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February 19, 1997, Vol 277, No. 7 >
ARTICLE | February 19, 1997

Does This Patient Have an Abnormal Systolic Murmur? FREE

Edward Etchells, MD, MSc; Chaim Bell, MD; Kenneth Robb, MD
[+] Author Affiliations

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.


JAMA. 1997;277(7):564-571. doi:10.1001/jama.1997.03540310062036
Text Size: A A A
Published online
Article
References

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.

REFERENCES

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Ballard DJ, Khanderia BK, Tajik AJ, Seward JB, Weber VP, Melton LJ.  Population-based study of echocardiography: time trends in utilization and diagnostic profile of an evolving technology . Int J Technol Assess Health Care . 1989;;5:249-261.
2 +
Rushmer RF, Sparkman DR, Polley RFL, et al.  Variability in detection and interpretation of heart murmurs . Am J Dis Child . 1952;;83:740-754.
3 +
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4 +
Sapira JD. The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1990;.
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Chatterjee K.  Bedside evaluation of the heart: the physical examination . In: Chatterjee K, et al, eds. Cardiology: An Illustrated Text/Reference . Vol 1. Philadelphia, Pa: JB Lippincott; 1991;.
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Marriot HJ. Bedside Cardiac Diagnosis . Philadelphia, Pa: JB Lippincott; 1991;:19.
7 +
Leach RM, McBrien DJ.  Brachioradial delay: a new clinical indicator of the severity of aortic stenosis . Lancet . 1990;;335:1199-1201.
8 +
Chun PKC, Dunn BE.  Clinical clue of severe aortic stenosis: simultaneous palpation of the carotid and apical impulses . Arch Intern Med . 1982;;142:2284-2288.
9 +
Levine SA.  The systolic murmur: its clinical significance . JAMA . 1933;;101:436-438.
10 +
Freeman AR, Levine SA.  The clinical significance of the systolic murmur: a study of 1000 consecutive cardiac cases . Ann Intern Med . 1933;;6:1371-1385.
11 +
Rivero-Carvallho JM.  Signo para el diagnostico de las insufficiencias tricuspideas . Arch Inst Cardiol Mex . 1946;;16:531-540.
12 +
Maisel A, Atwood JE, Goldberger AL.  Hepatojugular reflux: useful in the bedside diagnosis of tricuspid regurgitation . Ann Intern Med . 1984;;101:781-782.
13 +
Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA.  Diagnosis of left-sided regurgitant murmurs of transient arterial occlusion: a new maneuver using blood pressure cuffs . Ann Intern Med . 1986;;105:368-370.
14 +
Sharpey-Schafer EP.  Effects of squatting on the normal and failing circulation . BMJ . 1956;;1:1072-1074.
15 +
Ravin A, Craddock LD, Wolf PS, Shander D, ed. Auscultation of the Heart . 3rd ed. Chicago, Ill: Mosby-Year Book; 1977;:2:45-67.
16 +
Taranta A, Spagnuolo M, Snyder R, Gerbarg DS, Hofler JJ.  Auscultation of the heart by physicians and by computer . In: Data Acquisition and Processing in Biology and Medicine, Vol 3 . New York, NY: Macmillan Publishing Co Inc; 1964;:23-52.
17 +
Panidis JP, McAllister M, Ross J, Mintz GS.  Prevalence and severity of mitral regurgitation in the mitral valve prolapse syndrome: a Doppler echocardiographic study of 80 patients . J Am Coll Cardiol . 1986;;7:975-981.
18 +
Raftery EB, Holland WW.  Examination into the heart: an investigation into variation . Am J Epidemiol . 1967;;85:438-444.
19 +
Forssell G, Jonasson R, Orinius E.  Identifying severe aortic valvular stenosis by bedside examination . Acta Med Scand . 1985;;218:397-400.
20 +
Dobrow RJ, Calatayud JB, Abraham S, Caceres CA.  A study of physician variation in heart sound interpretation . Med Annu Dist Columbia . (July) 1964;.
21 +
Spodick DH, Sugiura T, Doi Y, Paladino D, Haffty BG.  Rate of rise of the carotid pulse: an investigation of observer error in a common clinical measurement . Am J Cardiol . 1982;;49:159-162.
22 +
Holleman DR, Simel DL.  Does the clinical examination predict airflow limitation? JAMA . 1995;;273:313-319.
