32 DALHOUSIE MEDICAL JOURNAL Functional Systolic Murmurs Milton Boniuk, '56 Although it is generally agreed University students, Reid found 20% that the diastolic murmur with rare with a systolic murmur. exceptions denotes a cardiac valvular pathologic lesion, the role and signi- Opposing Views: ficance of the systolic murmur have However, such a frequent routine not been fully established. The var- physical finding as this has not yet ious opinions given concerning its been clearly understood and opposing value range from complete accept- views on this matter have been ex- ance as a pathognomonic indication of pressed by some of our best known an organic lesion to almost total dis- clinicians. Some of those expressing regard of it as an aid in the diagnosis a poor prognostic view were : of heart disease. Because the nature 1. Laennec, who introduced auscul- of the murmur has been unsettled tation in physical diagnosis in 1819, this has been a frequent cause of thought that all murmurs were posi- cardiac neurosis. tive indications of presence of cardiac Although no attempt can be made valvular lesions. to elucidate this problem which has 2. White reported on 100 patients baffled clinicians for years, I would with apical systolic murmurs includ- like to review some of the literature ing some with accompanying diastolic which has been written on the sys- murmur. Although stating that tolic murmur and this article will slight apical systolic murmurs are briefly deal with the following : frequent and are in themselves of (1)Frequency of systolic murmurs ; little or no importance in the absence (2) Opposing views on significance of other signs of heart trouble, he of systolic murmurs; (3) Classifica- found that only 19% of patients had tion and Causes ; (4) Aids in Diagno- normal hearts, and that 6% were sis; (5) Pathologic Study and Evalu- doubtful. The rest of the patients ation; (6) Conclusions. had organic heart disease. Further- more the evidence of an organic Frequency : lesion increased with the intensity The frequency of the physical find- of the systolic murmur, ranging from ing of the systolic murmur in routine 56% in patients with slight mur - examinations is not generally real- murs to 98% in those with loud ones. ized. Walter showed that of 400 3. Levine also stated that a sys- routine examinations of the heart tolic murmur is not common in nor- 29.75% or 119 showed systolic mur- mal individuals and the louder ones murs. Levine examined 1000 nor- are always associated with some mal persons engaged in various oc- form of cardiovascular disease. cupations and found 19.6% with a On the other hand, some of the systolic murmur. In a group of more favorable prognostic outlooks DALHOUSIE MEDICAL JOURNAL were expressed by the following : 4. Contratto reported on 127 Har- 1. Cabot, "systolic murmurs with- vard students with apical or basal out presence of other signs of heart systolic murmurs, the significance of disease is of no importance." which was uncertain after the first examination. After follow-up of 2 2. White, at another occasion, said to 3 years, he was unable to make a that most systolic murmurs do not diagnosis on any case and several of indicate presence of organic heart the patients had played football and disease. other strenuous sports. 3. J. S. Blumenthal followed 100 patients with a systolic murmur for Classification and Causes: 7 years. After this time 4 patients It has become evident that systolic developed other cardiac abnormalit- murmurs are caused not only by de- ies. Blumenthal stated "if we find formity of valves but also by other in a heart of normal size and rhythm factors present, thus the systolic a systolic murmur with absence of murmur has become divided into two any signs that would indicate that it categories, organic and functional. Of is definitely organic in origin, and course, this is not a practical division with a good functioning organ, then as there is no definite distinction to we may conclude that the heart is be made between such murmurs clin- perfectly normal." ically. 140'4V There are immediate requirements for Medical Doctors in the Royal Canadian Air Force Permanent or Short Service Commission One year post graduate training during each five years of service using civilian teaching facilities. For full information, write the: R.C.A.F Recruiting Unit 254 Barrington Street Halifax, Nova Scotia Telephone 3-6945 34 DALHOUSIE MEDICAL JOURNAL Herrick has given the pathological uish the functional murmur from the and clinical causes of murmurs of the organic ones. organic type as : (a) Most organic murmurs are 1 Stenosis or insufficiency of val- better heard with patients reclining ; ves. this is also true of innocent murmurs but when the murmur is decidedly •) Congenital deformities including louder in upright position it is in- patent ductus Botalli (ductus nocent. arterious), Patent interauricular septum, (b) A functional murmur is nei- Patent interventricular septum, ther long nor loud ; one exception oc- Muscular bands, curs when the murmur is late in sys- Anomalous chordae tendinae tole and placed as near to the second and papillary muscles. sound as the first, it can be loud and yet be innocent. 