Basics on heart murmurs, differentiate physiologic murmur from pathologic. Learn when to investigate further and when to monitor. Know the effect of different maneuvers on murmurs and physiology behind them. Listen to the heart sounds on the slides to appreciate the distinctive nature of each murmur.

1. Heart Murmurs
Avaneesh Jakkoju, MD

2. Why is a murmur important…
• High yield on boards
• Understanding the physiology of heart
• Know when to reassure and when to further
investigate
• Important murmurs are easy to miss
• Look cool in front of your peers

3. Systolic vs. Diastolic
• Systole  MR, TR, AS, HOCM
• Diastole  AI, MS
• Continuous  PDA
• We are only covering high yield topics for boards, this list does not cover all the
murmurs

4. Mitral regurgitation
• Holosystolic murmur
• Location: Apex
• Quality: blowing high pitched
• Radiation: to axilla
• Could be end systolic in case of MVP

5. Mitral regurgitation
Source:http://www.texasheart.org/Education/CME/
explore/events/HSPS07_mitral_regurg.cfm
Source:
http://www.med.umich.edu/lrc/psb_open/html/repo/pr

6. Mitral stenosis
• Diastolic rumble
• Apex
• Severe disease- holodiastolic
• Loud S1, opening snap and soft S2

7. Mitral stenosis
Source:
http://www.cvphysiology.com/Heart%20Disease/HD004
.htm
Source:
http://www.med.umich.edu/lrc/psb_open/html/repo/pr
imer_heartsound/primer_heartsound.html

8. Aortic stenosis
• Harsh Crescendo-decrescendo mid systolic murmur
• Right upper sternal border
• Radiates to carotids
• Signs of severe disease:
• Decrease/soft S2 or single S2
• Pulsus parvus et tardus
• Late peaking in systole and prolonged murmur

9. Aortic stenosis

10. Aortic insufficiency
• Blowing diastolic murmur heard at the Left Upper sternal
border
• Best heard when sitting or leaning forward
• Widened pulse pressure seen in chronic but not in acute
• Acute setting caused by aortic dissection involving the root
• Decreased S1 and S2 (A2)
• Duration correlates with severity; pan-diastolic when very
severe

11. Aortic insufficiency

12. Tricuspid regurgitation
• Holosystolic murmur heard at left lower sternal border; may
even be present at apex if severe RV hypertrophy
• Loudness depends on degree of pulmonary hypertension
• Pulsatile jugular vein on exam, dynamic right ventricular heave
due to the dilated right ventricle
• Patients are often asymptomatic or murmur is hard to
appreciate
• Most often diagnosed on Echocardiography than auscultation

13. HOCM
• Harsh midsystolic crescendo-decrescendo murmur at left
sternal border
• Differentiate from AS by location (AS best heard at RUSP)
• Either no radiation or radiation to axilla (AS to carotids)
• Brisk carotid pulse (AS weak pulse)

15. Physiologic vs. pathologic murmurs
• Benign murmurs are midsystolic
• Never louder than 1-2/6, never diastolic
• Never radiate to carotids, do not improve with valsalva
• Children or young adults they are due to vibrations across the
pulmonary valve leaflets or pulmonary trunk, heard at LLSB or
precordium- still’s murmur
• Benign murmur in older patient is usually due to
Aortic valve sclerosis

16. What happens with different maneuvers?
• Murmurs increase in frequency when flow across the valve
increases except
• HOCM where increased ventricular volume relieves outflow
tract obstruction

18. Source: http://knowmedge.com/blog/internal-medicine-board-review-cardiac-murmurs/

19. Source: https://en.wikipedia.org/wiki/Heart_murmur#/media/File:Phonocardiograms_ from_
normal_and_abnormal_heart_sounds.png

20. Lilly, L. & Jung, H. (2011a). Locations of maximum intensity of common murmurs [Image]. In L. Lilly (Ed.), Pathyphysiology of Heart
Disease. (5th ed.). Baltimore, Maryland: Lippincott Williams & Wilkins.