Heart Murmurs - Physical Exam

Heart Murmurs

Timing of Murmurs

Listening for Murmurs

·        Areas of greatest intensity: Mitral regurgitation is loudest over the apex and radiates into the axilla – but may be heard over the whole praecordium. Aortic murmurs radiate into the carotid arteries

·        Benign murmur of pregnancy – ejection systolic.  Pan systolic or diastolic murmurs are abnormal

·        In general, systolic murmurs are easier to hear than diastolic murmurs

·        Loudness:  Doesn‟t always correlate with severity but a change is significant (eg after an MI).

o  For systolic:

§  Grade 1/6: very soft.  Consultants only!

§  Grade 2/6: soft.  Detected immediately by an experienced operator

§  Grade 3/6: moderate but no thrill

§  Grade 4/6: loud, thrill just palpable

§  Grade 5/6: very loud, thrill easily palpable

§  Grade 6/6: audible without stethoscope

o  For diastolic: Usually graded 1 to 4

·        Pitch: low pitched Þ turbulent flow under pressure (eg mitral stenosis), high pitched Þ high velocity (eg mitral regurgitation)

·        Clues can also be obtained from peripheral signs (eg tricuspid regurgitation ® pulsitile liver, slow rising pulse ® aortic stenosis)

·        Dynamic manoeuvre testing:

o   Respiration: Right sided murmurs louder on Inspiration (due to ­venous return), Left sided louder on Expiration (brings heart closer to the chest wall – especially for aortic regurgitation) – RILE

o   Valsalva manoeuvre (¯ preload): Hold nose, close mouth, breathe out hard to pop ears and hold. Listen over left sternal edge for changes in the systolic murmur of hypertrophic cardiomyopathy, and over the apex for mitral valve prolapse. Other murmurs will be quieter due to ¯left and right filling

o   Squatting or leg raise (­preload): ­venous return and ­arterial resistance ® most murmurs are louder

o   Handgrip (­afterload): aortic stenosis quieter