The document provides guidance on evaluating heart murmurs through careful auscultation and consideration of various attributes. Key attributes include timing, grade, quality, pitch, configuration, radiation, and variation with maneuvers. The cause of a murmur can be deduced by analyzing these attributes in combination with the clinical context and physical exam findings. Common causes of murmurs discussed include various valvular abnormalities, shunts, and innocent/benign murmurs. Dynamic auscultation maneuvers are also described that can help characterize murmurs.

1. Cardiac murmurs
And approach to a patient with murmurs

2. ● The d/d of a heart murmur begins with a careful
assessment of its major attributes and response to
bedside manoeuvres.
● The history, clinical context and a/w physical
examination findings provide additional clues to help
the significance of a heart murmur

4. ● Heart murmurs are caused by audible vibrations due
to :
1. increased turbulence from accelerated blood flow
through normal; or abnormal orifices
2. flow through a narrowed or irregular orifice into a
dilated vessel or chamber.
3. backflow through an incompetent valve, VSD, PDA

5. MURMURS ARE DESCRIBED UNDER
FOLLOWING HEADINGS
● TIMING
● GRADING
● QUALITY
● PITCH
● CONFIGURATION
● RADIATION/CONDUCTION
● BEST HEARD IN WITH DIAPHRAGM OR BELL
● PATIENT POSITION
● WITH BREATH HELD IN INSPIRATION OR EXPIRATION
● VARIATION WITH OTHER MANEUVERS
● LOCATION OF MAXIMUM INTENSITY

6. ● It may be systolic , diastolic or continuous.

7. Caption

8. Caption

9. INTENSITY
● GRADED FROM 1-6 BY LEVINE AND FREEMAN

11. Quality refers to the tonal effect of the murmurs.
Frequently used descriptors are blowing, musical, squeaking, whooping, honking,
harsh, rasping, grunting, and rumbling.

12. ▪ Relates to the velocity of the blood at the site of origin of the
murmur
▪ Designated as high, medium, or low.
▪ In general, the higher the velocity, the higher the pitch of the
murmur.
▪ Murmurs that emanate from areas of stenosis where velocity is lower
are typically low to medium pitched.

13. CONFIGURATION OF MURMUR

14. DURATION AND
CHARACTER
● Duration depends on the time during which the
pressure difference exists btn chambers and vessels
● This pressure difference along with geometry and
compliance of involved chambers and vessels dictate
the character , frequency and intensity of murmur.

15. LOCATION AND RADIATION

16. RADIATION CONDUCTION
IT IS THROUGH NON CARDIAC
STRUCTURES
IT IS THROUGH ANATOMICAL
CONTINUITY
INTENSITY DECREASES WITH
DISTANCE
INTENSITY REMAINS SAME OR
DECREASES WITH DISTANCE
MR MURMUR RADIATES TO
AXILLA
AS MURMUR CONDUCTS TO
CAROTIDS

17. Bell or diaphragm?
Best heard with bell
MDM of MS and TS
Best heard with diaphragm
Systolic murmur of MR, TR, AS and diastolic murmur of
AR

18. SUPINE
Accentuates
Valvular AS/PS TR
Attenuates
EDM of AR
Murmur of HOCM
MVP murmur and click
are delayed

19. Variation with position
LEFT LATERAL
RECUMBENT
Accentuates
MS
MR
Click and murmur of MVP
Austin Flint murmur (AR)
Caption

20. SITTING AND LEANING
FORWARDS
Accentuates
AR
PR
Caption

21. ▪ Right sided
murmurs increase
on inspiration
▪ TS
▪ TR (Carvallo’s sign*)
▪ PR
▪ Mild or moderate PS
▪ Severe PS
▪ Left sided murmurs increase on
expiration
▪ MS
▪ MR
▪ AS
▪ AR
▪ VSD
▪ Pericardial rub

23. ▪ Location refers to the point on the precordium where the
murmur is heard with maximum intensity.
▪ Many systolic murmurs are audible over multiple areas of the
precordium.
▪ Localizing their point of maximum intensity may aid greatly in
determining their site of evolution.
▪ Example
In aortic stenosis/aortic sclerosis—gallavardin phenomenon seen.
Two distinct systolic murmurs are heard; one high pitched
murmur in the aortic area and the other musical systolic murmur
in the mitral area

24. ▪ The murmur of mitral stenosis is a mid-diastolic low-pitched
rough rumbling murmur with presystolic accentuation best audible
at the apex (mitral area), in the left lateral position with the bell of
the stethoscope, breath held in expiration. The murmur increases
on isometric hand grip.
▪ The murmur of aortic regurgitation is a soft, high-pitched, early
diastolic, decrescendo murmur usually heard best at the third
intercostal space on the left (Erb’s point) with the diaphragm of
the stethoscope at end expiration with the patient sitting up and
leaning forward.

