This document describes various types of cardiac murmurs and added heart sounds. It defines different types of murmurs such as systolic, diastolic, and continuous murmurs. It also describes how to characterize murmurs based on timing, location, intensity, and other factors. Specific heart conditions are discussed in relation to the murmurs and sounds they may cause, such as mid-systolic murmurs indicating aortic stenosis or holosystolic murmurs indicating mitral regurgitation. Grading scales for murmur intensity and examples of maneuvers that may modify murmurs are also provided.

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.