Heart Murmurs Topic Review

10/28/2018 Heart Murmurs Topic Review - From Description to Auscultation | LearntheHeart.
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Heart Murmurs Topic Review

Describing Murmurs | Systolic Murmurs | Diastolic
Murmurs | Dynamic Auscultation
Introduction
Disease of the cardiac valves and other cardiac structures frequently
results in abnormal, turbulent blood flow within the heart, causing
murmurs. Careful auscultation of heart murmurs is an extremely
valuable tool in the diagnosis of many cardiac conditions. Heart
murmurs are discussed here. Heart sounds are discussed elsewhere.
When normal laminar blood flow within the heart is disrupted, an

audible sound is created by turbulent blood flow. Outside of the
heart, audible turbulence is referred to as a bruit, whereas inside the
heart it is called a murmur. A pictorial representation of systolic and
diastolic murmurs is below.
There are four major causes of cardiac murmurs.
1. Valvular stenosis: If blood is forced through a tight area,

turbulent blood flow ensues, as is the case in valvular
stenosis. Generally, the worse the stenosis, the louder the
murmur; however, if heart failure develops, adequate
pressures to create turbulent blood flow may not be able to be
achieved, and the murmur may lessen or even disappear.
Thus, the intensity of a murmur is not used to indicated
severity of disease.
2. Valvular insu iciency: Blood abnormally travels backward
through an incompetent valve in valvular insu iciency,
causing turbulence when it meets normal, forward blood flow.
3. Congenital anomaly: If blood is forced through a congenital
anomaly from one chamber to another, as in an atrial septal
defect or ventricular septal defect, a murmur is produced —
again due to turbulence.
4. Increased blood flow: Yet another cause of cardiac murmurs is
increased flow of blood through a normal valve. In high-
output states such as anemia, thyrotoxicosis or sepsis, a large
volume passes through the cardiac valves, and the normal
laminar blood flow may be disturbed. Still’s murmur is a
normal aortic flow murmur frequently heard in childhood that
frequently disappears over time.
Murmurs are described by their timing in the cardiac cycle, intensity,

shape, pitch, location, radiation and response to dynamic
maneuvers. Using the above, clinicians can accurately characterize
the nature of a murmur and communicate their findings in a precise
manner.
Describing Heart Murmurs

Timing
The timing of a murmur is crucial to accurate diagnosis. A murmur is
either systolic, diastolic or continuous throughout systole and
diastole. Remember that systole occurs between the S1 and S2 heart
sounds, whereas diastole occurs between S2 and S1.
With the knowledge of the possible cardiovascular conditions that

cause systolic or diastolic murmurs, the clinician can narrow their
di erential diagnosis. Thus, it is important to remember which
lesions result in systolic murmurs and which result in diastolic
murmurs.
Stenosis of the aortic or pulmonic valves will result in a systolic

murmur as blood is ejected through the narrowed orifice.
Conversely, regurgitation of the same valves will result in a diastolic
murmur as blood flows backward through the diseased valve when
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ventricular pressures drop during relaxation. Regarding the mitral

and tricuspid valves, stenosis would result in a diastolic murmur and
regurgitation a systolic murmur.
Other murmurs will be discussed in their respective sections below.

More in-depth discussion of valvular heart disease can be found
elsewhere.
Once it is determined if the murmur is systolic or diastolic, the

timing within systole or diastole also becomes important when
characterizing the murmur. Systolic murmurs can be classified as
either midsystolic (systolic ejection murmurs, or SEM), holosystolic
(pansystolic) or late systolic. A midsystolic murmur begins just a er
the S1 heart sound and terminates just before the P2 heart sound;
thus, S1 and S2 will be distinctly audible. Conversely, a holosystolic
murmur begins with or immediately a er the S1 heart sound and
extends up to the S2, making them di icult — if not impossible — to
hear. A mid-late systolic murmur begins significantly a er S1 and
may or may not extend up to the S2.
Grading
Systolic murmurs are graded on a scale of 6. This grading is, for the
most part, subjective. Grade I murmurs may not be audible to the
inexperienced examiner; however, grade 6 murmurs are heard even
without the stethoscope on the chest and may actually be visible.
Diastolic murmurs are graded on a scale of 4. This a completely

subjective grading scale. Once again, grade I murmurs may not be
audible to some, whereas grade IV murmurs are audible very easily.
The intensity of a murmur is primarily determined by the

volume/velocity of blood flowing through a defect and the distance
between the stethoscope and the lesion. For example, a very thin
patient with severe aortic stenosis and a high pressure gradient
across the valve (thus, high velocity of blood flow) will have a loud
murmur. Conversely, the exact same valvular lesion in a patient with

