Trisha Williams (Host): Hi, guys. Welcome to the Advanced Practice Perspectives. I'm Tricia Williams.

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Now that we have the housekeeping tasks out of the way, it's time to step back, tune in, and get started.

Today, we are pleased to have Aaron Hahn visiting with us, sharing his expertise on heart murmurs. Aaron welcome to the podcast and please introduce yourself for us.

Aaron Hahn, MSN, CPNP-AC (Guest): Oh, absolutely. Thank you for having me. So, my name's Aaron Hahn. I've been at Children's Mercy for about eight years now. The first five of it were in the consult role in cardiology and switched for a little bit to go work in the orthopedic complex care and then missed heart so much I came back to an outpatient role in cardiology.

Before that, this was my first kind of position coming out of Grad school. I did my first undergrad in psychology. My second one in nursing worked in a PICU for a little bit, and then I went back to NP school.

Trisha Williams (Host): And landed here at Children's Mercy. We are so lucky to have you. Welcome.

Aaron Hahn, MSN, CPNP-AC (Guest): Thank you. This was originally going to be a three to five year city stop for my wife and I, and I like Children's Mercy so much, and she, we both enjoy Kansas City so much, we just decided to stay.

Trisha Williams (Host): There you go. Fall in love and stay for a little bit. We love it.

Tobie O'Brien (Host): Well, good. Well, we're so excited to have you on the podcast today to talk about heart murmurs. It's always great to get a little reminder on how to evaluate heart murmurs. So let's start by talking about the different types of heart

Aaron Hahn, MSN, CPNP-AC (Guest): murmurs.

There's a bunch of different types of heart murmurs. But first I want to briefly go over just heart sounds in general. When you're listening for heart sounds, using the bell is always kind of better for low frequency. The diaphragm is a little bit better for high frequency sounds.

Although in a pinch, if you just use the bell and kind of push a little bit harder, you can pick up some of those high frequency sounds. If you're listening for sounds and they sound really muffled, they're really distant, that's an indication that you need more of a workup. Some of that can just be like with pericardial effusion can give you kind of those distant or muffled sounds.

And then when you do start listening, you know, the heart, you always get that lub dub, lub dub, lub dub, that lub or that we call it the S1 is that first heart sound. And it's from the closing of the mitral and the tricuspid valves. So you kind of hear that the best at your left lower sternal border. Sometimes you can hear them split a little bit and can be normal, but a pretty wide splitting can be indicative of some congenital heart disease, like an Epstein's anomaly type of picture.

But that splitting sound can also sound like an ejection click. Although that's more upper left sternal border and like pulmonary stenosis or like left lower bicuspid aortic valve. So sometimes it's hard to feel that like split versus that ejection click apart. That dub or that S2 is the sound of your aortic and pulmonary valves closing.

The first sound, so S2 can be split. The first sound is kind of the closure of your aortic valve. Obviously your pulmonary valve follows. It's normally split and kind of varies with the respiration. So it increases a little bit with inspiration, can narrow or even become single with expiration.

But when you're listening to the S2, a widely split and fixed S2 is really heard anything that can prolong your kind of RV ejection time or shorten your LV ejection time. So with an ASD, you have volume overload. With a pulmonary stenosis, you can have some pressure overload like with a right bundle branch block you kind of get a delay in activation of the right ventricle, which can then lead to a delay in the pulmonary valve closure.

So all those things can kind of give you a widely split and fixed S2. A narrowly split S2 is really essentially the opposite of the widely split. So it's delayed closure of the aortic valve or early closure of the pulmonary valve. So pulmonary hypertension gives you that early valve pulmonary valve closure. Aortic stenosis can give you that delayed aortic closure.

Sometimes those can be normal. So sometimes the narrowly split, or even a single S2 can be normal, but a single S2 can also mean that you only have one valve present. Like if you have aortic or pulmonary atresia or truncus arteriosus. If you have really bad aortic stenosis or pulmonary hypertension, it can also give you that single S2.

