7 Clinical decision-making for low-risk pediatric heart murmurs

• Published in: Paediatrics & child health 2019-05, Vol.24 (Supplement_2), p.e3-e3
• Main Authors: Penslar, Joshua, Webster, Richard, Jetty, Radha
• Format: Article
• Language: English
• Subjects: Abstract / Résumés; Cardiac arrhythmia; Cardiology; Clinical decision making; Decision making; Pathology; Patient-centered care; Pediatrics
• ISSN: 1205-7088; 1918-1485
• DOI: 10.1093/pch/pxz066.006

Background Only a small minority of children with heart murmurs have cardiac pathology. The American Academy of Family Practitioners (AAFP) has published a set of criteria for low-risk murmurs that do not require referral to pediatric cardiology. However, these criteria are not consistently followed, in part because they rely on specific auscultatory judgements with which many care providers are uncomfortable. The resultant superfluous referrals represent an opportunity to improve care from both patient-centred and resource utilization perspectives. Objectives - Evaluate the non-auscultatory AAFP criteria alone as a risk stratification tool for pediatric murmurs. - Identify characteristics of situations in which low-risk murmurs are actually pathological. - Assess the utility of ECG in evaluating low-risk murmurs. Design/Methods A retrospective chart review of all children (0–18 years) seen as new outpatient referrals in our pediatric cardiology clinic between January 1, 2016 and June 30, 2018 whose primary reason for referral was a murmur. Referrals were characterized as “low-risk” if they met all of the AAFP criteria aside from findings on auscultation: otherwise normal physical exam; asymptomatic; no risk factors for structural heart disease; age over 6 months. Results The AAFP criteria had a sensitivity of 95.9% and negative predictive value of 96.3% for pathology. The pathology rate was significantly different between the high-risk and low-risk groups (p