This document discusses systolic murmurs. It defines a systolic murmur as a prolonged vibration due to disturbed blood flow that manifests as turbulence, usually heard best at the site of turbulence. Systolic murmurs can be ejection or regurgitant in nature. Ejection murmurs occur with forward blood flow through the outflow tracts of the left or right ventricle. Regurgitant murmurs occur with retrograde blood flow from a high pressure to low pressure chamber. Common causes, characteristics, and features of different types of systolic murmurs are described in detail.

1. Dr Sujaya Raghavendra
Systolic murmurs

2. Definition
 Prolonged vibration due to disturbance in blood
flow that manifests as turbulence.
 Site of maximum intensity generally corresponds
to the site of turbulence.

3. Areas of auscultation

4. Cardiac cycle

5.  It is produced due to:
1. Due to increased blood flow from a normal or
abnormal orifice
2. Through a narrowed orifice to a dilated chamber
3. Backflow flow through an incompetent valve

6. Mechanism of murmur
 Due to turbulent blood flow
 It arises when the Reynolds number reaches > 2000
i.e
1.when blood flow velocity is high
2.orifice (vessel/chamber) diameter is small
3. Kinetic viscosity is low
 Reynold number = flow / [2 (diameter) x kinetic velocity]

7. Consequence of turbulence
 Vortex shedding: as the blood flow passes the
narrow orifice , vortices produced at the tip of the
orifice are shed laterally to hit the vessel wall
producing vibrations and thereby a high pitched
murmur
 Jet impact: a jet turbulent flow hit wall of heart or
blood vessel
 Cavitations : a high turbulent flow producing
theoretically micro – bubbles that generate a
sound of different frequencies – harsh murmur

8.  Eddies : a high velocity jet of blood produces
currents in the adjacent slow moving blood .
These eddies cause vibrations transmitted to the
soft tissue and skin surface, resulting in murmur
 Periodic wake phenomena : as blood passes to
either side of a structure a periodic wake
phenomena arises , producing relatively pure
musical tones .
 Flitter: A high speed jet of blood in a blood vessel
may pull the wall of blood vessel inward by
“Bernoulli effect” ,which causes vibrations in the
vessel wall hence generating a murmur .

9. VORTEX SHEDDING
PERIODIC WAKE
PHENOMENA
Vortices- oscillating flow that takes place when a fluid such as air / water flows
opposing a streamlined flow at certain velocities
Wake: disturbed flow or
turbulence downstream of
a solid body moving
through a fluid medium .

11. Characteristics of murmur
 Timing in relation to heart sounds
 Location
 Duration or length
 Intensity
 Frequency or pitch
 Configuration or shape
 Transmission of murmur
 Dynamic auscultation

12. Timing
 Systolic murmurs : murmur begins with or after
S1 and ends or before S2
 Diastolic murmurs begin with or after S2 and ends
before the subsequent S1
 Continuous murmur: begins in systole and
continues without interruption through S2 into all
or a part of diastole
 Further can be classified as early ,mid, late and
pan (holo)

13. LOCATION
 Murmurs at the apex
ONLY AT APEX BEST HEARD
SOMEWHERE
ELSE BUT ALSO
HEARD AT APEX
NOT HEARD AT
APEX
Systolic murmur
of MR
ESM of AS Murmurs of right
sided origin (but
can be heard when
RV forms the apex
ESM of calcified
AS in elderly
patients with
emphysema
(loss of jet effect)
Pansystolic
murmur of TR ,
VSD
ESM of PS
MDM of MS MDM of TS EDM of PR
Functional MDM of
MR

14. Murmurs at tricuspid area
AT TRICUSPID AREA
ONLY
BEST HEARD
SOMEWHERE ELSE
BUT ALSO HEARD
AT TRICUSPID AREA
NOT HEARD AT
TRICUSPID AREA
Systolic murmur of
TR
PSM of MR and VSD MDM of MS
MDM of TS ESM of AS and PS