There are two other heart sounds, your S3 and your S4. They're both lower frequency. Your S3 comes from the rapid filling of the ventricles. Left lower sternal border or the apex and pretty early diastole is when you hear it. This can be normal, although if it's loud and combines with tachycardia, you get a ventricular gallop.

So kind of the way I was always taught was a Kentucky gallop. So Kentucky, Kentucky, Kentucky, Kentucky. That's that gallop sound. S4, like I said, low frequency that's produced by the atrial contraction against a relatively stiff ventricle. So when tachycardic also gives you that gallop, so that Kentucky, Kentucky, or that lub a dub, lub a dub, lub a dub, that S4 is rarely normal.

So hearing a gallop is definitely an indication to go into more of a workup. Then you have extracardiac sounds like a rub, pericardial friction rub, that really is just like a sandpaper sound. You get this kind of to fro sound, it's pretty grating and it's from the friction of the heart against the pericardium.

So those are kind of like your general heart sounds before you get into kind of describing murmurs.

Trisha Williams (Host): Do you know any resources to where, you know, AI and technology these days are fantastic? If there's any free resources out there that people can go to, to specifically listen to those types? I mean, you, did an amazing job with the Kentucky and all of that, and but I just, it's for people to go and actually hear those types of heart sounds that they could refer to.

Aaron Hahn, MSN, CPNP-AC (Guest): So, I've looked and have been looking for a long time. The best one I've found so far is actually from Washington University not Washington Med School in St. Louis, but like Washington University, the state of Washington. But if you Google Washington University murmurs, it will pull up a list of all different congenital heart disease and what it sounds like. There is a normal on there, so you can click normal, listen to that, and then switch to whatever you want to listen to. And you can kind of hear whether it's in mid diastole, early diastole, like early systolic, kind of gives you all of those things to help you to be able to differentiate between them.

Trisha Williams (Host): Thank you for sharing that. That's fantastic.

Aaron Hahn, MSN, CPNP-AC (Guest): Absolutely. It comes in handy.

So, after you figure out your S1, S2, and you kind of get used to what those sound like, then you start talking about murmur classification. So, basing it off intensity, there's always the grade 1 through grade 6. So grade 1 is faint, it's barely audible. Grade 2 is a pretty soft murmur. Grade 3, easily audible, but without any palpable thrill, so you can't feel it.

Grade 4, easily audible, but you can actually feel it. Like it has a palpable thrill. Grade 5 is loud, audible with a stethoscope, kind of lightly touching the chest, and 6 is the loudest. And that's audible with a stethoscope and kind of hovering over the chest. It doesn't even have to touch it. And you can hear a grade 6 murmur.

Trisha Williams (Host): When you talk about a thrill, where are you palpating that pulse at to feel the thrill? Are you feeling a carotid or a radial or?

Aaron Hahn, MSN, CPNP-AC (Guest): I'm over the chest itself. So placing the palm of your hand directly over kind of that left chest, you can feel that thrill.

Trisha Williams (Host): Interesting. Thank you for that.

Tobie O'Brien (Host): I have another question. So a lot of our patients, which you may get to later, are kind of bigger chested patients, kind of just their mass in general, whether it be adipose tissue or whatever just with the obesity epidemic. So those kids are harder to hear, and so maybe you can touch on that a bit at some point, but that's, I guess, why it's really important to have a good stethoscope

Aaron Hahn, MSN, CPNP-AC (Guest): so with kids just in general being larger, sometimes it does get a little bit more difficult, but using your diaphragm and your bell, having them try to be a little more quieter for you. Listening directly on the skin. So don't try to listen through a t-shirt or through a sweatshirt. Especially on those larger kids, it just makes it more difficult. So kind of take out as many distractions as you possibly can. And then just do the best you can. And in a lot of this is just repetition and practice and repetition and practice until you get a lot more comfortable.

Tobie O'Brien (Host): Thank you.

