Cardiac murmurs

1.What is a murmur?
2.Pathophysiology of murmur
3.Systolic or diastolic
4.Physiological or pathological
5.Grades of murmur
6.Named murmurs
7.Causes of murmur
Auscultation has a reported sensitivity of 70 percent
and a specificity of 98 percent
for detection of valvular heart
disease .

The sensitivity and specificity vary substantially with

the expertise of the examiner.
The character of a murmur is described by
 intensity

 frequency, low pitch/ high pitch

 timing, systolic/ diastolic
 shape, crescendo/ decrescendo
 location, and mitral/ aortic/ pulmonary/
tricuspid
 radiation. transmitted to which area…
 
Intensity

The intensity of a murmur is determined by

The quantity and velocity of blood flow at the site of

its origin
The transmission characteristic of the tissues between
blood flow and stethoscope
The site of auscultation or recording, and the
distance of transmission.
The intensity declines in the presence of obesity,
emphysema, and pericardial effusion.
Murmurs are usually louder in children and in thin
individuals.
Intensity is graded on a 6 point scale

 Grade 1 = very faint

 Grade 2 = quiet but heard immediately
 Grade 3 = moderately loud
 Grade 4 = loud with thrill
 Grade 5 = heard with stethoscope partly off the chest
 Grade 6 = no stethoscope needed

Grade of more than 4 is associated with thrill.

Pitch — The frequency of the murmur determines the pitch,
high or low

The quality
harsh,
rumbling,
scratchy,
grunting,
blowing,
squeaky, and
musical
Configuration — The time course of murmur intensity
corresponds to the "shape" of a diagram

murmurs are recognized:

Crescendo (increasing)

Decrescendo (diminishing)

Crescendo-decrescendo (increasing-decreasing or
diamond shaped)

Plateau (unchanged in intensity)

Location —
The location on the patient's chest where the murmur is loudest
is typically described as

apical or parasternal

Parasternal murmurs –
intercostal space and
right or left side of the sternum
Timing — The duration of a murmur is assessed by the length
of systole or diastole that the murmur occupies.

Systolic murmurs
Midsystolic (or systolic ejection)
Holosystolic (or pansystolic)
Early systolic
Late systolic

Diastolic murmurs
Early diastolic
Mid-diastolic
Late diastolic (or presystolic)
Continuous murmurs
Systolic murmurs —

A systolic murmur starts with or after S1 and terminates before or at

S2
Recognized by identifying S1 and S2 and timing them with the
carotid pulse.

Midsystolic(Ejection systolic)murmur –
begins after S1 and ends before A2 or P2

Holosystolic (or pansystolic) murmur

starts with S1 and extends up to A2 or P2
obscuring both S1 and S2

Early systolic murmur -obscures S1 and extends for a variable length

in systole
but does not extend up to S2

Late systolic murmur - starts after S1 and obscures A2 or P2

Ejection systolic murmur
is related to flow of blood across the semilunar
valves

S1 occurs at the onset of isovolumic systole when ventricular

pressure rises;

ESM begins at the end of isovolumics ystole when the

ventricular pressure exceed the semilunar valve opening
pressure.

The onset of ESM is therefore separated from S1 and the

interval between S1 and the onset of the murmur is
proportional to the duration of isovolumic systole
The intensity of the ESM increases (crescendo) during
acceleration of blood flow early in systole;
intensity declines (decrescendo) with the later
deceleration of flow, resulting in a crescendo
decrescendo (DIAMOND SHAPED) configuration.

Forward flow from the ventricle stops when ventricular

pressure falls
below the aortic or pulmonary artery pressures, before the
closure of the semilunar valves.

The murmur terminates with cessation of flow, before A2

or P2, depending upon whether the murmur is left or
right sided, respectively.
Causes of ESM

1.Flow murmurs across pulmonary area in anaemia and other

hyperdynamic circulation
2.Aortic valve sclerosis
3.Aortic/ pulmonary stenosis
4.Idiopathic dilatation of pulmonary artery
Aortic stenosis murmur is described as crescendo descrescendo
murmur best heard in the aortic area conducted to carotid in
sitting and leaning forward position breath held in expiration
S2 is soft here.
Causes
1.Rheumatic
2.Bicuspid
3.Supravalvular AS
Holosystolic murmur/ Pansystolic murmur

Usually regurgitant murmurs

They occur when blood flows from a chamber whose pressure

throughout systole is higher than pressure in the chamber
receiving the flow.

