II. Physiology

  1. Turbulent Blood Flow results in vibratory changes picked up by stethoscope
  2. Ventricles fill most rapidly in the first third of diastole
    1. Aortic Regurgitation murmur is loudest in early diastole
    2. Mitral Stenosis murmur is also loudest in early diastole (with a slight delay for mitral valve opening)
  3. Ventricles empty most rapidly in the first third of systole
    1. However, the Aortic Stenosis murmur is a crescendo decrescendo Systolic Murmur (increases, peaks and decreases)
  4. Factors that increase murmur intensity
    1. Increased pressure gradients and velocity changes
    2. Increased Cardiac Output
  5. Factors that decrease murmur intensity
    1. Pericardial Effusion
    2. Decreased Cardiac Output
    3. Obesity

III. Images

  1. Cardiac Cycle Volumes and Pressures (Wiggers Diagram)
    1. cvCardiacCycleWiggers.png

IV. Exam

  1. Characteristics
    1. Identify beginning of systole and diastole
      1. S1 Heart Sound
      2. S2 Heart Sound
  2. Timing
    1. Determine timing of murmur
      1. Systolic Murmur
      2. Diastolic Murmur
      3. Continuous Murmur
    2. Determine Early, Middle or late in interval
  3. Severity
    1. Grade 1/6: Barely audible
    2. Grade 2/6: Just easily audible
    3. Grade 3/6:
    4. Grade 4/6:
    5. Grade 5/6: Loudest requiring a stethoscope
    6. Grade 6/6: Heard with stethoscope off chest
  4. Location
    1. Identify valve area involved
  5. Pattern
    1. Uniform: Constant
    2. Crescendo: Increasing
    3. Decrescendo (Diminuendo): Decreasing
    4. Crescendo-Decrescendo: Diamond Shaped Murmur
  6. Pitch
    1. Low pitched
      1. Best heard with bell chest-piece at light pressure
    2. High pitched
      1. Best heard with diaphragm at firm pressure
      2. Valve insufficiency murmurs are high pitched due to higher velocity Blood Flow
  7. Dynamic Maneuvers: Affecting Left Ventricular Preload (most useful single set of dynamic tests)
    1. Decreased Left Ventricular Preload (e.g. Valsalva, stand from squat, forced heavy expiration)
      1. Increases Hypertrophic Cardiomyopathy and Mitral Valve ProlapseSystolic Murmurs
      2. Decreases Aortic Stenosis, Mitral Regurgitation and innocent Systolic Murmurs
    2. Increased left Ventricular Preload (e.g. Squat, passive leg raise)
      1. Increases innocent Systolic Murmurs as well as Mitral Regurgitation and Aortic Stenosis
      2. Decreases Hypertrophic Cardiomyopathy and Mitral Valve ProlapseSystolic Murmurs
  8. Dynamic Maneuvers: Other
    1. Increased Afterload (e.g. hand grip, transient arterial Occlusion with Blood Pressure cuff)
      1. Increases Mitral Regurgitation, pulmonic stenosis and Ventricular Septal DefectSystolic Murmurs
      2. Decreases Hypertrophic Cardiomyopathy, Aortic Stenosis and Mitral Valve ProlapseSystolic Murmurs
      3. Increases Aortic Regurgitation, Ventricular Septal Defect (and possibly Mitral Stenosis) Diastolic Murmurs
    2. Increased venous return and increased left Ventricular Afterload (e.g. deep or exaggerated inspiration)
      1. Increases tricuspid regurgitation, pulmonic stenosis Systolic Murmurs
      2. Increases tricuspid stenosis (and possibly pulmonary regurgitation) Diastolic Murmurs
    3. Decreased jugular venous return (Jugular Vein compression, or transition supine from sitting)
      1. Decreases Venous Hum continuous murmur
  9. Consider auscultation in different positions
    1. Supine
    2. Erect
    3. Left lateral decubitus position

V. Interpretation

  1. Benign murmur findings
    1. Murmur characteristics
      1. Crescendo-decrescend character
      2. Musical or vibratory murmur
      3. Quiet murmur (Grade 2 or less)
      4. Timing: Early systolic or mid Systolic Murmur
      5. Location: Left sternal border or pulmonic area
    2. Associated findings absent
      1. Cardiopulmonary symptoms absent
      2. Family History absent
      3. Exam (BP, pulse, auscultation) otherwise normal
      4. Normal physiologic split S2 without gallup or click
  2. Pathologic murmur findings
    1. Murmur characteristics
      1. Timing: Diastolic, mid-late systolic, holosystolic
      2. Loud murmur (Grade 3 or greater)
      3. Murmur exacerbated by Valsalva Maneuver
      4. Murmur radiates to Carotid Artery or axilla
    2. Associated findings present
      1. Arrhythmia present
      2. Symptoms: Chest Pain, Palpitation, Dyspnea, Syncope
      3. Sudden Cardiac DeathFamily History
      4. Jugular Venous Pulsation abnormal
      5. Arterial pulsation abnormal
        1. Wide Pulse Pressure
        2. Water-Hammer Pulse (rapidly rising, bounding)
        3. Weak, slow rising pulse
      6. Other abnormal precordial exam
        1. Other heart sounds (e.g. Loud S1, fixed split S2)
        2. Left ventricular heave

