It is the sound produced due to sliding (apposition) of the two inflamed layers (visceral and parietal

pericardium) of the pericardium.

Phases: It is triphasic

midsystolic,

mid-diastolic and

presystolic.

Character: It is scratchy, grating, leathery or creaking in character. Its intensity varies over time, and

with the position of the patient.

Best heard: With diaphragm of stethoscope on the left sternal border (3rd and 4th intercostal space)

leaning forward at the end of expiration. It may be audible over any part of the precordium but is often

localized. It can be better appreciated with patient in knee elbow position.

A pleuropericardial rub is a similar sound that occurs in time with the cardiac cycle but is also

influenced by respiration and is pleural in origin.

MURMURS

Sudden deceleration of blood produces heart sounds while heart murmurs are produced by turbulent

flow (Reynold’s number >2,000) across an abnormal valve, septal defect or outflow obstruction, or by

increased volume or velocity of flow through a normal valve.

Mechanism

Increased blood velocity

Decreased blood viscosity

Valve—narrowed or incompetent; organic or relative

Abnormal connection

Vibration of loose structure

Diameter of vessel increased or decreased.

Rushmer RF postulated 6 mechanism of production of murmurs:

Murmurs are described under the following headings:

Timing

Grade

Quality

Pitch

Configuration

Radiation/conduction

7.

8.

9.

10.

11.

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Best heard with diaphragm or bell

Patient position

With breath held in inspiration or expiration

Variation with other maneuvers

Location of maximum intensity

1. Timing (Fig. 4E.23)

Timing refers to the portion of the cardiac cycle that the murmur occupies. Murmurs may be systolic,

diastolic, or continuous.

Systolic murmurs may be:

Early systolic murmurs

Midsystolic murmurs

Late systolic murmurs

Pansystolic murmurs.

Systolic Murmurs

Murmur and description Example

Early systolic murmurs (begin with the first heart sound and extend to middle or late systole) VSD (small muscular

VSD/large VSD with

pulmonary hypertension

Acute severe MR

Acute severe TR

Midsystolic/ejection systolic murmurs (begin following a murmur-free interval in early systole

and end with a murmur-free interval (of variable duration) in late systole

Aortic stenosis

Pulmonary stenosis

HOCM

Late systolic murmurs (begin during the last half of systole and may or may not extend to the

second heart sound)

Mitral valve prolapse

Tricuspid valve prolapse

Papillary muscle dysfunction

Pansystolic murmurs (begin with the first heart sound and extend to or through entire systole, muffling S1. They are sometimes called Holosystolic murmur but in holosystolic murmur S1 is

distinct (e.g. VSD)

Mitral regurgitation

Tricuspid regurgitation

Ventricular septal defect

Rare—early PDA/PDA with

Eisenmenger

(HOCM: hypertrophic obstructive cardiomyopathy; MR: mitral regurgitation; PDA: patent ductus

arteriosus; TR: tricuspid regurgitation; VSD: ventricular septal defect)

Diastolic murmurs may be:

Early diastolic

Mid-diastolic

Late diastolic/presystolic

1.

2.

1.

2.

3.

4.

5.

a.

b.

6.

7.

8.

9.

1.

2.

3.

1.

2.

3.

4.

5.

6.

Fig. 4E.23: Timing of murmurs and examples.

Diastolic Murmur

Murmur Example

Early diastolic murmur Aortic regurgitation

Pulmonary regurgitation

Mid-diastolic murmur Mitral stenosis

Tricuspid stenosis

Carey Coombs murmur of acute rheumatic fever

Austin Flint murmur of chronic aortic regurgitation

Flow MDM murmur:

Across mitral valve: MR, AR, VSD, PDA

Across tricuspid valve: ASD, TR, TAPVC

Atrial myxoma

Ball valve thrombus

Cortriatriatum

Rytand’s murmur of complete heart block

Late diastolic murmurs/Presystolic murmur Mitral stenosis

Tricuspid stenosis

Myxoma

(AR: aortic regurgitation; MDM: mid-diastolic murmur; MR: mitral regurgitation; PDA: patent ductus

arteriosus; TAPVC: total anomalous pulmonary venous connection; TR: tricuspid regurgitation; VSD:

ventricular septal defect)

Continuous Murmurs

The continuous murmur is the murmur that begins in systole and continues without interruption,

encompassing the second sound, throughout diastole or part of diastole.

Continuous murmurs

A. Systemic to pulmonary communication

Patent ductus arteriosus

Aortopulmonary window

Anomalous origin of left coronary artery from pulmonary artery (ALCAPA)

Tricuspid atresia

Truncus arteriosus

Shunts for tetralogy of Fallot (TOF) surgery—Waterson, Potts, or Blalock-Taussig shunt

B. Systemic to right heart connection

1.

2.

1.

1.

2.

1.

2.

3.

1.

i.

ii.

2.

i.

ii.

iii.

iv.

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Coronary AV fistula

Rupture sinus of Valsalva

C. Left atrium to right atrium connection

Lutembacher syndrome

D. Arteriovenous fistula

Systemic

Pulmonary

E. Normal flow through constricted arteries

Coarctation of aorta

Peripheral pulmonary stenosis

Renal artery stenosis

F. Increased flow through normal vessels

Venous

Cervical venous hum

Cruveilhier–Baumgarten murmur

Arterial

Mammary soufflé

Uterine soufflé

Thyrotoxicosis

Tumors—hepatoma, hypernephroma

Differential Diagnosis of Continuous Murmur

Systolic-diastolic murmurs To and fro murmurs

Murmur in systolic and murmur in diastolic but S2 is heard distinctly. The two murmurs are separated by small silence

differentiating them from continuous murmurs.

Occurs through different orifices Occurs through same orifice

VSD with AR

MR with MS

AS with AR

Pulmonary hypertension with pulmonary regurgitation

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

ventricular septal defect)

2. Grading of Murmurs

Systolic Murmurs

Levine and Freeman grading of systolic murmurs

Grade Description Thrill

Grade 1 Murmur so faint that it can be heard only with special effort

Grade 2 Murmur is faint but is immediately audible Absent

Grade 3 Murmur that is moderately loud

Grade 4 Murmur that is very loud

Grade 5 A murmur that is extremely loud and is audible with one edge of the stethoscope touching the chest wall Present

Grade 6 A murmur that is so loud that it is audible with the stethoscope just removed from contact with the chest wall

Diastolic Murmurs (by AIIMS)

Grade Description Thrill

Grade 1 Very soft Absent

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