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Dr. Almumtan, Ahmed Tahir Medical Intern Department of Cardiology King Fahad Specialised hospital Jordan University of Science and technology
The bell is used to hear low pitched sounds and the diaphragm is used to hear high pitched sounds.
Murmurs
How to describe a murmur?
Timing
Intensity
Shape Pitch
Location
Radiation Dynamic Auscultation (changes with maneuvers)
Murmurs
Describing murmurs - Timing
Murmurs may occur in systole, diastole, or may be continuous.
Systolic murmurs Aortic stenosis (AS) Pulmonic stenosis (PS) Mitral regurgitation (MR) Tricuspid regurgitation (TR) Mitral valve prolapse (MVP) Atrial septal defect (ASD) Ventricular septal defect (VSD)
Diastolic murmurs Aortic regurgitation (AR) Pulmonic regurgitation (PR) Mitral stenosis (MS) Tricuspid stenosis (TS) Continuous murmurs Patent ductus arteriosus Combination murmurs
Murmurs
Describing murmurs - Timing
Systolic murmurs occur between S1 and S2
Murmurs
Describing murmurs Intensity
Systolic murmur intensity is graded on a scale of 6.
Grade VI/VI
Murmurs
Describing murmurs Intensity
Diastolic murmur intensity is graded out of 4, a mistake made by many people (they often use the systolic scale).
Diastolic murmur grading
Murmurs
Describing murmurs - Shape
Murmurs can be described as creshendo, decreshendo, creshendodecreshendo, or uniform (holosystolic). Murmurs are also classified as either a systolic ejection murmurs (SEM) or holosystolic. SEMs include creshendo and creshendodecreshendo murmurs. A SEM does not overwhelm the S1 and S2 heart sounds while a holosystolic murmur does.
Murmurs
Describing murmurs - Pitch
Murmurs are classified as either high or low pitched.
High pitched murmurs result when there is a large difference in pressures on either side of the anomaly causing the murmur.
For example, the murmur of AS is high pitched since pressure gradients between the LV and aorta are large in this setting. On the other hand, the murmur of MS is low pitched since pressure gradients between the LA and LV are relatively small. Remember, high pitched sounds are heard with the diaphragm and low pitched sounds are heard with the bell!
Murmurs - Location
Describing murmurs - Location
The location that the murmur is best heard is crucial to determining its etiology. Aortic murmurs are heard at the aortic listening post, pulmonic murmurs are heard best at the pulmonic listening post etc
Murmurs
Describing murmurs - Radiation
Certain murmurs radiate to listening posts and other areas far away from which the murmur originates. For example, on occasion, the murmur of AS can radiate to the apex, although the aortic listening post is at the base. Also, the murmur of AS radiates to the carotid arteries and is sometimes mistaken for a carotid bruit. Other murmurs, such as mitral regurgitation, radiate to the axillary region.
Some non-physical maneuvers are also sometimes used. These include inhaling amyl nitrate or simply listening to the effect that a PVC (premature ventricular contraction) has on a murmur.
Effect of maneuver
Multiple effects, but most importantly a decrease in venous return to RV and LV, decreased afterload. Inspiration increases venous return to RV and decreases LV filling, expiration does opposite Increases afterload and venous return to RV and LV Decreases venous return to RV and LV Post PVC pause or pauses in afib result in increased LV filling due to increased time of diastole. Increases afterload Reduces afterload (arterial vasodilator)
afib = atrial fibrillation PVC = premature ventricular contraction
List of Murmurs
Basic murmurs Systolic
Systolic ejection murmurs - Aortic stenosis - Pulmonic stenosis - HOCM Pansystolic murmurs - Mitral/tricuspid regurgitation - Ventricular septal defect Late systolic murmur - Mitral valve prolapse
Diastolic
Early diastolic murmurs - Aortic regurgitation - Pulmonic regurgitation Mid/late diastolic murmur - Mitral stenosis - Tricuspid stenosis Other murmurs - ASD, VSD, PDA, other rare murmurs
Since the intensity of the murmur is loud immediately after the onset of S1 and extends to just before the S2, often the S1 and S2 sounds is overwhelmed by the murmur and are completely inaudible.
A ventricular septal defect (VSD) is a congenital hole in the part of the heart that separates the LV from the RV.
Blood abnormally flows from the LV (high pressure) to the RV (low pressure) creating turbulent blood flow and a holosystolic murmur heard best at Erbs point.
The murmur is a systolic ejection murmur (SEM) located at the pulmonic listening post without radiation.
Remember that an ASD is almost always associated with a fixed split S2.
Sudden squatting from a standing position will increase venous return to the heart and thus increase LV volume. This moves the click later in systole.
Dynamic auscultation
MR/VSD
Valsalva Inspiration Squat
AS
HOCM
MVP
TR/PR -
Standing
Post PVC/afib
Handgrip
Amyl nitrite