Aim: It has been reported that schizophrenia (SZ) patients had poor sleep quality and displayed evening chronotype, and certain behavioral differences had been observed between chronotypes. In this study, we aimed to compare chronotype and sleep quality in criminal SZ patients and to examine the correlation of chronotype with crime types.

Material and Methods: Ninety-one criminal SZ patients and 91 healthy controls were included. Participants were administered the Positive and Negative Syndrome Scale (PANSS), Pittsburgh Sleep Quality Index (PSQI), and the Morningness – Eveningness Questionnaire (MEQ).

Results: While 28.6 % of the patient group were evening-, 36.3 % were intermediate- and 35.2% waere morning-type, it was seen that 8.8% of the control group were evening-, 31.9% were intermediate- and 59.3% were morning-type, and a significant difference was observed between them (p<0.001). The sleep quality in the patient group was significantly lower than in the control group (p<0.001). In the patient group, the crime rate between 24:00 and 06:00 was found to be significantly higher among evening types compared to other types (p<0.001).

Discussion: Criminal schizophrenia patients are of the evening type compared to the control group and have poor sleep quality. Corrective interventions for sleep and chronotype in SZ patients may change the rates and nature of crimes.

Keywords: Sleep, Schizophrenia, Chronotype, Circadian Rhythms, Crime

Introduction

The largest diagnostic group among medical conditions, accompanied by sleep-related complaints, consists of mental conditions. An average of 50-80 % of persons with a mental condition have sleep disorders and approximately 50 % of patients with sleep disorders are diagnosed with a mental condition. One of such conditions is schizophrenia (SZ). Depending on the severity of the condition, sleep disorder is seen in approximately 30-80 % of SZ patients [1,2].
Sleep-related complaints since the first drug-free episode in SZ patients, which is a patient group, open to polypharmacy, suggest that patients have sleep problems independently from pharmaceutical treatment [1,2]. Polysomnographic changes, such as poor sleep quality and delay in REM sleep, decrease in REM intensity, and delayed onset of sleep have been observed in SZ patients [1,3]. In SZ patients, it has been shown that bad sleep quality was associated with increased positive and negative symptoms, worsened cognitive performance, decreased quality of life and decreased treatment response [2,4]. One of the physiological concepts, affecting sleep, is the chronotype.
Chronotype is a reflection of the endogenous circadian rhythm of an individual, which defines the time of physiological functions, including sleep. It has been reported that 60 % of adults were of “intermediate type” and the remaining 40 % were of “morning-type” or “evening-type” [5]. Chronotype subgroups, determined to be associated with psychiatric disorders, as well as physical conditions, have been studied in persons, demonstrating substance abuse disorders, anxiety disorders, attention deficit hyperactivity disorder, mood disorders, and it has been found that predominant subtypes were related with diseases [6]. It has been shown that evening-type chronotype was associated with mental conditions, in particular mood disorders (depressive disorders, bipolar disorder), yet a recent meta-analysis, similar to mood disorders, has demonstrated that SZ patients predominantly were of evening type compared to controls, and this could be a risk factor for SZ [7]. In a genomic study with extensive sampling, based on the hypothesis that chronotype could have an effect on the pathophysiology of schizophrenia, it has been shown that possession of morning chronotype was associated with a decrease in the risk of schizophrenia [8].
There are studies, in which differences in terms of psychopathology have been observed between chronotypes. For example, it has been determined that the evening type was more inclined to impulsivity, carelessness, aggressive behavior, crime and social problems [9]. In detailed compilations by Casey et al., an association between the evening type and aggressiveness has been reported. The transformation of chronotype tendency to a strong shift towards evening with the onset of puberty, has been explained by limbic system dominance and the process of maturation of the prefrontal cortex [10]. As a consequence of low executive function, impulsive responses and weak judgment are characteristics that are also observed in SZ patients, and in this sense, they have a similar neurobiological infrastructure with adolescence [7]. What are the chronotype characteristics in SZ patients, who have committed “crimes,” which are indicators of aggressiveness?
Despite the presence of studies in the literature, which have examined chronotypes and sleep quality in schizophrenia patients and reported different results, to the best of our knowledge, there are no data in the literature concerning chronotypes for forensic psychiatric patients, who have committed a crime. As far as we know, there are no data concerning the time of the day at which the crimes had been committed by these patients. The objective of the study is to compare chronotype and sleep quality in schizophrenia patients, treated in an inpatient setting at High-Security Forensic Psychiatry (HSFP) Clinic with healthy controls and to examine the relationship with the nature and time of crime.