26. INNOCENT MURMURS
● Sensitive, short duration, single, small, soft, sweet,
systolic
● Those murmurs which are due to recognisable lesions
of the heart or blood vessels. They are most common
in children and adolescents
● VIBRATORY SYSTOLIC MURMUR
● AORTIC SYSTOLIC MURMUR
● VENOUS HUM (CONTINOUS)

27. SYSTOLIC MURMURS
EARLY SYSTOLIC MURMUR
1.Acute MR
2.Small muscular VSD
3.TR

28. ACUTE MR
● Decrescendo
● Heard at or just medial to apex.
● Due to non compliant left atrium.
● causes :
1. Capillary muscle rupture in a/c MI
2. Chorda tympanic rupture in myxomatous MVP
3. IE
4. Blunt chest wall trauma

29. ● Posteromedial papillary muscle rupture is common
than anteromedial
● Distinguishing it from post MI ventricular septal
rupture is important.

30. SMALL MUSCULAR VSD
● Early systolic ,localised to left sternal border [grade
4/5].
● Signs of PHTN or left ventricular volume overload
absent.
● In case of large and uncorrected membranous VSD
with elevated pulmonary vascular resistance , may
have an early systolic murmur[in such cases , signs of
PHTN will predominate]

31. ● TR with normal pulmonary artery pressure may also
produce an early systolic murmur
● Murmur is usually soft is best heard at the lower left
sternal border and may increase with inspiration-
carvallo’s sign
● Regurgitant c-v waves may be visible in in the jugular
venous pulse

32. MIDSYSTOLIC MURMURS
Mid-systolic murmurs begin at a short interval
after S1, end before S2 and are usually
crescendo-decrescendo in configuration.
Aortic stenosis is the most common cause of a
mid-systolic murmur in an adult.
The murmur of AS is usually loudest to the right
of the sternum in the second intercostal space
and radiates into the carotids.

33. Differentiation of this apical systolic murmur from MR can be
difficult.
The murmur of AS will increase in intensity, or become louder,
in the beat after a premature beat, whereas the murmur of MR
will have constant intensity from beat to beat.
The intensity of the AS murmur also varies directly with the
cardiac output. With a normal cardiac output, a systolic thrill and
a grade 4 or higher murmur suggest severe AS.
The murmur is softer in the setting of heart failure and low
cardiac output.

34. ● signs of severe AS :
1. Systolic thrill
2. Grade 4 or higher murmur.
3. Soft S2
4. Paradoxical splitting of S2
5. Apical S4
6. Late peaking systolic murmur.
7. Pulsus parvus et tardus.

35. HOCM
● MDM heard along the left sternal border or b/w left
lower sternal border and the apex,
● caused by dynamic LVOT and MR
● Increased during maneuvers that increases LVOT
[reduction in preload and afterload ,inotropes]
● In contrast to AS , the carotid upstroke is rapid and of
normal volume,rarely bifid or bisferiens.

38. PULMONARY STENOSIS
● Best heard in pulmonary area.
● Murmur lengthens and intensity of P2 diminishes with
increasing degree of stenosis.

41. ASD
● Grade 2-3 midsystolic murmur at middle to upper left
sternal border.
● Most commonly by ostium secondum
● Primum ASD may be a/w MR due to cleft anterior
mitral valve leaflet.

43. STILL’S MURMUR
● Grade 2 benign murmur with musical or vibratory
quality at middle to lower left sternal border

44. LATE SYSTOLIC MURMUR
● MVP [common]
● TVP

45. MVP
● Flail determines the radiation of the murmur
● Post leaflet prolapse mimics AS , ant.leaflet prolapse
mimics MR.
● Maneuvers that decrease left ventricular preload will
increase the murmur as leaflet prolapse occurs earlier.

