Innocent Diastolic Murmurs

B. Argano and Aldo A. Luisada Chest 1971;59;443-445 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/59/4/443

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T H E SOUND OF T H E HEART
Innocent Diastolic Murmurs*
B . Argano, M.D.,and Aldo A. Luisada, M.D., F.C.C.P.

About 10 percent of children, adolescents, or adults with an innocent systolic murmur also have an "innocent* diastolic murmur, which may be either low pitched and apical, or high-pitched and basal. Tentative explanations are advanced.
iastolic murmurs have been considered evidence of organic valvular lesions for a long time. However, in the last 30 years, numerous clinical and phonocardiographic studies revealed the possibility of diastolic rumbles not caused by mitral stenosis. Following demonstration of such murmurs in congenital heart disease, our group described them in coronary, hypertensive, and anemic heart disease, as well as in cases of myocarditis.l-3 More recently a functional mid-diastolic rumble 'From the Division of Cardiology (Medicine) of The Chica o Medical School, University of Health Sciences, and B e hlount Sinai Hospital Medical Center. This study was aided by a Grant of the Henry Davis 400 Foundation and was made during tenure of Undergraduate Training grant HE-5002 of the National Heart and Lung Institute, USPHS.

was described in a few normal subjects.4 High frequency diastolic murmurs, not associated with heart disease, were recently described in a few normal children.5 We thought that a statistical study was indicated and reviewed the phonocardiographic tracings recorded within the last ten years in the Division of Cardiology.

The phonocardiograms of this Division were recorded with the subjects in the supine position. Equipment used was: first, routine Sanborn recorder with high pass filters; second, Sanborn recorder modified in this 1aboratory;s third, General Electric microphone and preamplifier with Sanborn amplifiers and galvanometers and band pass filters.? All tracing recorded in patients subsequently diagnosed as having "innocent" murmurs were reviewed. These subjects had normal chest x-ray films and normal electrocardiograms. Their total number was 320. Excluded were cases with history of heart disease or abnormal electrocardiograms. Seventeen children (ages 3 to 15) and 13 adults (ages 15 to 40) presented a diastolic murmur in addition to a systolic

FIGURE 1. Tracings from a 33-year-old woman with an innocent systolic murmur. At left: low frequency tracing disclosing a low frequency mid-diastolic murmur at the apex. At right: high frequency tracing disclosing a prolonged second sound and a high frequency diastolic murmur both at base and apex.

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ARGANO AND LUISADA

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FIGURE 2. At left: tracings from a 66-year-old patient with an innocent systolic murmur and a high frequency, small diastolic murmur. At right: tracings from a 9-year-old child with a vibratory, innocent systolic murmur and a low frequency, mid-diastolic murmur, best recorded over the midprecordium (lower tracing ). murmur, which was often midsystolic and vibratory in nature. This represents a total of 30 cases or 9.6 percent.

RESULTS
T~~ types of murmurs were recognized, a mid-diastolic, rumbling apical or midprecordial murmur and an early-diastolic, high frequency murmur at the secondthird left intercostal spaces.
( 1) Apical mid-diastolic murmur

l l cases had an "innocent" systolic murmur at or adults. A the base. Amy1 nitrite by inhalation increased the systolic murmur, decreased the early-diastolic murmur in most cases, and tended to increase the mid-diastolic murmur; this often became diastolic-presystolic because of the faster heart rate caused by the drug.
D~scuss~o~

This was found in nine &Idren and six or adults. It was usually associated with a low-pitched, prominent third sound, which it seemed to prolong. It was of low frequency as it disappeared with filters above 200 hz having a -24 db/octave slope (Fig 1 , 2 ) .
( .2 ,

Basal earlu-diastolic murmur

This was found in ten children and nine adolescents or adults. It was a small amplitude, diastolic series of vibrations with a crescendo-decrescendo configuration; it was often (but not always) well separated from the second sound. Exceptions were represented by a decrescendo murmur starting with the semnd sound. This murmur was of high frequency and was often well even with a ' 0 hz "ter having a -30 db/octave slope ( Fig 1 , 2 ) .