Material and Methods

The study was approved by the Firat University Clinical Research Ethics Committee (Date: 16 December 2021. Number: 2021/13-20). While calculating the sample of the study, the G*Power 3.1.9.2 program was used and the study “Quality of sleep in patients with schizophrenia is associated with quality of life and coping” was taken as a reference [11]. Accordingly, it was determined that at least 70 people, at least 35 with schizophrenia and 35 healthy groups should be reached with a 95% confidence interval and 95% power (Effect size=0.878).
Patients, who have been admitted to Elazığ Fethi Sekin City Hospital HSFP Clinic with schizophrenia diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and inpatients who satisfied the study criteria, were included. One hundred and thirty SZ patients were available for study; yet among these, eighteen were excluded due to a change of psychotropic treatment regime within the last 2 months, fifteen were excluded due to accompanying alcohol and substance use disorders, four were excluded due to non-completion of forms, and two due to discharge before completion of forms, and a total of 91 schizophrenia patients were included in the study. Ninety-one healthy controls with no psychiatric conditions according to DSM-5 have been included in the study. In the sleep routine of the clinic, all patients are taken to their rooms at 10:00 in the evening to sleep, and the staff wakes them up at 7 in the morning.
Our study is a descriptive study with case-control nature. The study was conducted in Elazığ Fethi Sekin Hospital HSFP Clinic following ethics committee approval. After a full description of the study, all participants gave written informed consent according to the Helsinki Declaration. Evaluations, structured according to DSM-5, were made by a psychiatry specialist. All participants were administered a socio-demographic data form, the Positive and Negative Syndrome Scale (PANSS), the Pittsburgh Sleep Quality Index (PSQI), the Morningness-Eveningness Questionnaire (MEQ). Questionnaire completion process has taken an average of 30-40 minutes.
The inclusion criteria for patients were age between 18 and 65, schizophrenia diagnosis according to DSM-5 diagnostic criteria, a conviction under the Turkish Criminal Code (TCC), no accompanying psychiatric conditions, continuing hospitalization in HSFP clinic, no cognitive dysfunction and medical obstacles, precluding the completion of form and affecting the distribution of existing psychiatric symptoms (such as dementia, epilepsy, cerebrovascular disease, history of head trauma), no alcohol and substance abuse disorder diagnosis within the last 6 months, the signed informed consent form, no mental retardation, no changes in psychotropic treatment regime within the last two months, no sleep disorder diagnosis according to DSM-5 (such as sleep terror, parasomnia, sleep paralysis, narcolepsy). Those who received hypnotic drugs in hospitalized patients were not included, but those who took sedative antipsychotic drugs were not excluded.

Data Collection Instruments

Socio-demographic Data Form: It was developed by the authors based on the aim of the study. The form aimed to collect demographic data such as age, marital status, education level, residency, employment, and economic status, and clinical evaluation data such as inpatient treatment anamnesis, smoking or alcohol use.

Morningness-Eveningness Questionnaire (MEQ): MEQ, created by Horne and Östberg [12] is a tool for determining chronotypes, designated as ‘morning-type,’ ‘intermediate’ and ‘evening-type.’ If the score, calculated in the scale is between 16 and 41, this shows ‘evening-type’ chronotype, if it is between 42-58, the ‘intermediate type chronotype’ and if it is between 59-86, the ‘morning-type chronotype.’

