Primary care referral criteria - heart murmurs

Referral for echocardiography and specialist assessment

Heart murmur - criteria for echocardiography referral

Consider an echocardiogram for adults with a murmur and no other signs or symptoms if valve disease is suspected based on:

• the nature of the murmur
• family history
• age (especially if over 75), or
• medical history (for example, a history of atrial fibrillation).

Offer an echocardiogram to adults with a murmur if valve disease is suspected (based on the nature of the murmur, family history, age or medical history) and they have:

• signs (such as peripheral oedema) or symptoms (such as angina or breathlessness) or an abnormal ECG, or
• an ejection systolic murmur with a reduced second heart sound but no other signs or symptoms.

Referral for urgent specialist assessment or urgent echocardiography

If valve disease is suspected (based on the nature of the murmur, family history, age or medical history):

• offer urgent (within 2 weeks) specialist assessment that includes an echocardiogram or if not available an urgent echocardiogram alone to adults with a systolic murmur and exertional syncope.
• consider urgent (within 2 weeks) specialist assessment that includes an echocardiogram for adults with a murmur and severe symptoms (angina or breathlessness on minimal exertion or at rest) thought to be related to valvular heart disease

Notes:

• for guidance on referral and assessment for adults with murmur and non-exertional syncope, follow the recommendations in the NICE guideline on transient loss of consciousness ('blackouts') in over 16s
• for guidance on referral and assessment for adults with breathlessness but no murmur, follow the recommendations in the NICE guideline on chronic heart failure in adults.

Referral to a specialist after echocardiography

Be aware that mild valve disease is common and rarely progresses to become clinically significant.

Offer referral to a specialist to:

• adults with moderate or severe valve disease* of any type
• adults with bicuspid aortic valve disease of any severity* (including mild valve disease)

* severity of valve disease is defined in line with the British Society of Echocardiography guidelines on the British Heart Foundation's website.

Reference:

• NICE (November 2021). Heart valve disease presenting in adults: investigation and management