Aaron Hahn, MSN, CPNP-AC (Guest): Absolutely. The second part of murmur classification is timing which is just based on the relation to the S1 and the S2 that we talked about before. So you could have systolic, diastolic, or continuous murmurs. And I'll kind of touch on those a little bit later. Location. So I always learned through the mnemonic apartment M.

So your upper right sternal area is your aortic area. Upper left is your pulmonary area. Lower right to middle is your tricuspid area and left lower over to your apex of the heart is more your mitral area. So from top right, top left, bottom right, bottom left, it's APTM. So apartment M.

Trisha Williams (Host): I learned an ape to man. That's hilarious.

Aaron Hahn, MSN, CPNP-AC (Guest): Yep.

Trisha Williams (Host): Like, I know that one.

Aaron Hahn, MSN, CPNP-AC (Guest): Yeah, there's a bunch of them out there and you just have to find whichever one works best that you're going to remember it, but it's, it sticks with you then. We also will comment on any transmission of sounds. So does it transmit to any other part of the body? For instance, loudest at the left upper sternal border, but radiates to the bilateral axilla.

That kind of helps distinguish what you're listening to. And the last is the quality. So quality can be like musical, vibratory, kind of a blowing murmur, a real harsh murmur, a mechanical murmur sound to it, or the pitch, high frequency or low frequency. For types of murmurs, when we talked about timing there's two different ways to describe them. Lethem in 1958 called them ejection or regurgitant. And then Perloff later on came in and said, it's either midsystolic, holosystolic, early systolic, or late.

For ours, we'll just look at kind of systolic, diastolic, or continuous murmurs. So, systolic murmurs occur anywhere between S1 and S2. You'll see notes that say, ejection systolic murmur. An ejection systolic murmur just means it starts after S1 and ends before S2. And that can be blood flow across a deformed aortic or pulmonary valve, or just accelerated blood flow due to increased cardiac output for a kid who's anemic, dehydrated, has a fever.

Holosystolic murmurs start with S1, so at the very start of S1 and go to the start of S2. And that's just flow of blood from a chamber of high pressure to low pressure throughout all of systole. Those generally occur when your aortic valve and your pulmonary valve are closed. So VSD, mitral regurgitation, tricuspid regurgitation can give you that holosystolic murmur.

Early systolic start with S1 and end well before S2. Those can also be a VSD, mitral regurgitation, or tricuspid regurgitation. So it can be early systolic or holosystolic. Those defects give you this either or sounds. Late systolic is our last kind of systolic murmur, and that one starts kind of midway through and goes all the way to S2, and that's really your mitral valve prolapse. Every once in a while that can have a click with it as well.

Tobie O'Brien (Host): So, is this systolic murmur the most common that we hear?

Aaron Hahn, MSN, CPNP-AC (Guest): Yes, the systolic is going to be the majority of your pathologic and innocent murmurs are going to, you'll end up hearing more of a systolic murmur. Diastolic murmurs, really your flip side is a curve between S2 and S1. So, early diastolic is immediately after that S2, and that's caused by regurgitation from either the pulmonary or the aortic valves.

Mid diastolic murmurs, you often hear them called a rumble, that's caused by mitral stenosis, or you can have a large left to right shunt, so a PDA, a VSD, and therefore the mitral valve might be normal in size. But it's relatively smaller just due to the increased blood flow across the normal mitral valve. You can have that kind of rumble as well. Then tricuspid stenosis or relative stenosis, kind of the same way the mitral valve was, although this can be an atrial septal defect or like an anomalous pulmonary venous return. And then you have presystolic or late diastolic, and sometimes they're kind of interchangeable, which is just before the start of S1, and that's, you actually have some anatomic stenosis of your mitral valve or your tricuspid valve.

And then the last one is a continuous murmur. So they begin in systole, continue through S2, and at times all the way through diastole. Really any sort of aortopulmonary or arterial venous connections, PDA will give you this type of a murmur. AV fistula will do this or any abnormal flow patterns in veins or arteries themselves can kind of give you a continuous all the way through murmur.