15. Murmurs at left sternal border of 3rd
intercostal space
ONLY AT LSB BEST HEARD
ELSEWHERE BUT
ALSO ALONG LSB
NEVER HEARD
PSM of VSD ESM of valvular
PS,and TR
MDM of MS
ESM of infundibular
PS
EDM of AR

16. Murmurs at Pulmonary area
BEST HEARD BEST HEARD
ELSEWHERE BUT
ALSO ALONG PA
NEVER HEARD
ESM of PS AS MDM of MS and TS
Flow murmur of
pulmonary origin in
ASD
VSD
Continuous murmur of
PDA
MR,AR
Murmur of sub
pulmonary VSD

17. Murmurs at Aortic area
BEST HEARD RARELY HEARD: ESM of PS
ESM of AS(valvular, subvalvular ),
aortic sclerosis
Never heard : MDM OF MS
EDM of AR

18. Duration /length of murmur
 Short , long or holo
 Duration of pressure gradient between the two sites
or chambers
 reflects the severity of the lesion.(true for stenotic
lesions like MS,AS,PS)
 Regurgitant murmurs(PSM) are longer than stenotic
lesions and the length is not related to severity of the
lesion (MR ,VSD, TR) as the very prsence of these
lesions produce the murmur
 In aortic regurgiation length of the murmur better
correlates than MR in severity but is not reliable

19. Grading(Freeman & Levine
1933)
Grade of murmur Basis
Grade 1 Faint murmur heard on careful
auscultation
Grade 2 Easily audible not loud
Grade 3 Easily audible loud murmur but no
thrill
Grade 4 Murmur with thrill
Grade 5
Grade 6
Murmur audible stethoscope audible
to chest
Murmur audible half an inch from
the chest.
Associated with thrill.
GRADE 3/6 or more intensity of systolic murmur is clinically significant
with few exceptions but diastolic murmur of any degree of intensity is
organic in nature .

20. Factors affecting intensity of murmur
 Quantity and velocity of blood flow across the
sound producing area i.e degree of turbulence
1.high output states , murmurs are
accentuated while in hypo dynamic states
intensity decreases
2. high velocity of blood flow through a small
VSD produces loud murmur, whereas a large
flow at low velocity through an ASD produces no
murmur

21.  Accentuated in thin individuals
 Obesity, pericardial or pleural effusion
emphysema will reduce the intensity.

22. Functional murmurs and thrills
SITE THRILL Organic
LESION
CAUSE
Apex Diastolic MS Severe MR
Carotids Systolic Aortic stenosis Severe AR
Pulmonary area Diastolic PR Severe PAH
Pulmonary area Systolic PS Moderate to
large ASD
Neck veins Continuous Mimicking PDA
/AV fistula
Cervical venous
hum

23. Character and frequency
 Directly related to velocity of blood flow
 High pressure gradient – high pitched (soft in AR
blowing in MR, musical in papillary muscle
rupture
 Low pressure gradient – low pitched (rough –
MS)
 Mixed frequency – harsh in ASD,VSD, PS,
transmission seen

24. Configuration or shape of
murmur
 Related to the pattern of blood flow velocity
 Help in identification of the lesion
1. Crescendo (increasing) – ESM of AS
2. Decrescendo (decreasing)-EDM of AR
3. crescendo- decrescendo – (diamond
shaped )- systolic murmur of AS and PS
4. Plateau- (even or unchanged)- PSM of
MR

25. Transmission of murmurs
 Conduction occurs when there is direct
anatomical continuity is present – systolic murmur
of AS to carotids , PSM of MR to left axilla or
back.
 loud murmurs transmit widely whereas soft
murmurs are confined to their area of origin
 High frequency murmur or sound transmits
proximally to its origin while low frequency goes
distally.
 Low frequency murmur transmits better through
the thorax and can be felt as thrill as compared to
high frequency murmur.