47. HOLOSYSTOLIC MURMUR
● MR
● TR
● VSD

48. MR
● Max intensity over apex
● Radiation to axilla or base
● Soft A2
● May be primary or secondary;
● Primary : hyperdynamic left ventricular apex, wide
splitting of S2
● Secondary : sustained left ventricular apex , single S2
or narrow splitting of S2.

49. ● CHRONIC MR is caused by :
1. Rheumatic scarring of leaflets
2. Mitral annular calcification
3. Postinfarction LV remodelling
4. Severe LV chamber enlargement.
● MR begets MR

52. TR
● Max intensity over left sternal border
● Radiation to epigastrium and right sternal border
● Prominent c-v wave with sharp y descent in JVP.
● Carvello sign
● Primary TR causes myxomatous disease
,endocarditis,rheumatic disease ,radiation, carcinoid,
ebstein anomaly

53. ● Primary TR :
1. Prominent left diastolic parasternal impulse
2. Normal left parasternal systolic impulse
3. Normal P2
● Secondary TR:
1. Sustained left ventricular parasternal impulse
2. Narrow splitting of S2
3. Loud P2

55. VSD
● Max intensity over lower left 3rd and 4th ics , with
widespread radiation ,palpable thrill & wide splitting
of S2 .
● No change in intensity with respiration
● Small restrictive VSD, Maladie de roger creates a loud
murmur.

57. DIASTOLIC HEART
MURMURS
● Early diastolic murmurs :
1. AR
2. PR

58. AR
● High pitched blowing decrescendo , best heard at 2nd
RICS.
● Primary valve diseases such as cong.bicuspid disease ,
prolapse or endocarditis,radiates along the left sternal
border.
● Aortic root diseases causes radiation along right
sternal border.[marfan syndrome , Ankylosing
spondylitis,aortic dissection]

61. AUSTIN FLINT MURMUR
● Seen in severe AR.
● Differentiating it from MDM due to MS is
important.[vasodilator challenge by amyl nitrate will
decrease austin flint murmur ]
● In severe AR, a crescendo decrescendo MSM is heard
at the base of the heart due to inc. volume and rate of
systolic flow.
● Acute severe AR causes short and low pitched murmur
.

62. PR
● Graham steell murmur best heard at 2nd left ICS and
radiates along lest sternal border
● Most commonly due to pulmonary artery HTN.
● PR in the absence of pulm. Artery HTN is due to
endocarditis or cong. deformed valve

64. MDM
● CAUSES:
1. MS
2. Carey coombs murmur
3. TS
4. Increased flow
5. Severe AR

65. MS
● RF is the MC cause .
● Loud S1
● Opening snap[high pitched]
● Presystolic accentuation may be present.
● Murmur increases with increase in mitral valve flow
and cardiac output .
● P2-OS gap is inversely proportional to LA-LV pressure
gradient.

68. TS
● Best heard at lower left sternal border
● prolonged y descent in JVP.

70. OTHER MDMs
● Large left atrial myxoma causes MDM that change in
duration and intensity with changes in body position.
● Acute rheumatic fever causes MDM due to mitral
valvulitis
● CHB causes intermittent MDM
● Severe isolated TR
● Large ASD

71. Continuous murmurs
● Causes :
1. PDA : at upper left sternal border, along the course of 1 or 2
ribs
2. RSOV :at upper right sternal border
3. Coronary AV fistula
4. Cervical venous hum at the right supraclavicular fossa
5. Mammary souffle of pregnancy
6. Aortic septal defect
7. Anomalous left coronary artery
8. Bronchial collateral circulation
9. Small [restrictive] ASD with MS
10. Intercostal AV fistula

72. Dynamic Auscultation
● 1. Respiration: left sided murmurs may be heard at end
expiration & right sided murmurs are heard at end
inspiration
● 2. Alternations of systemic vascular resistance: Systolic
murmurs of MR and VSD becomes louder during
sustained hand grip & infusion of a vasopressor agent.
Murmur of AS or HOCM increases with inhaled amyl
nitrite

73. ● 3. Changes in venous return:
*Valsalva maneuver causes decrease in venous
return, ventricular filling and cardiac output. All
murmurs except that of MVP & HOCM decreases in
intensity
*Standing from squatting position causes rapid
decrease in the venous return
● 4. Post premature ventricular contraction: Systolic
murmurs due to LVOT increase in intensity after a
premature beat(due to enhanced left ventricular filling