American Board of Internal Medicine (ABIM) Certification Practice Exam

In which scenario is transthoracic echocardiography warranted for a murmur?

1. In patients with any systolic murmur

2. In asymptomatic patients with a grade 3/6 or higher systolic murmur

3. In patients who have had previous surgery

4. In patients without known heart conditions

The correct answer is: In asymptomatic patients with a grade 3/6 or higher systolic murmur

Transthoracic echocardiography is particularly warranted in asymptomatic patients who present with a grade 3/6 or higher systolic murmur due to the increased likelihood of underlying structural heart disease that may require further evaluation or intervention. A grade 3 murmur indicates a loud murmur but does not necessarily correlate with significant pathology on its own. However, when it reaches this level, it raises clinical suspicion for possible valvular heart disease, septal defects, or other cardiac abnormalities that can be critically evaluated via echocardiography. The necessity for echocardiography is based on both the intensity of the murmur and the patient's overall assessment. A murmur of grade 3 or greater, particularly in asymptomatic individuals, necessitates investigation to rule out potential cardiac issues, thereby justifying the use of echocardiography. In contrast, having any systolic murmur does not automatically indicate the need for echocardiography, as many murmurs can be benign, particularly in the absence of other clinical findings. Previous surgery may require monitoring but doesn't inherently warrant an echocardiogram unless accompanied by relevant symptoms or new murmurs. Similarly, in patients without known heart conditions, a thorough evaluation may be conducted first,