are abnormal
Heart Sounds that are produced as a result of turbulent blood flow, which is sufficient to produce audible noise. This most commonly results from narrowing or leaking of valves or the presence of abnormal passages through which blood flows in or near the heart. Murmurs are not part of the normal cardiac physiology and warrants further investigations.
When describing a murmur, one can generally use the following six attributes:
. Intensity is determined by quantity and velocity of flow at the site of its origin. In general, the intensity decreases in the presence of obesity, emphysema, and pericardial effusion. It may increase in children and in thin individuals. There are six grades of murmur intensity:
- ''Grade I'': very faint, difficult to hear
- ''Grade II'': faint, but can be readily identified
- ''Grade III'': moderately loud
- ''Grade IV'': loud
- ''Grade V'': very loud, but still needs stethoscope to hear
- ''Grade VI'': audible without a stethoscope
. Configuration is essentially the "shape" of the murmur.
- Crescendo (increasing)
- Decrescendo (decreasing)
- Crescendo-Decrescendo (diamond-shaped)
- Plateau (unchanged)
. Murmurs can be described as squeaky, musical, harsh, scratchy, rumbling, grunting, or blowing.
. The length of systole or diatsole a murmur occupies.
. The timing of the murmur in relation to the normal cardiac cycle is one of the most important steps in determining the cause of the murmur (see below):
Systolic murmurs start at or after S1 and ends before or at S2. There are several types:
- ''Ejection midsystolic murmur'' begins after S1 and ends before S2
- ''Holosystolic murmur'' begins at S1 and extends up to S2
- ''Early systolic murmur'' begins at S1 and ends at a variable length before S2
- ''Late systolic murmur'' starts after S1 and extends up to S2
Midsystolic ejection murmurs are due to blood flow through the semilunar valves. They occur at the start of blood ejection --- which starts after S1 --- and ends with the cessation of the blood flow --- which is before S2. Therefore, the onset of a midsystolic ejection murmur is separated from S1 by the isovolumic contraction phase; the cessation of the murmur and the S2 interval is the aortic or pulmonary hangout time. The resultant configuration of this murmur is a crescendo-decrescendo murmur. Causes of midsystolic ejection murmurs include outflow obstruction, increased flow through normal semilunar valves, dilation of aortic root or pulmonary trunk, or structural changes in the semilunar valves without obstruction.
- . Can be due to aortic valve stenosis or hypertrophic cardiomyopathy (HCM), with a harsh and rough quality.
- ---''Valvular aortic stenosis'' can produce a harsh, or even a musical murmur over the right second intercostal space which radiates into the neck over the two carotid arteries. The most common cause of AS is calcified valves due to aging followed by congenital bicuspid aortic valves (normal valve is tricuspid). The distinguishing feature between these two causes is that bicuspid AS has little or no radiation. It can be confirmed if it also has an aortic ejection sound, a short early diastolic murmur, and normal carotid pulse. The murmur in valvular AS decreases with standing and straining with Valsalva maneuver.
- ---''Supravalvular aortic stenosis'' is loudest at a point slightly higher than in that of valvular AS and may radiate more to the right carotid artery.
- ---''Subvalvular aortic stenosis'' is usually due to hypertrophic cardiomyopathy (HCM), with murmur loudest over the left sternal border or the apex. The murmur in HCM increases in intensity with a standing position as well as straining with Valsalva maneuver.
- . A harsh murmur usually on left second intercostal space radiating to left neck and accompanied by palpable thrill. It can be distinguished from a VSD by listening to the S2, which is normal in VSD but it is widely split in pulmonary stenosis.
- . Produces a jeection sound, with a short ejection systolic murmur and a relatively wide split S2. There is no hemodynamic abnormality. This is similar to pulmonary hypertension except the latter has hemodynamic instabilities.
- . This can occur in situations such as anemia, pregnancy, or tyrotoxicosis.
- . This is due to degenerative thickening of the roots of the aortic cusps but produces no obstruction and no hemodynamic instability and thus should be differentiated from aortic stenosis. It is heard over right second intercostal space with a normal carotid pulse and normal S2.
- . These murmurs are not accompanied by other abnormal findings. One example is Still's murmur in children.
Usually due to regurgitation in cases such as mitral regurgitation, tricuspid regurgitation, or ventricular septal defect (VSD). These murmurs start at S1 and extends up to S2.
- . In the presence of incompetent mitral valve, the pressure in the L ventricle becomes greater than that in the L atrium at the onset of isovolumic contraction, which corresponds to the closing of the mitral valve (S1). This explain why the murmur in MR starts at the same time as S1. This difference in pressure extends throughout systole and can even continue after the aortic valve has closed, explaining how it can sometimes drown the sound of S2. The murmur in MR is high pitched and best heard at the apex with diaphragm of the stethoscope with patient in the lateral decubitus position. Left ventricular function can be assessed by determining the apical impulse. A normal or hyperdynamic apical impulse suggests good ejection fraction and primary MR. A displaced and sustained apical impulse suggests decreased ejection fraction and chronic and severe MR.
- . Can be best heard over left second and third intercostal spaces and left sternal border. The intensity can be accentuated following inspiration (Carvello's sign) due to increased regurgitant flow in right ventricular volume. Tricuspid regurgitation is most often secondary to pulmonary hypertension. Primary tricuspid regurgitation is less common and can be due to bacterial endocarditis following IV drug use, Ebstein's anomaly, carcinoid diseae, or prior right ventricular infarction.