3 Vegetations & Sclerotic changes of valves. (c) When a trivial systolic mitral Causes of Functional Murmurs are : murmur becomes louder in reclining posture and a murmur develops as at Stretching of valve rings, the base of the heart and particularly Dilatation of chambers, in the pulmonary area, the murmur Hypertrophy, is innocent. Anemia, Tachycardia, (d) Any heart murmur is loudest at expiration, but if a murmur dis- Fevers, Neurocirculatory asthenia, appears during expiration it belongs Decreased cardiac tone and con- to the innocent type. traction, (e) A systolic murmur of organic Drugs — such as epinephrine. nature gains intensity, but the in- nocent often weakens, as the heart Aids in Diagnosis: rate increases. What can aid us in distinguishing 3 Thirdly, laboratory aids. Parker the organic from the functional mur- and White using three types of mur- murs ? murs — systolic murmurs found in 1 First of all, a complete and mitral stenosis, functional systolic thorough history and physical exam- murmur — systolic murmur occuring ination may reveal information and in mitral regurgitation. physical signs which will help to ex- Law showed the following in their plain the nature of the murmur. This reviews of laboratory aids for diag- requires no elaboration. nosis : 2 Secondly, a thorough study of (a) The anatomical changes assoc- the murmur — William Evans de- iated with mitral stenosis were found scribes some very important clinical to be reflected in the electrocardio- characteristics which help to disting- gram ; a P wave of 3.0 m.m. in height DALHOUSIE MEDICAL JOURNAL 35 in the second lead being found in these changes where considered as a 23%; and a P wave .12 seconds or part of the entire clinical picture, are more in width in any lead being frequently helpful. found in 27% of cases. The changes in organic systolic murmurs were too Pathological Study and Evaluation small to be of diagnostic value. P A pathological survey by Rednick wave is due to spread of impulse at Grasslands Hospital, New York from SA node over auricles. It is may throw some light on the problem normally upright in leads I and II but under discussion. This study included may be flat, diphasic or inverted in an examination of autopsy records of lead III. P wave is not more than 1148 consecutive cases of whom 268 2.5 or 3.0 m.m. high or more than .10 or 23.1% had shown systolic mur- seconds in duration. murs. (b) Enlargement of the left aur- (1) 44 cases or 16.4% showed val- icle usually demonstrated by fluoros- vular incompetence due to, rheumatic copy, was found in 5% of subjects fever, arteriosclerosis, syphilis, and with functional systolic murmurs, in congenital malformation. These pa- 43% with organic systolic murmurs, tients had shown additional signs and and in 72% with mitral stenosis, symptoms of heart involvment, pre- thereby establishing itself of consid- cordial thrills, diastolic murmurs, erable value as a diagnostic criterion. blood pressure changes, cardiac en- (c) Exercise tolerance tests were largement and serological reaction. found to be of no value in differenti- (2) 136 or 58% showed valvular ating between functional and organic deformity but were still competent. systolic murmurs. Changes noted were (a) vegetation (d) Heart sound tracings were nodules and calcification of valve leaf- found to be of value in isolated in- lets ; (b) stretched and scarred val- stances where the precise timing of ves. Some of these represented a a murmur or sound was important. mild stage of rheumatic involvement This was particularly true in regard or various degrees of arteriosclerotic to reduplication of the first heart changes which had become arrested sound and duration of systolic mur- and which were generally regarded murs. These were too uncommon to as functional. These conditions were warrant widespread use of stetho- compatible with long life and the graphic equipment. average age was 73 to 74 years. Thus, in the presence of mitral (3) Aneurysms were found in regurgitation certain x-ray and elec- 1.4% and cardiac hypertrophy in trocardiographic abnormalities fre- 9.3%. quently occur. The percentage is not (3) In 18.1% of cases the heart sufficiently high, nor are the changes was anatomically normal and the ap- highly specific, to constitute a basis pearance of a systolic murmur was for diagnosis to the exclusion of attributed to fever, tachycardia, auscultation. On the other hand, anemia or hypertension. 36 DALHOUSIE ME DICAL JOURNAL Thus in 209 cases or 78.2% some (b) complete cardiac study including pathological cause.