Pittsburgh Sleep Quality Index (PSQI): This is a 19-item self-report scale, developed by Buysse et al. [13] evaluating the sleep quality and disorders in the previous month. Any score above 5 shows poor sleep quality.

Positive and Negative Syndrome Scale (PANNS): This is a 30-item scale, developed by Kay et al. [14] with 7 items related to the positive symptom subscale, 7 items, related to the negative symptom subscale and the remainder 16 to general psychopathology subscale. It is expressed as a total score and varies between 30 and 210.

Data analysis

In the evaluation of findings, provided in the study, SPSS (Statistical Package for Social Sciences) for Windows 22.0 program was used for statistical analyses. In the study, descriptive data have been shown as n, % values in categorical data, and in continuous data, as mean±standard deviation (Mean±SD) values. In the comparison of categorical variables between groups, chi-square analysis (Pearson Chi-Square) was applied. The consistency of continuous variables with normal distribution was evaluated with the Kolmogorov-Smirnov test. When comparing two groups, Student’s t-test was used and when comparing more than two groups, the One-Way ANOVA test was used. In order to determine the source of significance, the Tukey test was used as a post-hoc analysis. Significance was considered at a level of p<0.05.

Ethical Approval

Ethics Committee approval for the study was obtained.

Results

A total of 182 participants, including 91 patients and 91 controls, were included in the study. There were no significant differences between the groups with respect to socio-demographic characteristics (other than prevalence of psychiatric conditions (68.1 %), history of suicide (6.6 %) and smoking (67 %)) (p>0.05) (Table 1).
Twenty-one patients (23.1%) had a diagnosis term of less than 5 years, 28 (30.8%) between 5-10 years and 42 (46.2 %) greater than 10 years; 29 patients (31.9 %) had been admitted to HSFP Clinic for observation and 62 (68.1 %) for protection. While 70 patients (76.9%) had been admitted to HSFP once, twelve (9.9 %) had been admitted twice and 9 (9.9%) had been admitted three or more times, 25 (27.5%) did not have non-HSFP psychiatric hospitalization, 29 (31.9 %) had 1-2 and 37 (40.7%) had 3 or more non-HSFP psychiatric hospitalizations.
Twenty-eight patients (30.8%) had committed bodily injury, 9 (9.9 %), sexual offenses, 8 (8.8%) murder, 3 (3.3%) insulting, 23 (25.3 %) other offenses (theft, property damage, intimidation, slander, plunder) and 20 (22%) have committed multiple crimes (Figure 1).
While 28.6 % of the patient group were evening-type, 36.3 % were intermediate and 35.2 % were morning-type, it was seen that 8.8 % of the control group were evening-type, 31.9 % were intermediate and 59.3 % were morning-type and a significant difference was observed between the groups (p<0.001). Accordingly, it can be said that the patient group was the evening-type and the control group was the morning-type. By taking cut-off value according to PSQI, as 5, the good sleep quality in the patient group (39.6 %) was significantly lower than good sleep quality in the control group (75.8%) (p<0.001). Accordingly, the sleep quality in the patient group was lower (Table 2).
It was determined that there was no significant difference among patients’ MEQ categories and sleep qualities in terms of PANSS scores (p>0.05). There was no significant difference in terms of PANNS-positive between the MEQ categories in the patient group (p=0.381) (dual p values: evening-mid=0.722; evening-morning=0.851; mid-morning=0.350). There was no significant difference in terms of PANNS-negative between the MEQ categories in the patient group (p=0.746) (dual p-values: evening-mid=0.728; evening-morning=0.872; mid-morning=0.960). There was no significant difference in terms of PANNS-total between the MEQ categories in the patient group (p=0.700) (dual p-values: evening-mid=0.954; evening-morning=0.690; mid-morning=0.839).
It was observed that 25 % of patients were convicted for bodily harm, 11.1 % for sex offenses and 62.5 % for murder and 47.8 % for other crimes, and 10 % of those were convicted for multiple crimes and were found as evening-type. There was a significant difference between crimes in terms of chronotype (p=0,038). There was no significant difference between the duration of schizophrenia diagnosis (p=0.132) and the number of admissions to HSFP (p=0.238) in terms of chronotype (Table 3).
In the patient group, the crime rate between 24:00 and 06:00 was found to be significantly higher among evening types (57.7%) compared to intermediate (9.1%) and morning types (6.3%) (p<0.001).

