Category
Heart

Many general practitioners (GPs) will be managing patients with cardiac murmurs. Here, we’d like to share with you a summary of guidelines developed by a group of GPs and consultants in London including Dr Shelley Rahman Haley, a consultant cardiologist at Harefield Hosptial.

 

What is a heart murmur

Even those who have a healthy heart can occasionally have murmurs.

However, heart murmurs are sometimes present because of a problem with the heart’s valves. It could be a sign of a serious problem that might need treatment – for example, if the heart valve is narrowed, prolapsed (weak or floppy) or leaking.

Other causes of heart murmurs include congenital heart defects and anaemia. Murmurs can also be found in pregnant women, because of the large amount of blood flowing through their hearts.

Determining whether a heart murmur requires follow-up by a cardiologist depends on the symptoms and characteristics of the murmur, as well as the general condition of the patient.

Considerations

Before referring a patient, you should consider the following:

Patient history
Does the patient have a history of any of the following

  • chest pain (especially with exercise)
  • symptoms of heart failure
  • palpitations
  • syncope
  • exercise intolerance
  • dyspnoea
  • chronic cough
  • presence of blood tinged frothy sputum
  • fatigue
  • anaemia
  • fever

Family history
Does the patient’s family have a history of sudden cardiac death, relatives with murmurs, or other cardiac conditions?

Physical examination
Is there presence of a murmur, other abnormal heart sounds, changes in pulse (rhythm and volume) or signs of right or left-sided heart failure?

Investigations
Are there any abnormalities when looking at the patient’s baseline electrocardiogram (ECG)? Requesting blood tests and a chest x-ray should also be considered, according to the clinical picture.

When to refer to a cardiologist

Referral via a loacl community cardiology service is appropriate for GPs in clinical commissioning groups (CCGs) that have a community pathway, or to outpatient cardiology in secondary care. However, a same day or more rapid assessment may be deemed clinically necessary by the GP.

GPs should refer a patient in the following scenarios:

  • If there is a new murmur present and echocardiogram findings warrant referral, then refer to a cardiologist
  • If there is a known murmur or valve disease and the patient exhibits deteriorating symptoms, then refer them to a cardiologist.
  • If there is the presence of a murmur associated with unexplained pyrexia, then refer the patient to a medical registrar for immediate assessment, and consider ambulatory transfer if they are actually unwell as this could mean inefective endocarditis.

If the patient is asymptomatic and has a normal echo, onward referral is not required. But, if the GP is concerned, this can be discussed through advice and guidance routes with a cardiologist.

Indications for echocardiogram

An echocardiogram is a scan that gives a detailed view of the structures of the heart. The following guidance can help you to decide if one is needed:

Indicated

  • Any previously undocumented or unheard murmur, unless the GP is confident to identify it and that it is not clinically significant.
  • Murmur in the presence of new or deteriorating symptoms.

Not indicated

  • Unchanged murmur in an asymptomatic individual with previous normal echocardiogram and a clear management plan – requires no further monitoring.

Referral requirements

To make a referral to a cardiologist, you will need:

  • patient history and examination findings
  • echocardiogram report
  • ECG
  • chest x-ray and bloods – if considered clinically appropriate by the GP.

This guide is intended to help GPs to manage patients with cardiac murmurs. Further advice is available from a cardiologist, including those at Royal Brompton & Harefield Hospitals Specialist Care.


Dr Shelley Rahman Haley
Consultant cardiologist

Dr Rahman Haley specialises in adult heart valve disease, transoesophageal echocardiography, and cardio-oncology (heart problems in cancer patients).