Cardiac murmurs and added sounds

1. CARDIAC MURMURS
AND
ADDED SOUNDS
GUIDE- DR. GAYATRI B H.
STUDENT- DR. RAHUL S. BELAVI.

2.  Heart Murmur : It is an extra or unusual sound
heard due to turbulent blood flow within a heart
during a heart beat.

3. DESCRIBING A HEART MURMUR :
 Time
 Shape
 Location of Maximum intensity
 Intensity
 Pitch
 Quality
 Radiation
 Variation with maneuvers

4. CLASSIFICATION:
Systolic Murmurs – Early systolic
- Mid systolic
- Late systolic
- Holosystolic
Diastolic Murmur – Early diastolic
- Mid diastolic
Continuous Murmur.

5. INTENSITY OF MURMUR:
Grade 1- Faintest murmur heard under optimal
conditions.
Grade 2- Soft but readily audible.
Grade 3- Prominent
Grade 4- Loud murmur that is palpable.
Grade 5- Louder
Grade 6- Without stethescope.

6.  Factors affecting the intensity of murmur:
Increased intensity-
- High cardiac output
- Thin chest wall
- Narrow thoracic diameter
- Anaemia

7. Decreased intensity-
- Low cardiac output
- Obesity
- Thick chest wall
- Barrel chest
- Pericardial fluid

8. SYSTOLIC MURMURS:
 Early Systolic Murmur:
- Acute severe MR
- Small VSD
- TR with normal PA pressure

9.  Mid systolic murmurs - Ejection murmur:
- Most common murmur heard in everyday practice.
- Crescendo Decrescendo
- Ends before S2
- intensity of murmur is related to velocity of blood.
- Types: Flow murmur
Pathological murmur

10.  Flow / Functional / Physiological / Innocent murmur:
- Occurs due to abnormally increased blood
flow across structurally normal heart valves.
- common causes are exercise, excitement,
tachycardia, anemia, pregnancy
- better heard at 2-4 ICS along left sternal
border.
- low-moderate intensity
- never extend into late 1/3rd of systole.

11.  Pathological ejection murmur:
- Valvular, subvalvular, supravalvular narrowing
of right or left ventricular outflow tract.
- dilatation of aorta and pulmanory artery.

13.  Holosystolic murmurs:
- begins with S1 and end with S2
- constant amplitude and shape throughout the
systole.
eg; MR
- TR
- VSD.

14.  Late systoilc murmur:
- Begins in later half of systole and extend into S2
- typically reflects milder degree of MR

16. DIASTOLIC MURMURS
 Early diastolic Murmur:
- Signify regurgitant blood flow through
incompetant semilunar valves. Eg: AR
- Begins with S2
- Shape and length of the murmur reflects the
pressure gradient betwwen greater vessels and
respective ventricles.
- high frequency sounds.

17.  Mid diastolic Murmur:
- AV valve stenosis. Eg: MS
- low pitched murmurs
Increased AV valve flow without valvular stenosis-
- filling murmurs
- eg; Austin flint murmur of AR
ASD, VSD, PDA
MR, TR

18.  Pre systolic murmur:
- late diastolic
- heard in mild-moderate MS, TS
- occurs due to augmented AV flow following
atrial contraction.
- extend into S1
- always associated with mid diastolic murmur.

20. CONTINUOUS MURMURS
 Results from persistent gradient between high
pressure site and a lower pressure site.
- begins in systole and spill over into early diastole
- peak in mid to late systole
eg; PDA

22. MANEUVERS
 Respiration –
Right sided heart murmurs – louder on inspiration.
Exception : Severe PAH with right sided heart failure
Left sided heart murmurs – louder on expiration.

23.  Postural changes –
Recumbant – standing : all murmurs of right and
left side decrease in intensity except HC and MVP.
Squatting - all murmurs of right and
left side increase in intensity except HC and MVP.

24.  Valsalva maneuver-
all murmurs of right and left side decrease in
intensity during strain phase of valsalva.
Upon release of valsalva murmurs of right side
return to baseline intensity in 2-3 heart beats and that
of left side return to baseline intensity in 5-10 heart
beats.

25.  Isometric handgrip-
Causes increased arterial pressure, cardiac
contractility and cardiac output.
Increased – AR, MR, MS, VSD
Unchanged – right sided murmurs, AS, HC

26.  Amyl nitrite
causes systemic vasodilatation and reduces systemic
BP resulting in reflux increase in HR and CO.
Increaseas – AS, MS, PS, TS, HC, TR
Decreases – MR, AR, VSD, PDA

27. EJECTION SOUNDS
 High frequency transient sounds that occur in early
systole immidietely followng S1.
 Mechanism-
The snapping open or doming of a stenotic thickened
malformed semilunar valves.
Sound produced by sudden tensing or reverberation
of proximal aorta or PA

28. - high frequency, sharp, discrete sounds
- equal in intensity to S1
- aortic ejection sounds are better heard at aortic area
- pulmonic ejection sounds are better heard at left
2-3 ICS at sternal border

29.  Aortic Conditions associated with ejection sound;
- congenital valvular AS
- Bicuspid aortiv valve
- aortic aneurysm
- aortic root dilatation
- syst HTN
- severe TOF

30.  Aortic stenosis – an ejection click is almost always
present in congenital abnormalities of aortic valves.
Eg; bicuspid valve
 In aquired AS ejection clicks are less common and
A2 is poorly heard.

