Heart murmurs

Differential Diagnosis

Valvular Emergencies

• Mitral stenosis
• Mitral regurgitation
  • Mitral valve prolapse
• Aortic stenosis
• Aortic regurgitation

Evaluation

Lesions

• Aortic Stenosis
  • Systolic murmur heard best in the aortic area; rarely at apex. Crescendo-decrescendo, radiates to carotids. A2 decreased. Paradoxical splitting of S2; narrow pulse pressure. Pulsus parvus et tardus.
• Aortic Insufficiency
  • Diastolic blowing murmur heard at left sternal border in 3rd and 4th interspace. Wide pulse pressure. Quincke's sign (capillary pulsations at fingertips), DeMusset's sign (bobbing head), Muller's sign (pulsing uvula), Corrigan's pulse (water hammer). Pistol shot sounds.
• Pulmonic stenosis
  • systolic murmur heard in pulmonic area, transmitted to back and neck. A2 is decreased, P2 is delayed, RVH with parasternal lift.
• Pulmonic insufficiency
  • High pitched diastolic murmur; heard in pulmonic area; decrescendo; RVH
• Mitral Stenosis
  • low rumbling diastolic murmur heard best at apex c bell. Opening snap sometimes present worse c closer to S2. Loud S1. (associad c L atrium dilation)
  • Can hear presystolic sound confused c systolic murmur.
• Mitral Insufficiency
  • loud, holosystolic, high-pitched, heard best at apex and transmitted to axilla. Soft S1. Severity gauged by s3, rumble.
  • paradoxical splitting:

Sounds

• Gallavardin Effect
  • AS sounds like MR--high frequency vibrations to the apex through a calcific AV
• Austin-Flint
  • MS sounds like AR--Soft, rumbling murmur, likely due to functional mitral valve stenosis as the backflow of blood from the aorta presses on anterior leaflet of MV.
• Parodoxical S2
  • Splittin during expiration and goes away during inspiration. secondary to inc L sided volume; AS, HOCM
• Wide S2
  • secondary to Inc R sided volume; PE, ASD, VSD, Pulmonic stenosis
• S3
  • AKA ventricular gallop produced during passive LV filling when blood strikes a compliant LV; CHF, Inc Vol, CAD, benign in youth, train athletes
• S4
  • AKA atrial gallop produced when blood is force into a stiff/hypertrophic ventricle ;MI, HTN, restrictive cardiomyopathy

Maneuvers

• Valsalva
  • Increases thoracic pressure and lowers preload; then then decreased CO and afterload
  • Increases murmur in MP & HOCM
  • With release: R heart murmurs return first
• Hand grip
  • Increases HR + CO
  • Increases murmur in MR, MS, AR
  • Decreases murmur in AS and HOCM
• Squatting
  • Increased venous return
  • Delays MP click
• Standing
  • Dec in both R & L venous return & SV
  • Decreases murmur of PS, AS, AR, TR, VSD
  • Increases murmur of HOCM
• Inspiration
  • Increases R sided venous return while decreasing L sided return
  • Increases S2 splitting with P2 further from A2
  • Increases in R sided S3 & S4
  • Increases TS opening snap & murmur, PR, TR
  • Decreases MS opening snap, MVP murmur

See Also

• Valvular emergencies
• Innocent Murmurs (Peds)