Background

Assessment

1. When a documented Asymptomatic Murmur Present, determine type and grade.
   • Which Type and Grade?

     Grade of Murmur:

     • Systolic murmurs are graded on a 1-6 scale
     • Grade 1 - 2 murmurs are very faint or soft
     • Grade 3 is easily heard
     • Grade 4 or higher have a thrill associated
     • Any diastolic murmur

Management

1. If Grade 1-2 mid systolic
   • Step 1: ECG
   • Step 2: Determine if unrecognized symptoms or associated findings are present

     Unrecognised Symptoms or Associated Findings

     • Radiation to neck and back
     • Clicks or extra heart sounds
     • Clinical evidence for heart failure
     • Abnormal ECG particularly LV hypertrophy, bundle block
     • Rheumatic fever
   • Step 3: if yes, unrecognised symptoms or associated findings are present: Refer to cardiology clinic
   • Step 3 if no and over age 60: Have GP monitor

     GP monitor for Grade 1-2 Midsystolic murmurs

     • A flow murmur - best heard along left sternal border, no radiation beyond precordium, no associated signs or symptoms.
     • A murmur from a thickened/sclerotic. Aortic valve - best heard over right upper sternal border, no radiation to neck, no associated signs or symptoms.
     • Many are of no importance.
     • If there are no symptoms and no significant findings, no further evaluation is needed.

     We recognize there is limited echocardiography resource and we cannot offer echocardiography to every patient who may potentially benefit from the examination.  We have taken a pragmatic stance that in demonstrating degenerative valve disease in the absence of symptoms in the older age group is unlikely to change management.  If symptoms develop or if these patients are being evaluated for elective surgical procedures it is likely that they would be offered an echocardiogram as part of usual clinical management.  Options in primary care is careful regular clinical follow up monitoring for symptoms of cardiac compromise with rereferral if these occur, or consideration of referral to the private sector for an echocardiogram.

   • Step 3 if no and under age 60: Refer to cardiology for consideration of echo
2. Grade 3-6 mid systolic or diastolic or pansystolic or late systolic
   • Step 1: ECG
   • Step 2: Refer to Cardiology Clinic

Disclaimer: These pathways, for the care and management of patients within Bay of Plenty, have been developed jointly by primary and secondary care clinicians. They provide guidance for General Practice teams to diagnose and manage patients suffering from a number of different conditions, and contain patient information resources. The pathways are maps of publicly-funded services accessed by referral from the community, and are strongly evidence based, but are not full clinical guidelines. As the pathways are suggested guidance only, while using them you must exercise your own clinical judgement and pertinent clinical data when treating your patient. This site is intended to be flexible and frequently updated. While every effort has been made to ensure accuracy, all information should be verified.