Heart Murmurs

Dr. Almumtan, Ahmed Tahir Medical Intern Department of Cardiology King Fahad Specialised hospital Jordan University of Science and technology

What are heart murmurs?

A heart murmur is an audible sound within the heart due to turbulent blood flow across a valve. Murmurs can occur in systole or diastole. If a murmur-like sound occurs outside of the heart (peripherally), it is called a bruit. In general, murmurs occur due to valve stenosis, valve regurgitation, or congenital cardiac defects.

How to listen to the heart

A = aortic listening post

P = pulmonic listening post

T = tricuspid listening post

M = mitral listening post E = Erbs point

The stethoscope basics

The stethoscope
Every stethoscope has a bell and a diaphragm.

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

Diastolic murmurs occur between S2 and S1

Remember can you tell S1 and S2 apart?

Murmurs
Describing murmurs Intensity
Systolic murmur intensity is graded on a scale of 6.

Systolic murmur grading

Grade Grade Grade Grade Grade I/VI II/VI III/VI IV/VI V/VI Barely audible Audible, but soft Easily audible Easily audible and associated with a thrill Easily audible with a thrill and heard with the stethoscope lightly on the chest Easily audible with a thrill and heard with the stethoscope off of the chest

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

Grade Grade Grade Grade

I/IV II/IV III/IV IV/IV

Barely audible Audible, but soft Easily audible Loud

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.

Murmurs Dynamic auscultation

Describing murmurs Dynamic auscultation
Many physical maneuvers exists to alter the hemodynamics within the heart and circulation. These maneuvers have specific effects on specific murmurs and are frequently used to help determine the etiology of the murmur.

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.

Murmurs Dynamic auscultation

Maneuver
Valsalva__________ _ Respiration ________ Squat/Leg raise Standing Post PVC/afib ______ Handgrip/TAO Amyl nitrite
TAO = transient arterial occlusion

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

The murmur of aortic stenosis

Basic murmurs aortic stenosis (AS)
The murmur of AS is a systolic, creshendo-decreshendo, high pitched murmur located at the aortic listening post (right upper sternal border or RUSB), and it radiates to the carotid arteries. Depending on the severity of AS, the murmur may change. As AS worsens, the murmur peaks later in systole. Also, in severe AS, the closing of the aortic valve is delayed, often resulting in a paradoxical split S2 heart sound (if the S2 is audible).

The murmur of aortic stenosis

Basic murmurs aortic stenosis (AS)
When AS worsens, the intensity of the A2 (and thus S2) heart sound decreases. In severe AS, the S2 heart sound is almost absent!

The murmur of aortic stenosis

Basic murmurs aortic stenosis (AS)
Note: The murmur of AS often also radiates to the apex of the heart (the mitral listening post) where it may actually sound holosystolic! As you can imagine, this makes it difficult to tell if there is coexistent AS and MR, or simply radiation of the AS to the apex. Dynamic auscultation is used to determine which valvular lesion is present (see later section). This phenomenon of AS radiating to the apex confusing the examiner is called the Gallavaradin effect.

The murmur of pulmonic stenosis

Basic murmurs pulmonic stenosis (PS)
The murmur of PS is similar to that of AS, however since the A2 usually comes before P2, the murmur of PS extends through the A2 sound making it difficult (mild PS) or impossible (severe PS) to hear. The murmur of PS is best heard at the pulmonic listening post (left upper sternal border or LUSB) and does not radiate to the carotids. The PS murmur may, however, radiate to the left shoulder and supraclavicular region.

The murmur of pulmonic stenosis

Basic murmurs pulmonic stenosis (PS)
As a general rule, all right sided heart murmurs will increase in intensity with inspiration due to the increase in venous return, although this change is most pronounced in tricuspid regurgitation (TR) and minimal in PS. As PS worsens, the time that it takes for RV ejection increases, thus delaying the closure of the pulmonic valve. This results in a delayed P2 and thus a widened split S2. As PS worsens, the mobility of the pulmonic valve leaflets decreases. This diminishes the intensity of the P2 sound.

The murmur of pulmonic stenosis

Basic murmurs pulmonic stenosis (PS)
Pulmonic stenosis is much less common than aortic stenosis (except in pediatrics).

The murmurs of AS and PS

Note: AS is much more common than PS!

The murmur of mitral regurgitation

Basic murmurs mitral regurgitation (MR)
The murmur of MR is a holosystolic, uniform, high pitched murmur heard best at the mitral listening post (apex) radiating to the axilla. The intensity of the murmur does not change with respiration (helps to distinguish from TR).

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.

The murmur of mitral regurgitation

Basic murmurs mitral regurgitation (MR)
Remember there are three different holosystolic murmurs which may be difficult to distinguish: MR, TR, and VSD.

The murmur of tricuspid regurgitation

Basic murmurs tricuspid regurgitation (TR)
The murmur of TR is holosystolic in indistinguishable from the murmur of MR, except TR radiates to the right lower sternal border (not the left axilla), and the murmur of TR increases with inspiration (Carvallos sign).