Trisha Williams (Host): So it's a very complex categorization of a murmur. So everybody thinks of these overbranching terms as a heart murmur, but it's super complex depending on where the actual lesion is. So give us those actual parts again of everything that we should document if we hear a heart murmur.

Aaron Hahn, MSN, CPNP-AC (Guest): So if you hear a heart murmur, the biggest things to document are kind of the intensity. So start there. So grade 1 through grade 6. If you're not 100 percent sure on the timing, don't worry about it. Don't take a guess at it. We'd rather not have it and just say like, it's a grade 3 murmur, and then give us the location.

So if you're going to refer grade 3 or grade 4 murmur upper left sternal border and you say does or does not transmit to a different part of the body. And then what it sounds like, if it sounds like a harsh murmur, if it sounds mechanical, if it sounds like it's a click, those are all important identifiers to know if you're going to send someone to cardiology.

Tobie O'Brien (Host): That's super helpful. It is way more complex than you think, actually, just like Trisha said. So I love hearing those details of what to include. So when you are talking with families, how do you explain these in terms they can understand?

Aaron Hahn, MSN, CPNP-AC (Guest): If I go in for just a murmur evaluation, I'll do my full history and all of those things. If it's an innocent murmur, the way I describe it is, it's just the sound of blood flowing through the heart. At any point in time, depending upon what source you look at, a third to three quarter of kids will have an innocent murmur at some time between the ages of 1 and 14.

But of all of those kids, less than 1 percent of those murmurs are actual congenital heart disease. An analogy that I use almost every time is, it's as though you turn the water on at your house and you hear the water coming through the pipes. It does not mean that your plumber messed up and there's a leak or something's improperly connected or going where it's not supposed to go.

It just means that you can hear the water coming through the pipes. And at its very core, the heart is a pump and tubes. That's what it breaks down to. So if you can hear the water coming through the pipes, at times you can just hear the blood flowing through the heart. It does not mean that there's a hole or that anything's connected improperly. It just means that you can hear the blood flowing through the heart.

Tobie O'Brien (Host): Great. Now say someone hears just like, a grade 1 murmur on an exam. Does that always need to be worked up? Especially if it's new, or if someone feels super comfortable with those sounds, like the S1, S2, and all of the categories that you have kind of gone through in detail, you know, at what point do you think it is reasonable to refer to cardiology based off murmurs and what say a primary care person might hear or even outpatient setting type subspecialty when they hear a murmur?

Aaron Hahn, MSN, CPNP-AC (Guest): It really depends a lot on the history. So birth history is important. If there's like maternal diabetes, maternal infections, so like a TORCH type infection, prematurity, maternal drug use, all of those things are important to know. And then family history, family history of cardiomyopathy or someone in the family needed a transplant. Someone in the family, like a sibling or a parent, aunt or uncle had severe congenital heart disease or a bicuspid aortic valve. Bicuspid aortic valve, now you get cascade screening. So every first degree relative of someone with the bicuspid aortic valve should be screened with an echocardiogram. And then moving on, like if they're a little bit older, you know, not an infant, any new fatigue and they're just not able to do things that they used to be able to do.

Or, they're always kind of have been a little bit slower and not a little bit slower because they can't run as fast, but a little bit slower because they can run, but they are always out of breath significantly sooner than their peers. So those sorts of things combined with a new murmur that is when you should refer.

And then you have to look at, you know, weight and growth development. If they were on their normal growth chart, like an infant is at 25 percent and then 25%, then it all of a sudden just drops off and you're 15, 10, 5, and you have a murmur, that should definitely be looked into.

Trisha Williams (Host): I feel like as a subspecialty, like we do pre op history and physicals, of course. And so we are listening to heart sounds and I have an ICU background. So I feel like I hear all the murmurs, right? It's just, Oh, you have a murmur. And I am able to pick those up. And I think I am like the 1 percent of my patients have something actually wrong with them, right?

