The Heart Murmurs section is part of the Cardiology section which provides High Yield information for the USMLE, COMLEX, Medical School, Residency, and as practicing Physicians. Prepare and Learn Ahead! Educating, Preparing, and Proving high-yield content, quizzes, and medical resources. to students who are interested in the medical field.
Systolic Murmurs
- Aortic Stenosis
- Pulmonic Stenosis
- Mitral Regurgitation/Insufficiency
- Tricuspid Regurgitation/Insufficiency
- MVP (click not murmur)
- VSD
- ASD
- PDA (continuous)
Other
Murmurs
Heart Murmur Grades
| Grade | Definition |
|---|---|
| Grade I | Barely audible |
| Grade II | Faint-medium intensity |
| Grade III | Easily heard no thrill |
| Grade IV | Easily heard, +/- thrill |
| Grade V | Very easily heard, but still requires a stethoscope |
| Grade VI | Audible w/out stethoscope |
Murmur Location on Auscultation
| Right ICS Location | Left ICS Location |
|---|---|
| 2nd Right ICS Sternal Border (Aortic Area) | 2nd Left ICS Sternal Border (Pulmonic Area) |
| Systolic Murmur: Aortic Stenosis Flow Murmur | Systolic Ejection Murmur: Pulmonic Stenosis Atrial Septal Defect (ASD) Flow Murmur |
| 3rd Left ICS Sternal Border | |
| Diastolic Murmur: Aortic Regurgitation Pulmonic Regurgitation Systolic Murmur: Hypertrophic Cardiomyopathy | |
| 5th Left ICS Sternal Border (Tricuspid Area) | |
| Holosystolic Murmur: Tricuspid Regurgitation Ventricular Septal Defect (VSD) Diastolic Murmur: Tricuspid Stenosis | |
| 5th Left Mid Clavicular Line (Mitral Area – Apex) | |
| Holosytolic Murmur: Mitral Regurgitation Systolic Murmur: Mitral Valve Prolapse Diastolic Murmur: Mitral Stenosis |
Systolic Murmurs
Aortic Stenosis
Presentation
- Elderly
- Atherosclerotic disease
- Chest pain
- CHF
- Syncope
- Bicuspid
Type/Etiology
- Mid-systolic murmur
- Caused by Ca2+ deposition
Physical Exam
- Murmur heard best at the 2nd right ICS, which radiates to the neck and left sternal border.
- Harsh, crescendo-decrescendo
Diagnosis
- Better with:
Valsalva maneuver
(decreased venous return) - Worse with:
Squatting
Leg lift
(increased venous return) - TEE (Echo)
- Heart Cath
Treatment
- Asymptomatic:
- Drugs that maintain preload
- Symptomatic:
- Replace Valve (TAVR)
Pulmonic Stenosis
Presentation
- Newborn/Infants
- Cyanosis
- Fatigue
- Poor Weight Gain
- Failure to Thrive
- Hepatomegaly
- Edema
Type/Etiology
- Systolic crescendo decrescendo murmur
- Congenital
Physical Exam
- Murmur heard best at the 2nd- 3rd left ICS, radiating to the left shoulder or neck
Diagnosis
- TEE (Echo)
Treatment
- Balloon valvuloplasty
Atrial Septal Defect
Presentation
- Newborn & Infants
- SOB
- Fatigue
- Edema
Type/Etiology
- Systolic ejection murmur
Physical Exam
- Murmur heard best at the 2nd left ICS with an early to mid-systolic rumble
- Crescendo-Decrescendo
Diagnosis
- TEE (Echo)
Treatment
- Minor: Furosemide (Decreases blood volume)
- Large: Open Surgical Repair or Percutaneous Repair
Hypertrophic Obstructive Cardiomyopathy (HOCM)
Presentation
- Young Athletes
- SOB
- Chest Pain
- Syncope with Exertion
- Palpitations
Type/Etiology
- Systolic crescendo decrescendo murmur
- Thickened Myocardium
- L Ventricular Stiffness
- Sarcomere mutations
Physical Exam
- Better with:
Squatting
Leg lift
(increased venous return - Worse with:
Valsalva maneuver
(decreased venous return)
Diagnosis
- TEE (Echo)
Treatment
- Avoid dehydration
- Beta blockers
Mitral Regurgitation (Insufficiency)
Presentation
- Children & Adults
- SOB
- Fatigue
- Arrhythmia
Type/Etiology
- High Pitched Holosystolic Murmur
- Infection and infarction
Assoc. w/ Afib in 1/3 of pts - Causes: Rheumatic fever
Physical Exam
- Apex and L 5th ICS
- Loudest at apex, radiates to axilla
- Better with: Valsalva maneuver (decreased venous return)
- Worse with: Squatting
Leg lift (increased venous return)
Diagnosis
- TEE (Echo)
Treatment
- Valve Replacement
Tricuspid Regurgitation (Insufficiency)
Presentation
- Young Athletes
- SOB
- Chest Pain
- Syncope with Exertion
- Palpitations
Type/Etiology
- Pan-systolic Blowing Murmur
Physical Exam
- Murmur heard best at the left lower sternal border which radiates to the right sternum and xiphoid.
