26 year old male reviewed for police service. Very healthy, walks and jogs regularly. Absolutely no symptoms with vigorous exercise. Mildly overweight, BMI 29. Has been diagnosed with a heart murmur since he was a young child but no treatment was recommended by pediatric cardiology. No family history of cardiovascular disease or diabetes. Nonsmoker.
On examination he appears healthy. BP 122/82, pulses are normal. The heart action is normal with no apical displacement. No thrills are felt. You listen especially at the left lower sternal edge and apical areas.
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5.1 S2 d) Single 5.2 Systole b) holosystolic murmur 5.3 Diastole a) normal 5.4 Assessment d) VSD or possibly mitral insufficiency
Discussion:
This patient likely has a VSD which is small and produces a harsh pan- or holosystolic murmur, due to turbulence in the jet from left to right ventricle. The harsh murmur and absence of signs of left ventricular enlargement, as well as absence of symptoms, are consistent with a small defect. Mitral insufficiency can produce a similar murmur but in that case he would likely have been given advice for more specific follow up. If echocardiography of this defect confirms the small VSD, no restrictions or precautions such as endocarditis prophylaxis are indicated. It should be emphasized that a restrictive VSD will not enlarge as the patient ages; in fact it may become smaller. Long term studies of such small defects have not shown adverse effects such as pulmonary hypertension, although endocarditis is possible. Antibiotic prophylaxis has not proven effective against endocarditis in this setting but regular dental care is advisable.
So this patient’s cardiac lesion is benign and not progressive. He should be cleared for police service without reservation. Individual life insurance however may be expensive, difficult or impossible to obtain depending on the insurer.