Low frequency functional diastolic murmurs in hearts with an abnormal myocardium are often of high voltage. 0" the contrary, those that we found in cases with a normal myocardium were of low voltage. High frequenCY functional diastolic murmurs in hearts with a normal myocardium were also of low voltage. This may explain why, contrary to the experience of others,S these murmurs were not disclosed by auscultation. While the low frequency rumbling murmur can be explained by the modality of left ventricular filling, possibly more tumultuous on a-unt of tachycardia, several alternative explanations can be advanced for the caused high frequency murmur: minimal fenestration of fie aortic or pulmonic by uinnocentn Ieageu;. minimal regurgitation on account of a bicuspid by incornaortic valve; or minimal plete closure of the aortic or pulmonary valve. We have no way to decide among them. 'Fenestrations of either the aortic or pulmonary leaflets were found by Foxes in 82 percent of a series of 300 hearts.

( 3 ) Both
This occurred in two children and in two adolescents

CHEST, VOL. 59, NO. 4, APRIL 1971

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INNOCENT DIASTOLIC MURMURS

These murmurs should be known because otherwise they may be accepted as evidence of a significant valvular lesion when reading a phonocardiogram. Unfortunately such murmurs may also occur in pathologic hearts. W e had the experience of recording them in patients with aortic or mitral valve lesions in whom biplane angiocardiography and cineangiocardiography failed to disclose any regurgitation. 3 Luisada AA, Szatkowski J, Testelli MR, et al: Apical diastolic and presystolic murmurs of proved functional nature. Amer J Cardiol4:501-507, 1959 4 Ferinelli A, Sbrighi V: I1 rumore mesodiastolico. Studio semeiologico con fonocardiografia filtrata e ad alta ve1ocit.A. Cardiol Prat-Arch 5:276,310, 1964 5 Liebman J, Sood S: Diastolic murmurs in apparently normal children. Circulation 38:755-762, 1968 6 Luisada AA, Bernstein JG: Better resolution and quantitation in clinical phonocardiography. Cardiologia 47:113126,1965 7 Luisada AA, MacCanon DM, Feigen LP, et al: Design and first results of a new phonocardiograph. Amer J Cardiol ( in press ) . 8 Foxe AN: Fenestrations of the semilunar valves. Amer J Path 5: 179-182,1929 Reprint requests: Dr. Luisada, 2020 West Ogden, Chicago 60612.

1 Luisada AA, Perez Montbs L: A phonocardiographic study of apical diastolic murmurs simulating those of mitral stenosis. Ann Intern Med 33:56-71, 1950 2 Luisada AA, Haring OM, Zilli AB: Apical diastolic murmurs simulating mitral stenosis. 11. Graphic differentiation. Ann Intern Med 42:644-653, 1955

Comments on Prevention of Myocardial lschemia

Autoptic findings reveal severe narrowing of the coronary arteries in uncomplicated angina pectoris in 92 to 100 percent of the cases. The same is true of massive transmural myocardial infarction. The "coronary reserve" ranges between the coronary flow and oxygen consum~tiona t rest. on the one hand and their comto the ~ o i n twhich still bined Aaximal au&nentation " permits an adequate oxygen availability to myocardial tissue, on the other. The trained, efficient heart with its lower sympathetic and higher vagal tone (augmented coronary reserve) requires less oxygen for a given amount of work than the inefficient faster beating heart of the sedentary individual. In addition, the trained body requires for a given physical performance a smaller myocardial energy expenditure. These combined metabolic and dynamic effects of training, together with an improved development of collaterals, protect the heart against myocardial ischemia even in the presence of some degree - of coronary atherosclerosis. Schimmert, G C and Schwalb, H: Functional and Metabolic Factors in the Origin and Prevention of Myocardial Ischemia, in Raab, W: Prevention of Ischemic Heart Disease, C. C Thomas, Springfield, 1966

CHEST, VOL. 59, NO. 4, APRIL 1971

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Innocent Diastolic Murmurs B. Argano and Aldo A. Luisada Chest 1971;59; 443-445 This information is current as of May 4, 2012
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