I think in my 10 years, I've referred thousands to cardiology for a murmur and three patients have had a congenital heart issue. But I really feel super strongly about the fact that that's not my subspecialty. And for the best of these patients, for those three patients that I referred they had to undergo cardiac repair.

So like, I guess there's that fine balance because we don't want to inundate the system with unnecessary referrals. So I think it behooves me to become more experienced with the normal, and what that normal heart murmur, the innocent heart murmurs are because I will ask those questions and talk to families and they'll be like, hey, has your pediatrician mentioned this?

And that's like, oh yeah, my pediatrician's all over it or my pediatric provider. And I'm like, great, okay, I'm gonna let them take it from there. And there's no, none of those things that you had recommended, or none of those things have that you had talked about were present. However, it's the ones that are like, oh yeah, we don't really have a primary care provider. And we haven't heard that before. And I'm like, Oh my goodness. Okay. We're going to send you.

Tobie O'Brien (Host): Yeah, I would agree, Trisha. I think that's the same.

Aaron Hahn, MSN, CPNP-AC (Guest): And we would much rather screen those kids to be sure than to have someone kind of waffle back and forth, especially in, if it's a pre op setting, like that would be something that is very important to know. And like a PCC setting, like, well, if they have a fever or they're anemic, and it's kind of the first time hearing it, but they're otherwise doing great.

We can come back and listen again in six months. And if it's still there and it sounds a little bit abnormal to you, absolutely send them. We're happy to evaluate those kids. We would rather evaluate them than miss something that's going to cause more long term damage.

Trisha Williams (Host): I would rather you evaluate them as well. What is that? I remember hearing, I think, in grad school about, like, with innocent murmurs, if you change the patient's position or have them lay down, it goes away. Is that a myth, or can you

Aaron Hahn, MSN, CPNP-AC (Guest): It is not. With innocent murmurs, there's a couple of different kinds of innocent murmurs. The big one is a Still's murmur. It's actually named after Dr. George Still in, I think it was 1908 or 1909. He had a textbook like common disorders and diseases of childhood, but it's this kind of musical, almost like a twanging string vibratory sound most often heard in like the three to six year old age group, can be heard in infancy.

Most or best heard at the left sternal border, lower to mid left sternal border. Generally grade 2 to 3 out of 6, but it is loudest when they're lying down and changes when they sit or stand. So you have this change in pressure, changing gravity in general going from sitting to standing and it can cause a change in the way that the blood is flowing through the heart.

So it'll be louder one way and it changes when they sit upright.

Trisha Williams (Host): Okay. That's a good trick. I'm going to try it.

Aaron Hahn, MSN, CPNP-AC (Guest): It works. Really if a pathologic murmur really doesn't change with position changes. So there's a couple other types of innocent murmurs, like your newborn pulmonary flow murmur. It's also a systolic murmur, really preemies and full term newborns. This is normally gone by about six months of age, but it can be a grade 1 to 2 out of 6, upper left sternal border transmits to bilateral chest axilla. Sometimes you can hear it on the back. And this is, to do in fetal life, there's a large main pulmonary artery trunk and you get smaller branch PAs.

So those branch pulmonary arteries are a little bit smaller. So you have this transition from this big pulmonary artery trunk to the smaller branch pulmonary arteries and gives you this flow murmur. As these kids grow, this is normally gone by like six months of age. So that's your newborn kind of pulmonary flow murmur.

You can also have like a pulmonary ejection murmur. Also a systolic murmur. This one's most common in adolescents. Also upper left sternal border. This one can be a little confusing because it can be kind of grating sounding. So it can get confused with like a pulmonary valve stenosis or an ASD, but it's really just the normal ejection vibrations within that pulmonary trunk for adolescents.

Trisha Williams (Host): Is it like related to hormone influx or something like that?

Aaron Hahn, MSN, CPNP-AC (Guest): I don't know if it's hormones or just growth spurts.

Trisha Williams (Host): Growth. Yeah. Interesting. Interesting. Okay.