26.  Table

27. Systolic murmurs
 Classified into two basic categories :
1. Ejection mid systolic murmur
2. Regurgitant murmur
Systolic ejection murmurs – forward flow across the
LV or RF out flow tract.
Systolic regurgitant murmurs – retrograde flow from
a high pressure cardiac chamber to a low
pressure cardiac chamber

30. Ejection systolic murmurs
 It begins shortly after the pressure in RV or LV
exceeds the aortic or pulmonic diastolic pressure
sufficiently to open the aortic or pulmonic valve
 There is a delay between the s1, which occurs
after AV pressure cross over and the beginning of
the murmur.

31.  The murmur is a crescendo- decresendo type
(diamond shaped or spindle shaped in
configuration).
 Intensity of the murmur is proportional to the rate of
ventricular ejection
 The shape depends on the instantaneous flow
velocity during the ejections
 Flow characteristics of normal RV ejections are of
rounded contour
 As early ejection rates are not high and flow curve
peaks are late( ASD , straight back syndrome )
 If LV or RV obstruction is severe systole is prolonged
and the closure sound of the semilunar valve is
delayed.

34. Innocent murmur
 Systolic ejection in nature
 Without the evidence of physiologic or structural
abnormalities in CVS
 Grade < 3/6
 No radiation to carotids or axilla
 Flow across the normal LVOT/RVOT
 30-50% childeren

35. Still s murmur
 Young children 3-8 years , disappears by puberty
 flow across normal LVOT
 Related to small ascending aorta diameter with a
concomitant high aortic blood flow velocity
 Short medium frequency murmur
 Croaking or buzzing in character
 Best heard : left sternal border at the 3rd or 4th
ICS.

36. Innocent Pulmonary murmur
 Common in children , adolescents, and young
adults .
 Flow across RVOT
 low to medium frequency
 mid systolic
 Blowing character
 Best heard: PA with radiation to left sternal border

37. LVOT obstruction
 Causes
valvular supravalvular subvalvular
rheumatic Hour glass type HOCM
Bicuspid/unicuspid
valve
Diffuse type Discrete
membranous
Acommissural/unic
omissural with
eccentric opening
Aortic dissection Tunnel type
Myxoid dysplasia Healing
aortotomy site
hyperlipidemia Rubella
Fabry s disease
Calcific
degenerative

38. Features of aortic stenosis
murmur
Site of best audibilty Aortic area (second right ICS )
rt sternal border , apex
conducted to the neck vessels (rt
carotid)
Timing Ejection systolic
Grade Usually 3/6
Length of murmur Short , medium or long
Relation to physiological act Does not increase on inspiration
Decrease on standing and valsalva
character harsh
Accompanying features Slow rising arterial pulse
Sustained left ventricular impulse
S4, ejection click
Symptoms of angina , syncope and
dyspnoea

40. Site of best audibilty/selective
conduction
significance
Best audible at Right second space
conducted to carotid
Valvular non calcific AS, congenital
bicuspid AS (withsystolic ejection
sound)
Best audible at left sternal border ,
no conduction
Subvalvular AS(fixed or dynamic)
Calcific AS
Mistaken VSD/MR
Carotid murmur with/without right
second space murmur
Supravalvular AS(elfien facies)
Carotid stenosis
Audible only at apex Calcific AS in elderly with
emphysema
Mistaken as MR(not radiated to
axilla )

41. Length of the murmur
 Longer the murmur and later in systole peaks ,
more the severity of AS
 Duration is the reflection of the pressure
difference across the valve
 Any change in the cardiac output makes the
severity of the lesion unreliable
 Overestimation can be made in high output states
like anemia, thyrotoxicosis , pregnancy
associated AR ,PDA anxiety

42. Condition Mechanism
CCF Low cardiac output
Polycythemia Increased viscosity of blood
Associated with proximal obstruction MS,TS, low CO
Associated with proximal
regurgitation or shunt
MR,VSD
Associated with SHT/coarctation Obliteration of gradient
CAD/MI/
Hypothyroidism
Elderly female
AF
Low cardiac output
UNDER ESTIMATION OF THE
MURMUR

