American Board of Internal Medicine (ABIM) Certification Practice Exam

What type of murmurs requires a transthoracic echocardiogram (TTE) for further evaluation?

1. Grade 1/6 systolic murmurs

2. Systolic murmurs ≥grade 3/6 and diastolic murmurs

3. Continuous murmurs only

4. Any murmur regardless of grading

The correct answer is: Systolic murmurs ≥grade 3/6 and diastolic murmurs

A transthoracic echocardiogram (TTE) is a valuable diagnostic tool for evaluating cardiac murmurs, particularly when the murmurs are of a certain nature and magnitude. Systolic murmurs that are graded 3/6 or higher indicate a significant flow disturbance in the heart, which can be associated with underlying structural heart conditions. Similarly, diastolic murmurs, typically associated with more severe pathology such as aortic regurgitation or mitral stenosis, warrant further investigation. Murmurs graded at 3/6 or higher suggest that there is a noticeable turbulence in blood flow, which can reflect important cardiovascular issues that need to be diagnosed accurately to determine the appropriate management. Diastolic murmurs signal hemodynamic changes that can lead to serious complications if not assessed and treated. Therefore, TTE is essential in these cases to visualize cardiac structures, assess hemodynamic significance, and guide treatment options. In contrast, lower-grade systolic murmurs, such as 1/6, may not provide enough information about significant underlying pathology and may often be benign, thus not necessitating an echocardiogram. Continuous murmurs, while they can be indicative of certain conditions, do not exclusively require a TTE for