Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 38-year-old man is evaluated during a routine health examination. He exercises two or three days each week by jogging for 30 minutes without shortness of breath or chest discomfort. During stressful emotional situations, he occasionally feels “skipped heart beats” but has not had prolonged palpitations, presyncope, or syncope. He generally feels in good health. He has no history of medical problems and takes no medications. He has not had fever or chills.

Physical examination shows normal temperature, blood pressure is 124/68 mm Hg, pulse rate is 64/min and regular, and respiration rate is 14/min. BMI is 23. Cardiac examination demonstrates a grade 2/6 early systolic crescendo-decrescendo murmur heard best at the lower left sternal border without radiation. Lungs are clear. Peripheral pulses are normal.

Electrocardiogram is normal.

Which of the following is the most appropriate next test?

A: Ambulatory electrocardiography
B: Transesophageal echocardiography
C: Transthoracic echocardiography
D: No additional testing

MKSAP Answer and Critique

The correct answer is D: No additional testing. This item is available to MKSAP 16 subscribers as item 3 in the Cardiology section.

MKSAP 16 released Part A on July 31. More information is available online.

No additional testing is needed for this patient. He has an asymptomatic benign systolic ejection murmur. The benign characteristics of the murmur include its intensity or grade (<3/6), timing (early and brief systolic), lack of radiation of the murmur, and the absence of additional abnormal heart sounds. The remainder of the physical examination and the electrocardiogram are normal, without any evidence of cardiac enlargement or dysfunction. In this common situation, the patient should be reassured, and no additional diagnostic testing is indicated.

Ambulatory electrocardiography, either continuously for 24 to 48 hours or as event-activated recordings, is not indicated. The patient’s brief episodes of palpitations are sporadic and not associated with hemodynamic abnormalities. In patients with repetitive, frequent palpitations, ambulatory electrocardiography may be diagnostically useful.

Transesophageal echocardiography may be useful in patients with poor imaging by transthoracic study or to evaluate the feasibility of surgical repair when surgery is planned but is not indicated in this patient.

Transthoracic echocardiography is recommended for diagnosis of systolic murmurs grade 3/6 or greater in intensity, diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks, or murmurs that radiate to the neck or back. This patient’s murmur does not have any of these characteristics.

Key Point

• Echocardiography is not indicated for patients with brief, early systolic, low-intensity murmurs detected by physical examination without symptoms or associated findings of valvular or cardiac dysfunction.

Learn more about ACP’s MKSAP 16.

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