43. Gallavardin phenomena
 Elderly patient with aortic sclerosis/AS due to fibro calcific changes have
gallavardin dissociation
Two distinct mid diastolic murmurs are heard –
 A noisy medium pitched murmur at the right second space(due to turbulence
caused by the high velocity jet within aortic root)
 A high frequency musical murmur at the apex (due to periodic wake
phenomena caused by high frequency vibrations of the fibrocalcific aortic
cusps
 Simulates murmur of MR but without radiation to the axilla or back or is
accentuated with slowing of heart rate such as a compensatory pause or pre
mature beat

44. Relationship with physiological
act
maneuver Fixed obstruction (AS) Dynamic obstruction
(HOCM)
Respiration No change Increase with expiration
Standing decrease increase
valsalva decrease increase
Squatting increases decreases
•HOCM is associated with pulsus bisfirens with double or triple apex
•A2 is of normal intensity and S2 maybe single or reversed split
•Usually doesnot exceed grade 3 intensity
•Murmur decreases with increase in preload or afterload(squatting,
passive leg raising vasopressors) or reduce contractility(B blockers
) and increases with inotropic administration
•Best heard : apex & lower left sternal edge.

47. FEATURE Aortic valve sclerosis AS
murmur Short medium pitched Long/rough
AR Absent Maybe present
A2 Normal /increased Diminished or absent
S2 Normal split Single / reversed split
LVH absent present
S4 Absent Maybe present
Calcification rare Maybe present
Arterial pulse Normal Slow rising

48. Other features
 The slow rising and sustained pulse (pulsus
parvus et tardus ) Is accompanied with a long
ejection systolic murmur and a delayed peak
 Normal arterial pulse is consistent with a short
ejection murmur with early peak

49.  Arterial pulse is normal + long ejection
murmur- likely to be MR(along with S3)/VSD
 long ejection murmur+ S4- fixed obstruction (AS)
 Short murmur or no murmur(decreased
ventricular compliance) + S4- Dynamic
obstruction –HOCM .
 Ejection click(mobile non calcific valve - PS>AS

50. AR with AS
 Fixed valvular or subvalvular obstruction is likely
 The accompanying systolic murmur is likely due
to AS or VSD and not due to PS
 A “new murmur” of AR in AS may mean infective
endocarditis in a febrile patient with AS.

51. Summary

52. Valvular PS
 Congenital or acquired usually with intact
ventricular septum
 Best heard: left 2nd- 3rd ICS , (conducted to the
left supraclavicular and left side of the neck
 Begins with systolic ejection sound (accentuates
with expiration) , severe PS the ejection sound
fuses with S1 and S4.
 Early peaking with a short duration or a late
peaking with prolonged duration- severity of
obstruction

53.  P2 soft
 S2 split widens – increasing severity of stenosis
 Prominent a waves in JVP, left parasternal heave,
And RV S4 which increases with inspiration
 Associated with PR in dysplastic pulmonary
valve(Noonan s syndrome) or with IE
 Hypertelorism and moon facies

54.  It increases with inspiration
 Decreases on standing , valsalva
 Grade 4/6

56. Infundibular PS
 Associated with TOF
 Best heard – 3rd left ICS
 Shorter as severity of obstruction increases
 Ejection click can be there
 Shortens and decreases in intensity with amyl
nitrate inhalation
 P2 absent

58. Supravalvular PS
 Maybe associated with supravalvular AS
 Best heard: upper left sternal border,
infraclavicular region and laterally
 Murmur is Less harsh high pitched with varying
intensity.
 On branched PA stenosis : murmur is heard more
laterally with transmission to right chest , back
and both axillae. Can become continuous with
increased severity

59. Functional murmurs
Due to
dilatation of
aortic root
Dilatation of
pulmonary
artery
Due to
increased flow
into aorta
Due to
increased flow
into the PA
Sclerotic aorta in
elderly
Idiopathic PA
dilatation
Pregnancy ASD
Dilated PA
secondary to
PAH
Anemia VSD
Thyrotoxicosis straight back
syndrome and
pectus
excavatum
Fever
Peripheral A-V
Fistula