There are three causes of holosystolic murmurs:

1.MR
2.Tricuspid regurgitation
3.VSD
The timing and duration of holosystolic murmurs are best explained by the
hemodynamic changes of MR

Hemodynamically significant MR

regurgitant flow from the left ventricle to the left atrium begins with the
onset of isovolumic systole when pressure in the left ventricle just exceeds
pressure in the left atrium.

Throughout systole and extending to the early part of the isovolumic relaxation
phase, the left ventricular pressure remains higher than the left atrial pressure.

Thus, the regurgitant flow continues throughout systole, and even after aortic valve
closure, explaining the holosystolic character of the regurgitant murmur.

This also explains why A2 is often drowned by the murmur over the cardiac apex.

The same mechanism applies to TR and VSD

 MR TR VSD
Point of maximum Apex Tricuspid Lft. 3 rd or 4
intensity area th intercostal
spaces

Changes with Increases with Increases Increases

respiration expiration with with
inspiration( expiration
CARVALLOS
SIGN)
Heart sounds S1 soft S 1 soft, assc S1, S2
with loud P2 normal
intensity
Assc features S3 gallop Raised JVP
Mitral regurgitation — The holosystolic murmur of MR is high
pitched and best heard with the diaphragm of the
stethoscope and the patient in the left lateral decubitus
position breath held in expiration

The direction of radiation follows the direction of the

regurgitant jet into the left atrium.
When anterior leaflet is involved the murmur radiates towards
axilla and when posterior leaflet is involved it radiates
towards the sternum
EARLY SYSTOLIC MURMURS
Early systolic murmurs begin with S1, do not
extend to S2, and
generally have a decrescendo configuration.

Common causes
1.Acute MR
2.Chronic mild MR
LATE SYSTOLIC MURMUR

A late systolic murmur starts after S1 and, if left-sided, extends to

A2, usually in a crescendo manner
Mitral valve prolapse — Mitral valve prolapse is the most common
cause of a late systolic murmur.
It is best heard with the diaphragm of the
stethoscope, over or just medial to the cardiac apex.
It is usually preceded by single or multiple
clicks

The murmur is heard as a whoop" or "honk," which is a high-

frequency, musical, loud, and widely transmitted murmur, can
appear intermittently in some patients with mitral valve prolapse
and may be precipitated by a change of posture.

Papillary muscle dysfunction

Tricuspid valve prolapse
Diastolic murmurs — A diastolic murmur starts with or after S2
and ends at or before S1.

Early diastolic murmur

starts with A2 or P2 and extends
into diastole for a variable duration

Mid-diastolic murmur- starts after S2 and terminates before S1

Late diastolic (presystolic) murmur -starts well after S2 and

extends up to the
S1
EARLY DIASTOLIC MURMURS —

Early diastolic murmurs occur due to aortic or pulmonary

regurgitation, typically start at the time of semilunar valve
closure and their onset coincides with S2.

An aortic regurgitation murmur begins with A2; pulmonary

regurgitation begins with P2.

Two common causes

1.Aortic reurgitation
2.Pulmonary reurgitation
The murmur of aortic regurgitation

Best heard with the diaphragm of the stethoscope.

Low-intensity, high-pitched

Heard with firm pressure applied with the diaphragm of the

stethoscope over the left sternal border or over the right
second interspace,

patient in sitting position and leaning forward with the breath

held in full expiration

Not associated with thrill

The radiation of an aortic regurgitation murmur is
towards the cardiac apex

Radiation of the murmur to the right sternal border is

more common in aortic regurgitation caused by aortic
root or aortic cusp anomalies

The configuration of the aortic regurgitation murmur is usually

decrescendo because the magnitude of regurgitation
progressively declines.