Discussion

In our study, it was seen that 36.3% of criminal SZ patients were of intermediate type, consistent with the general population, followed by morning types with 35.2 % and evening types with 28.6%. However, when we compared SZ patients with healthy controls, they had significant evening type. We may say that criminal SZ patients were of evening-type, compared to healthy persons. When evening-type is broadly considered in combination with neurophysiological and environmental factors, it has been generally shown as tendency to impulsivity, aggressive behavior and crime [9]. At the same time, it is reported that evening-type demonstrates intensive psychopathological bias with mediator factors, such as difficulties in mood regulation and disturbed reward pathway and impulsivity [5]. In addition to these, sleep qualities of patients in our study were significantly worse compared to healthy controls. Poor sleep qualities in SZ patients have been previously reported. Independently from relapse and remission phases in these patients, poor sleep quality has been shown both with scales and polysomnographic changes [1,3]. We provided similar findings among SZ patients in HSFP.
As another finding of our study, the presence of evening-type chronotype in 62.5 % of SZ patients who were treated at HSFP Clinic due to murder was striking. It is known that there are phase differences between chronotypes in the secretion of hormones, such as physiological adrenalin, melatonin and cortisol, which play a crucial role in response to stress [15]. Also, neurological, cognitive and behavioral performances vary in individuals depending on chronotypes. Both with this aspect and effects on sleep, chronotype may pave the way for loss of control in emotional reactions. In this respect, chronotype may have a direct effect on “committing a crime.” On the other hand, it is known that poor sleep deteriorated stabilization of affection and increased the emotional reaction rate [16]. It has been reported that poor sleep quality was related to hostile and aggressive behavior and aggressiveness and loss of sleep affected prefrontal cortical functionality and could cause mitigation of behavioral reaction inhibition [17]. When all these are considered together, high levels of emotional reactivity may be expected from SZ patients in the study, who have poor sleep quality, together with a neurophysiological deficiency. From this aspect, our study shows promise for future studies, concerning the effects of chronotypes on crimes.

Limitations and Strengths

The strong point of our study is that it is the first study, examining the relationship between chronotypes and crime in SZ patients and the findings can provide inspiration for future studies. Restrictions of our study are the selection of samples from a single center and the inclusion of patients also in the psychotic attack phase. Since sleep quality may also be affected in psychotic attacks, we have to state that this issue must be considered in the results of the study.

Conclusion

In conclusion, criminal schizophrenia patients are of evening type compared to the control group and have poor sleep quality. Evening-type patients predominantly commit crimes after midnight. A difference was seen between chronotypes in terms of the nature of the crime. Schizophrenia patients, who have committed murder, predominantly have evening chronotype. Chronotype itself may have an effect on crime. However, it must be considered that chronotype is a rhythm, which may be affected by factors, such as age, gender, heredity, and environment [5]. Future studies, involving biological, psychosocial and individual factors, are required. Chronotype-crime relationship in SZ patients, which is poorly known, may provide a new perspective to forensic psychiatry and corrective interventions in these patients, related to sleep and chronotype may allow mitigation of crime rates.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No animal or human studies were carried out by the authors for this article.

Funding: None

Conflict of interest

None of the authors received any type of financial support that could be considered potential conflict of interest regarding the manuscript or its submission.

