Heart murmurs in neonates

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The physical examination remains an important aspect of the evaluation of potential heart disease in neonates. However, with increasing sophistication of non-invasive testing, it is important to evaluate the diagnostic accuracy of components of the physical examination, such as cardiac auscultation. In this issue of The Journal, Mackie et al evaluate the sensitivity, specificity, and predictive value of the assessment of cardiac murmurs by pediatric cardiologists. They found that clinical assessment detected all complex congenital heart disease, but some simple abnormalities were missed. The features of the murmur were important and this information can be quite useful for non-cardiologists examining a neonate. The predictive features were harsh murmur quality, location at the right upper sternal border, left lower sternal border and the apex, and murmurs that were pansystolic, diastolic, or continuous. When one of these features of the murmur was present, the sensitivity for the detection of congenital heart disease increased to 88%. The inclusion of an electrocardiogram did not improve test characteristics. These results emphasize the importance of the physical examination in this setting.