Heart Murmurs

By Steven Lome
Describing Murmurs

- Systolic Murmurs - Diastolic Murmurs - Dynamic Auscultation - Multiple Choice Questions

Disease of the cardiac valves and other cardiac structures frequently result 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 will be discussed below. 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, while inside the heart it is called a murmur. A pictorial representation of systolic
and diastolic murmurs are below:

There are four major causes of cardiac murmurs.

First, if blood is forced through a tight area, turbulent blood flow ensues. This is the case
in valvular stenosis. As a general rule, 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.
A second cause of a murmur is valvular insufficiency in which blood abnormally travels
backward through an incompetent valve causing turbulence when it meets normal,
forward blood flow.
If blood is forced through a congenital anomaly from one chamber to another, as in an
atrial septal defect (ASD) or ventricular septal defect (VSD), a murmur is produced again
due to turbulence.
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 amount of
volume is passing 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.
This 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, a clinician

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 while 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 differential 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 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. A complete discussion of valvular heart disease is found elsewhere.

Once it is determined if the murmur is systolic or diastolic, the timing of the murmur
within systole or diastole also becomes important when characterizing murmur. Systolic
murmurs can be classified as either midsystolic (a.k.a. systolic ejection murmurs or
SEM), holosystolic (pansystolic), or late systolic. A midsystolic murmur begins just after

the S1 heart sound and terminates just before the P2 heart sound, so S1 and S2 will be
distinctly audible. Conversely, a holosystolic murmur begins with or immediately after the
S1 heart sound and extends up to the S2 making them difficult, if not impossible to hear.
A mid-late systolic murmur begins significantly after 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, however 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 with 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 morbidly obese person or a person with severe 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 since there is usually a large pressure gradient between the LV
and the aorta. Conversely, the murmur of mitral stenosis is low pitched since there is a
lower pressure gradient between the LA and the LV during diastole. Remember high
pitched sounds are heard with the diaphragm of the stethoscope while low pitched
sounds are heard with the bell.

Location
The anatomic location that the murmur is best heard is an important factor in
determining the etiology of the lesion. There are four main "listening posts" on the chest
(see picture below).
A = aortic valve post (right upper sternal border or RUSB)
P = pulmonic valve post (left upper sternal border or LUSB)
T = tricuspid valve post (left lower sternal border or LLSB)
M = mitral valve post (apex)
E = "Erb's point"
Note: 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 whichever listening post 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, however it may
radiate to the apex. This radiation of the AS murmur is called the "Gallavardin
dissociation".

Radiation
While murmurs are usually most intense at one specific listening post, they often 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 left axillary region. It is often difficult to distinguish if one murmur is radiating to
multiple sites or if there are multiple murmurs present from many different causes.
Dynamic auscultation and echocardiography is helpful in determining the exact lesion
present.

Systolic Heart Murmurs

Midsystolic murmurs
Midsystolic murmurs (a.k.a systolic ejection murmurs or SEM) include the murmurs of
aortic stenosis (AS), pulmonic stenosis (PS), hypertrophic obstructive cardiomyopathy
(HOCM) and atrial septal defects (ASD). A midsystolic murmur begins just after the S1
heart sound and terminates just before the P2 heart sound, so S1 and S2 will be
distinctly audible. The term midsystolic is preferred to SEM since 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 aortic stenosis murmur is often mistaken for a carotid bruit. The
aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion,

making it difficult to distinguish if mitral regurgitation is also present. This radiation of the
aortic stenosis murmur to the apex is known as "Gallavardin dissociation". It requires
dynamic auscultation or echocardiography to determine if coexisting mitral regurgitation
is the cause of the apical murmur in a patient with aortic stenosis.
The intensity of the murmur of aortic stenosis is not a good indicator as to the severity of
disease. As aortic stenosis worsens, the LV begins to fail and the ejection fraction
declines to the point where sufficient 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 the severity of
aortic stenosis, 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 crescendodecrescendo murmur moves to later in systole. Thus mild aortic stenosis would have an
early peaking murmur while the murmur of severe aortic stenosis peaks later in systole.
Remember from the heart sounds section 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, the murmur of pulmonic stenosis demonstrates increased intensity during
inspiration due to the increased venous return to the right heart resulting in greater flow
across the pulmonic valve.

While the murmur of aortic stenosis extends up to the A2 heart sound, the murmur of
pulmonic stenosis extends through the A2 sound up to the P2 heart sound. Severe
pulmonic stenosis results in decreased mobility of the pulmonic valve leaflets and thus a

softer P2 sound. Also, as the pulmonic stenosis worsens, the closure of the pulmonic
valve is delayed, since more time is required to eject blood through the stenotic valve,
resulting in a widely split S2 heart sound that still exhibits inspiratory delay. Note that the
murmur of an atrial septal defect (see 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, thus it is remarkably similar to that of pulmonic stenosis. The difference
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 in fixed-split in a person with an ASD. This differs from the widened split S2 seen
in severe pulmonic stenosis. 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 review). The murmur
is high-pitched, crescendo-decrescendo, mid systolic murmur heard best at the left lower
sternal border. The murmur of HOCM does not radiate to the carotids like that of AS. The
important auscultory features of HOCM that distinguish it from AS relate to dynamic
auscultation (see below).

Holosystolic Murmurs
Holotsystolic murmurs are also known as pansystolic and include the murmurs of mitral
regurgitation (MR), tricuspid regurgitation (TR), and ventricular septal defects (VSD).
Since the intensity of these murmurs is high immediately after the onset of S1 and it
extends to just before the S2, often the S1 and S2 sounds are overwhelmed by the
murmur and may be difficult to hear.