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Burcu Sırlıer Emir, Aslı Kazgan Kılıçaslan, Sevler Yıldız, Osman Kurt. Relationship of chronotype and sleep quality with crime in schizophrenia patients in the high-security forensic psychiatry clinic. Ann Clin Anal Med 2023;14(9):782-787

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Aim: Heart murmur is one of the most common reasons for evaluation in the pediatric cardiology clinic. The aim of this study is to evaluate the physical examination and echocardiographic findings of patients referred due to murmur.

Material and Methods: Patients admitted to the pediatric cardiology clinic due to murmur were evaluated retrospectively. The intensity of the murmurs was graded as 1-2/6, 3/6, and >3/6. The type of murmur was classified as innocent or pathological. Echocardiographic findings were classified as normal, normal for age, or pathological.

Results: Two hundred patients were included in the study. Murmur was graded 1-2/6 in 72.5% of patients, 3/6 in 7%, and>3/6 in 1%. Innocent murmur was detected in 54.5%, pathological murmur in 26% of the patients. Echocardiographic findings were normal in 54% of the presenting cases, normal for age in 15.5%, and pathological in 30.5%. Patients without murmur had normal echocardiographic findings in 64.1%, pathologic findings in 7.69%. Echocardiography was normal in the majority of the patients with a grade of 1-2/6, but was pathological in those with a grade of ≥3/6. Echocardiography was pathological in 7.69% of the patients without murmur, in 10.09% with an innocent murmur, and in 90.38% with a pathological murmur. The intensity of murmur was observed as significant (p=0.001), but the characteristics of the murmur was not observed as significant determinant in distinguishing echocardiographic findings (p=0.115).

Discussion: Echocardiographic findings are not always related to physical examination findings of murmur, therefore we suggest that auscultation alone may not be sufficient in the evaluation, and a detailed assessment with echocardiography may be more appropriate.

Keywords: Child, Echocardiography, Auscultation, Murmur

Introduction

Murmurs are sounds that are produced by turbulent blood flows in the heart and vascular structures and are transmitted to the chest wall. They have frequencies between 20 Hz and 2000 Hz [1-3]. Murmurs may be heard in approximately one-third of routine physical examinations [1]. Murmur is a cause of anxiety for parents and physicians, therefore it is one of the most frequent reasons for admission to pediatric cardiology clinics. While 75-80% of murmurs are innocent, it may sometimes be the only finding to raise suspicion of congenital heart disease. Differentiations and diagnoses of the conditions are easily made with echocardiography [4-7]. The purpose of this study is to evaluate the physical examination and echocardiographic findings of the patients referred to the pediatric cardiology clinic due to murmur.

Material and Methods

Patients presenting to the pediatric cardiology clinic due to murmur during January 2023 and February 2023 were evaluated retrospectively. Anamnesis, physical examination and echocardiographic data were obtained from records of the hospital system. Murmur intensity was classified as 1-2/6, 3/6, and >3/6. The type of murmur was classified as innocent or pathological.
Echocardiographic findings were classified as normal, normal for age, or pathological. Normal for age echocardiographic findings included physiologically normal findings, including patent foramen ovale (PFO), peripheral pulmonary stenosis (PPS), and patent ductus arteriosus (PDA).

Ethical Approval

The study was approved by the Ethics Committee of the Health Sciences University, Bakırköy Dr. Sadi Konuk Training and Research Hospital (decision number: 2023-06-13, date: 20.03.2023). Informed consent was obtained from all the patients and their parents.

Statistical Analysis

Statistical analyses and graphics were performed using SPSS 29 Statistical Software. Categorical data were presented with frequency and percentage. Continuous variables were evaluated with mean, Standard deviation, median, minimum and maximum values. The results of the evaluation with physical examination and echocardiography were compared with the McNemar test. In order to evaluate the physical examination results according to the echocardiographic findings, the rates of sensitivity, specificity, positive and negative predictive values and accuracy were calculated.