Aaron Hahn, MSN, CPNP-AC (Guest): You can have a venous hum as well. That's a continuous murmur, right or left kind of infra or supraclavicular areas. Kids aged three to six most often will have a venous hum. It's a grade 1 to 3. And it's just turbulent flow in those jugular veins. And this one is heard only in the upright position. So venous hum is heard when they're upright, should go away when they're laying down. In innocent murmurs, the story that I give families is that innocent murmurs come and go throughout childhood. So you can hear it, it can go away and then it can come back. And that can be a normal progression through childhood. Anything that makes the heart work harder is going to make an innocent murmur sound louder.

So, fever, anemia, dehydration, all those things can make it more prominent. So, if you have your kid in the ER with 103 fever, like, well, we hear a murmur now, believe you probably do. If that's the first time it's ever been heard. Following up with the PCP when you feel better, you know, your infection's gone, and determining if there's still a murmur or not a murmur, that's a great second step for that.

Tobie O'Brien (Host): Now, you mentioned the Washington University, I believe, on the S1, S2, S3, S4. Do they also have a good sound regarding like all of these innocent murmurs?

Aaron Hahn, MSN, CPNP-AC (Guest): I believe so.

Tobie O'Brien (Host): Okay.

Trisha Williams (Host): Perfect. Aaron, this has been very enlightening and educational in regards to murmurs. I feel like you were able to really break it down for our listeners, so your knowledge is greatly appreciated.

Aaron Hahn, MSN, CPNP-AC (Guest): Absolutely. This is, like I said earlier, I left cardiology and realized how much I missed it, so this is the stuff that I can talk about all day.

Tobie O'Brien (Host): Sure. Well, it sounds like you understand it very well. And my head was kind of spinning. I was really trying to focus on all of the things as you were saying it. So I'll have to go back and listen again and take some notes, and review the anatomy of the heart again, because I think what you said all makes sense.

And I think it's very applicable to what everyone does on a daily basis when listening to kids hearts. So I think it's going to be really helpful to everyone.

Aaron Hahn, MSN, CPNP-AC (Guest): Yeah. And if you're having to explain this to a family in clinic that you think it's an innocent heart murmur, I always recommend using a picture.

Trisha Williams (Host): Okay. Perfect. I love that.

Aaron Hahn, MSN, CPNP-AC (Guest): Yes, a normal heart just with an explanation goes so much better than that blank stare you get from families when you're trying to explain something and they're just not grasping the picture aspect

Trisha Williams (Host): Yeah. Right. Well, and just saying that it's, you're hearing the water through the pipes, you're hearing the blood through the pipes. So I think that that's amazing. We do really truly thank you for your knowledge set and during each season, if you're an active listener of our podcast, we like to kind of end each episode with a question of the season.

And this question for season five, if you're ready for it, is what is filling your cup in this season of your life?

Aaron Hahn, MSN, CPNP-AC (Guest): Oh, coffee.

Trisha Williams (Host): You're so literal.

Aaron Hahn, MSN, CPNP-AC (Guest): I have two elementary school aged children who are both active and like doing all sorts of different things. So coffee to keep me going. But, but outside of that, just kind of watching them develop their own personalities, their own interests and likes and dislikes has been really, really fun.

Trisha Williams (Host): That's the best part of parenting, right?

That's Great.

Tobie O'Brien (Host): Yeah, absolutely. Well, Aaron, thanks again so much for coming on the podcast today. We really appreciate your time.

Aaron Hahn, MSN, CPNP-AC (Guest): Yep, absolutely. Thank you for having me on.

Tobie O'Brien (Host): If you have a topic that you would like to hear about or you are interested in being a guest, you can email us at tdobrian at cmh. edu or twilliams at cmh. edu. As a reminder, to complete your evaluation and ensure that you get the credit for listening, visit childrensmercy.

org. APPEVAL. That's childrensmercy. org slash APPEVAL. Once again, thanks so much for listening to the Advanced Practice Perspectives podcast.  

Tobie O'Brien (Host): No relevant financial relationships were identified for any member of the planning committee or any presenter author of the program content.