23 +
Mishra M, Chambers JB, Jackson G.  Murmurs in pregnancy: an audit of echocardiography . BMJ . 1992;;304:1413-1414.
24 +
Ahuja IM.  Functional systolic murmurs . Indian Heart J . 1982;;34:241-244.
25 +
Lockhart PB, Crist D, Stone PH.  The reliability of the medical history in the identification of patients at risk for infective endocarditis . J Am Dental Assoc . 1989;;119:417-422.
26 +
Xu M, McHaffie DJ.  Nonspecific systolic murmurs: an audit of the clinical value of echocardiography . N Z Med J . 1993;;106:54-56.
27 +
Aronow WS, Kronzon I.  Correlation of prevalence and severity of valvular aortic stenosis determined by continuous-wave Doppler echocardiography with physical signs of aortic stenosis in patients aged 62 to 100 years with aortic systolic ejection murmurs . Am J Cardiol . 1987;;60:399-401.
28 +
Hoagland PM, Cook EF, Wynne J, Goldman L.  Value of noninvasive testing in adults with suspected aortic stenosis . Am J Med . 1986;;80:1041-1050.
29 +
Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA.  Bedside diagnosis of systolic murmurs . N Engl J Med . 1988;;318:1572-1578.
30 +
Jaffe WM, Roche AHG, Coverdale HA, McAlister HF, Ormiston JA, Greene ER.  Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease . Circulation . 1988;;78:267-275.
31 +
McKillop GM, Stewart DA, Burns JMA, Ballantyne D.  Doppler echocardiography in elderly patients with ejection systolic murmurs . Postgrad Med J . 1991;;61:1059-1061.
32 +
Gaasch WH, John RM, Aurigemma GP.  Managing asymptomatic patients with chronic mitral regurgitation . Chest . 1995;;108:842-847.
33 +
Dajani AS, Bisno AL, Chung KJ, et al.  Prevention of bacterial endocarditis: recommendations by the American Heart Association . JAMA . 1990;;264:2919-2922.
34 +
Seneviratne B, Morre GA, West PD.  Effect of captopril on functional mitral regurgitation in dilated heart failure: a randomized double blind placebo controlled trial . Br Heart J . 1994;;72:63-68.
35 +
Meyers DG, McCall D, Sears TD, Olson TS, Felix GL.  Duplex pulsed Doppler echocardiography in mitral regurgitation . J Clin Ultrasound . 1986;;14:117-121.
36 +
Rahko PS.  Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography . Ann Intern Med . 1989;;111:466-472.
37 +
Lehmann KG, Francis CK, Dodge HT, and the TIMI study group.  Mitral regurgitation in early myocardial infarction: incidence, clinical detection, and prognostic implications . Ann Intern Med . 1992;;117:10-17.
38 +
Kinney EL.  Causes of false-negative auscultation of regurgitant lesions: a Doppler echocardiographic study of 294 patients . J Gen Intern Med . 1988;;3:429-434.
39 +
Buda A, Mackenzie G, Wigle D.  The Mueller maneuver in muscular subaortic stenosis . Circulation . 1977;;56( (suppl 3) ):III-138. Abstract.
40 +
Nellen M, Gotsman MS, Vogelpoel L, Beck W, Schrire V.  Effects of prompt squatting on the systolic murmur in idiopathic hypertrophic obstructive cardiomyopathy . BMJ . 1967;;3:140-143.
41 +
Braunwald E, Oldham HN Jr, Ross J Jr, Linhart JW, Mason DT, Fort L III.  The circulatory response of patients with idiopathic hypertrophic subaortic stenosis to nitroglycerin and the Valsalva maneuver . Circulation . 1964;;29:422-431.
42 +
Kramer DS, French WJ, Criley JM.  The postextrasystolic murmur response to gradient in hypertrophic cardiomyopathy . Ann Intern Med . 1986;;104:772-776.
43 +
Petrin TJ, Tavel ME.  Idiopathic hypertrophic subaortic stenosis as observed in a large community hospital . J Am Geriatr Soc . 1979;;27:43-46.
44 +
Rosenblum R, Delman AJ.  Valsalva's maneuver and the systolic murmur of hypertrophic subaortic stenosis . Am J Cardiol . 1965;;15:868-870.
45 +
Stefadouros MA, Mucha E, Frank MJ.  Paradoxic response of the murmur of idiopathic hypertrophic subaortic stenosis to the Valsalva maneuver . Am J Cardiol . 1976;;37:89-92.
