This document provides an overview of how to approach heart murmurs. It discusses the basics of heart sounds and cardiac cycle timing. It describes the locations used to auscultate heart sounds. Murmurs are defined as audible vibrations caused by increased turbulence in blood flow. Pathological murmurs have distinguishing characteristics like timing within the cardiac cycle. The document outlines how to describe murmurs and provides examples of different types of murmurs heard in various locations based on their timing within the cardiac cycle. It also discusses classifications of murmurs and potential causes.

1. APPROACH TO MURMURS
DR KIRAN D YADAV
1ST YEAR PG
DEPARTMENT OF GENERAL MEDICINE

2. BASICS
• S1 : CLOSURE OF AV VALVES
• S2 : CLOSURE OF SEMILUNAR VALVES
• SYSTOLE : PERIOD BETWEEN S1 AND S2
BLOOD FLOWS ACROSS AORTIC AND PULMONARY VALVE
• DIASTOLE : PERIOD BETWEEN S2 AND S1
BLOOD FLOWS ACROSS MITRAL AND TRICUSPID VALVE

3. CARDIAC VALVES AND ASSOCIATED AUSCULTATORY
AREAS
Erb’s area : 3rd L IC
space close to
sternum
Gibson’s area : 1st L
IC space close to
sternum

4. • HEART MURMURS ARE AUDIBLE VIBRATIONS CAUSED BY INCREASED
TURBULENCE IN BLOOD FLOW AND ARE DEFINED BY THEIR TIMING
WITHIN THE CARDIAC CYCLE.
• TURBULENCE IS CAUSED BY
INCREASE IN VELOCITY OF BLOOD FLOW
INCREASE IN PRESSURE GRADIENT
BLOOD MOVES FROM SMALL LARGE CHAMBER
LOW BLOOD VISCOSITY
• SIGNIFICANCE OF A MURMUR : WHETHER PHYSIOLOGICAL OR
PATHOLOGICAL

5. Clues to identify pathologic murmurs
• All diastolic murmurs
• All pansystolic and late systolic murmurs
• Continuous murmurs
• Very loud murmurs (grade 4 or higher)
• Associated cardiac abnormalities

6. Describing a murmur
• Timing - systolic, diastolic, continuous
further categorised into early mid late
can be done by simultaneously feeling for the carotid pulse in
tachycardia
• Duration – Short, long or pansystolic/pandiastolic murmurs
• Shape – crescendo, decrescendo, crescendo-decrescendo, plateau
• Location of maximum intensity – depends on the site of origin
• Radiation – reflects the intensity of the murmur and direction of
blood flow
• is determined by the site where the murmur originates
• e.g. A, P, T, M listening areas

7. • Intensity – Graded on intensity scale at the site of maximal intensity
grade 1 – very soft heard with great effort
grade 2 – easily heard
grade 3 – loud but without thrill
grade 4 – loud with thrill
grade 5 – heard with stethoscope edge touching the chest
grade 6 – heard with stethoscope slightly off the chest
Grade 3 or more indicates a structural heart disease, intensity decreases as distance
between cardiac structure and stethoscope decreases
• Pitch – high manifested as whistling
low manifested as rumbling
V

8. • Other characteristics
Respiration- inspiration right heart murmurs increase in intensity
expiration left heart murmurs increase in intensity
Postural changes – supine to standing intensity of all murmurs decrease
except murmurs of hocm and mvp
standing to squatting intensity of right heart murmurs
increase, MR and AS increase
Cardiac cycle length – longer increase intensity of ejection murmurs
regurgitant murmurs do not change
Valsalva strain phase – heart sound and murmurs decrease in intensity
Valsalva release phase- murmurs of right side return to baseline within 2-3
heart beats, left side murmurs after 5-10 heart beats
Isometric Hand grip increases murmurs of left side MR,AR,VSD,MS

9. Classification of Murmurs

10. Early systolic murmurs
• Begin with S1 and end well before S2
• Eg : 1 Acute severe MR - decrescendo, apex
causes MI, MVP, IE,Blunt chest wall
trauma
2 small muscular VSD – left sternal
border, grade 4 or 5
3 Acute severe TR – left sternal border,
grade 1 or 2, increase in intensity with
respiration( carvallo sign)

11. Mid Systolic Murmurs
• Begin a short interval after S1 and end before S2
• Crescendo-decrescendo in configuration
• Eg : 1 Aortic stenosis – Aortic area, radiates to
carotids,
Gallavardin Effect
2 HOCM – lower left sternal border
3 PS – pulmonary area
4 AV Sclerosis - aortic area grade1 or grade 2
5 Physiological murmur – lower left sternal
border
6 Stills murmur

12. Late Systolic Murmurs
• Best heard at left ventricular apex
• Mostly due to MVP – introduced by ejection click
post leaflet radiates to the
base
ant leaflet radiates to axilla
or left infrascapular
region

13. Holosystolic murmurs
• Begin with S1 continue through systole to S2
• Eg : 1 Chronic MR – left ventricular apex,
high pitched, plateau
radiates to the axilla
Causes of chronic MR : Rheumatic scarring, Mitral
annular calcification, Severe LV enlargement
2 Chronic TR – lower left sternal border,
increase with inspiration
Causes of chronic TR : Endocarditis, RHD,
Carcinoid, Ebsteins Anomaly
3 VSD – mid to lower left sternal border,
radiates widely, thrill present

15. Early Diastolic Murmurs
• Begin immediately after S2 and end well before
S1, Decrescendo in configuration
• Eg : 1 Chronic AR – high pitched, blowing ,
second right space,
auscultated with patient leaning forward
causes – Marfans syndrome, ankylosing
spondylitis, aortic
dissection
2 PR – begins after p2, second left space,
radiates along left sternal border,
mostly due to pulmonary hypertension

16. Mid Diastolic Murmurs
• Produced due to obstruction/augmented flow at mitral or
tricuspid valve
• Eg : 1 Mitral stenosis – opening snap f/b low pitched murmur best
heard at LV apex patient in lateral decubitus position, presystolic
accentuation present only in sinus rhythm
2 Tricuspid stenosis – lower left sternal border increase in
intensity with inspiration, prolonged y descent in jvp
waveform
3 Atrial Myxoma – prolapse across Mitral valve
4 carey coombs murmur – short mid diastolic murmur in arf

18. Continuous murmur
• Begin in systole, peak near the second heart
sound and continue into all or part of a
diastole
• Eg : PDA – Upper left sternal border
Ruptured sinus of Valsalva – upper right
sternal border
coronary arteriovenousfistula, cervical
bruit, venous hum, mammary
souffle

19. References
• Essential of cardiac physical diagnosis – Jonathan Abrams
• Harrisons principles of internal medicine
• Manual of Practical Medicine – R Alagappan

20. THANK YOU