The document discusses the characteristics and classifications of heart murmurs, detailing the mechanisms behind their production, techniques for describing them, and various types of murmurs associated with different cardiac conditions. It emphasizes the timing, intensity, location, pitch, and configuration of murmurs, along with their clinical significance and diagnostic approaches. Additionally, the document covers a variety of specific murmurs related to conditions such as aortic stenosis, mitral regurgitation, and the physiological factors influencing murmur audibility.

1. APPROACHTOA
PATIENTWITH
HEARTMURMUR
DR ANUJA JACOB
DNB RESIDENT
GENERAL MEDICINE
BMH CALICUT

2. DEFINITION
A cardiac murmur is defined as a relatively prolonged
series of auditory vibrations .
Characterised by timing in cardiac
cycle,intensity,pitch,configuration,duration and radiation.

3. MECHANISM OF
MURMUR
PRODUCTION
TURBULENT BLOOD
FLOW

4.  Forward flow through a constricted or irregular orifice or into a dilated
vessel or chamber
 Backward or regurgitant flow through an incompetent valve/septal defect
 Vibration of loose structure or vegetation
 Increased velocity or high rate of blood flow (hyperkinetic murmur)

5. HOW TO DESCRIBE A MURMUR
1. TIMING
2. LOCATION
3. DURATION
4. INTENSITY
5. FREQUENCY(PITCH)
6. CONFIGURATION
7. RADIATION
8. DYNAMIC AUSCULTATION

6. 1. TIMING OF MURMUR • SYSTOLIC MURMUR
• DIASTOLIC MURMUR
• CONTINUOUS
MURMUR

7. 2.INTENSITY OR LOUDNESS
GRADE 1 Audible with difficulty
GRADE 2 Faint but can be heard easily
GRADE 3 Moderately loud
GRADE 4 Very loud
GRADE 5 Extremely loud-with only edge of stethoscope in
contact with skin
GRADE 6 Exceptionally loud-stethoscope just removed from
contact with chest
FREEMAN AND LEVINE GRADING
Systolic thrill-Grade 4 or louder
INTENSITY=SEVERITY??
OTHER FACTORS??

8. 3.LOCATION OF
MURMURS

9. 4.Shape of murmur
• Ejection systolic
murmur of AS
Pan systolic
murmur of MR
Mid systolic
murmur of
MVP
Early diastolic
murmur of AR

10. 5.PITCH OF MURMUR
• Frequency of murmur.
• Depends on velocity jet/pressure gradient
• Lowpitch(MS),Medium (AS) ,High pitch(MR,AR)
6.QUALITY OF MURMUR
• Refers to unusual characteristics of murmur
• Such as blowing(MR,AR),harsh(AS/VSD),rumbling(MS) or
musical/honking sound MR due to MVP.
7.DURATION OF MURMUR
• Depend on length of time over which pressure gradient
exists
• Reflect severity of lesion
FREQ
PITCH
PRE.GRAD

11. • DURATION
• RADIATION

12. SYSTOLIC
MURMURS
• EARLY SYSTOLIC
• MID SYSTOLIC
• LATE SYSTOLIC
• HOLO SYSTOLIC

14. EARLY SYSTOLIC MURMURS
CAUSES-
Ventricular septal defect
Very small muscular VSD
Large VSD with pulmonary
hypertension
Acute severe Tricuspid
Regurgitation
Acute severe Mitral
Regurgitation
Early systolic murmurs begin with S1 and extend for
variable period of time, ending well before S2 (high pitch
,decrescendo)

15. ACUTE SEVERE MR CAUSES
• Pappillary muscle rupture-MI
• Chordae tendinae-MV disease
• IE
• Blunt trauma
ACUTE SEVERE TR
•IE
•Blunt trauma
•Lower LSB
•Increases with inspiration

16. MID (EJECTION) SYSTOLIC
MURMUR
Begin at a short interval following S1,
end before S2 .
AORTIC STENOSIS
PULMONARY STENOSIS
HOCM
ASD
Idiopathic Dilatation of Pulmonary
Artery(pulmonary ejection sound+MSM(Upper L sternal
border)

17. AORTIC STENOSIS
• Ejection click f/b harsh, medium pitch,
crescendo-decrescendo systolic
murmur
• Loudest in aortic area
• Radiates along the carotid arteries
• Breath in expiration in a leaning
patient
• Reversed splitting of S2/soft or absent
S2-SEVERE
• Gallavardian phenomenon-
Musical apical murmur due to periodic
high frequency vibrations of the
fibrocalcific aortic cusps