46 +
Bartall H, Amber S, Desser KB, Benchimol A.  Normalization of the external carotid pulse tracing of hypertrophic subaortic stenosis during Muller's maneuver . Chest . 1978;;74:77-78.
47 +
Cassidy J, Aronow WS, Prakash R.  The effect of isometric exercise on the systolic murmur of patients with idiopathic hypertrophic subaortic stenosis . Chest . 1975;;67:395-397.
48 +
Battle WE, Siegel FA, Fox LM.  The older patient with idiopathic hypertrophic subaortic stenosis . Geriatrics . 1977;;1:61-69.
49 +
Klein HO, DiSegni E, Dean H, Beker B, Bakst A, Kaplinsky E.  Increased intensity of the murmur of hypertrophic obstructive cardiomyopathy with carotid sinus pressure . Chest . 1988;;93:814-820.
50 +
Perloff JK, Child JS, Edwards JE.  New guidelines for the clinical diagnosis of mitral valve prolapse . Am J Cardiol . 1986;;57:1124-1129.
51 +
Devereux RB, Kramer-Fox R, Shear K, Kligfield P, Pini R, Savage DD.  Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic, and prognostic consideration . Am Heart J . 1987;;113:1265-1280.
52 +
Devereux RB, Kramer-Fox R, Brown WT, et al.  Relation between clinical features of the mitral valve prolapse syndrome and echocardiographically documented mitral valve prolapse . J Am Coll Cardiol . 1986;;8:763-772.
53 +
Olive KE, Grassman ED.  Mitral valve prolapse: comparison of diagnosis by physical examination and echocardiography . South Med J . 1990;;83:1266-1269.
54 +
Abbasi AS, DeCristofaro D, Anabtawi J, Irwin L.  Mitral valve prolapse: comparative value of M-mode, two-dimensional and Doppler echocardiography . J Am Coll Cardiol . 1983;;2:1219-1223.
55 +
Barron JT, Manrose DL, Liebson PR.  Comparison of auscultation with two-dimensional and Doppler echocardiography in patients with suspected mitral valve prolapse . Clin Cardiol . 1988;;11:401-406.
56 +
Retchin SM, Waugh RA, Fletcher RH.  The impact of echocardiographic results on treatment decisions for patients suspected of mitral valve prolapse . Med Care . 1987;;25:652-657.
57 +
Nishimura RA, McGoon MD, Shub C, Miller FA Jr, Ilstrup DM, Tajik AJ.  Echocardiographically documented mitral-valve prolapse: long-term follow-up of 237 patients . N Engl J Med . 1985;;313:1305-1309.
58 +
Orencia AJ, Petty GW, Khanderia BK, et al.  Risk of stroke with mitral valve prolapse in populationbased cohort survey . Stroke . 1995;;26:7-13.
59 +
Marks AR, Choong CY, Sanfilippo AJ, Ferre M, Weyman AE.  Identification of high-risk and low-risk subgroups of patients with mitral valve prolapse . N Engl J Med . 1989;;320:1031-1036.
60 +
Tofler OB, Tofler GH.  Use of auscultation to follow patients with mitral systolic clicks and murmurs . Am J Cardiol . 1990;;66:1355-1358.
61 +
Zuppiroli A, Rinaldi M, Kramer-Fox R, Favilli S, Roman MJ, Devereux RB.  Natural history of mitral valve prolapse . Am J Cardiol . 1995;;75:1028-1032.
62 +
McCracken D, Everett JE.  An investigation of the incidence of cardiac murmurs in young healthy women . Practitioner . 1976;;216:308-309.
63 +
Stewart IMG.  Systolic murmurs in 525 healthy young adults . Br Heart J . 1951;;13:561-565.
64 +
Vaughan JP.  Blood pressure and heart murmurs in a rural population in the United Republic of Tanzania . Bull World Health Organ . 1979;;57:89-97.
65 +
Cotter L, Logan RL, Poole A.  Innocent systolic murmurs in healthy 40-year-old men . J R Coll Physicians London . 1980;;14:128-129.
66 +
Markiewicz W, Stoner J, London E, Hunt SA, Popp RL.  Mitral valve prolapse in one hundred presumably healthy young females . Circulation . 1976;;53:464-473.
