American Board of Internal Medicine (ABIM) Certification Practice Exam

Which murmur would typically require additional diagnostic workup with TTE?

1. Systolic murmurs grade 1/6

2. Acute systolic murmurs

3. Late systolic murmurs grade 2/6

4. Holosystolic murmurs

The correct answer is: Holosystolic murmurs

Holosystolic murmurs, which are characterized by their continuous sound throughout the entirety of systole, often indicate significant underlying pathology, particularly in the context of valvular heart disease. These murmurs are commonly associated with conditions such as mitral regurgitation or ventricular septal defects. Given their potential to indicate serious structural or functional cardiac issues, a thorough evaluation through transthoracic echocardiography (TTE) is essential in these cases. The diagnostic workup via TTE helps to visualize cardiac structures, assess the severity of regurgitation or shunting, and guide further management decisions. It is crucial for identifying the exact cause of the holosystolic murmur and determining appropriate treatment options. In contrast, systolic murmurs that are either very low-grade or acute may not immediately necessitate further imaging unless there are other concerning clinical features present. Late systolic murmurs, while meaningful, may also not always require urgent echocardiographic evaluation compared to holosystolic murmurs, which are more definitively indicative of serious conditions that need further investigation.