18. PULMONARY STENOSIS
• Congenital
• ESM heard best in 2 &3rd Left ICS
• With increasing degree of stenosis-intensity decreases
And duration increases.
• Severe PS-RVH Signs,ECG,CXR

19. HOCM
• MSM of HOCM is a crescendo decrescendo murmur
• Heard in left sternal border /between left sternal border
and apex.
• Murmur is due to LVOT obstruction and MR
• It is due to systolic anterior movement of mitral leaflet
• SAM narrows already obstructed LVOT
• Characteristic feature : intensity
– Increases in Valsalva / standing /Ionotropes –all
increase degree of obs
– Decreases during squatting / handgrip/beta blockers

20. ASD
• Due to increased pulmonary blood flow
• Grade 2-3
• Upper to middle left sternal border
• Mostly a/w ostium secundum ASD
• Ostium primum-coexistent MR due to cleft in anterior MV
leaflet
• Sinus venosus ASD- Shunt is not large enough to
produce murmur

21. LATE SYSTOLIC MURMUR
MITRAL VALVE PROLAPSE
SYNDROME(Isolated/Marfans)- LV Apex
TRICUSPID VALVE PROLAPSE SYNDROME

22. MVP
• Posterior leaflet-Jet of MR directed anteriorly and murmur
radiates to base of heart
• Anterior leaflet –Jetof MR directed posteriorly and
murmur radiates to axilla/left infrascapular region.

23. MVP

24. Pansystolic
(Holosystolic)
Murmurs
1. Mitral valve
regurgitation
2. Tricuspid
valve
regurgitation
3. Ventricular
septal defect
Murmur begins immediately with S1 and continues up to S2

25. CHRONIC MITRAL REGURGITATION
CAUSES
• Rheumatic scarring of leaflet
• Mitral annular calcification
• Post infarction LV remodelling
• MR begets MR

26. CHRONIC TR
• Primary
Myxomatous d/s,IE,RHD,Radiation,Carcinoid,Ebstein
Anomaly,Leaflet trauma due to intracardiac device
leads,chordal detachment due to biopsy
• Secondary
From annular enlargement due to RV dilatation secondary
To RV remodelling due to pressure/volume overload.

27. • CARVALLO SIGN-Pan systolic murmur of TR-
louder during inspiration
• ROGER MURMUR-Pansystolic murmur of VSD-4th
ICS

28. PHYSIOLOGICAL CAUSES
• INNOCENT SYSTOLIC MURMUR
– Stills murmur-benign grade 2,musical or vibratory midsystolic murmur at
mid or lower left sternal border in normal children
– Aortic sclerosis-Carotid upstroke normal,No conduction ,ECG-No LVH
– Systolic mammary soufflé
– Grade1/2 MSM at left sternal border-pregnancy,anemia

29. DIASTOLIC
MURMUR
• EARLY DIASTOLIC MURMUR
• MID DIASTOLIC MURMUR

30. Diastolic murmur-mechanism of production

31. EARLY
DIASTOLIC
MURMUR
• AORTIC REGURGITATION
• PULMONARY
REGURGITATION

32. AORTIC REGURGITATION
• 1.Early diastolic high pitch,blowing,decrescendo murmur after A2 –Left 3rd
ICS(valvular)/Right 3rd ICS(Aortic root diseases)-expiration in a patient leaning
forward
• 2.Mid systolic ejection murmur –due to increased flow across aortic valve during
systole
• 3.Austin Flint murmur-soft ,low pitch rumbling mid to late diastolic murmur-at apex-
due to displacement of anterior leaflet of mitral valve by AR stream(c/c)
• 4.Cole Cecil murmur-rare –early diastolic murmur –heard over axilla

33. AR
• Vasodilators-murmur soft & short
• In absence of heart failure-C/C Severe AR – Peripheral
signs of AR +

34. PULMONARY REGURGITATION
• GRAHAM STEEL MURMUR- High pitched EDM –left sternal
edge -2nd ICS,Increases with inspiration.
• MCC:Dilatation of valve annulus from c/c elevation in
pulmonary artery pressure.(PAH signs+)
• IE/congenitally deformed
• After repair of TOF
• In absence of PAH,Murmur is soft,lower pitch than classical
Graham steel murmur

