Still's murmur

Associate Editor-In-Chief:

Synonyms: Fiddle string murmur, Vibratory murmur

Overview
Still's murmur is a short, vibrating murmur in systolic ejection manner and can be heard over the mid precordium (slightly lateral to left lower sternal border) or apex in children that is not accompanied by any other abnormalities.

First described by Sir George Still (1868-1941) and thought to arise from vibrations of the attachments of the pulmonary valve leaflets.

Epidemiology
It is most common in children ages 2 to 8 years old.

Diagnosis
This short, early systolic murmur changes with posture, and provoked by fever and anemia and heard better in supine position. EKG and echocardiography findings are in normal range.

Differential Diagnosis

 * Left ventricular outflow tract obstruction (e.g. Aortic stenosis)
 * Hypertrophic cardiomyopathy
 * Ventricular septal defect

Prognosis
The murmur usually disappears at puberty.

Additional Reading

 * Moss and Adams' Heart Disease in Infants, Children, and Adolescents Hugh D. Allen, Arthur J. Moss, David J. Driscoll, Forrest H. Adams, Timothy F. Feltes, Robert E. Shaddy, 2007 ISBN 0781786843
 * Hurst's the Heart, Fuster V, 12th ed. 2008, ISBN 978-0-07-149928-6
 * Willerson JT, Cardiovascular Medicine, 3rd ed., 2007, ISBN 978-1-84628-188-4