Diagnosis
- TEE (Echo)
Treatment
- With CHF symptoms: Diuretics
- Valve repair
Ventricular Septal Defect
Presentation
- Newborn & Infants
- Failure to Thrive
- Poor suck
- Fatigue
- Weight Loss
Type/Etiology
- Most common congenital systolic murmur
- An opening in the septum separating the ventricles
- Complication:
- Eisenmenger Syndrome,
- Hypotension
Physical Exam
- Murmur heard best at the left lower sternal border
Diagnosis
- TEE (Echo)
Treatment
- Minor: Spontaneous closure
- Large: Require surgical suture or patch
Mitral Valve Prolapse
Presentation
- Congenital or Young Woman
- Palpitation
- Chest pain
- Fatigue
- Syncope
Type/Etiology
- Mid-systolic Click
Physical Exam
- Better with:
Squatting
Leg lift
(increased venous return - Worse with:
Valsalva maneuver
(decreased venous return)
Diagnosis
- TEE (Echo)
Treatment
- Beta Blockers
- Avoid dehydration
Diastolic Murmurs
| Type | Etiology | Presentation | Physical Exam | Diagnosis | Treatment | |
| Aortic Regurgitation (Insufficiency) | Blowing, diastolic decrescendo murmur | Infection, infarction, aortic dissection | Acute = cariogenic shock, flash plum edema, cp ; Chronic = chf, cp | Better with: Worse with: | heard best at the 2nd-4th Left ICS, radiating to the apex and right sternal border Accentuated by having pt sit up lean forward and hold breath after expiration Echo | Asx: serial echo Sx: avoid exertion Acute = emergent replacement Chronic = urgent replacement |
| Pulmonic Regurgitation (Insufficiency) | Early Diastolic | Mitral leaflet displacement; regurgitant flow on anterior leaflet mitral valve | Echo | Tx primary cause replacement in select cases | ||
| Austin-Flint | Early Diastolic | Murmur at apex Echo | ||||
| Mitral Stenosis | Low pitch, Mid-diastolic murmur heard | Rheumatic heart disease | Young pt, CHF sxs, A. Fib | Better with: Worse with: | heard best at the apex Echo | Balloon valvuloplasty, balloon valvotomy, or replacement |
| Tricupsid Stenosis | Mid/late Diastolic | Echo | Balloon valvotomy | |||
| PDA Arteriosus | Continuous machine like murmur | Abnormal congenital connection b/t aorta & Pulm artery which causes a continuous murmur due to a constant pressure gradient in both systole and diastole forcing blood from the aorta into the pulmonary artery | Murmur with a wide pulse pressure (PDA) Murmur Echo | To close: To Keep Open: Surgery | ||
| S3/S4 (not a murmur) | Extra heart sounds heard during diastole |
Innocent Murmur
| Type | Etiology | Presentation | Physical Exam | Diagnosis | Treatment | |
| Still Murmur | Early Systolic | 2-6 years old | Early Systolic at the Apex & Left lower sternal border vibratory murmur | Self Limiting | ||
| Venous Hum | Continuous humming/roaring murmur | R and L Upper sternal Border Humming from venous blood returning to heart | Murmur Low pitch (BELL) Radiates to 1&2ICS | Self Limiting | ||
| Flow Murmur | common when fevers | Superior chest, head and neck, high pitched | Self Limiting | |||
| Vibratory Murmur | Vibrating sound | Self Limiting |
Seven S’s for Innocent Murmurs
- Systolic
- Small (limited area)
- Soft (Low amplitude)
- Short
- Single (no clicks or gallops)
- Sweet (never harsh except systolic flow)
- Sensitive (to posture or respirations)
- NEVER holo or pansystolic
Other Heart Murmurs
| Type | Etiology | Presentation | Physical Exam | Diagnosis | Treatment | |
| Pericardial Friction Rub Murmur | Continuous course grinding murmur | MI, connective tissue dz, ischemia, pericarditis | Murmur High pitch, intermittent, Increases when pt sits up & leans FWD holding their breath on expiration | |||
| Pleural Rub | Heard on Inspiration |
Clinical Murmur Tests
| Preload and Afterload | Intensity | |
|---|---|---|
| Inspiration | Preload— Increase Afterload— n/a | Increase intensity— All R-sided murmurs (TR & PR) EXCEPT PS |
| Valsalva/Standing | Preload— decrease Afterload— decrease | Increase intensity— HCM, MVP Decrease intensity— MS, AS, MR, AR, VSD |
| Squatting/Laying down & elevating legs | Preload— increase Afterload— increase | Increase intensity— MS, AS, MR, AR, VSD Decrease intensity— HCM, MVP |
| Handgrip | Preload— n/a Afterload— increase | Increase intensity— MR, AR, VSD Decrease intensity— AS, HCM, MVP |
| Amyl Nitrate | Preload— decrease Afterload— decrease | Increase intensity— AS, HCM, MVP Decrease intensity— MR, AR, VSD |
Phonocardiogram of Normal and Abnormal Heart Sounds
Madhero88, CC BY-SA 3.0, via Wikimedia Commons
