GoTo Telemed, the nation’s leading integrated telehealth ecosystem serving over 10 million patients nationwide, today announced the release of its Comprehensive Heart Murmur Evaluation Guide, a detailed clinical resource designed to help healthcare providers and families understand, differentiate, and manage heart murmurs through evidence-based telehealth protocols. The guide provides a structured framework for distinguishing between innocent (benign) murmurs and pathologic murmurs that may indicate underlying structural heart disease.

Heart murmurs are among the most common reasons for pediatric cardiology referrals, affecting an estimated 30% to 75% of children between ages 1 and 14 years. While the vast majority are innocent—benign sounds of normal blood flow through a healthy heart—a small percentage signal potentially serious congenital or acquired heart conditions requiring prompt evaluation and intervention. The challenge lies in accurate differentiation without over-referring or causing unnecessary anxiety for families. GoTo Telemed’s new guide bridges this gap by providing clear, actionable criteria for telehealth-based murmur assessment, referral triage, and family education.

“A heart murmur discovered during a routine physical or school sports exam can be a source of tremendous anxiety for parents, yet the overwhelming majority are completely harmless,” said a GoTo Telemed spokesperson. “Our Heart Murmur Evaluation Guide equips primary care providers with the clinical tools to confidently identify innocent murmurs using tele-auscultation and structured algorithms, while ensuring that children with pathologic murmurs receive timely cardiology referral. Through integrated digital stethoscopes and AI-enhanced analysis, we are bringing the ‘art of auscultation’ into the virtual care setting—expanding access to expert cardiac evaluation for families in rural and underserved communities.”

Differentiating Innocent from Pathologic Murmurs: A Structured Framework

The guide provides a comprehensive comparison table and clinical algorithm to help providers distinguish between innocent and pathologic murmurs based on key acoustic and clinical features:

Feature Innocent Murmur Pathologic Murmur
Timing Always systolic (between S1 and S2); never diastolic Diastolic, holosystolic, or continuous
Quality Musical, vibratory, “sweet,” or twanging (e.g., Still’s murmur) Harsh, blowing, grinding, or rasping
Intensity Grade I–II (quiet); often changes with position Grade III or higher; may be associated with a palpable “thrill”
Location Left lower sternal border or pulmonic area Variable; may radiate to back, axilla, or neck
S2 Sound Normal splitting Fixed split S2 or single S2
Associated Findings Asymptomatic; normal growth and development Poor weight gain, cyanosis, tachypnea, hepatomegaly, or syncope on exertion
Innocent murmurs are caused by normal blood flow through normal structures—comparable to the sound of water rushing through a garden hose where the hose isn’t leaking. The most common types include Still’s vibratory murmur (low-pitched, musical sound along the left sternal border), pulmonary flow murmur (soft ejection murmur in the second left intercostal space), venous hum (continuous blowing noise below the clavicles that varies with respiration and disappears when lying down), and supraclavicular murmurs.

In contrast, pathologic murmurs indicate structural heart disease such as ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), coarctation of the aorta, or valvular stenosis. These conditions may require echocardiography, cardiology referral, and long-term management.

Telehealth-Enabled Cardiac Auscultation: The Role of Digital Stethoscopes and AI

The guide incorporates the latest advances in telehealth technology for remote cardiac assessment. The U.S. Food and Drug Administration (FDA) has expanded clearance for AI-powered platforms such as eMurmur, which works with digital stethoscopes to detect heart murmurs using advanced analytics rather than relying solely on a provider’s hearing through a traditional stethoscope exam. The platform analyzes recorded heart sounds, identifies primary S1 and S2 sounds, and flags abnormal whooshing or swishing noises that may indicate a murmur.

These digital tools support tele-auscultation—live streaming of stethoscope audio between patients and providers, enabling real-time remote cardiac assessment. Studies have demonstrated that the quality of heart sounds and murmur auscultation via digital stethoscope during telehealth visits is subjectively equivalent to in-person findings, with excellent inter-rater agreement (98%). A study of telecardiographic evaluations of pediatric patients found that telemedicine appears to be effective and useful for the cardiac evaluation of pediatric patients.

Clinical Algorithm for Murmur Evaluation and Referral

The guide outlines a step-by-step algorithm for telehealth-based murmur evaluation, aligned with American Academy of Pediatrics and National Institute for Health and Care Excellence (NICE) guidelines:

Step 1: Comprehensive History and Symptom Assessment

Detailed birth history, feeding history, activity level

Presence of cyanosis, dyspnea, syncope (particularly on exertion), chest pain, or palpitations

Family history of congenital heart disease or sudden cardiac death

Maternal history of infections or teratogens during pregnancy

Step 2: Telehealth Physical Examination with Digital Auscultation

Vital signs including blood pressure in all limbs when feasible

Palpation of peripheral pulses (strength, equality)

Thorough auscultation of the heart from base to apex, including axillae and back

Assessment of murmur characteristics: timing, intensity, location, radiation, pitch, and quality

Step 3: Identify Red Flags for Pathologic Murmur

Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. Any infant less than 3 months of age who presents with a murmur associated with breathlessness or sweating when feeding, cyanosis, tachypnoea, hepatomegaly, or failure to thrive should prompt urgent referral to pediatric cardiology.

Step 4: Escalation and Referral Pathways

Clinical Scenario Recommended Action
Asymptomatic child with classic innocent murmur features Reassurance and routine follow-up; no further testing required
Suspected innocent murmur but any atypical feature Review child when well; if murmur persists and no other signs, consider cardiology referral
Any diastolic, holosystolic, or grade ≥3 murmur Refer to pediatric cardiology for echocardiography
Infant