morbid obesity or severe chronic obstructive pulmonary disease, or
COPD, and a widened anterior-posterior chest diameter may be
inaudible.
Shape
The shape of a murmur describes the change of intensity
throughout the cardiac cycle. Murmurs are either crescendo,
decrescendo, crescendo-decrescendo or uniform.
Pitch
A murmur will be high pitched if there is a large pressure gradient
across the pathologic lesion and low pitched if the pressure gradient
is low. For example, the murmur of aortic stenosis is high pitched
because there is usually a large pressure gradient between the le
ventricle and the aorta. Conversely, the murmur of mitral stenosis is
low pitched because there is a lower pressure gradient between the
le atrium and the le ventricle during diastole. Remember high-
pitched sounds are heard with the diaphragm of the stethoscope,
whereas low-pitched sounds are heard with the bell.
Location
The anatomic location where the murmur is best heard is an
important factor in determining the etiology of the lesion. The four
main “listening posts” on the chest are described below.
A = aortic valve post (right upper sternal border or RUSB)

P = pulmonic valve post (le upper sternal border or LUSB)
T = tricuspid valve post (le lower sternal border or LLSB)
M = mitral valve post (apex)
E = “Erb’s point”
Note that both the aortic and pulmonic listening posts are
considered to be near the “base” of the heart.
In general, a murmur will be the most intense over the listening post
that corresponds to the diseased valve. Many murmurs will radiate
to more than one listening post. For example, the murmur of aortic
stenosis is best heard at the LUSB, but it may radiate to the apex.
This radiation of the aortic stenosis murmur is called the
“Gallavardin dissociation.”
Radiation
While murmurs are usually most intense at one specific listening
post, they o en radiate to other listening posts or areas of the body.
For example, the murmur of aortic stenosis frequently radiates to
the carotid arteries and the murmur of mitral regurgitation radiates
to the le axillary region. It is o en di icult to distinguish if one
murmur is radiating to multiple sites or if there are multiple
murmurs present from many di erent causes. Dynamic auscultation
and echocardiography are helpful in determining the exact lesion
present.
Systolic Heart Murmurs

Midsystolic Murmurs
Midsystolic murmurs — also known as systolic ejection murmurs, or
SEM — include the murmurs of aortic stenosis, pulmonic stenosis,
hypertrophic obstructive cardiomyopathy and atrial septal defects.
A midsystolic murmur begins just a er the S1 heart sound and
terminates just before the P2 heart sound, thus S1 and S2 will be
distinctly audible. The term midsystolic is preferred to SEM because
many lesions that produce midsystolic murmurs are unrelated to
systolic ejection.
Aortic stenosis (AS)

The classic murmur of aortic stenosis is a high-pitched, crescendo-
decrescendo (diamond shaped), midsystolic murmur located at the
aortic listening post and radiating toward the neck.
The radiation of the AS murmur is o en mistaken for a carotid bruit.

The AS murmur is also known to radiate to the cardiac apex on
occasion, making it di icult to distinguish if mitral regurgitation is
also present. This radiation of the AS murmur to the apex is known
as “Gallavardin dissociation.” Determining if coexisting mitral
regurgitation is the cause of the apical murmur in a patient with AS
requires dynamic auscultation or echocardiography.
The intensity of the murmur of AS is not a good indicator as to the

severity of disease. As AS worsens, the LV begins to fail, and the
ejection fraction declines to the point where su icient force to
create turbulent flow is no longer produced, resulting in a decrease
in the intensity of the murmur.
While the intensity of the murmur may not be an accurate

determinant of aortic stenosis severity, the shape of the murmur can
be very helpful. As aortic stenosis worsens, it takes longer for blood
to eject through the valve, so the peak of the crescendo-
decrescendo murmur moves to later in systole. Therefore, mild
aortic stenosis would have a murmur that peaks early in systole,
whereas the murmur of severe aortic stenosis would peak later.
Remember from the Heart Sounds Topic Review that the delay in
aortic valve closure can cause a paradoxically split S2 heart sound
and, as the aortic valve becomes more heavily calcified, the
intensity of the S2 heart sound declines. Also, in patients with
bicuspid aortic valves, an ejection click may be heard just before the
murmur begins.
Pulmonic stenosis (PS)