35. •
AR PR
Right 2nd
intercostal space
and Erbs area
Left 2nd
intercostal
space
On expiration On inspiration
DOCK MURMUR-EDM heard in left
anterior descending artery stenosis

36. MID DIASTOLIC MURMUR
COMMON CAUSES-
• Mitral stenosis
• Tricuspid stenosis
UNCOMMON CAUSES-
• LA Myxoma
• Carey Coombs murmur in acute rheumatic valvulitis-apex
• Austin Flint murmur of chronic AR
• Acute severe AR-( due to diastolic flutter of anterior mitral leaflet by regurgitant
blood stream)
• Ritan ’s murmur in complete heart block
• Organic pulmonary regurgitation

37. Flow MDM may be heard
across tricuspid valve on
right side of the heart in-
• ASD(largewith shunt)
• Isolated severe Tricuspid
regurgitation
Flow MDM may be heard across
mitral valve on left side of the
heart in-
• VSD(large)
• Severe isolated Mitral regurgitation

38. Mitral stenosis
• Loud S1
• S2 followed by high pitch
OS
• Low pitch rumbling mid
diastolic murmur at apex
in left decubitus position
• Pre systolic accentuation
• Length-severity

40. TS
• MDM
• Best heard at lower left sternal border
• Increases with inspiration
• Prolonged y descend in JVP

41. CONTINUOUS
MURMUR
• Begin in systolic and continue without
interruption through the timing of S2
into all or part of diastole without
change in character
HIGH TO LOW PRESSURE SHUNTS
Systemic to pulmonary communication
• Patent ductus arteriosus- GIBBSON MURMUR(UPPER LSB)
(if PAH develops-obliteration of diastolic
component,shunt reversal and differential cyanosis)
• Aortopulmonary window
• Tricuspid atresia
• Pulmonary atresia
• Anomalous origin of left coronary artery from pulmonary
artery
Systemic to right heart connection
• Coronary AV Fistula(LSB)
• Rupture sinus of Valsalva(right heart chamber)(Abrupt
onset,UPPER RSB)
Left atrium to right atrium connection
• Lutembacher syndrome(ASD+Acquired MS)
Arteriovenous fistula
• Systemic(HD)
• Pulmonary
Venovenous shunts
• Portosystemic shunts

42. • NORMAL FLOW THROUGH
CONSTRICTED ARTERIES
• Coarctation of aorta
• Peripheral pulmonary
artery stenosis
• Carotid stenosis(High
grade cervical bruit with
sys &dias components)
• Coeliac artery stenosis
• Mesentric artery stenosis
• Renal artery stenosis
• INCREASED FLOW THROUGH
NORMAL VESSELS
VENOUS
• Umblical vein(Cruveilheir
–Baumgarten murmur)
• Right supraclavicular area-
children,young
adults,pregnancy-hum
obliterated by pressure on
R- IJV
ARTERIAL
• Mammary souffle
• Uterine souffle
• Hepatoma
• Nephroma

43. To and fro murmur

44. DYNAMIC AUSCULTATION.
INSPIRATION Blood flow rt side increase TS,TR,PS,PR
EXPIRATION Blood flow left side increase MS,MR,AS,AR
MVP,HOCM
VALSALVA EFFECT
(Persistent expiration)
Blood flow decrease in rt f/b left ALL R + L WILL DECREASE
MVP,HOCM
STANDING POSITION Blood flow decrease on rt+left ALL MURMUR WILL
DECREASE
MVP,HOCM
SUPINE POSITION
(Passive leg raising)
Blood flow increase on rt+left ALL MURMUR WILL
INCREASE
MVP,HOCM
SQUATTING Blood flow increase rt f/b left ALL MURMUR WILL
INCREASE
MVP,HOCM

45. AS Pressure gradient=LV PRESSURE-AORTIC PRESSURE
AR Pressure gradient=AORTIC PRESSURE-LV PRESSURE
• HAND GRIP /INCREASE BP
AND PHENYLEPHRINE
• Increase total peripheral
resistance (afterload)
• Increase AR,MR,VSD
• Decrease AS,MVP,HOCM
• INHALED AMYL NITRATE
• Vasodilation-decrease TPR
and afterload
• Increases –AS,MVP,HOCM
• Decreases-AR,MR,VSD

46. All MURMURS TO BE EVALUATED ?

47. APPROACH
• HISTORY
• EXAMINATION OF PULSE,BP,JVP,APEX,RVH
SIGNS,PALPABLE EVENTS
• INVESTIGATIONS

48. THANK YOU