I. Clinical Cases
II. Clinical Diagnosis of Heart Murmurs
III. Investigative Tests

GLOSSARY
cardiac output the volume of blood pumped by the ventricle per unit time expressed in liters per minute; it is the function of the stroke volume multiplied by the heart rate.
heart failure failure of the heart to pump sufficient blood from the chambers into the aorta; inadequate supply of blood reaches organs and tissues.
51 the first heart sound caused by closure of the mitral and tricuspid valves.
52 the second heart sound caused by closure of the aortic and pulmonary valves.
A HEART MURMUR IS A SOUND (BRUIT) HEARD on auscultation with a stethoscope placed at various locations over the chest or neck vessels and over dilated arteries. Typically these sounds are periodic and of short duration. They coincide with the short systolic or diastolic timing of the heart’s contraction and relaxation during which blood is ejected or the chambers are filled during systole and diastole, respectively. Heart murmurs result from disturbances of normal blood flow patterns in the heart. They are classified on the basis of their timing as systolic, diastolic, or continuous (systolic and diastolic).
The most common murmur is systolic. Systolic mur¬murs occur during the contraction of the ventricles. Many systolic murmurs are nonsignificant in that they may occur in individuals where no evidence of heart disease can be found and do not disturb the function of the heart. Murmurs that occur when the ventricles are relaxed, that is, during diastole, are termed diastolic murmurs and are always of significance. Murmurs are usually caused by disease of the heart valves (see the chapter Valve Diseases).

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• I. CLINICAL CASES A. Questions Posed
  A female, age 30, posed the following questions: My family doctor says that I have a systolic murmur at the apex of the heart and referred me to a cardiologist. I would like to know:
• II. CLINICAL DIAGNOSIS OF HEART MURMURS
  A. Diagnostic Clues
• III. INVESTIGATIVE TESTS
  Chest x-ray, ECG, and echocardiogram are helpful to confirm the clinical opinion obtained from the patient’s history and relevant examination. In a few individuals with serious heart murmurs causing symptoms such as severe shortness of breath with or without heart failure, cardiac catheterization tests are invaluable to corroborate the findings on echocardiography. This is often done if surgical correction is planned. The technique of catheterization is outlined in the chapter Tests for Heart Diseases, and echocardiographic diagnostic points are given in the chapter Valve Diseases.
• BIBLIOGRAPHY
  Khan, M. Gabriel. On Call Cardiology, second edition. W. B. Saunders, Philadelphia, 2001.

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