ECG Quiz: A Murmur in an Asymptomatic Athlete

Janus D. Butcher, MD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 25 - NO. 8 - AUGUST 97

A 35-year-old, active duty Army officer presented for a screening physical exam before entering special training for HALO (High Altitude Low Opening) parachute qualification. This training involves jumping from aircraft at extreme altitudes with deployment of the parachute at relatively low altitudes (free fall). At the time of this evaluation he was assigned to a special operations airborne unit on active jump status. Careful review of his recent exercise history revealed a gradual decrease in endurance over the past several years, which he felt was due to decreased training intensity. His exercise consisted of running 3 to 4 miles four times a week and physical fitness training with his military unit three times a week. He continued to achieve high scores on the Army Physical Readiness Test.

The patient had previously been evaluated for an asymptomatic heart murmur. His medical history was significant for one syncopal episode that had occurred 7 years prior to this exam and was diagnosed at that time as vasovagal in origin. He reported no subsequent syncopal episodes. The patient denied any other medical problems and was using no medications.

On physical exam, he was a healthy appearing male in good physical condition. Cardiovascular exam revealed a grade 4 holosystolic murmur with a widely split second heart sound; the murmur appeared to increase with inspiration. No jugular venous distention, jugular V waves, peripheral cyanosis, or digital clubbing was noted. A 12-lead electrocardiogram (ECG) and chest radiograph were obtained (figures 1 and 2).

What is your diagnosis, and what management steps would you recommend?

Dr Butcher is director of primary care sports medicine at Dwight D. Eisenhower Army Medical Center at Fort Gordon, Georgia, and a clinical assistant professor at Uniformed Services University of Health Sciences and the Medical College of Georgia in Augusta. Address correspondence to Janus D. Butcher, MD, Department of Family Practice, D.D. Eisenhower Army Medical Center, Ft Gordon, GA 30905.

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