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. Systematic cardiovascular examination includes vital signs, inspection, palpation, and auscultation, with the seven characteristics of a heart murmur including timing, shape, location, radiation, intensity, pitch, and quality.

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. 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. Artificial intelligence (AI)-powered digital support is emerging as an aid to assist with the interpretation of auscultated sounds, converting acoustic signals into objective electronic data for automated classification and predictive analytics.

FDA-Approved AI Murmur Detection: eMurmur Heart AI has received FDA 510(k) clearance for its next-generation heart murmur detection software, which assists healthcare providers using digital stethoscopes in screening, monitoring and diagnosing abnormalities in the heart of pediatric and adult patients through its machine learning-based web portal and mobile app. The AI automatically identifies primary heart sounds and detects both the presence and absence of abnormal heart murmurs, providing objective analysis to a technique that traditionally relies on what providers hear.

Clinical Validation: Studies highlight improved classification of pediatric heart murmurs (AUC up to 0.92), reliable detection of valvular heart disease (e.g., 93.2% sensitivity for aortic stenosis), and identification of lung pathology. A dedicated pediatric digital auscultation platform, StethAid, achieved high sensitivity and specificity for Still's murmur identification (sensitivity of 91.9% and specificity of 92.6%) using deep learning algorithms.

Remote Auscultation: During the COVID-19 pandemic, AI-powered auscultation software was adapted to be used remotely during telehealth visits. Digital stethoscopes can be used by trained staff at remote clinic locations to connect patients to qualified providers who can assess heart sounds from a distance. Tele-auscultation using digital stethoscopes enables live streaming of heart sounds between patients and providers, supporting real-time remote cardiac assessment.

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 international clinical 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 III 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. Innocent murmurs do not require review from a cardiology consultant, and most do not require referral to cardiology clinic
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 ≥III murmur Refer to pediatric cardiology for echocardiography
Infant