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Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Ballard DJ, Khanderia BK, Tajik AJ, Seward JB, Weber VP, Melton LJ.  Population-based study of echocardiography: time trends in utilization and diagnostic profile of an evolving technology . Int J Technol Assess Health Care . 1989;;5:249-261.
2 +
Rushmer RF, Sparkman DR, Polley RFL, et al.  Variability in detection and interpretation of heart murmurs . Am J Dis Child . 1952;;83:740-754.
3 +
Constant J. Bedside Cardiology . 3rd ed. Boston, Mass: Little Brown & Co Inc; 1985;.
4 +
Sapira JD. The Art and Science of Bedside Diagnosis . Baltimore, Md: Urban & Schwarzenberg; 1990;.
5 +
Chatterjee K.  Bedside evaluation of the heart: the physical examination . In: Chatterjee K, et al, eds. Cardiology: An Illustrated Text/Reference . Vol 1. Philadelphia, Pa: JB Lippincott; 1991;.
6 +
Marriot HJ. Bedside Cardiac Diagnosis . Philadelphia, Pa: JB Lippincott; 1991;:19.
7 +
Leach RM, McBrien DJ.  Brachioradial delay: a new clinical indicator of the severity of aortic stenosis . Lancet . 1990;;335:1199-1201.
8 +
Chun PKC, Dunn BE.  Clinical clue of severe aortic stenosis: simultaneous palpation of the carotid and apical impulses . Arch Intern Med . 1982;;142:2284-2288.
9 +
Levine SA.  The systolic murmur: its clinical significance . JAMA . 1933;;101:436-438.
10 +
Freeman AR, Levine SA.  The clinical significance of the systolic murmur: a study of 1000 consecutive cardiac cases . Ann Intern Med . 1933;;6:1371-1385.
11 +
Rivero-Carvallho JM.  Signo para el diagnostico de las insufficiencias tricuspideas . Arch Inst Cardiol Mex . 1946;;16:531-540.
12 +
Maisel A, Atwood JE, Goldberger AL.  Hepatojugular reflux: useful in the bedside diagnosis of tricuspid regurgitation . Ann Intern Med . 1984;;101:781-782.
13 +
Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA.  Diagnosis of left-sided regurgitant murmurs of transient arterial occlusion: a new maneuver using blood pressure cuffs . Ann Intern Med . 1986;;105:368-370.
14 +
Sharpey-Schafer EP.  Effects of squatting on the normal and failing circulation . BMJ . 1956;;1:1072-1074.
15 +
Ravin A, Craddock LD, Wolf PS, Shander D, ed. Auscultation of the Heart . 3rd ed. Chicago, Ill: Mosby-Year Book; 1977;:2:45-67.
16 +
Taranta A, Spagnuolo M, Snyder R, Gerbarg DS, Hofler JJ.  Auscultation of the heart by physicians and by computer . In: Data Acquisition and Processing in Biology and Medicine, Vol 3 . New York, NY: Macmillan Publishing Co Inc; 1964;:23-52.
17 +
Panidis JP, McAllister M, Ross J, Mintz GS.  Prevalence and severity of mitral regurgitation in the mitral valve prolapse syndrome: a Doppler echocardiographic study of 80 patients . J Am Coll Cardiol . 1986;;7:975-981.
18 +
Raftery EB, Holland WW.  Examination into the heart: an investigation into variation . Am J Epidemiol . 1967;;85:438-444.
19 +
Forssell G, Jonasson R, Orinius E.  Identifying severe aortic valvular stenosis by bedside examination . Acta Med Scand . 1985;;218:397-400.
20 +
Dobrow RJ, Calatayud JB, Abraham S, Caceres CA.  A study of physician variation in heart sound interpretation . Med Annu Dist Columbia . (July) 1964;.
21 +
Spodick DH, Sugiura T, Doi Y, Paladino D, Haffty BG.  Rate of rise of the carotid pulse: an investigation of observer error in a common clinical measurement . Am J Cardiol . 1982;;49:159-162.
22 +
Holleman DR, Simel DL.  Does the clinical examination predict airflow limitation? JAMA . 1995;;273:313-319.
23 +
Mishra M, Chambers JB, Jackson G.  Murmurs in pregnancy: an audit of echocardiography . BMJ . 1992;;304:1413-1414.
24 +
Ahuja IM.  Functional systolic murmurs . Indian Heart J . 1982;;34:241-244.
25 +
Lockhart PB, Crist D, Stone PH.  The reliability of the medical history in the identification of patients at risk for infective endocarditis . J Am Dental Assoc . 1989;;119:417-422.