31.  Pulmonic Conditions associated with ejection
sound;
- PV stenosis
- idiopathic dilatation of PA
- ASD
- chronic pulmanory HTN
- TOF

32. OPENING SNAP
 It results from maximal opening excursion of the
mitral valve cusps into left ventricular cavity in the
early diastole after LV pressure falls below that in
the left atrium.
 High frequency, distinct, sharp sound
- initiates diastolic rumble
- better heard medial to the apex

33.  OS in MS ;
- marker of pliability of valves
- does not represent the severity of MS
- A2 – OS duration is an indicator of severity of lesion
- severity of MS lesion is inversely related to A2-OS

34.  Decreaseed intensity of OS seen in ;
- extensive calcifacation
- mild MS
- severe PAH
- CHF
- associated with MR
- AS / AR
- dilated RV

35.  Mitral valve origin ;
- MS
- MR
- PDA
- VSD
 Tricuspid valve origin ;
- TS
- TR
- ASD
- TOF
- Ebstein anamoly

36. AORTIC STENOSIS
 S1 – Usually unremarkable
 S2 – A2 is soft or absent
P2 is normal
as the severity of lesion increases A2 moves
to P2 causing single S2
 Murmur – Systolic ejection murmur
- Crescendo decrescendo
- harsh, rough, grunting
- better heard at right second ICS

37. - radiates along the carotids
- Gallavardian phenomenon; high pitched
systolic murmur heard at the apex in aquired
aortic stenosis
- length and time to the peak intensity of
murmur indicates severity of lesion.

39. HYPERTROPHIC CARDIOMYOPATHY
 S1 – normal to accentuated
 S2 – as the severity of lesion increases A2
approaches P2 and may cross it causing
reverse splitting.
 S3 – not common in HOCM
 S4- be wary of making diagnosis of HOCM in any
person who does not have S4

40.  Murmur – harsh systolic ejection murmur
- crescendo decrescendo
- well heard lower left sternal border
at 3-4 ICS
- vary in intensity

41. AORTIC REGURGITATION
 S1 - Normal
 S2 – A2 is softer
- splitting of S2; It is often single bcz of inaudible
A2 or P2 is lost in diastolic murmur.
 S3 – common in severe AR.

42.  Cardiac murmur - Early diastolic
- Decrescendo
- High pitched
- Blowing quality
- Better heard in left 2nd ICS at sternal edge
- Radiation Left sternal border – Valvular pathology
Right sternal border – Root pathology
- length of the murmur depends on severity of lesion.

43. Associated murmur with AR,
Mid systolic murmur – flow murmur.
Named murmurs in AR,
- Austin flint M
- Cole celil M
- Sea gull M / cooing dove M

45. MITRAL STENOSIS
 S1 – lous and snappy
 S2 – normal
 Opening snap
 Murmur –
- Mid diastolic component: Due to rapid ventricular filling
- Pre Systolic component : Due to atrial contraction
- Low pitched

46. - Rough rumbling
- better heard at apex with no radiation
- begins after opening snap
- decrescendo crescendo
- anything that increases the heart rate will
enhance the audibility of diastolic rumble.

48. MITRAL REGURGITATION
 S1 – soft
 S2 – widely split
 S3 – common
 S4 – seen in acute MR
 Murmur – holosystolic
- constant amplitude
- medium to high frequency
- better heard at LV apex

49. - other configuration of MR;
tapering holosystolic – trivial MR
mid systolic accentuation – severe MR
late systolic crescendo– papillary rupture
- greater the degree of reflux, louder the murmur
- radiation ; ant leaflet – to axilla
post leaflet – base

50. TRICUSPID REGURGITATION
 S1 – may be diminished or normal
 S2 – P2 loud if ass with pul HTN
- widely split
 S3 – audible
 S4 – in acute TR

51.  Murmur – holosystolic
- constant amplitude
- left 4-5 ICS along sternal border
- very loud
- medium frequency
- may radiate to lower right sternal border,
upper left sternal edge, xiphoid area.
 Severe TR will have associated diastolic flow
murmur.

52. ATRIAL SEPTAL DEFECT
 S1 – increased amplitude of T1
 S2 – wide and fixed split
- accentuated P2
 Murmur – systolic ejection murmur
- crescendo decrescendo
- upper left 2nd ICS
- radiates to posterior thorax, interscapular
 associated murmur- mid diastolic flow murmur

53. VENTRICULAR SEPTAL DEFECT
 S1 – normal
 S2 – single S2 as A2 is lost in pan systolic murmur,
only P2 heard
 Murmur – pansystolic
- lower left sternal border
- mixed frequency
- intensity vary with amount of shunting
 associated murmur – mid diastolic flow murmur

54. REFERENCES
 Essentials of cardiac physical diagnosis – Jonathan
abrahama
 Clinical examination in cardiology-
B.N. Vijay Raghav Rao

55.  THANK YOU.