- . VSD is a defect in the ventricular wall, producing a shunt between the left and right ventricles. Since the L ventricle has a higher pressure than the R ventricle, flow during systole occurs from the L to R ventricle, producing the holosystolic murmur. It can be best heard over the left third and fourth intercostal spaces and along the sternal border. It is associated with nomal pulmonary artery pressure and thus S2 is normal. This fact can be used to distinguish from pulmonary stenosis, which has a wide splitting S2. If the shunt becomes reversed in the Eisenmenger complex because the L ventricle becomes too "tired", The murmur may be absent and S2 can become markedly accentuated and single.
These murmurs are almost identical to holosystolic murmurs, which start at S1 but ends before S2. It is also associated with MR, TR, or VSD. The reason an early systolic murmur is heard rather than a holosystolic murmur is because the condition is more acute and more severe.
Late systolic murmurs starts after S1 and, if left sided, extends up to S2, usually in a crescendo manner. Causes include mitral valve prolapse, tricuspid valve prolapse, and papillary muscle dysfunction.
- . This is the most common cause of late systolic murmurs. It can be heard best over the apex of the heart, usually preceded by clicks. The most common cause of mitral valve prolapse is "floppy" valve (Barlow's) syndrome. If the prolapse becomes severe enough, mitral regurgitation may occur. Any maneuver that decreases left ventricular volume --- such as standing, sitting, Valsalva maneuver, and amyl nitrate inhalation --- can produce earlier onset of clicks, longer murmur duration, and decreased murmur intensity. Any maneuver that increases left ventricular volum --- such as squatting, elevation of legs, hand grip, and phenylephrine --- can delay the onset of clicks, shorten murmur duration, and increase murmur intensity.
- . Uncommon without concomitant mitral valve prolapse. Best heard over left lower sternal border.
- . Usually due to acute myocardial infarction or ischemia, which causes mild mitral regurgitation.
start at or after S2 and ends before or at S1. There are several types:
- ''Early diastolic murmur'' begins at S2 and ends at a variable length before S1
- ''Mid-diastolic murmur'' begins after S2 and ends before S1
- ''Late diastolic murmur'' begins after S2 and extends up to S1
They start at the same time as S2 with the close of the semilunar valves and typically ends before S1. Common causes include aortic or pulmonary regurgitation and left anterior descending artery stenosis.
. The murmur is low intensity, high-pitched, best heard over the left sternal border or over the right second intercostal space, especially if the patient leans forward and holds breath in full expiration. The radiation is typically toward the apex. The configuration is usually decrescendo and has a blowing character. The presence of this murmur is a good positive predictor for AR and the absence of this murmur strongly suggests the absence of AR. An Austin Flint murmur is usually associated with significant aortic regurgitation.
. Pulmonary regurgitation is most commonly due to pulmonary hypertension (Graham-Steell murmur). It is a high-pitched and blowing murmur with a decrescendo configuration. It may increase in intensity during inspiration and best heard over left second and third intercostal spaces. The murmur usually does not extend to S1.
. This murmur, also known as Dock's murmur, is similar to that of aortic regurgitation and is heard at the left second or third intercostal space. A Coronary artery bypass surgery can eliminate the murmur.
These murmurs start after S2 and ends before S1. They are due to turbulent flow across the atrioventricular valves during the rapid filling phase from mitral or tricuspid stenosis.
. This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular impulse area with the patient in the lateral decubitus position. It usually starts with an opening snap. In general, the longer the duration, the more severe the mitral stenosis. However, this rule can be misleading in situations where the stenosis is so severe that the flow becomes reduced, or during high-output situations such as pregnancy where a less severe stenosis may still produce a strong murmur.
. Best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting S1. May increase in intensity with inspiration (Carvallo's sign). Tricuspid stenosis often occurs in association with mitral stenosis. Isolated TS are often associated with carcinoid disease and right atrial myxoma.
. Atrial myxomas are benign tumors of the heart. Left myxomas are far more common than right myxomas and those may cause obstruction of the mitral valve producing a mid-diastolic murmur similar to that of mitral stenosis. An echocardiographic evaluation is necessary.
. This can also produce a mid-diastolic murmur, such as in severe mitral regurgitation where a large regurgitant volume in the left atrium can lead to "functional mitral stenosis."
. An apical diastolic rumbling murmur in patients with pure aortic regurgitation. This can be mistaken with the murmur in mitral stenosis and should be noted by the fact that an Austin Flint murmur does not have an opening snap that is found in mitral stenosis.
. A mid-diastolic murmur over the left ventricular impulse due to mitral valvulitis from acute rheumatic fever.
These murmurs start after S2 and extends up to S1 and have a crescendo configuration. They include mitral stenosis, tricupsid stenosis, myxoma, and complete heart block.
. A short late diastolic murmur can occasionally be heard (Rytand's murmur).
These murmurs are due to blood flow from a high pressure chamber or vessel to a lower pressure system. They begin in S1 and extend up to S2 without interruption.
. PDA is an abnormal connection between the aorta and the pulmonary artery, which normally should be closed in infancy. Since aortic pressure is higher than pulmonary pressure, a continuous murmur occurs, which is often described as a "machinery murmur," or Gibson's murmur.
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. Usually a left to right shunt through a small atrial septal defect in the presence of mitral valve obstruction.