26 +
Xu M, McHaffie DJ.  Nonspecific systolic murmurs: an audit of the clinical value of echocardiography . N Z Med J . 1993;;106:54-56.
27 +
Aronow WS, Kronzon I.  Correlation of prevalence and severity of valvular aortic stenosis determined by continuous-wave Doppler echocardiography with physical signs of aortic stenosis in patients aged 62 to 100 years with aortic systolic ejection murmurs . Am J Cardiol . 1987;;60:399-401.
28 +
Hoagland PM, Cook EF, Wynne J, Goldman L.  Value of noninvasive testing in adults with suspected aortic stenosis . Am J Med . 1986;;80:1041-1050.
29 +
Lembo NJ, Dell'Italia LJ, Crawford MH, O'Rourke RA.  Bedside diagnosis of systolic murmurs . N Engl J Med . 1988;;318:1572-1578.
30 +
Jaffe WM, Roche AHG, Coverdale HA, McAlister HF, Ormiston JA, Greene ER.  Clinical evaluation versus Doppler echocardiography in the quantitative assessment of valvular heart disease . Circulation . 1988;;78:267-275.
31 +
McKillop GM, Stewart DA, Burns JMA, Ballantyne D.  Doppler echocardiography in elderly patients with ejection systolic murmurs . Postgrad Med J . 1991;;61:1059-1061.
32 +
Gaasch WH, John RM, Aurigemma GP.  Managing asymptomatic patients with chronic mitral regurgitation . Chest . 1995;;108:842-847.
33 +
Dajani AS, Bisno AL, Chung KJ, et al.  Prevention of bacterial endocarditis: recommendations by the American Heart Association . JAMA . 1990;;264:2919-2922.
34 +
Seneviratne B, Morre GA, West PD.  Effect of captopril on functional mitral regurgitation in dilated heart failure: a randomized double blind placebo controlled trial . Br Heart J . 1994;;72:63-68.
35 +
Meyers DG, McCall D, Sears TD, Olson TS, Felix GL.  Duplex pulsed Doppler echocardiography in mitral regurgitation . J Clin Ultrasound . 1986;;14:117-121.
36 +
Rahko PS.  Prevalence of regurgitant murmurs in patients with valvular regurgitation detected by Doppler echocardiography . Ann Intern Med . 1989;;111:466-472.
37 +
Lehmann KG, Francis CK, Dodge HT, and the TIMI study group.  Mitral regurgitation in early myocardial infarction: incidence, clinical detection, and prognostic implications . Ann Intern Med . 1992;;117:10-17.
38 +
Kinney EL.  Causes of false-negative auscultation of regurgitant lesions: a Doppler echocardiographic study of 294 patients . J Gen Intern Med . 1988;;3:429-434.
39 +
Buda A, Mackenzie G, Wigle D.  The Mueller maneuver in muscular subaortic stenosis . Circulation . 1977;;56( (suppl 3) ):III-138. Abstract.
40 +
Nellen M, Gotsman MS, Vogelpoel L, Beck W, Schrire V.  Effects of prompt squatting on the systolic murmur in idiopathic hypertrophic obstructive cardiomyopathy . BMJ . 1967;;3:140-143.
41 +
Braunwald E, Oldham HN Jr, Ross J Jr, Linhart JW, Mason DT, Fort L III.  The circulatory response of patients with idiopathic hypertrophic subaortic stenosis to nitroglycerin and the Valsalva maneuver . Circulation . 1964;;29:422-431.
42 +
Kramer DS, French WJ, Criley JM.  The postextrasystolic murmur response to gradient in hypertrophic cardiomyopathy . Ann Intern Med . 1986;;104:772-776.
43 +
Petrin TJ, Tavel ME.  Idiopathic hypertrophic subaortic stenosis as observed in a large community hospital . J Am Geriatr Soc . 1979;;27:43-46.
44 +
Rosenblum R, Delman AJ.  Valsalva's maneuver and the systolic murmur of hypertrophic subaortic stenosis . Am J Cardiol . 1965;;15:868-870.
45 +
Stefadouros MA, Mucha E, Frank MJ.  Paradoxic response of the murmur of idiopathic hypertrophic subaortic stenosis to the Valsalva maneuver . Am J Cardiol . 1976;;37:89-92.