VI. Resources

  1. University of Michigan Heart Sound and Murmur Library
    1. http://www.med.umich.edu/lrc/psb/heartsounds/

Images: Related links to external sites (from Bing)

Related Studies

Ontology: Heart murmur (C0018808)

Definition (MSHCZE) Zvuky srdce způsobené vibracemi, které jsou vydávány při průtoku krve srdcem. Srdeční šelesty mohou být zkoumány poslechem (SRDCE – POSLECH) a analyzovány podle jejich intenzity (6 stupňů), podle jejich trvání, rytmu (systolický, diastolický nebo kontinuální), podle umístění, přenosu a kvality (muzikální, vibrační, foukavý, atd.)
Definition (NCI) A periodic humming or blowing sound heard on auscultation of the heart that can indicate the presence of cardiac disease; murmurs are the result of vibrations caused by the turbulent flow of blood in the heart or great vessels. Murmurs are characterized according to the area of generation (mitral, aortic, tricuspid, or pulmonary) and according to the period of the cycle (systolic or diastolic).
Definition (MSH) Heart sounds caused by vibrations resulting from the flow of blood through the heart. Heart murmurs can be examined by HEART AUSCULTATION, and analyzed by their intensity (6 grades), duration, timing (systolic, diastolic, or continuous), location, transmission, and quality (musical, vibratory, blowing, etc).
Concepts Finding (T033)
MSH D006337
ICD10 R01.1
SnomedCT 421493004, 274249001, 288315006, 88610006, 158342004, 158337007, 301129009, 414786004
English Cardiac Murmurs, Heart Murmurs, Murmur, Cardiac, Murmur, Heart, Murmurs, Cardiac, Murmurs, Heart, HEART MURMUR, Cardiac murmur, unspecified, [D]Heart murmur (context-dependent category), [D]Heart murmur NOS (context-dependent category), Heart murmur (observable entity), Heart murmur [D], [D]Heart murmur NOS, heart murmur on auscultation (physical finding), heart murmur, heart murmur on auscultation, murmurs, Cardiac murmur NOS, Heart murmurs, Heart Murmur, Heart murmur NOS, Heart Murmurs [Disease/Finding], Murmur;cardiac, murmuring, cardiac murmurs, heart murmuring, heart murmurs, Cardiac Murmur, [D]Heart murmur NOS (situation), [D]Heart murmur, Finding of heart murmur (finding), [D]Heart murmur (situation), Heart murmur [D] (situation), Cardiac murmur, Observation of heart murmur, Finding of heart murmur, Heart murmur (finding), Heart/arterial murmur nos, heart valve; murmur, heart; murmur, murmur; heart, murmur, Cardiac murmur, NOS, Heart murmur, NOS, Murmur, NOS, Heart murmur [D] (finding), Heart murmur, Murmur, Murmur (finding), cardiac murmur
German HERZGERAEUSCHE, Herzgeraeusch NNB, Herzgeraeusch, nicht naeher bezeichnet, Herzgeraeusch, Herzgeräusche
Italian Soffio cardiaco, Soffio cardiaco NAS, Soffi al cuore, Soffi cardiaci
Spanish soplo cardíaco, soplo cardíaco (entidad observable), Soplo cardiaco NEOM, [D]soplo cardíaco, SAI (categoría dependiente del contexto), soplo cardíaco (categoría dependiente del contexto), SOPLO CARDIACO, murmullo, soplo cardíaco (hallazgo), soplos cardíacos (hallazgo), murmullo cardíaco, soplos cardíacos, hallazgo de soplo, hallazgo de soplo (hallazgo), [D]soplo cardíaco, SAI (situación), soplo cardíaco (situación), [D]soplo cardíaco, SAI, soplo del corazón, Soplo cardiaco, soplo (hallazgo), soplo, Soplos Cardíacos
Dutch hartgeruis NAO, Hartgeruis/vaatgeruis nao, geruis; hart, hart; geruis, hartklep; geruis, Hartgeruis, niet gespecificeerd, hartgeruis, Geruis, hart-, Hartgeruis
French Souffle cardiaque SAI, Souffle au coeur, Souffles cardiaques, Souffle du coeur, Souffle cardiaque, SOUFFLE CARDIAQUE
Portuguese Sopro cardíaco NE, SONS CARDIACOS, Sopro cardíaco, Sopros Cardíacos
Japanese 心雑音NOS, シンザツオンNOS, シンザツオン, 心雑音
Swedish Blåsljud
Finnish Sydämen sivuäänet
Czech Srdeční šelest NOS, Srdeční šelest, šelest na srdci, srdeční šelesty, srdeční šelest, srdce - šelesty
Korean 상세불명의 심장잡음
Polish Szmery serca
Hungarian Szívzörej k.m.n., Szívzörej
Norwegian Kardial bilyd, Hjertebilyd, Bilyd i hjertet