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Early diastolic[edit]

Time Condition Description


Early
diastolic
Aortic
regurgitation
The murmur is low intensity, high-pitched, best heard over the
left sternal border or over the right second intercostal space,
especially if the patient leans forward and holds breath in full
expiration. The radiation is typically toward the apex. The
configuration is usually decrescendo and has a blowing
character. The presence of this murmur is a good positive
predictor for AR and the absence of this murmur strongly
suggests the absence of AR. An Austin Flint murmur is usually
associated with significant aortic regurgitation.
Early
diastolic
Pulmonary
regurgitation
Pulmonary regurgitation is most commonly due to pulmonary
hypertension (Graham-Steell murmur). It is a high-pitched and
blowing murmur with a decrescendo configuration. It may
increase in intensity during inspiration and best heard over left
second and third intercostal spaces. The murmur usually does
not extend to S1.
Early
diastolic
Left anterior
descending
arterystenosis
This murmur, also known as Dock's murmur, is similar to that of
aortic regurgitation and is heard at the left second or third
intercostal space. A Coronary artery bypass surgery can
eliminate the murmur.





Mid-diastolic[edit]
Time Condition Description
Mid-
diastolic
Mitral stenosis
This murmur has a rumbling character and is best heard with
the bell of the stethoscope in the left ventricular impulse area
with the patient in the lateral decubitus position. It usually
starts with an opening snap. In general, the shorter the
duration (S2 to Opening Snap), the more severe the mitral
stenosis. However, this rule can be misleading in situations
where the stenosis is so severe that the flow becomes
reduced, or during high-output situations such as pregnancy
where a less severe stenosis may still produce a strong
murmur. In mitral stenosis, tapping apical impulse is present.
Mid-
diastolic
Tricuspid stenosis
Best heard over the left sternal border with rumbling character
and tricuspid opening snap with wide splitting S1. May
increase in intensity with inspiration (Carvallo's sign). Tricuspid
stenosis often occurs in association with mitral stenosis.
Isolated TS are often associated with carcinoid disease and
right atrial myxoma.
Mid-
diastolic
Atrial myxoma
Atrial myxomas are benign tumors of the heart. Left myxomas
are far more common than right myxomas and those may
cause obstruction of the mitral valve producing a mid-diastolic
murmur similar to that of mitral stenosis. An echocardiographic
evaluation is necessary.
Mid-
diastolic
Increased flow
across the
atrioventricular
valve
This can also produce a mid-diastolic murmur, such as in
severe mitral regurgitation where a large regurgitant volume in
the left atrium can lead to "functional mitral stenosis."
Mid-
diastolic
Austin Flint
murmur
An apical diastolic rumbling murmur in patients with pure aortic
regurgitation. This can be mistaken with the murmur in mitral
stenosis and should be noted by the fact that an Austin Flint
murmur does not have an opening snap that is found in mitral
stenosis.
Mid-
diastolic
Carey-Coombs
murmur
A mid-diastolic murmur over the left ventricular impulse due to
mitral valvulitis from acute rheumatic fever.