The murmur is high-frequency and has a "blowing" character.

Occasionally the murmur can be musical in quality (diastolic

whoop); this has been attributed to a flail everted aortic cusp.
An Austin Flint murmur( Mid Diastolic Murmur) is usually
associated with significant aortic regurgitation

Reversed splitting of S2, suggests significant aortic

regurgitation.

Reduced intensity of S 1 is usually associated with an elevated

left ventricular end-diastolic pressure, which is more likely to
occur in severe aortic regurgitation.

Physical findings of pulmonary venous and arterial hypertension

and right-sided heart failure indicate hemodynamically
significant aortic regurgitation.
Pulmonic regurgitation is a result of pulmonic hypertension
(Graham- Steell murmur) or residual after Tetralogy of Fallot
repair in adults

The murmur of pulmonic regurgitation ,

is high-pitched and "blowing."

decrescendo configuration
differentiation from AR is difficult if by auscultation alone.
The murmur increase in intensity during inspiration more
localized.
It is best heard over the left second and third interspaces.
Mid diastolic murmur

MID-DIASTOLIC MURMURS —
Mid-diastolic murmurs result from turbulent flow
across the
atrioventricular valves during the rapid filling phase
because of
mitral or tricuspid valve stenosis and an abnormal
pattern of
flow across these valves.

1.Mitral stenosis
2.Tricuspid stenosis
3.Atrial myxoma
4.Right bunde branch block
5.Austin flint murmur
6.Flow murmur in VSD, ASD and PDA
7.Carey coombs murmur
Mitral stenosis —

The mid-diastolic murmur of mitral stenosis has a rumbling

character and is best heard with the bell of the stethoscope
over the left ventricular impulse with the patient in the left
lateral decubitus position

The murmur is present both in sinus rhythm and in atrial

fibrillation.

It characteristically starts with an opening snap.

The longer the duration of the murmur, the more severe is the
mitral stenosis.

Associated with pre systolic accentuation.

Tricuspid stenosis —
Tricuspid stenosis may be associated with a mid-
diastolic rumble
that is best heard along the left sternal border.

The most characteristic feature is the increase in

intensity of the
murmur with inspiration (Carvallo's sign)

Atrial myxoma —
Atrial myxoma may cause obstruction of the
atrioventricular
valves and a mid-diastolic murmur.

In left atrial myxoma, the auscultatory findings can

be similar to
those of mitral stenosis.
Austin Flint murmur — An apical diastolic rumbling murmur
has been described in patients with pure aortic regurgitation

Three mechanisms proposed

1.Fluttering of the mitral valve from the impingement by the

aortic regurgitant jet

2.Premature partial closing movement of the mitral valve at

mid-diastole due to the regurgitant flow, leading to
functional mitral stenosis.

3. Murmur arises from the regurgitant jets that are directed at

the left ventricular free wall
Carey-Coombs murmur —

In acute rheumatic fever

a mid-diastolic murmur over the left ventricular impulse

Two causes

1.Acute mitral valvulitis.

2.First-degree atrioventricular block may contribute to a Carey-

Coombs murmur.
Continuous murmur —
A continuous murmur begins in
systole and continues to diastole without
interruption, encompassing the S2
Cervical venous hum Heard in anaemia, disappears on
compression
of jugular pulse

Hepatic venous hum Disappears with hepatic pressure

Mammary souffle Disappears upon pressing hard with

stethoscope

Patent ductus arteriosus left 1 st intercostal space

Coronary arteriovenous
fistula lower intercostal spaces left

Ruptured aneurysm of
sinus of Valsalva sudden , upper right sternal border
Bronchial collaterals Assc with TOF

High-grade coarctation Due to collaterals

(SUZZMAN S SIGN)

Anomalous left coronary artery

arising from pulmonary artery
( ALCAPA) ECG shows MI like
picture

Pulmonary artery branch

stenosis
Pulmonary AV fistula outside cardiacdullness
Interventions that change murmur
Carvallo's Maneuver