Results

Two hundred patients were included in the study. Boys represented 51% of the cases. The majority of patients consisted of children older than 49 months, the second most common group consisted of the patients aged up to three months. No murmur was detected in 19.5% of the patients referred for this reason, while 1-2/6 murmur was present in 72.5%, 3/6 in 7%, and >3/6 in 1% of the patients. Innocent murmur was detected in 54.5% and pathological murmur was detected in 26% of the patients. Echocardiographic findings were normal in 54% of the presenting cases, normal for age in 15.5%, and pathological in 30.5% of them (Table 1).
Patients without murmur had normal echocardiographic findings in 64.1%, pathological findings in 7.69%, normal for age findings in 28.21% of the patients. Patients with grade 1-2/6 murmurs had normal echocardiographic findings in 57.24%, normal for age findings in 12.41% of the patients,while 30.35% of the patients had pathological findings. Patients with grade 3/6 murmur had mostly (85.72%) pathological findings with a small percentage (14.28%) of normal for age findings. All of the patients with murmurs greater than 3/6 had pathological echocardiographic findings. Patients that are classified to have innocent murmur had normal echocardiographic findings mostly (76.15%). Further, 13.76% of the patients had echocardiographic findings that were normal for age, while 10.09% of the patients had pathological findings. Patients with pathological murmur had mostly pathological findings (90.38%), with a small percentage (9.62%) of echocardiographic findings that were normal for age (Table 2).
None of the patients with pathological murmur had normal echocardiographic findings. Pathological echocardiographic findings were present in 3 patients without murmur, in 11 patients with innocent murmur and in 47 patients with pathological murmur. Echocardiographic findings normal for age were detected in 11 patients without murmur, 15 patients with innocent murmur and 5 patients with pathological murmur (Table 2).
Pathological echocardiographic findings included mostly atrial septal defect (ASD), ventricular septal defect (VSD), PDA, mitral valve prolapse, mitral and aortic insufficiency, bicuspid aortic valve, tetralogy of Fallot and operated congenital heart diseases.
Aortic stenosis, aortic coarctation, subaortic membrane, interventricular septal hypertrophy, pulmonary insufficiency, non-compaction cardiomyopathy were also present among the patients with pathologic echocardiographic findings. It was determined that there was a significant difference between echocardiography results and physical examination results involving the intensity of murmur. The two diagnostic methods do not give similar results (p=0.001) (Table 3). When murmur intensity was used as a determinant for distinguishing echocardiographic findings, the sensitivity of the physical examination was 21.67%, the specificity was 97.86%, the positive predictive value was 81.25%, the negative predictive value was 74.46%, and the accuracy rate was 75%, odds ratio 12.63%, 95% confidence interval was 3.448-46.272. Murmur intensity was observed as a significant determinant for distinguishing echocardiographic findings.
It was determined that there were no significant differences between echocardiographic results and physical examination results in terms of characteristics of the murmur. The two diagnostic methods give similar results (p=0.115) (Table 3). When murmur characteristics were used as determinants for distinguishing echocardiographic findings, the sensitivity of the physical examination was 76.67%, specificity was 95.71%, the positive predictive value was 88.46%, the negative predictive value was 90.54%, and the accuracy rate was 90%, the odds ratio was 73.38%, 95% confidence interval was 26.638- 202.144. The characteristics of murmur were not observed as significant determinants in distinguishing echocardiographic findings (p=0.115).