The murmur of pulmonic stenosis is very similar to that of aortic
stenosis. It is a midsystolic, high-pitched, crescendo-decrescendo
murmur heard best at the pulmonic listening post and radiating
slightly toward the neck; however, the murmur of pulmonic stenosis
does not radiate as widely as that of aortic stenosis. The murmur of
pulmonic stenosis peaks early if the disease is mild and peaks later
as the disease progresses. Also, this murmur demonstrates
increased intensity during inspiration due to the increased venous
return to the right heart, resulting in greater flow across the
pulmonic valve.
Compared with the murmur of aortic stenosis that extends up to the

A2 heart sound, the murmur of pulmonic stenosis extends through
the A2 sound up to the P2 heart sound. Severe PS results in
decreased mobility of the pulmonic valve leaflets, and thus a so er
P2 sound. Also, as the PS worsens, the closure of the pulmonic valve
is delayed, because more time is required to eject blood through the
stenotic valve; this results in a widely split S2 heart sound that still
exhibits inspiratory delay. Note that the murmur of an ASD,
discussed below, is also midsystolic; however, it has a fixed split S2.
Atrial septal defect (ASD)

The murmur produced by an atrial septal defect is due to increased
flow through the pulmonic valve, making it remarkably similar to
that of PS. The di erence lies in the intensity and splitting pattern of
the S2 heart sound. The intensity of S2 should remain unchanged
and may, in fact, be accentuated if pulmonary hypertension
develops. The S2 is fixed-split in a patient with an ASD. This di ers
from the widened split S2, seen in severe PS. Also, the murmur of an
ASD does not increase in intensity with inspiration.
Hypertrophic obstructive cardiomyopathy (HOCM)
The murmur of hypertrophic obstructive cardiomyopathy is

important to detect due to its clinical implications; see Hypertrophic
Obstructive Cardiomyopathy Topic Review. The murmur is high-
pitched, crescendo-decrescendo, midsystolic murmur heard best at
the le lower sternal border. The murmur of HOCM does not radiate
to the carotids like that of AS. The important auscultatory features of
HOCM that distinguish it from AS relate to dynamic auscultation,
discussed in the respective section below.
Holosystolic Murmurs
Holotsystolic murmurs — also known as pansystolic — include the
murmurs of mitral regurgitation, tricuspid regurgitation and
ventricular septal defects. Because the intensity of these murmurs is
high immediately a er the onset of S1, and extends to just before
the S2, the S1 and S2 sounds are o en overwhelmed by the murmur
and may be di icult to hear.
Mitral regurgitation (MR)

The murmur of mitral regurgitation is described as a high-pitched,
“blowing” holosystolic murmur best heard at the apex. Although the
direction of radiation of the murmur depends on the nature of the
mitral valve disease, it usually radiates to the axilla. The intensity of
the murmur of MR does not increase with inspiration, helping to
distinguish it from the murmur of tricuspid regurgitation.
Tricuspid regurgitation (TR)

The murmur of tricuspid regurgitation is similar to that of MR in that
it is high pitched and holosystolic; however, it is best heard at the
le lower sternal border, and it radiates to the right lower sternal
border. The intensity significantly increases with inspiration, helping
to distinguish it from MR. This inspiratory enhancement of the TR
murmur is called “Carvallo’s sign.”
Ventricular septal defect (VSD)

A ventricular septal defect produces yet another holosystolic
murmur. Blood abnormally flows from the LV (high pressure) to the
RV (low pressure), thereby creating turbulent blood flow and a
holosystolic murmur heard best at “Erb’s point.” The smaller the
VSD, the louder the murmur.
Late Systolic Murmurs

The murmur of mitral or tricuspid valve prolapse is the only
significant late systolic murmur. Tricuspid valve prolapse is relatively
rare and usually not clinically significant.
Mitral valve prolapse (MVP)
Mitral valve prolapse produces a midsystolic click, typically followed

by a uniform, high-pitched murmur. The murmur is actually due to
MR that accompanies the mitral valve prolapse; thus, it is heard best
at the cardiac apex. Mitral valve prolapse responds to dynamic
auscultation.
Summary of Systolic Murmurs
Diastolic Heart Murmurs

