20 year old female, having a routine assessment for work. She is active, cycles and jogs frequently and with no symptoms. No cardiovascular risk factors known. Past history is unremarkable but she thinks she may have been told when she was in elementary school she had an extra sound from her heart but not to worry about it. Her cardiovascular family history is apparently normal. On examination she looks healthy and fit, with a BMI of 23, heart rate 60 and regular, BP 112/75. Her heart action and pulses are normal. You listen to the chest in the usual areas, particularly at the apical area, with the bell of the stethoscope.
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2.1 S2: d) Single 2.2 Systole: d) ejection murmur, mid systolic, vibratory 2.3 Diastole: a) normal 2.4 Assessment: c) functional or innocent murmur
Discussion:
This patient has a normal heart. S2 is single at the apex which is normal. The murmur has a vibratory, buzzing quality which is commonly heard in young children, sometimes even up to the age of puberty. It can occasionally be heard in adults, often those who are athletic. Some clinicians describe the sound as musical. The murmur is not due to turbulence as with most murmurs heard in adults, but arises from tissue vibration and has a narrow frequency band. Exactly what tissue is vibrating is controversial but may be the upper thin portion of the interventricular septum. The important point on auscultation however is that the murmur is not harsh or high pitched, as one would expect from a valve lesion or septal defect. Innocent mumurs may diminish in the upright position. It is worth listening now to a recording of a pathological case such as aortic stenosis (Case 4), to appreciate the marked difference in the sound of the two murmurs.
While these vibratory murmurs are fairly easy to assess as normal by auscultation, the unusual feature of this presentation is the patient’s age. Other, rare causes of a similar murmur may be mild subaortic stenosis or hypertrophic cardiomyopathy. Consequently, especially if the murmur is very easily heard or moderately loud, an echocardiogram would be reasonable to confirm the absence of pathology. In a young child this murmur could be confidently diagnosed without echocardiography. It will be most important to emphasize to such a patient and her referring physician that she is normal, and if a report is sent to an insurer the absence of pathology needs to be made very clear. The murmur may gradually disappear or may persist, and in future if she becomes pregnant, it may be confused with functional murmurs of pregnancy.