Discussion

Innocent murmurs develop as a result of increased flow velocity caused by regions of different widths between the chambers of the heart and vessels or between two vessels due to tissue vibrations [1]. Heart murmur is one of the main causes of evaluation in pediatric cardiology clinics. The majority of murmurs are innocent, without accompanying structural heart disease, and can generally be differentiated from pathological murmurs through accurate history and physical examination. However, murmur differentiation requires gradual skill development [3]. Studies have described various characteristics of innocent heart murmurs. Accordingly, innocent murmurs are soft musical sounds on the left of the sternum that do not spread to other regions. They are short, systolic murmurs that show differences in characteristics with respiration or position [8]. Studies have declared that pansystolic murmurs greater than grade 3/6, accompanied with an early or mid-systolic click, the presence of abnormal S2, all diastolic murmurs should be accepted as pathological [9,10]. Consistent with this knowledge, murmur grade was 1-2/6 in the majority of the patients in our study, most of the murmurs were innocent, and echocardiography was normal in the majority of these patients. In our study, murmurs with low grade were also detected in the patients with echocardiographic findings normal for age. Echocardiographic evaluation was normal in the majority of the cases classified as innocent murmur. Patients with murmurs >3/6 do not have normal echocardiographic findings. We can suggest that in our study, echocardiographic findings were not pathologic in 92.31% of the patients without murmur, in 89.91% of the patients with innocent murmur, while it was pathological in 90.38% of the patients in the study.
Pathological murmurs can be missed with auscultation, particularly because children may be irritable during examination, and the diagnosis depends on the clinical experience of the physician [7,11]. Murmurs may not be heard exactly if conditions during examination are not appropriate for physical examination or if the physician lacks adequate clinical experience. As a result, intensity and type of murmurs that are heard may not be accurately evaluated [7]. Yıldız et al. [7] detected innocent murmurs in 92.1% of their patients, and Karacan et al. [12] in 80% of their patients. In the present study, no murmur was detected in 19.5% of the patients who were referred for this reason, while innocent murmur was present in 54.5% the participants.
Pathological murmur was present in 26% of all the patients. Pathological echocardiographic findings were detected in 30% of all the patients in our study. The American Heart Association does not recommend echocardiography in cases of murmurs of with grade 2/6 or lower intensity, which are interpreted as innocent by an experienced physician [13]. However, patients with murmurs that are thought to be innocent were examined with echocardiography in Yıldız et al.’s study [7], and different cardiac pathologies were detected. Some of these pathologies include conditions that were not expected to cause murmur and do not require follow-up, but some of them include valvular pathologies that necessitate follow-up and small atrial and ventricular septal defects and pulmonary stenosis [7]. Therefore, they suggested that murmurs that are described as innocent should also be evaluated with echocardiography. We stated 14 patients without murmur and with innocent murmur who had pathologic echocardiographic findings. These echocardiographic findings were in concordance with the previous study.
Atrial and ventricular septal defects are more commonly detected under two years of age, for this reason physical examination should be performed more carefully in these ages [7]. Children under two years of age constituted 35% of all the patients in the present study. ASD and VSD, Tetralogy of Fallot, operated congenital heart diseases were present in patients under 2 years of age. Children under 3 months of age consisted of 30 patients and pathologic findings included included VSD, ASD, interventricular septal hypertrophy.
Only half of the congenital heart diseases can be detected in the first weeks of life during routine examinations of healthy newborns. Diagnosis via physical examination is difficult since hemodynamic changes are not yet complete during this period [14]. Studies in the literature, have also reported that echocardiography definitely should be performed for the diagnosis of murmurs detected in the neonatal period [7]. Cardiac murmurs detected in patients over 12 years of age are also important because the prevalence of valvular diseases increases with age. Valve problems have been shown to be more common in patients over 5 years of age. Therefore, such problems are not expected to produce physical examination findings in the first weeks of life. Patients older than four years of age constituted 53.5% of the children in this study. Pathologic echocardiographic findings included valvular diseases in 21 patients. They were mitral insufficiency, mitral valve prolapses with mitral insufficiency, bicuspid aortic valve with aortic insufficiency and aortic stenosis and pulmonary stenosis.
