Gen Med: Heart Murmurs

The following article is specific to heart murmurs, for a basic template on the cardiac
examination, click here.
Every patient you will ever come across should at some point have their heart checked, so you
must know what the heart SHOULD sound like. To do this, there's nothing for it but to
EXAMINE EVERY PATIENT you can get your hands on - when you know whats normal, you
can determine what's abnormal.
Listen to the heart:
After you've checked the position of the apex beat, you should start your examination there...
The apex is also known as the MITRAL area. Then move to the lower left sternal edge
(TRICUSPID area), to the upper left sternal edge (PULMONARY area) and finally to the upper
right sternal edge (AORTIC area). A useful way to remember where each of these areas are is
to think about where the murmur would be best heard based on the DIRECTION the blood
flows through the valve. It would be good to sit down and work this out.
REMEMBER THIS MNEMONIC: MR AS's ARMS (pronounced mister asses arms)
1. MR/TR - Pan-systolic murmur, radiate to axilla
2. AS/PS - Ejection systolic murmur, AS: radiates to the carotids, PS: radiates to the back
3. AR/PR - Early diastolic murmur, radiate along the sternal edge
4. MS/TS - Mid-diastolic murmur
You should be able to decide what the murmur might be based on
1. Location - where is it? Apex (Mitral), LLSE (Tricuspid), ULSE (Pulmonary) or URSE (Aortic)
2. Timing of the murmur - time the murmur against the CAROTID pulse: is it systolic or
diastolic?
3. Where in the cycle does it come?/What does it sound like? I.e. is it pan systolic, ejection
systolic etc
4. What is the radiation of the murmur?
5. What other signs is the murmur associated with?

Aortic Sclerosis

Ejection systolic murmur heard loudest over R USE. Differential for aortic stenosis, but
aortic sclerosis should not radiate to the carotids.
Common in elderly patients, especially those who have hypertension and
cardiomegaly.
Due to calcification of the valve.

Risk factors for incident aortic valve calcification include older age, male gender, a
higher body mass index, smoking and the use of lipid-lowering and antihypertensive
medications
Severity of the murmur:
1. What is the grade of the murmur?

Systolic murmurs are graded from 1-6, diastolic from 1-4.

1 - Soft, barely audible murmur
2 - Soft but murmur detected immediately
3 - Clearly audible murmur, no thrill
4 - Murmur with a palpable thrill
5 - Murmur heard with stethoscope only partially touching chest
6 - Murmur heard without stethoscope on the chest

Markers of severe aortic stenosis

Triad of:
1. Chest pain
2. Syncope
3. Heart failure (Symptoms: shortness of breath, creps on auscultation, pulmonary
hypertension if severe)

Aortic regurgitation
Aortic regurgitation is characterised by a early diastolic murmur which is loudest over the right
upper sternal edge and radiates along the sternal edge. It may be associated with a collapsing
pulse, and several signs such as:
Corrigan's sign (prominent carotid artery pulsations)
Muller's sign (pulsations of the uvula)
Quinkes sign (pulsations of the capillary bed seen at the nails)
De-Musset's sign (bobbing of the head in time with pulsations)
Traube's sign (pistol shot sound heard over the femoral pulse)
Duroizez's sign (to and fro murmur heard over the femoral artery on slight compression)

A collapsing pulse may be due to:

Aortic regurgitation
PDA
Hyperdynamic states: pregnancy, thyrotoxicosis, anaemia, high fever
Aortopulmonary window

Ruptured aneurysm of the aortic sinus

References
http://www.uptodate.com/contents/aortic-valve-sclerosis?
source=search_result&search=aortic+sclerosis&selectedTitle=1%7E15#H9