Diastolic murmurs include aortic and pulmonic regurgitation (early
diastolic) and mitral or tricuspid stenosis (mid- to late-diastolic).
Tricuspid stenosis is very rare and is discussed further in the
Tricuspid Stenosis Topic Review.
Early Diastolic
Aortic regurgitation (AR)
The murmur of aortic regurgitation is a so , high-pitched, early
diastolic, decrescendo murmur usually heard best at the third
intercostal space on the le (Erb’s point) at end expiration with the
patient sitting up and leaning forward. However, if the aortic
regurgitation is due to aortic root disease, the murmur will be best
heard at the right upper sternal border — not at Erb’s point. As AR
worsens in severity, the pressure between the LV and the aorta
equalize much faster, and the murmur becomes significantly
shorter.
In patients with AR, an early diastolic rumble may also be heard at

the apex due to the regurgitant jet striking the anterior leaflet of the
mitral valve and causing it to vibrate. This murmur is termed the
Austin-Flint murmur.
In addition to the above two murmurs, a systolic ejection murmur

may be present in patients with severe aortic regurgitation at the
right upper sternal border simply due to the large stroke volume
passing through the aortic valve with each systolic contraction of
the LV.
Pulmonic regurgitation (PR)

Pulmonic regurgitation produces a murmur that is o en
indistinguishable from that of AR. PR produces a so , high-pitched,
early diastolic decrescendo murmur heard best at the pulmonic
listening post (LUSB). The murmur of PR increases in intensity
during inspiration, unlike that of AR. The murmur of PR is classically
referred to as the Graham-Steele murmur, a er the experts that
initially described the sound.
Mid- to Late-diastolic
Mitral stenosis
Mitral stenosis results in a uniquely-shaped, low-pitched, diastolic
murmur best heard at the cardiac apex. The opening of the mitral
valve produces an “opening snap” due to the high le atrial
pressures, immediately followed by a decrescendo murmur as blood
flows passively from the le atrium to the le ventricle through the
stenosed mitral valve, creating turbulence. Immediately before the
S1 sound, active le ventricular filling occurs when the LA contracts
and forces more blood through the stenosed mitral valve, creating a
late diastolic, crescendo murmur. In the presence of atrial
fibrillation, the active le ventricular filling phase does not take
place, and the latter part of the mitral stenosis murmur disappears.
As mitral stenosis worsens, le atrial pressure increases, forcing the

mitral valve open earlier in diastole. Thus, in severe mitral stenosis,
the opening snap occurs earlier — as does the initial decrescendo
part of the murmur. The opening snap and murmur of mitral
stenosis also respond to dynamic auscultation.
Continuous Murmurs
The murmur of a patent ductus arteriosus, or PDA, is continuous
throughout systole and diastole. O en, the S2 heart sound is
di icult to detect. The murmur begins just a er S1 and crescendos,
peaking at S2, then decrescendos to S1.
Summary of Diastolic Murmurs
Dynamic Auscultation of Heart Murmurs
Dynamic auscultation refers to using maneuvers to alter

hemodynamic parameters during cardiac auscultation in order to
diagnose the etiology of a heart sound or murmur.
Valsalva Maneuver
The Valsalva maneuver is performed by having a patient “bear
down” — as if they are going to have a bowel movement, exhaling
forcefully with the airway closed. The hemodynamic changes that
occur are complex; however, the ultimate result is a decrease in le
ventricular preload.
The most important use of the Valsalva maneuver is to distinguish

the murmur of aortic stenosis from hypertrophic obstructive
cardiomyopathy — or simply to bring forth the murmur of HOCM.
Aortic stenosis will so en or not change, whereas the murmur of
HOCM becomes quite loud with Valsalva.
The Valsalva maneuver is also performed during routine

echocardiographic examinations to see if a patient with grade II or
worse diastolic function can decrease his or her le ventricular
filling pressures adequately. If the Valsalva maneuver fails to reduce
the le ventricular pressure in the setting of diastolic heart failure,
then grade IV diastolic dysfunction is said to be present — indicating
a poor prognosis.
Squatting from a Standing Position
Squatting forces the blood volume that was stored in the legs to
return to the heart, increasing preload and thus increasing le
ventricular filling.
This maneuver will decrease the murmur of HOCM, as the increased

le ventricular volume helps displace the hypertrophied
interventricular septum, causing less outflow tract obstruction.
This maneuver causes the click of MVP to move later in systole.
Standing from a Squatting Position

Standing quickly from a squatting position causes blood to move
from the central body to the legs, resulting in less blood returning to
the heart and decreasing le ventricular preload — similar to the
e ect seen with the Valsalva maneuver.
This maneuver will increase the murmur of HOCM and decrease that
of aortic stenosis.
This maneuver causes the click of MVP to move earlier in systole.
Leg Raising
Passive leg raising is done simply by raising the legs high in a patient
lying supine. This results in blood that was pooled in the legs
returning to the heart, increasing le ventricular filling and preload
— similar to the e ect seen with squatting from a standing position.
This maneuver will decrease the murmur of HOCM, as the increased