46 +
Bartall H, Amber S, Desser KB, Benchimol A.  Normalization of the external carotid pulse tracing of hypertrophic subaortic stenosis during Muller's maneuver . Chest . 1978;;74:77-78.
47 +
Cassidy J, Aronow WS, Prakash R.  The effect of isometric exercise on the systolic murmur of patients with idiopathic hypertrophic subaortic stenosis . Chest . 1975;;67:395-397.
48 +
Battle WE, Siegel FA, Fox LM.  The older patient with idiopathic hypertrophic subaortic stenosis . Geriatrics . 1977;;1:61-69.
49 +
Klein HO, DiSegni E, Dean H, Beker B, Bakst A, Kaplinsky E.  Increased intensity of the murmur of hypertrophic obstructive cardiomyopathy with carotid sinus pressure . Chest . 1988;;93:814-820.
50 +
Perloff JK, Child JS, Edwards JE.  New guidelines for the clinical diagnosis of mitral valve prolapse . Am J Cardiol . 1986;;57:1124-1129.
51 +
Devereux RB, Kramer-Fox R, Shear K, Kligfield P, Pini R, Savage DD.  Diagnosis and classification of severity of mitral valve prolapse: methodologic, biologic, and prognostic consideration . Am Heart J . 1987;;113:1265-1280.
52 +
Devereux RB, Kramer-Fox R, Brown WT, et al.  Relation between clinical features of the mitral valve prolapse syndrome and echocardiographically documented mitral valve prolapse . J Am Coll Cardiol . 1986;;8:763-772.
53 +
Olive KE, Grassman ED.  Mitral valve prolapse: comparison of diagnosis by physical examination and echocardiography . South Med J . 1990;;83:1266-1269.
54 +
Abbasi AS, DeCristofaro D, Anabtawi J, Irwin L.  Mitral valve prolapse: comparative value of M-mode, two-dimensional and Doppler echocardiography . J Am Coll Cardiol . 1983;;2:1219-1223.
55 +
Barron JT, Manrose DL, Liebson PR.  Comparison of auscultation with two-dimensional and Doppler echocardiography in patients with suspected mitral valve prolapse . Clin Cardiol . 1988;;11:401-406.
56 +
Retchin SM, Waugh RA, Fletcher RH.  The impact of echocardiographic results on treatment decisions for patients suspected of mitral valve prolapse . Med Care . 1987;;25:652-657.
57 +
Nishimura RA, McGoon MD, Shub C, Miller FA Jr, Ilstrup DM, Tajik AJ.  Echocardiographically documented mitral-valve prolapse: long-term follow-up of 237 patients . N Engl J Med . 1985;;313:1305-1309.
58 +
Orencia AJ, Petty GW, Khanderia BK, et al.  Risk of stroke with mitral valve prolapse in populationbased cohort survey . Stroke . 1995;;26:7-13.
59 +
Marks AR, Choong CY, Sanfilippo AJ, Ferre M, Weyman AE.  Identification of high-risk and low-risk subgroups of patients with mitral valve prolapse . N Engl J Med . 1989;;320:1031-1036.
60 +
Tofler OB, Tofler GH.  Use of auscultation to follow patients with mitral systolic clicks and murmurs . Am J Cardiol . 1990;;66:1355-1358.
61 +
Zuppiroli A, Rinaldi M, Kramer-Fox R, Favilli S, Roman MJ, Devereux RB.  Natural history of mitral valve prolapse . Am J Cardiol . 1995;;75:1028-1032.
62 +
McCracken D, Everett JE.  An investigation of the incidence of cardiac murmurs in young healthy women . Practitioner . 1976;;216:308-309.
63 +
Stewart IMG.  Systolic murmurs in 525 healthy young adults . Br Heart J . 1951;;13:561-565.
64 +
Vaughan JP.  Blood pressure and heart murmurs in a rural population in the United Republic of Tanzania . Bull World Health Organ . 1979;;57:89-97.
65 +
Cotter L, Logan RL, Poole A.  Innocent systolic murmurs in healthy 40-year-old men . J R Coll Physicians London . 1980;;14:128-129.
66 +
Markiewicz W, Stoner J, London E, Hunt SA, Popp RL.  Mitral valve prolapse in one hundred presumably healthy young females . Circulation . 1976;;53:464-473.
67 +
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To understand the clinical management of acute heart failure syndromes.
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Compression-Only CPR: Pushing the Science Forward
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AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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