Some pathological murmurs are highly determinant for some cardiac diseases, especially for VSD. Kocabaş et al. [3] detected VSD with a high incidence, according to the characteristics of the murmur. Similarly in the present study, VSD, pulmonary stenosis, and mitral valve pathologies were suspected with a high probability of pathological murmur.
Correct identification of cardiac murmurs characteristics is of very great importance. Correct recognition of innocent murmurs is important in terms of avoiding anxiety, unnecessary drug therapy, and restriction of physical activity. If pathological murmurs are misidentified as innocent, the diagnosis and management of the present congenital heart disease will be delayed. Besides, the delay in prophylaxis of infective endocarditis or surgical treatment will cause a very important problem [7]. Mahnke et al. [15] reported that 40% of research assistants identified innocent murmurs as ‘pathological’ and 21% diagnosed pathological murmurs as ‘innocent’ and concluded that auscultation experience levels were below than those required. Yıldız et al. [7] reported that echocardiographic examinations revealed pathological findings in 17.75% of patients initially regarded as having innocent murmurs, while echocardiography was normal in 7.54% of patients initially regarded as having pathological murmurs. In our study, we determined pathological echocardiographic findings in 30.35% of the patients with grade 1-2/6 murmurs and in 7.69% of the patients without murmurs. Besides, there were echocardiographic findings that were normal for age in 14.28% of the patients with grade ≥ 3/6. In addition, pathological echocardiographic findings were stated in 10.09% of the patients regarded as having innocent murmurs, while echocardiographic findings normal for age were detected in 9.62% of the patients with pathological murmurs. Yıldız et al. [7] demonstrated that physical examination is a significant determinant of echocardiographic findings with a high specificity, positive and negative predictive values and accuracy suggesting that murmurs should be also evaluated with echocardiography for evaluating possible insignificant cardiac defect that has been dismissed and should be followed up in the future. McCrindlle et al. [9] did not suggest evaluating with echocardiography if the physical examination was performed by experienced physicians. But Çimen et al. [11] declared that patients without significant murmur may have minor cardiac defects that should be evaluated during follow ups, so they suggested the necessity of echocardiography for evaluation of cardiac murmurs. We demonstrated in our study that characteristics of murmur is a not a significant determinant for echocardiographic findings. Therefore, the presence of murmur independent from its characteristics should be evaluated with echocardiography.
To our knowledge, this is the first study in the literature that examines the relation of the intensity of murmur with echocardiographic findings. We showed that murmur intensity was observed as a significant determinant for distinguishing echocardiographic findings, suggesting that high grades of murmur shows a high probability of echocardiographic findings. This finding if supported by other studies, would decrease the necessity of echocardiographic findings in lower grades of murmur and in the absence of murmur, and also will increase the requirement of echocardiographic evaluation with the presence of high grades of murmur.

Conclusion

Although the majority of murmurs were innocent and cardiac findings were normal, pathological findings were also detected in patients without murmurs or initially regarded as innocent murmurs. Pathological echocardiographic findings were detected in the majority of pathological murmurs, but findings normal for age were also observed. The intensity of murmurs is valuable in determining the need for further evaluation with echocardiography, while murmur characteristics are an independent factor to make a decision for the necessity of echocardiographic evaluation. In light of these knowledge, these findings suggest that auscultation alone may not be sufficient for the evaluation of the patients with murmur, therefore echocardiographic evaluation may be more appropriate for evaluation.

Scientific Responsibility Statement

The authors declare that they are responsible for the article’s scientific content including study design, data collection, analysis and interpretation, writing, some of the main line, or all of the preparation and scientific review of the contents and approval of the final version of the article.

Animal and human rights statement

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.

Funding: None

Conflict of interest

The authors declare no conflict of interest.

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Ajda Mutlu Mıhçıoğlu. Assessment of the patients referred to the pediatric cardiology clinic due to murmur. Ann Clin Anal Med 2023;14(9):849-853

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