le ventricular volume helps displace the hypertrophied
interventricular septum, causing less outflow tract obstruction.
This maneuver causes the click of MVP to move later in systole.
Handgrip Exercise
Isometric handgrip exercises are performed by having a patient
squeeze hard repetitively. This results in increased blood pressure,
similar to exercise, and thus increased a erload. Elderly individuals
may have a hard time with this maneuver, and transient arterial
occlusion (described below) can be used instead.
This maneuver will increase the intensity of le -sided regurgitant

murmurs including MR and AR. However, handgrip exercises will
have no e ect on the murmur of AS, which helps distinguish the
presence of coexistent MR from Galliverdin phenomenon.
Transient Arterial Occlusion
This maneuver is performed by placing a blood pressure cu on

both arms and inflating it to 20 to 40 mmHg above the systolic blood
pressure for 20 seconds — e ectively resulting in increased
a erload.
This maneuver will increase the intensity of le -sided regurgitant

murmurs including MR and AR and is especially useful in elderly
individuals who are unable to perform adequate handgrip exercises.
Amyl Nitrate Inhalation

Amyl nitrate decreases le ventricular a erload by dilating the
peripheral arteries and would decrease the murmur of MR.
When the a erload is decreased, there is less resistance to blood

flow from the LV through the aortic valve; this means less blood
regurgitates through the mitral valve, thereby decreasing the
intensity of the murmur.
Amyl nitrate can be given via inhalation to reduce a erload for

diagnostic purposes in the cardiac catheterization laboratory (to
invoke a LV outflow tract gradient in patients with HOCM) or as a
diagnostic tool during cardiac physical examination. Due to the
advancement of echocardiography, it is not commonly used any
longer.
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10/28/2018 Heart Murmurs Topic Review - From Description to Auscultation | LearntheHeart.

When normal laminar blood flow within the heart is disrupted, an

There are four major causes of cardiac murmurs.

1. Valvular stenosis: If blood is forced through a tight area,

Murmurs are described by their timing in the cardiac cycle, intensity,

Describing Heart Murmurs

With the knowledge of the possible cardiovascular conditions that

Stenosis of the aortic or pulmonic valves will result in a systolic

ventricular pressures drop during relaxation. Regarding the mitral

Other murmurs will be discussed in their respective sections below.

Once it is determined if the murmur is systolic or diastolic, the

Diastolic murmurs are graded on a scale of 4. This a completely

The intensity of a murmur is primarily determined by the

murmur. Conversely, the exact same valvular lesion in a patient with

A = aortic valve post (right upper sternal border or RUSB)

Systolic Heart Murmurs

Aortic stenosis (AS)

The radiation of the AS murmur is o en mistaken for a carotid bruit.

The intensity of the murmur of AS is not a good indicator as to the

While the intensity of the murmur may not be an accurate

Pulmonic stenosis (PS)

Compared with the murmur of aortic stenosis that extends up to the

Atrial septal defect (ASD)

Hypertrophic obstructive cardiomyopathy (HOCM)

The murmur of hypertrophic obstructive cardiomyopathy is

Mitral regurgitation (MR)

Tricuspid regurgitation (TR)

Ventricular septal defect (VSD)

Late Systolic Murmurs

Mitral valve prolapse (MVP)

Mitral valve prolapse produces a midsystolic click, typically followed

Summary of Systolic Murmurs

Diastolic Heart Murmurs

In patients with AR, an early diastolic rumble may also be heard at

In addition to the above two murmurs, a systolic ejection murmur

Pulmonic regurgitation (PR)

As mitral stenosis worsens, le atrial pressure increases, forcing the

Summary of Diastolic Murmurs

Dynamic Auscultation of Heart Murmurs

Dynamic auscultation refers to using maneuvers to alter

The most important use of the Valsalva maneuver is to distinguish

The Valsalva maneuver is also performed during routine

Squatting from a Standing Position

This maneuver will decrease the murmur of HOCM, as the increased

This maneuver causes the click of MVP to move later in systole.

Standing from a Squatting Position

This maneuver causes the click of MVP to move earlier in systole.

This maneuver will decrease the murmur of HOCM, as the increased

This maneuver causes the click of MVP to move later in systole.

This maneuver will increase the intensity of le -sided regurgitant

Transient Arterial Occlusion

This maneuver is performed by placing a blood pressure cu on

This maneuver will increase the intensity of le -sided regurgitant

Amyl Nitrate Inhalation

When the a erload is decreased, there is less resistance to blood

Amyl nitrate can be given via inhalation to reduce a erload for

RELATED CONTENT: Heart Murmurs Quiz | Heart Sounds Topic

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