade 1-3/6 musical or vibratory
2. Early systolic
3. Heard best midway between the apex and the lower sternal border
4. Loudest when supine and diminishes when sitting up
, A __________ ________ is a common innocent murmur heard in children ages 2 and up. It is the
result of turbulence at the union of the jugular and subclavian veins. - ANS Venous hum
Five characteristics of a venous hum - ANS 1. Grade 1-2/6 continuous low to medium pitch musical
hum
2. Best heard in the right infraclavicular area
3. Accentuated in diastole and with inspiration
4. Best heard in the sitting position
5. Turning the child's neck, placing them supine, and compressing the jugular vein will obliterate the
hum
Fourteen features of pathologic murmurs - ANS 1. Positive family history of CHD
2. Abnormal prenatal US
3. Symptoms suggestive of heart disease
4. grade ≥3 in intensity
5. Maximum intensity at the left upper sternal border
6. Increased intensity with upright position
7. Diastolic murmur
8. Gallops, clicks or rubs
9. Abnormal vital signs