The murmur of a VSD

Basic murmurs VSD

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 of a ASD

Basic murmurs ASD
An atrial septal defect (ASD) is a congenital hole in the part of the heart that separates the LA from the RA. Blood abnormally flows from the LA (high pressure) to the RA (low pressure) creating turbulent flow and a typical flow murmur across the pulmonic valve.

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.

The murmur of a ASD

Basic murmurs ASD
During inspiration there is increased venous return to the right side of the heart leading to increased pulmonic valve flow and thus delay in the closure of pulmonic valve (P2). During expiration there is less venous return to the right heart decreasing right sided pressures thus allowing more blood to flow through the ASD resulting in increased flow through the pulmonic valve and again a delayed P2. So the P2 is always delayed resulting in a fixed split S2!

The murmur of a ASD

Basic murmurs ASD
Note the fixed split S2 and note that the murmur extends through to the P2 heart sound.

The murmur of a PDA

Basic murmurs PDA
A patent ductus arteriosus (PDA) refers to a persistent communication between the pulmonary artery and the aorta which normally closes shortly after birth. Since the aortic pressure always exceeds the pulmonic artery (PA) pressure, blood is always moving from the aorta to the pulmonary artery (during both systole and diastole) creating turbulent blood flow and thus a continuous murmur.

The murmur of a PDA

The murmur of a PDA

Basic murmurs PDA
This continuous murmur is often referred to as a machinery murmur or Gibsons murmur. The murmur peaks at the S2 heart sound (which is often heard to hear) and is creshendo-decreshendo in shape.

The murmur of mitral valve prolapse

Basic murmurs mitral valve prolapse (MVP)
The murmur of MVP does not start until mid-systole and occurs due to mitral valve regurgitation after the abnormal valve prolapses into the LA. The sudden tensing of the valve and the chordae tendineae causes a click to occur just before the murmur.

The murmur of mitral valve prolapse

Basic murmurs mitral valve prolapse (MVP)
The timing of the click heard in MVP can be altered using dynamic auscultative maneuvers. Sudden standing from a squatting position will decrease venous return to the heart and thus decrease LV volume. This moves the click earlier in systole.

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.

The murmur of mitral valve prolapse

Basic murmurs mitral valve prolapse (MVP)
Extreme increases in LV volume can actually eliminate the click and the murmur of MVP. Conversely, extreme decreases in LV volume can cause MVP to sound holosystolic! So these maneuvers can be helpful to distinguish MVP from pure MR.

The murmur of aortic regurgitation

Basic murmurs aortic regurgitation (AR)
The murmur of AR is a high pitched, early diastolic murmur usually heard best NOT at the aortic listening post, but at the left lower sternal border. If the AR is due to aortic root disease (see valvular heart disease section), then the murmur may be heart at the aortic listening post. This murmur is heard best at end-expiration with the patient sitting up and leaning forward.

The murmur of aortic regurgitation

Basic murmurs aortic regurgitation (AR)
AR is often associated with a separate murmur termed the Austin-Flint murmur. This occurs when the regurgitent jet from the aortic valve strikes the anterior leaflet of the mitral valve causing it to vibrate. Often, a systolic flow murmur is also heard since there is a large amount of forward flow through the aortic valve in the setting of severe AR.

The murmur of aortic regurgitation

Basic murmurs aortic regurgitation (AR)
As the AR worsens, it takes less time for the aortic pressure and the LV pressure to equalize, thus the murmur shortens.

The murmur of pulmonary regurgitation

Basic murmurs pulmonary regurgitation (PR)
The murmur of PR is exactly the same as the murmur of AR, except it is heard best at the pulmonic listening post and the intensity may increase with inspiration. This murmur is called the Graham-Steell murmur.

The murmur of mitral stenosis

Basic murmurs mitral stenosis (MS)
The murmur of MS is a low pitched, uniquely shaped diastolic murmur heard best at the mitral listening post and often times associated with an opening snap.

The murmur of HOCM

Basic murmurs HOCM
The murmur of Hypertrophic Obstructive Cardiomyopathy (a.k.a. IHSS) is similar to that of AS. It is a high-pitched creshendo-decreshendo systolic ejection murmur heard best at the left lower sternal border. The murmur of HOCM does not radiate to the carotid arteries, unlike AS. The S2 heart sound is clearly audible, unlike severe AS. Like AS, paradoxical splitting of the S2 heart sound may be present.

The murmur of HOCM

The murmur of HOCM

Basic murmurs HOCM
Maneuvers are crucial to distinguish HOCM from AS. Any maneuver that decreases LV volume will worsen the obstruction thus increasing the murmur. The opposite is also true. The Valsalva maneuver decreases LV volume which increases the murmur of HOCM while decreasing that of AS. Standing from a squatting position would do the same. Squatting from a standing position increases LV volume thus relieving the obstruction and decreasing the murmur of HOCM, however the murmur of AS increases since more blood must be forced through the stenotic aortic valve.

The murmur of HOCM

Basic murmurs Comparing AS and HOCM

Summary Systolic murmurs

Summary Diastolic murmurs

Dynamic auscultation
MR/VSD
Valsalva Inspiration Squat

AS

HOCM

MVP

TR/PR -

Standing
Post PVC/afib

Handgrip
Amyl nitrite