Inhalation will increase the amount of blood filling

into the
right ventricle, thereby prolonging ejection time.
This will affect the closure of the pulmonary valve. All
right sided
murmurs increase
Abrupt standing
Squatting
Valsalva maneuver. One study found the valsalva maneuver to
have a sensitivity of 65%, specificity of 96% in detecting
Hypertrophic obstructive cardiomyopathy (HOCM).
Hand grip
Amyl nitrite
Methoxamine
Positioning of the patient
Named cardiac murmurs
1.Carey coombs
2.Graham steele
3.Austin flint
4. Gibsons murmur
5.Rittons murmur
S 2 / systolic murmur variation with posture
 Definition
◦ The term “ palpitation” refers to unpleasant
awareness of one own heart beat.
 Normal palpitations occur with exercise,
emotions, and stress, or after taking
substances that increase adrenergic tone or
diminish vagal activity.

 Abnormal palpitations usually point to a

cardiac arrhythmia.
 Clinical symptoms and signs
◦ Flip-flopping in the chest
 APCs, VPCs.
◦ Rapid fluttering in the chest
 Atrial or ventricular arrhythmias, including sinus
tachycardia.
◦ Pounding in the neck ( frog sign)
 Dissociation of atrial and ventricular contractions
 Noncardiac disorders
◦ Anxiety
◦ Anemia
◦ Fever
◦ Thyrotoxicosis
◦ Hypoglycemia
◦ Increased release of cathecolamine
◦ Electrolyte disturbances
◦ Drugs ( epinephrine, amphetamine, etc)
◦ Caffeine
◦ Nicotine
 Cardiac disorders
◦ Valvular heart disease
◦ Congenital heart disease
◦ Coronary heart disease
◦ Marked cardiomyopathy
◦ Acute left ventricular failure
◦ Pericarditis
◦ Prosthetic valve
◦ Electronic pacemakers
Diagnosis evaluation
1. History taking
2. Physical examination
3. 12-lead electrocardiography (ECG)
4. Ambulatory monitoring or reassurance
5. Electrophysiologic study
 Elements in history of patient with
complaints of paroxysmal palpitation
◦ Characteristics of palpitation
◦ Mode of onset
◦ Mode of termination
◦ Initiating factors
◦ Associated symptoms
◦ Incidence
◦ Effects of previous treatments
Tachycardias Atrial rates Ventricular rates Regularity Onset and termination

Sinus tachycardia 100 to 150 100 to 150 Regular gradual

Paroxysmal reentrant 140 to 200 140 to 200 Usually regular abrupt
supraventricualr
tachycardia
Paroxysmal automatic 100 to 180 100 to 180 Usually regular Usually abrupt
atrial tachycardia

Paroxysmal atrial 100 to 250, usually Variable Regular or Gradual

tachycardia with block 120 to 180 with 2:1 irregular
block
Multifocal atrial 100 to 180 100 to 180 Irregular gradual
tachycardia

Atrial flutter 220 to 350 Variable Regular or abrupt

irregular
Atrial fibrillation >350 Variable Irregular abrupt

Paroxysmal automatic 100 to 180 with 100 to 180 Regular Usually abrupt
AV-junctional AV dissociation,
tachycardia usually NSR
Paroxysmal ventricular With AV 140 to 200 Regular or abrupt
tachycardia dissociation, slightly irregular
usually NSR
 No predisposing factors : most
 Exercise or emotion : suggesting a role of

adrenergic system
 At rest or after exercise : suggesting a role of

the vagus.
 Chest pain
 Anxiety
 Fear
 Dizziness
 Syncope
 Atrial Atrio- Circus Ventricular
fibrillation ventricular movement tachycardia
nodal tachycardia/
tachycardia atrial
tachycardia
Blood Variable Fixed Fixed Variable
pressure
Heart sounds Variable Fixed Fixed Variable
Arterial Irregular Regular Regular Regular
pulsations
Jugular Absent Frog+ Frog- Cannon
pulsations waves
 Radio-frequency ablation
◦ Most types of supraventricular tachycardia
◦ Many types of ventricular tachycardia
 Beta-blockers
◦ Isolated VPCs, APCs
 Calcium-channel blockers.
THAN
K YOU