Mid-systolic ejection[edit]
Time Condition Description
Mid-
systolic
ejection
Aortic outflow
obstruction (Aortic
Stenosis)
Can be due to aortic valve stenosis or hypertrophic
cardiomyopathy (HCM), with a harsh and rough quality.
**Valvular aortic stenosis can produce a harsh, or even a
musical murmur over the right second intercostal space
which radiates into the neck over the two carotid arteries.
The most common cause of AS (Aortic Stenosis) is
calcified valves due to aging. The second most common
cause is congenital bicuspid aortic valves (normal valve
is tricuspid). In aortic stenosis, heaving apical impulse is
present. The distinguishing feature between these two
causes is that bicuspid AS has little or no radiation. It can
be confirmed if it also has an aortic ejection sound, a
short early diastolic murmur, and normal carotid pulse.
The murmur in valvular AS decreases with standing and
straining with Valsalva maneuver.
** Supravalvular aortic stenosis is loudest at a point
slightly higher than in that of valvular AS and may radiate
more to the right carotid artery.
**Subvalvular aortic stenosis is usually due to
hypertrophic cardiomyopathy (HCM), with murmur
loudest over the left sternal border or the apex. The
murmur in HCM increases in intensity with a standing
position as well as straining with Valsalva maneuver.
Mid-
systolic
Pulmonic outflow
obstruction(Pulmonic
A harsh murmur usually on left second intercostal space
radiating to left neck and accompanied by palpable thrill.
ejection Stenosis) It can be distinguished from a VSD (Ventricular septal
defect) by listening to the S2, which is normal in VSD but
it is widely split in pulmonary stenosis. However, VSD is
almost always pansystolic where the murmur of
pulmonary stenosis is diamond-shaped and ends clearly
before S2. Many innocent murmurs also arise from this
location but S1 and S2 must split normally.
Mid-
systolic
ejection
Dilation of aortic root or
pulmonary artery
Produces an ejection sound, with a short ejection systolic
murmur and a relatively wide split S2. There is no
hemodynamic abnormality. This is similar to pulmonary
hypertension except the latter has hemodynamic
instabilities.
Mid-
systolic
ejection
Increased semilunar
blood flow
This can occur in situations such as anemia, pregnancy,
or hyperthyroidism.
Mid-
systolic
ejection
Aortic valve sclerosis
This is due to degenerative thickening of the roots of the
aortic cusps but produces no obstruction and no
hemodynamic instability and thus should be differentiated
from aortic stenosis. It is heard over right second
intercostal space with a normal carotid pulse and normal
S2.
Mid-
systolic
ejection
Innocent midsystolic
murmurs
These murmurs are not accompanied by other abnormal
findings. One example of a benign paediatric heart
murmur is Still's murmur in children.
Late systolic[edit]
Time is
important
Condition Description
Late
systolic
Mitral valve
prolapse
This is the most common cause of late systolic murmurs. It can
be heard best over the apex of the heart, usually preceded by
clicks. The most common cause of mitral valve prolapse is
"floppy" valve (Barlow's) syndrome. If the prolapse becomes
severe enough, mitral regurgitation may occur. Any maneuver
that decreases left ventricular volume such as standing,
sitting, Valsalva maneuver, and amyl nitrate inhalation can
produce earlier onset of clicks, longer murmur duration, and
decreased murmur intensity. Any maneuver that increases left
ventricular volume such as squatting, elevation of legs, hand
grip, and phenylephrine can delay the onset of clicks, shorten
murmur duration, and increase murmur intensity.
Late
systolic
Tricuspid
valve
prolapse
Uncommon without concomitant mitral valve prolapse. Best
heard over left lower sternal border.
Late
systolic
Papillary
muscle
dysfunction
Usually due to acute myocardial infarction or ischemia, which
causes mild mitral regurgitation.
Holosystolic (pansystolic)[edit]
Time Condition Description
Holosystolic
(pansystolic)
Tricuspid
insufficiency
Intensifies upon inspiration. Can be best heard over the
fourth left sternal border. The intensity can be accentuated
following inspiration (Carvallo's sign) due to increased
regurgitant flow in right ventricular volume. Tricuspid
regurgitation is most often secondary to pulmonary
hypertension. Primary tricuspid regurgitation is less common
and can be due to bacterial endocarditis following IV drug
use, Ebstein's anomaly, carcinoid disease, or prior right
ventricular infarction.
Holosystolic
(pansystolic)
Mitral
regurgitationor
MR
No intensification upon inspiration. In the presence of
incompetent mitral valve, the pressure in the L ventricle
becomes greater than that in the L atrium at the onset of
isovolumic contraction, which corresponds to the closing of
the mitral valve (S1). This explains why the murmur in MR
starts at the same time as S1. This difference in pressure
extends throughout systole and can even continue after the
aortic valve has closed, explaining how it can sometimes
drown the sound of S2. The murmur in MR is high pitched
and best heard at the apex with diaphragm of the
stethoscope with patient in the lateral decubitus position. Left
ventricular function can be assessed by determining the
apical impulse. A normal or hyperdynamic apical impulse
suggests good ejection fraction and primary MR. A displaced
and sustained apical impulse suggests decreased ejection
fraction and chronic and severe MR.
Holosystolic
(pansystolic)
Ventricular
septal defect
No intensification upon inspiration. VSD is a defect in the
ventricular wall, producing a shunt between the left and right
ventricles. Since the L ventricle has a higher pressure than
the R ventricle, flow during systole occurs from the L to R
ventricle, producing the holosystolic murmur. It can be best
heard over the left third and fourth intercostal spaces and
along the sternal border. It is associated with normal
pulmonary artery pressure and thus S2 is normal. This fact
can be used to distinguish from pulmonary stenosis, which
has a wide splitting S2. When the shunt becomes reversed
("Eisenmenger syndrome"), the murmur may be absent and
S2 can become markedly accentuated and single.