60. Regurgitant
murmurs

61. Early systolic murmur
 High pitch
 Decrescendo
 Begin at S1 and end well before S2 , mid systole
 Regurgitant murmurs flow from high pressure
chamber to low pressure cardiac chamber.
 Acute severe MR(associated with exp. Split S2)
 TR(with normal RV systolic pressure)
 Small VSD or non restrictive VSD with PAH

63. Regurgitant or holosystolic or
Pansystolic murmur
 High pitched
 Blowing in quality
 Produced by retrograde flow from high chamber to
low chamber .
 Begins with S1 occupies whole of systole and ends
with S2 at its origin
Causes
 Chronic MR
 Chronic TR
 Restrictive VSD
 Aorto- pulmonary connection : AP window and PDA
with PAH(rise in PVR abolishes the diastolic portion of
continuous murmur and PSM is audible)

64. CHRONIC MR
 LV Pressure exceeds the LA throughout systole
 High pitched ,
 blowing in quality,
 plateau like in configuration
 grade 3/6 in intensity
 No thrill
 No little variation with respiration /cardiac cycle
during arrhythmias
 Best heard: apex , radiating to left axilla , angle of
the scapula and occasionally to the vertebral
column .

66.  Anterior mitral leaflet involvement : the regurgitant jet
is directed posterolaterally within LA with bone
conduction from cervical to lumbar spine .
 Posterior mitral leaflet: left sternal edge, base and
may even radiate into the neck when the direction of
the intra –atrial jet is forward and medial against the
interatrial septum.
 Presence of LVS3 with muffled S1- significant MR.

67. Chronic TR
 Holosystolic – RV pressure is elevated or
secondary to PAH/PS
 Soft , high pitched and blowing
 Grade <3/6
 Increases in intensity with inspiration (Carvallo’ s
sign ) but absent when associated with severe RV
failure or organic TR

69.  In severe RV failure , RV fails to take up
additional venous return with inspiration , CO falls
, decrease in murmur
 Associated organic TS with TR prevents increase
in venous return into RV, hence murmur
decreases

70.  Best heard at the lower left sternal border
(Tricuspid area) with no selective radiation
 RV forms apex , murmur can be heard t the apex
(simulating MR)
 Associated with prominent ‘v’ wave with rapid ‘y’
decent in JVP
 RVS3,left parasternal heave .
 Organic TR:murmur is non- holosystolic low
frequency , RV systolic pressure normal.

71. Murmur of VSD(restrictive )
 Left ventricular systolic pressure and systemic
vascular resistance exceed right ventricular
systolic pressure and pulmonary vasculature
resistance from the onset to the end of systole.
 Medium pitched harsh , >4/6 grade and
associated with thrill
 Best heard along the left sternal border in 3rd to
5th ICS spaces during expiration

72.  Supracristal VSD: PA conducted to infraclavicular
area and left neck (confused with PS
 In Gerbode’s defect (VSD of LV to RA) – murmur
conducted to right sternum
 VSD of L- TGA may be best heard at the apex
 Valsalva maneuver and amyl nitrate inhalation
decrease the murmur intensity

74.  Non PSM – large non restrictive VSD(>0.8cm sq.
/meter sq.),
 Very small VSDs,
 multiple VSDs
 Eisenmanger syndrome (pulmonary ESM maybe
present )

75. SUMMARY
Features MR TR VSD
Best heard apex Lower left sternal
area
Left sternal
border in 3rd -4th
ICS
Selective
transmission
Radiation to
axilla and back
No No
Thrill Rare (with
chordal rupture )
- common
Character High pitched ,
blowing
High pitched ,
soft and blowing
Medium pitched ,
rough and harsh
Respiration No change Increases during
inspiration
Increases during
expiration
Accompanying
features
Eccentric left
ventricular
hypertrophy ,
soft S1, LV S3
Right ventricular
hypertrophy ‘v ‘
wave in JVP
.signs of PAH
Biventricular
enlargement and
have signs of PH

76. Late systolic murmur
 Begin at mid to late systole and proceed upto S2
 MVP – prolapse of posterior mitral leaflet
 High pitched
 Musical quality(whoop or honk)
 Best heard : apex introduced by single or multiple
ejection clicks

79.  Thank you