Grade 2 Soft

Grade 3 Loud

Grade 4 Very loud Present

3. Character/Quality

Quality refers to the tonal effect of the murmurs. Frequently used descriptors are blowing, musical,

squeaking, whooping, honking, harsh, rasping, grunting, and rumbling.

4. Frequency or Pitch

Relates to the velocity of the blood at the site of origin of the murmur and is designated as high, medium, or low. In general, the higher the velocity, the higher the pitch of the murmur.

Murmurs that emanate from areas of stenosis where velocity is lower are typically low to medium

pitched.

5. Configuration (Figs. 4E.24 to 4E.26):

Configuration of a murmur refers to its shape.

To a large degree it is a function of intensity and duration.

Crescendo murmurs progressively increase in intensity.

Decrescendo murmurs progressively decrease in intensity. With crescendo-decrescendo murmurs (diamond or kite-shaped murmurs), a progressive increase in

intensity is followed by a progressive decrease in intensity.

Plateau murmurs maintain a relatively constant intensity.

Fig. 4E.24: Configuration of systolic murmurs.

Fig. 4E.25: Configuration of diastolic murmurs.

Fig. 4E.26: Configuration of continuous and to-fro murmurs.

6. Radiation/Conduction (Fig. 4E.27)

Reflects the intensity of the murmur and the direction of blood flow.

Radiation Conduction

It is through noncardiac structures It is through anatomical continuity

Intensity decreases with distance Intensity remains same or decreases with

distance

Mitral regurgitation murmur (PSM) radiates to axilla. Tricuspid regurgitation

radiates to epigastrium

Aortic stenosis murmur (ESM) conducts to

the carotid

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Fig. 4E.27: Radiation of murmurs: (1) ESM of AS conducting to carotids; (2) EDM of AR in right 2nd

ICS radiating to left 3rd ICS; (3) PSM of TR radiating to upper left sternal border; (4) ESM of PS

conducting towards clavicle; (5) Murmur of PDA at infraclavicular area radiates to back; (6) PSM of MR

radiating to axilla or base of heart.

7. Best Heard with Bell or Diaphragm

Best heard with bell Best heard with diaphragm

MDM of MS and TS

(Other sounds: S3, S4, pericardial knock)

Systolic murmur of MR, TR, AS and diastolic murmur of AR

(Other sounds: S1, S2, ESC, OS)

(AR: aortic regurgitation; AS: aortic stenosis; MDM: mid-diastolic murmur; MR: mitral regurgitation; MS:

mitral stenosis; TR: tricuspid regurgitation; TS: tricuspid stenosis)

8. Variation with position

Left lateral recumbent position Sitting and leaning forward Lying flat or passive leg raising in supine position

Accentuates

Sounds:

S1

LVS3 and LVS4

OS of MS

Murmurs:

MS

MR

Click and murmur of MVP

Austin Flint murmur

Accentuates

Murmurs:

AR

PR

Accentuates

Sounds:

S3 and S4

Murmurs:

Valvular AS/PS

TR

Attenuates

EDM of AR

Murmur of HOCM

MVP murmur and click are delayed

(AR: aortic regurgitation; AS: aortic stenosis; EDM: early diastolic murmur; HOCM: hypertrophic

obstructive cardiomyopathy; MR: mitral regurgitation; MS: mitral stenosis; MVP: mitral valve prolapse;

OS: opening snap; TR: tricuspid regurgitation; TS: tricuspid stenosis)

9. Variation with Respiration

Breathing produces a greater effect on the right side of the heart than the left side.

RIght-sided murmurs increase on Inspiration LEft-sided murmurs increase on Expiration

Inspiration increases venous return to the right side of the heart

by increasing flow in the vena cava but decreases venous return

to the left side of the heart due to pooling of blood in pulmonary

venous capacitance vessels

Expiration decreases venous return to the right side of the

heart by reducing vena cava flow, but increases venous

return to the left side of the heart due to collapse of

pulmonary venous capacitance vessels

TS

TR (Carvallo’s sign*)

PR

Mild or moderate PS

MS

MR

AS

AR

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Severe PS VSD

Pericardial rub

(AR: aortic regurgitation; AS: aortic stenosis; MR: mitral regurgitation; MS: mitral stenosis; PS:

pulmonary stenosis; TR: tricuspid regurgitation; TS: tricuspid stenosis; VSD: ventricular septal defect)

Note:

Carvallo’s sign*—when the murmur of tricuspid valve regurgitation gets louder with deep inspiration.

The effects of inspiration on systolic murmurs can be accentuated by employing Muller’s maneuver

(forced inspiration on a closed glottis).

10. Variation with Other Maneuvers

The physiologic maneuvers are breathing, standing, sudden squatting, isometric hand grip exercise,

Valsalva maneuver (described at the end), passive leg raising, and attention to the beat following a

post-extrasystolic pause.

The pharmacological interventions used most commonly in clinical practice are amyl nitrite

administration and intravenous infusion of alpha-adrenergic agonists (phenylephrine or

methoxamine).

