Systolic murmurs can occur in various parts of the cardiac cycle. Ejection systolic murmurs are most common, occurring after some time from S1 and peaking in mid-systole or later. Causes include ventricular outflow obstruction, dilation of the aorta/pulmonary trunk, or accelerated flow. Pan systolic murmurs occur throughout systole due to pressure gradients across valves. Mitral regurgitation and ventricular septal defects cause holosystolic murmurs. Early systolic murmurs begin with S1 and peak in early systole, often caused by small VSDs or innocent murmurs. Late systolic murmurs in mitral valve prolapse occur as leaflets overshoot in late syst

1. Systolic Murmurs
Dr Muhammed Aslam
Junior Resident
Pulmonary Medicine
ACME Pariyaram
Presented at Sahakarana Hrudayalaya

2. Definition of murmur
• Relatively prolonged series of audible
vibrations , Characterized by the timing in
cardiac cycle, intensity (loudness),
frequency (pitch), quality, configuration,
duration and direction of radiation
• Due to disturbance in blood flow which
manifest as turbulence

3. Description of a Murmur
• Position in the cardiac cycle , configuration or shape
• Site of best audibility
• Intensity
• length
• Quality & Pitch
• Selective Conduction
• Relation to a physiological act or maneuver

4. FREEMAN & LEVINE GRADING
GRADE 1- faintest murmur which can be
heard only with special effort.
GRADE 2- soft but readily audible
GRADE 3- loud without thrill
GRADE 4- loud with thrill
GRADE 5- heard with steth partially off the chest
GRADE 6- heard with steth held off the chest wall.

5. Classification & types of murmurs
Systolic murmur
early systolic,
mid systolic,
late systolic,
pan/holo systolic
Diastolic murmur
early diastolic
mid diastolic
pre systolic
Continuous murmur

6. Systolic Murmurs

8. Ejection systolic murmur
• Most common murmur heard in everyday practice.
• “Murmur starting after some time interval from first
heart sound and reaching peak by mid-systole or
later and ending before the second heart sound of
its origin”.
• It could be PATHOLOGICAL or INNOCENT/PHYSIOLOGICAL
1. Ventricular outflow obstruction
2. Dilation of aorta and pulmonary trunk
3. Accelerated systolic flow into aorta or pulmonary trunk
4. Innocent midsystolic murmur( including those due to
morphological changes of valve with no obstruction)

9. Ventricular outflow obstruction

10. Causes of Left Ventricular Outflow Obstruction
Valvular
a) Rheumatic
b) Congenital- bicuspid and unicuspid valve
c)Myxoid dysplasia
d)Annular Hypoplasia
e)Calcific Degenerative
f)Hyper lipidemia
g) Fabry’s disease
h) Infective endocarditis
i) Ochronosis

11. Causes of Left Ventricular Outflow Obstruction
Supra Valvular
a) Congenital – Hour glass type , Diffuse
type , Discrete membrane
b) Aortic Dissection
c) Homozygous type 2 hyperlipidemia
d) Healing Aortotomy site
e) Rubella

12. Causes of Left Ventricular Outflow Obstruction
Sub valvular
a) Dynamic – HOCM
b) Discrete (Membranous)
Sub Aortic Stenosis
c) Tunnel Aortic Stenosis

13. Aortic Stenosis
• Iso Volumetric Contraction - ventricular
pressure increases -opening of Aorta and
pulmonary valve- ejection commences and
murmur begins
• Ejection increases -murmur becomes crescendo
• Ejection declines -murmur in decrescendo
• Murmur ends before ventricular pressure drops
below aortic pressure at which aortic valve and
pulmonary valve closes generating a2 and p2

14. Murmur Of Valvular Aortic Stenosis
• Site Of Best Audibility –Aortic Area -conducted
to carotid (best heard with the patient sitting up, leaning
forwards and breath held in expiration). Also heard at left
sternal border and apex
• Character- Harsh or rough quality

15. Site of Best Audibility And
Significance in Aortic Stenosis
Best audible at right 2nd space ,
conducted in right carotid
Valvular non calcific AS
Best audible in left sternal border ,
no carotid conduction
Sub valvular AS , calcific AS ,
mistaken VSD , mistaken MR
Carotid murmur with or without right
second space murmur
Supra valvular AS , carotid stenosis
Audible only at apex Calcific AS in elderly with
emphysema , mistaken for MR

16. • Longer the murmur and
later in systole the
murmur peaks , the more
severe the Aortic stenosis
, when cardiac out put is
within normal limits
• Severity is over estimated
in high cardiac output
states and under
estimated in low cardiac
output states.

17. Aortic Stenosis
• At times, as one moves downwards from aortic area to mitral
area, the murmur initially becomes softer and then again
increases in intensity. This phenomenon is known as
'hourglass conduction'.
• In calcific aortic stenosis, the murmur is loud and harsh in the
aortic area, but it has a musical quality along the left sternal
border and at apex. This difference in quality of the same
murmur at two different sites is referred to as `Gallavardin
phenomenon

18. Influence Of Various Maneuver In
Aortic Stenosis
Manaeuver Fixed Obstruction Dynamic Obstruction
Respiration No change May ↑ with inspiration
Standing ↓ ↑
Valsalva ↓ ↑
Squatting ↓ ↑

19. HOCM
• Dynamic LVOT obstruction
• Murmur will increase in intensity with any manoeuvre
that decreases the volume of blood in the left ventricle
(such as standing abruptly or the strain phase of
a valsalva manoeuvre )
• Administration of amyl nitrite will also accentuate the
murmur by decreasing venous return to the heart.
• Classically, the murmur is loudest at the left
parasternal edge, 4th intercostal space

