Referral to a pediatric cardiologist is recommended for patients with any other abnormal physical examination findings, a history of conditions that increase the likelihood of structural heart disease, symptoms suggesting underlying cardiac disease, or when a specific innocent murmur cannot be identified by the family physician. Electrocardiography and chest radiography rarely assist in the diagnosis. Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S 2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Physical examination should focus on vital signs age-appropriate exercise capacity respiratory or gastrointestinal manifestations of congestive heart failure and a thorough cardiovascular examination, including features of the murmur, assessment of peripheral perfusion, and auscultation over the heart valves. Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease.
Heart murmurs are common in healthy infants, children, and adolescents.