Valvular disease Accentuated by Attenuated by

MS Expiration

Exercise, squatting, amyl nitrate, isometric hand grip

Inspiration, sudden standing

MR Expiration

Squatting

Isometric exercise

Sudden standing

Valsalva

Amyl nitrate

AS Expiration

Post-PVC beat

Squatting

Lying flat from standing

Valsalva

Standing

Handgrip

AR Expiration

Sitting up and leaning forward

Squatting

Isometric exercise

Vasopressors

Amyl nitrate

Valsalva

MVP Murmur and click later

If LV volume increases

Squatting

Postectopic

Isometric exercise (intensity increases)

Murmur and click earlier if LV volume decreases

Standing

Valsalva

HOCM Expiration

Valsalva strain

Standing

Postectopic

Amyl nitrate

Inspiration

Sustained handgrip

Squatting

Methoxamine

(AR: aortic regurgitation; AS: aortic stenosis; HOCM: hypertrophic obstructive cardiomyopathy; LV: left

ventricular; MVP: mitral valve prolapse; PVC: premature ventricular contraction; MR: mitral regurgitation;

MS: mitral stenosis)

11. Location of Maximum Intensity of Murmur

Location refers to the point on the precordium where the murmur is heard with maximum intensity.

Many systolic murmurs are audible over multiple areas of the precordium. Localizing their point of

maximum intensity may aid greatly in determining their site of evolution.

Example:

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In aortic stenosis/aortic sclerosis—gallavardin phenomenon seen. Two distinct systolic murmurs are

heard; one high pitched murmur in the aortic area and the other musical systolic murmur in the mitral

area. This is due to periodic wake phenomenon or the Hour-glass murmur.

Examples for How to Describe a Murmur

The murmur of mitral stenosis is a mid-diastolic low-pitched rough rumbling murmur with presystolic accentuation best audible

at the apex (mitral area), in the left lateral position with the bell of the stethoscope, breath held in expiration. The murmur

increases on isometric hand grip.

The murmur of aortic regurgitation is a soft, high-pitched, early diastolic, decrescendo murmur usually heard best at the third

intercostal space on the left (Erb’s point) with the diaphragm of the stethoscope at end expiration with the patient sitting up and

leaning forward.

Innocent Murmurs

Innocent murmurs are those those murmurs which are not due to recognizable lesions of the heart or

blood vessels. They are most common in children and adolescents.

The Seven S’s of innocent murmurs

Examples of Innocent Murmurs

Systolic Vibratory systolic murmur (Still’s murmur)

Pulmonic systolic murmur (pulmonary trunk)

Mammary soufflé

Peripheral pulmonic systolic murmur (pulmonary branches)

Supraclavicular or brachiocephalic systolic murmur

Aortic systolic murmur

Diastolic All diastolic murmurs are pathological (not innocent)

Continuous Venous hum

Continuous mammary soufflé

Named murmurs

Carey Coombs murmur

Mid-diastolic murmur, in rheumatic fever

Austin Flint murmur Mid-late diastolic murmur, in aortic regurgitation (AR)

Graham-Steel murmur High pitched, diastolic, in pulmonary regurgitation

Rytand’s murmur Mid-diastolic atypical murmur, in complete heart block

Docks murmur Diastolic murmur, left anterior descending (LAD) artery stenosis

Mill wheel murmur Due to air in right ventricle (RV) cavity following cardiac catheterization

Stills murmur Inferior aspect of lower left sternal border, systolic ejection sound, vibratory/musical quality in subaortic

stenosis, small ventricular septal defect

Gibson’s murmur Continuous machinery murmur of patent ductus arteriosus (PDA)

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Key–Hodgkin murmur Diastolic murmur of aortic regurgitation. Hodgkin correlated this diastolic murmur with retroversion of

the aortic valve leaflets, seen in syphilitic aortic regurgitation

Cabot–Locke murmur Diastolic murmur heard best at the left sternal border. heard in anemic patients. The murmur resolves

with treatment of anemia

Roger’s murmur It is the loud pansystolic murmur which is heard maximally at the left sternal border in small ventricular

septal defect (VSD).

Pontains murmur Cervical venous hum in severe anemia

Cole-Cecil murmur AR murmur in left axilla due to higher position of apex

CruveilhierBaumgarten venous

hum

It is diagnostic of portal venous hypertension

Auscultation for Mitral Stenosis (Fig. 4E.28)

Patient in left lateral position

Breath held in expiration

Using bell of stethoscope

Time the murmur with carotid.

Auscultation of Tricuspid Area (Fig. 4E.29)

Patient in supine position

Breath held in inspiration

Using diaphragm of stethoscope

Murmur increases on hepatic compression or passive leg raise.

Fig. 4E.28: Auscultation of mitral area—mid-diastolic murmur of mitral stenosis.

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Fig. 4E.29: Auscultation of tricuspid regurgitation.

Auscultation of Aortic Area (Fig. 4E.30)

Patient in sitting up and leaning forward position

Breath held in expiration

Using diaphragm of stethoscope

Time the murmur with carotid.

Fig. 4E.30: Auscultation of aortic area (Erb’s maneuver).

Changing murmurs

Murmurs which change in character or intensity from moment to moment:

Carey Coombs murmur

Infective endocarditis

Atrial thrombus

Atrial myxomas

OTHER SYSTEM EXAMINATION

Respiratory system Hoarseness of voice (enlarged left atrium—Ortner’s syndrome)

Hemoptysis

Left lower lobe collapse or consolidation (pericardial effusion)

Basal crepitations [left ventricular failure (LVF)]

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