Comprehensive Guide to Heart Murmurs: Types, Characteristics, and Maneuvers

What is a heart murmur?

Turbulent blood flow through the heart; can be valvular disease or an "innocent" murmur.

How is a murmur distinguished from a normal heart sound?

By pitch and longer duration.

What 7 characteristics describe a murmur?

Timing/duration, pitch, intensity, pattern, quality, location/radiation, respiratory variation.

Grade 1 systolic murmur

Very faint; may not be heard in all positions.

Grade 2 systolic murmur

Quiet, but heard immediately after placing the stethoscope.

Grade 3 systolic murmur

Moderately loud.

Grade 4 systolic murmur

Loud, with a palpable thrill.

Grade 5 systolic murmur

Very loud with a thrill; heard even partly off the chest.

Grade 6 systolic murmur

Very loud with a thrill; heard without the stethoscope touching the chest.

Grade 1 diastolic murmur

Barely audible.

Grade 2 diastolic murmur

Faint but immediately audible.

Grade 3 diastolic murmur

Easily heard.

Grade 4 diastolic murmur

Very loud.

Early systolic murmur (timing)

Early onset obscuring S1, ends before S2.

Midsystolic murmur (timing)

Onset after S1, ends before S2; most common timing.

Late systolic murmur (timing)

Onset after S1, ends obscuring S2.

Holosystolic/pansystolic murmur (timing)

Obscures both S1 and S2 (spans all of systole).

Early diastolic murmur (timing)

Early onset obscuring S2, ends before S1.

Mid-diastolic murmur (timing)

Onset after S2, ends before S1.

Late diastolic murmur (timing)

Onset late in diastole, ends obscuring S1.

Are midsystolic murmurs pathologic?

Can be either physiologic/innocent OR pathological (most common type).

Are holosystolic murmurs pathologic?

ALWAYS pathologic.

Are diastolic murmurs pathologic?

Almost ALWAYS pathologic.

Standing (maneuver) - physiology

Decreases venous return and preload; decreases BP, stroke volume, LV volume.

Standing (maneuver) - clinical use

Helps identify mitral valve prolapse; distinguishes HCM from aortic stenosis.

Squatting (maneuver) - physiology

Increases venous return and preload; increases BP, stroke volume, LV volume.

Squatting (maneuver) - clinical use

Helps identify mitral valve prolapse; distinguishes HCM from aortic stenosis.

Valsalva (maneuver) - physiology

Increases intrathoracic pressure during the strain phase, decreasing preload.

Valsalva (maneuver) - clinical use

Distinguishes hypertrophic cardiomyopathy from aortic stenosis.

Isometric hand grip (maneuver) - physiology

Increases afterload (blood volume in arms); minimal effect on preload.

Isometric hand grip (maneuver) - clinical use

Increases murmurs of MR, pulmonic stenosis, VSD, AR, and mitral stenosis.

Innocent/physiologic murmur - characteristics

Midsystolic, soft, no other abnormal heart sounds; most common in the pulmonic region.

Innocent murmur - cause

Turbulence from normal ventricular ejection; common in children/young adults, no valvular disease.

Physiologic murmur - cause

Turbulence from a temporary increase in blood flow (pregnancy, anemia, hyperthyroidism).

Innocent/physiologic murmur - maneuver effect

Decreases with hand grip or sitting.

Aortic stenosis - timing/significance

Midsystolic, pathologic.

Aortic stenosis - location

Right 2nd-3rd intercostal space.

Aortic stenosis - radiation

Neck/carotids.

Aortic stenosis - quality

Medium pitch, crescendo-decrescendo, harsh (more musical at apex).

Aortic stenosis - best heard

Sitting, leaning forward.

Aortic stenosis - maneuvers

Decreases with standing, Valsalva strain, and hand grip; increases with squatting.

Hypertrophic cardiomyopathy murmur - mechanism

Mitral valve hitting the hypertrophied septum (not turbulence).

Hypertrophic cardiomyopathy murmur - timing/significance

Midsystolic, pathologic.

Hypertrophic cardiomyopathy murmur - location

Left lower sternal border (3rd/4th space).

Hypertrophic cardiomyopathy murmur - radiation

Does NOT radiate to the neck.

Hypertrophic cardiomyopathy murmur - quality

Medium pitch, harsh.

