Objective: The objective of this review was to assess the role of auscultation, electrocardiography (ECG), and radiography(CXR) in the evaluation of children with innocent heart murmurs.

Methods: The MEDLINE database from 1966 to 1996 was searched using the following MESH terms: heart murmurs, diagnosis, auscultation, physical examination, electrocardiography and radiography. Reference lists were also used. Excluded from the study were: review articles, abstracts, commentaries, and letters to the editor. The outcome measures were sensitivity(sens) and specificity (spec), or the number of incorrect diagnosis when data were insufficient to calculate these two. Two content experts(B.W.M.,W.F.) were also consulted.

Results: Eleven studies were retrieved. Six evaluated auscultation:5 were prospective descriptive studies, one was a case-control study. Five prospective descriptive studies evaluated ECG and CXR. The number of children assessed per study ranged from 100 to 322. Patients were ages 1 month to 18 years and were referred for evaluation of new heart murmurs. The gold standard was echocardiography. The observers were pediatric cardiologists or paediatricians*. The sens. and spec. of auscultation is summarised in the table. None of the organic heart lesions missed by auscultation were considered significant. The sens. and spec. of ECG were 13% and 100%, and for CXR, 43% and 82% respectively. ECG and CXR caused many false positive results (11%) and did not contribute significantly to the differentiation of heart murmurs.

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Full size table

Summary: Auscultation is a simple and low cost test. It has excellent sens. and spec.. CXR and ECG lack similar qualities. There is good evidence to support the use of auscultation alone as the best initial strategy to evaluate children with innocent heart murmurs.