If a pre-participation murmur is graded 3 or 4, what action is typically recommended?

• A. No referral is needed
• B. Refer to a cardiologist for evaluation
• C. Only observation without evaluation
• D. Start heart failure medications

Answer: (B)

A loud heart murmur in a pre-participation screen suggests possible structural heart disease and warrants specialist evaluation. Grading 3 or 4 indicates a murmur that is clearly audible and may be associated with underlying valvular or congenital heart issues. The appropriate step is to refer to a pediatric cardiologist for a thorough assessment, which typically includes targeted history and physical, and often echocardiography, to define the anatomy and function and to determine if it’s safe to participate in sports. Starting heart failure medications or choosing observation without evaluation would be inappropriate in this context, as they could miss a potentially serious condition.