Hypertrophic cardiomyopathy murmur - maneuvers

Increases with standing/Valsalva strain; decreases with squatting.

Which maneuver pattern is opposite between aortic stenosis and HCM?

Standing/Valsalva decreases AS but increases HCM; squatting increases AS but decreases HCM.

Pulmonic stenosis - timing/significance

Midsystolic, pathologic.

Pulmonic stenosis - location

Left 2nd-3rd intercostal space.

Pulmonic stenosis - radiation

If loud, toward the left shoulder/neck.

Pulmonic stenosis - quality

Crescendo-decrescendo, harsh.

Pulmonic stenosis - associated sounds

Ejection click, fixed split S2.

Pulmonic stenosis - maneuver

Increases with isometric hand grip.

Mitral valve prolapse - presentation

Midsystolic click extending to late systole; most common extra heart sound.

Mitral valve prolapse - location

Apex/left lower sternal border.

Mitral valve prolapse - sound quality

High-pitched click, followed by late systolic murmur (MR) crescendoing to S2.

Mitral valve prolapse - squatting effect

Delays the click, shortens/decreases the murmur.

Mitral valve prolapse - standing/Valsalva effect

Moves click earlier, lengthens/increases the murmur.

Pulmonary valve prolapse - timing

Late systolic.

Pulmonary valve prolapse - location

2nd left intercostal space.

Pulmonary valve prolapse - quality

Crescendo-decrescendo, harsh; associated with S2 split.

Pulmonary valve prolapse - maneuver

Increases with deep inspiration.

Pulmonary valve prolapse - associated condition

Often part of a congenital disorder (e.g., Tetralogy of Fallot).

Mitral regurgitation - timing/significance

Holosystolic, pathologic.

Mitral regurgitation - location

Apex.

Mitral regurgitation - radiation

Left axilla (less often left sternal border).

Mitral regurgitation - quality

High pitched, harsh/blowing.

Mitral regurgitation - maneuvers

Increases with hand grip; no change with inspiration.

Tricuspid regurgitation - timing/significance

Holosystolic, pathologic.

Tricuspid regurgitation - location

Left lower sternal border.

Tricuspid regurgitation - radiation

Epigastrium.

Tricuspid regurgitation - quality

Medium pitch, blowing.

Tricuspid regurgitation - maneuver

Increases with inspiration.

Ventricular septal defect - timing/significance

Holosystolic, pathologic.

Ventricular septal defect - location

Left 2nd-4th intercostal space (over the septum).

Ventricular septal defect - intensity

Often loud with a thrill; smaller defects can be louder.

Ventricular septal defect - quality

High pitched, harsh.

Ventricular septal defect - maneuver

Increases with isometric hand grip.

Aortic regurgitation - timing/significance

Diastolic, pathologic.

Aortic regurgitation - location

Left 2nd-4th ICS (Erb's point).

Aortic regurgitation - radiation

If loud, to the apex; occasionally right sternal border.

Aortic regurgitation - quality

High pitched, blowing decrescendo.

Aortic regurgitation - best heard

Sitting, leaning forward, breath held after expiration.

Aortic regurgitation - maneuver

Increases with isometric hand grip.

Pulmonic regurgitation - quality

High pitched, decrescendo, blowing.

Pulmonic regurgitation - location

Pulmonic area.

Pulmonic regurgitation - maneuvers

Increases with sitting/leaning forward and with inspiration.

Mitral stenosis - timing/significance

Diastolic, pathologic.

Mitral stenosis - cause

Commonly rheumatic heart disease.

Mitral stenosis - location

Apex (more prominent in left lateral decubitus position).

Mitral stenosis - quality

Low pitched, rumbling, often with an opening snap.

Mitral stenosis - maneuver

Increases with isometric hand grip.

Tricuspid stenosis - quality

Rumbling.

Tricuspid stenosis - location

Tricuspid area.

Tricuspid stenosis - maneuver

Increases with a deep breath.

Tricuspid stenosis - associated sound

Opening snap may be heard.

Late diastolic murmur - causes

Mitral/tricuspid stenosis (late component) or atrial myxoma obstructing an AV valve.

Patent ductus arteriosus - cause

Congenital right-to-left shunt from the aorta to the pulmonary artery.

Patent ductus arteriosus - timing

Continuous (systole AND diastole), crescendo-decrescendo.