Mitral regurgitation (MR)

The murmur of mitral regurgitation is described as a high-pitched, "blowing" holosystolic
murmur best heard at the apex. The direction of radiation of the murmur depends on the
nature of the mitral valve disease, however 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 mitral regurgitation. It is a high
pitched, holosystolic murmur however it is best heard at the left lower sternal border and
it radiates to the right lower sternal border. The intensity significantly increases with
inspiration helping to distinguish it from mitral regurgitation. This inspiratory
enhancement of the tricuspid regurgitation 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) creating turbulent blood flow
and a holosystolic murmur heard best at "Erb's point". The smaller the ventricular septal
defect, 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 mid-systolic click usually followed by a uniform, highpitched murmur. The murmur is actually due to mitral regurgitation 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-late diastolic). Tricuspid stenosis is very rare and is discussed
further in the valvular heart disease section.

Aortic regurgitation (AR)

The murmur of aortic regurgitation is a soft, high-pitched, early diastolic decrescendo
murmur usually heard best at the 3rd intercostal space on the left (Erb's point) at end
expiration with the patient sitting up and leaning forward. If the aortic regurgitation is due
to aortic root disease, the murmur will be best heard at the right upper sternal border and
not at Erb's point. As aortic regurgitation worsens in severity, the pressure between the
left ventricle and the aorta equalize much faster, thus the murmur becomes significantly
shorter.

In people with aortic regurgitation, an early diastolic rumble may also be heard at the
apex due to the regurgitant jet striking the anterior leaflet of the mitral valve 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
people 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 often indistinguishable from that of
aortic regurgitation. Pulmonic regurgitation produces a soft, high-pitched, early diastolic
decrescendo murmur heard best at the pulmonic listening post (LUSB). The murmur of
pulmonic regurgitation increases in intensity during inspiration, unlike that of aortic
regurgitation. The murmur of pulmonic regurgitation is classically referred to as the
"Graham-Steell murmur" after it's initial describers.

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 left atrial pressures, which is immediately followed by a decrescendo murmur as
blood flows passively from the left atrium to the left ventricle through the stenosed mitral
valve creating turbulence. Immediately before the S1 sound, active left ventricular filling
occurs when the left atrium contracts and forces more blood through the stenosed mitral
valve creating a late diastolic crescendo murmur. In the presence of atrial fibrillation, the
active left ventricular filling phase does not take place and the latter part of the mitral
stenosis murmur disappears.
As mitral stenosis worsens, left 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 is continuous throughout systole and diastole.
Often the S2 heart sound is difficult to detect. The murmur begins just after S1 and
crescendos peaking at S2, the 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 like they are going to have a bowel movement and exhaling forcefully with the

airway closed. The hemodynamic changes that occur are complex, however the ultimate
result is a decrease in left ventricular preload.
The most important use of the Valsalva maneuver is to distinguish the murmur of aortic
stenosis from hypertrophic obstructive cardiomyopathy (HOCM) or simply to bring for the
murmur of HOCM. Aortic stenosis will soften or not change while the murmur of HOCM
becomes quite loud with Valsalva.

The Valsalva maneuver is also performed during routine echocardiographic

examinations to see if patients with grade II or worse diastolic function can decrease
their left ventricular filling pressures adequately. If the Valsalva maneuver fails to reduce
the left ventricular pressure in the setting of diastolic heart failure, then grade IV diastolic
dysfunction is said to be present which indicates 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 left
ventricular filling.
This maneuver will decrease the murmur of hypertrophic obstructive cardiomyopathy
has the increased left ventricular volume helps displace the hypertrophied
interventricular septum causing less outflow tract obstruction.
This maneuver causes the click of mitral valve prolapse 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 decreasing left ventricular preload similar to that seen with the Valsalva maneuver.
This maneuver will increase the murmur of hypertrophic obstructive cardiomyopathy and
decrease that of aortic stenosis.
This maneuver causes the click of mitral valve prolapse to move earlier in systole.
Leg raising: Passive leg raising is permed 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
increase left ventricular filling and preload similar to squatting from a standing position.
This maneuver will decrease the murmur of hypertrophic obstructive cardiomyopathy
has the increased left ventricular volume helps displace the hypertrophied
interventricular septum causing less outflow tract obstruction.
This maneuver causes the click of mitral valve prolapse to move later in systole.
Handgrip exercise: Isometric handgrip exercises are performed by having a patient
squeeze hart repetitively. This results in increased blood pressure (similar to exercise)
and thus increased afterload. Elderly individuals may have a hard time with this
maneuver and thus transient arterial occlusion can be used instead.
This maneuver will increase the intensity of left-sided regurgitant murmurs including
mitral regurgitation and aortic regurgitation. Handgrip exercises will have no effect on the
murmur of aortic stenosis which helps distinguish the presence of coexistent mitral
regurgitation from that of the Galliveridin phenomenon.
Transient arterial occlusion: This maneuver is performed by placing a blood pressure
cuff on both arms and inflating it to 20 to 40 mmHg above the systolic blood pressure for
20 seconds. This results effectively in increased afterload.
This maneuver will increase the intensity of left-sided regurgitant murmurs including
mitral regurgitation and aortic regurgitation and is especially useful in elderly individuals
who are not able to perform adequate handgrip exercises.

Amyl nitrate inhalation: Amyl nitrate decreases left ventricular afterload by dilating the
peripheral arteries. and would decrease the murmur of mitral regurgitation.
When the afterload is decreased, there is less resistance to blood flow from the left
ventricle through the aortic valve and thus less blood regurgitates through the mitral
valve, decreasing the intensity of the murmur.
Amyl nitrate can be given via inhalation to reduce afterload for diagnostic purposes in
the cardiac catheterization laboratory (to invoke a LV outflow tract gradient in
hypertrophic obstructive cardiomyopathy patients) 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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