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Edward Etchells, MD, MSc; Chaim Bell, MD; Kenneth Robb, MD

JAMA. 1997;277(7):564-571.

Abstract
Our objective was to review the available evidence of the precision and accuracy of the clinical examination for abnormal systolic murmurs. We conducted a MEDLINE search, manually reviewed all reference lists, and contacted authors of published studies. Each study was independently reviewed by 2 observers and graded for methodologic quality. We found that most studies were conducted using cardiologist examiners. In the clinical setting, the reliability of detecting systolic murmurs was fair (k, 0.30-0.48). The most useful findings for ruling in aortic stenosis are a slow rate of rise of the carotid pulse (positive likelihood ratio, 2.8-130), mid to late peak intensity of the murmur (positive likelihood ratio, 8.0-101), and decreased intensity of the second heart sound (positive likelihood ratio, 3.1-50). The most useful finding for ruling out aortic stenosis is the absence of murmur radiation to the right carotid artery (negative likelihood ratio, 0.05-0.10). Smaller, lower-quality studies indicate that cardiologists can accurately rule in and rule out mitral regurgitation, tricuspid regurgitation, hypertrophic cardiomyopathy, and echocardiographic mitral valve prolapse. We conclude that the clinical examination by cardiologists is accurate for detecting various causes of abnormal systolic murmurs. Studies of the clinical examination by noncardiologists are needed.

Author Affiliations
From the Division of General Internal Medicine and Clinical Epidemiology, Department of Medicine, University of Toronto; and The Toronto Hospital, Toronto, Ontario.

Footnotes
Corresponding author: Edward Etchells, MD, MSc, The Toronto Hospital, 200 Elizabeth St, eng-248, Toronto, Ontario M5G 2C4 (e-mail: eetchells@torhosp.toronto.on.ca).

The Rational Clinical Examination section editors: David L. Simel, MD, MHS, Durham Veterans Affairs Medical Center and Duke University Medical Center, Durham, NC; Drummond Rennie, MD, Deputy Editor (West), JAMA.

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