20. Right Ventricular Outflow Obstruction

21. Causes
Valvular Sub Valvular Supra Valvular
1.Congenital –
Domed,tricuspid,bicuspid
,unicommissural,hypopla
stic Annulus,dysplastic
1.Congenital-infundibular
Stenosis,double
Chambered RV,
1.Congenital
2.Carcinoid Neoplasm Tumor Compression
3.Rheumatic Thrombus Thrombus,rubella

22. PS Murmur
• Best audible at left 2nd or 3rd ICS , but is
also audible at fourth space along left
sternal border.
• Conducted to supra clavicular area and
left side of neck

23. Site of best audibility / conduction Significance
Left second space Valvular PS
Infraclavicular and away from
midline
Supra valvular PS
Left 3rd or 4th space Infundibular PS or double
chambered RV
Right second or third space PS with TGA
Conduction to left side of neck Valvular PS
Failure of conduction to left side •Valvular PS is less likely
•Ventricular septal diffect is more
likely
•Infundibular PS is likely

24. • Louder ,longer and late peaking murmur is
associated with more severe PS .
• PS murmur is selectively conducted to the
infraclavicular region and the left side of
neck
• PS murmur ↑ during inspiration and ↓
during straining phase of valsalva
maneuver

25. Other causes of MSM
Dilation of Aorta & Pulmonary trunk
• Short soft midsystolic murmur
• Left sided murmurs in marfan’s syndrome, syphilis
• Right sided murmurs in idiopathic dilation of
pulmonary artery, pulmonary hypertension
MSM of Hyperdynamic circulation
• Normal aorta or pulmonary trunk but increased flow
• Anaemia, pregnancy, fever, thyrotoxicosis

26. Other causes of MSM
OS-ASD
• Rapid flow across pulmonary valve to
dilated pulmonary trunk
Pure AR
• Due to Accelerated LV ejection

27. Physiological causes
Innocent systolic murmur
• Still’s murmur
• Pulmonary mid systolic murmur
• Peripheral pulmonary systolic murmur
• Supraclavicular or brachiocephalic systolic murmur
• Aortic sclerosis
• Systolic mammary soufflé

28. Pan Systolic/ Holo Systolic Murmur
Flow from a chamber or vessel whose pressure or
resistance throughout systole is higher than
pressure or resistance of the chamber receiving the
flow
• Mitral Regurgitation
• Tricuspid Regurgitation
• Ventricular Septal Defect
• Aorto Pulmonary Window
• Patent Ductus Arteriosus with PAH

29. Mitral Regurgitation
• S1 to S2 provided MV remains
incompetent and gradient remains
Holosystolic
Early systolic
Late systolic
Sometimes MSM
• Best audible at apex
• Radiates to left axilla and back
becos jet directed posterolaterally
in LA
LLSB when jet directed against
atrial septum near base of aorta

30. Mitral Regurgitation
• Usually 3/6 grade
• Presence of systolic thrill suggest chordal
rupture, IE with vegetations, AS or VSD
mistaken as MR
• Soft and blowing or musical in character

31. Mitral Regurgitation
Relation with various maneuvers
• Decreases on standing and valsalva
• Increases with supine

32. Tricuspid Regurgitation
• Best audible at tricuspid area
(left 4th space)
• No selective conduction but is often heard
to right of sternum
• Higher the frequency and longer the
murmur , more the right ventricle pressure

33. Tricuspid Regurgitation
Rivero Carvallo’s sign-
• TR murmur increases during inspiration
• Increased VR → increased RV volume → Increased SV
→ velocity of regurgitant flow increases
• Sometimes TR heard only during inspiration
• Carvallo’s sign disappears in RV failure

34. Ventricular Septal Defect
• Size of VSD is the most important determinant of
Auscultatory findings.Other determinants are PAH,
Location of defect , and associated defects.
• Best audible along the left sternal border anywhere
from 2nd to 4th spaces and is not selectively
conducted to any where.
• In supracristal VSD murmur is best heard at
pulmonary area and may be selectively conducted to
the infraclavicular area and the left side of neck

35. Ventricular Septal Defect
• Intensity usually above 4/6 grade
• Rough or Harsh in character
• Better heard during expiration and is
diminished with inspiration
• Usually appear between 2-6 weeks after
birth

36. Other PSM
• Aorto Pulmonary Window with PAH
– Otherwise continuous murmur
– Diastolic component reduced with increasing PAH
• PDA with PAH
– Similar mechanism

37. Early Systolic Murmurs
• Begin with the first sound and peak in the first
third of systole.
• Common causes are a small ventricular septal
defect (VSD), VSD with PVR or the innocent
murmurs of childhood.
• Other causes are Acute Mitral Regurgitation and
Normal pressure TR, Organic TR

38. LSM
MVP
• Leaflets remains competent during early ventricular contraction but
overshoot in late systole
• One or more mid systolic clicks precede murmur [sudden deceleration
of the column of blood against the prolapsed leaflet or scallops]
• Any maneuver that decreases left ventricular volume — such as
standing, sitting, Valsalva maneuver ,and amyl nitrate inhalation —
can produce earlier onset of clicks, longer murmur duration, and
decreased murmur intensity.
• Any maneuver that increases left ventricular volume — such as
squatting, elevation of legs, hand grip, and phenylephrine — can delay
the onset of clicks, shorten murmur duration, and increase murmur
intensity.
Other LSM- papillary muscle dysfunction , Tricuspid valve prolapse