P murmurs are common in young asymptomatic adults, occurring in 5% to 52% of screened populations.1 Frequent cardiac consultation is requested for evaluation of murmurs detected during routine physical examinations. Echocardiograms are often requested by referring and consulting physicians. However, screening echocardiography is not indicated for 2 principle reasons: first, the cost is not trivial, and second, the current resolution of echocardiography can reveal details of cardiac function that may be physiologic but interpreted as pathologic, resulting in unnecessary testing or therapy. Murmur examination before echocardiography is recommended by the 1997 American College of Cardiology/American Heart Association (ACC/AHA) Guidelines for the Clinical Application of Echocardiography.2 In these guidelines, innocent murmurs are defined as short systolic ejection murmurs that occur at the left sternal border, that are soft in intensity (grades 1 to 2/4), that are associated with a normal second heart sound, and do not have other cardiac examination abnormalities. This is based on clinical research showing that these features, when assessed together with normal electrocardiography and plain chest x-rays, seem to be associated with the absence of cardiac pathology.3–6 However, the only blinded study in nonpregnant adults utilizing the above murmur criteria showed only a 62% sensitivity for predicting normal echocardiography (38% of those with “innocent murmurs” had abnormalities on echocardiography).7 We sought to evaluate the ACC/ AHA echocardiographic guidelines for murmur evaluation in a young, healthy population. • • • We prospectively enrolled the cohort of all military patients referred to the cardiology clinic for an abnormal precordial murmur. Patients were excluded if they had previously documented echocardiographic abnormalities or were being referred for evaluation of other cardiac complaints. All patients received a standardized questionnaire, which included questions on cardiovascular and valvular disease risk factors, as well as any previous cardiovascular symptoms. All patients underwent a detailed cardiovascular examination performed by a staff cardiologist or senior cardiology fellow. This included standardized auscultation, determining the presence, location, timing, duration, quality, and intensity of the murmur. Further, the character of S1 and S2 and the presence of gallops or extra heart sounds were noted. Examiners were blinded to the results of echocardiography. Innocent murmurs were defined using the ACC/AHA echocardiographic guidelines.2 All other murmurs were considered abnormal murmurs. All patients underwent electrocardiography and echocardiography. Trained technologists performed a complete 2-dimensional Doppler echocardiogram, utilizing Hewlett-Packard Sonos (Palo Alto, California) 1500 and 2500 commercial ultrasound units in standard imaging planes and recorded on SuperVHS videotape. The studies were read in a standardized format by cardiologists blinded to the physical examination results. Abnormal echocardiograms were defined as requiring bacterial endocarditis prophylaxis (AHA guidelines8), medical therapy, surgery, other invasive procedure, or any medical follow-up. All others were considered normal. Normal echocardiograms included some patients with mild amounts of mitral or tricuspid regurgitation and structurally normal valves. Consent was obtained for the use of the patient’s data in the study. The institutional review board approved the study protocol. The statistical analyses performed were determined before study inception. The primary analysis evaluated the test characteristics and predictive value of the physical examination, using echocardiography as the gold standard. A total of 72 patients were referred; 31 were activeduty military personnel and 41 were Reserve Officer Training Corps cadets. Significantly, the 41 cadets with murmurs represented 1% of all cadets screened in a one-time physical examination. Mean age was 25 6 5.7 years. There were 28 women and 44 men. Although not referred for other complaints, 11 patients had 14 complaints on detailed cardiovascular history: 8 had experienced palpitations, 3 had shortness of breath, and 3 had prior syncope. All patients were without symptoms at the time of examination. Six patients had chronic medical conditions: 4 had hypertension, 1 had Graves’ disease, and 1 had Ehlers-Danlos syndrome. Detailed cardiovascular physical examinations were normal in all patients except for the precordial murmurs and blood pressures. Of the 72 patients, 30 patients did not meet the ACC/AHA criteria for an innocent murmur, and were thus defined as having an abnormal murmur. Murmur examination findings are listed in Table 1. Twenty-nine patients had innocent murmurs. Thirteen patients had transient murmurs (murmurs that prompted the referral but were not present at the time of evaluation). Four patients were found to be hypertensive. Nine patients (13%) had abnormal echocardioFrom the Cardiology Division, Brooke Army Medical Center, San Antonio, Texas; Pike’s Peak Cardiology Group, Colorado Springs, Colorado; and Cardiology Division, Walter Reed Army Medical Center, Washington, DC. Dr. Shry’s address is: Cardiology Service, 3851 Roger Brooke Drive, Bldg. 3600, Brooke Army Medical Center, San Antonio, Texas 78234-6200. E-mail: Eric.Shry@CEN. AMEDD.ARMY.MIL. Manuscript received September 8, 2000; revised manuscript received and accepted January 9, 2001.