Heart Murmurs

Know your lubs from your dubs!!!

Nish Dalavaye
Cardiff University
 What we will cover

Basic principles Abnormal Heart Sounds Systolic Murmurs Diastolic Murmurs

Maneuvers Animations/SBAs
throughout!
SUBSCRIBE FOR MORE VIDEOS
 PULMONARY AORTIC
VALVE VALVE
PA AORTA

RIGHT LEFT
ATRIUM ATRIUM

MITRAL
TRICUSPID
VALVE
VALVE
RIGHT LEFT
VENTRICLE VENTRICLE
Normal Heart Sounds
SYSTOLE DIASTOLE

S1 S2 S1

AUSCULTATION
AORTIC VALVE = Second intercostal space.
Right sternal border
PULMONARY = Second intercostal space
VALVE Left sternal border

TRICUSPID VALVE = Fourth intercostal space

Left sternal border
MITRAL VALVE = Fifth intercostal space
Midclavicular line
 Reduced Increased
Inspiration Intrathoracic venous return to
Pressure RV

1 Pulmonary Increased
Expiration capillaries venous return to
constrict LV

Right-sided murmurs Left sided murmurs

are loudest on are loudest on
inspiration expiration
Rinspiration Lexpiration
A 45-year-old man with a background of QUICKFIRE
hypertrophic obstructive cardiomyopathy
(HOCM) attends the cardiology clinic. During QUESTION
the examination, a sound is heard which
correlates with the p wave on an ECG.
What is this sound?
 The 3rd Heart sound
SYSTOLE DIASTOLE

S1 S2 S3 S1
VOLUME
S3 GALLOP KEN-TUCK-EE OVERLOAD

NORMAL S3 ABNORMAL S3 Best heard

• Heart Failure with bell at
• Children & young adults
• Dilated Cardiomyopathy cardiac apex
• Pregnancy
• Trained athletes • Mitral Regurgitation (severe) in left lateral
• Aortic Regurgitation (severe) position
 The 4th Heart sound
SYSTOLE DIASTOLE

S1 S2 S4 S1
PRESSURE
S4 GALLOP TEN-NESS-EE OVERLOAD

CAUSES
S4 is almost (CONDITIONS THAT LEAD TO VENRICULAR
HYPERTOPHY & STIFFENING)
Best heard with
bell at cardiac
ALWAYS • Hypertension • Heart Failure
apex in left
• Aortic Stenosis • HOCM
PATHOLOGICAL • Mitral Regurgitation • Restrictive lateral position
• Ischaemic Heart Disease Cardiomyopathy
 Break time!
LET'S TAKE A 2 MINUTE BREAK TO
RECHARGE...
Any questions? Drop them in the Q and A!
Coming Up Systolic Murmurs!!!
 Gold standard to
diagnose valvular heart
disease
=
Echocardiogram
Grading Murmurs
1 Very faint murmur
2 Soft murmur

3 Moderately loud murmur, no palpable thrill

4 Moderately loud murmur with palpable thrill

5 Murmur easily audible with stethoscope partially off chest

6 Murmur audible with stethoscope completely off chest

 SYSTOLIC MURMURS

AORTIC AORTIC INNOCENT/ PULMONIC ATRIAL MITRAL MITRAL TRICUSPID VENTRICULAR HOCM
STENOSIS VALVE FUNCTIONAL STENOSIS SEPTAL REGURGITATION VALVE REGURGITATION SEPTAL
SCLEROSIS MURMURS DEFECT PROLAPSE DEFECT

HEARD
BEST AT
HEARD BEST LEFT
HEARD BEST HEARD BEST HEARD BEST
AT AORTIC STERNAL
AT AT MITRAL AT TRICUSPID
AREA BORDER
PULMONARY AREA AREA
AREA
An 81 year old woman attends a cardiology outpatient

clinic for her stable angina. On auscultation, she has an

QUICKFIRE
ejection systolic murmur at the right sternal edge. Carotid QUESTION
pulse has good volume and character, and there is no

murmur radiation. BP: 120/80, HR: 60

What is the likely diagnosis?

A 35 year old man presents to the GP with intermittent

palpitations and feeling faint, especially during exercise.

QUICKFIRE
He has an ejection systolic murmur heard at the left lower QUESTION
sternal edge that gets quieter when he is squatting. There

is no radiation to the carotids.

What is the likely diagnosis?

 Aortic Stenosis
Causes
• Degenerative calcification
• Congenital Bicuspid valve Complications
• Rheumatic heart disease • Heart failure

• Infective Endocarditis
Symptoms
• Haemolytic Anaemia
Many individuals asymptomatic

If severe:
• Syncope
• Angina
• Dyspnea
 Aortic Stenosis
SYSTOLE DIASTOLE

S1 CRESCENDO- S2 S1
DECRESCENDO SYSTOLIC
MURMUR

Ejection systolic murmur Other signs Maneuvers

RADIATING TO THE CAROTIDS • Slow rising pulse
Made louder by held Standing Squatting
• Soft S2 Valsalva
expiration with the patient sitting
forward • Signs of heart failure
↓ Intensity of ↑ Intensity of
HEAD LOUDEST IN AORTIC AREA • Ejection click if not severe murmur murmur
Hypertrophic obstructive cardiomyopathy
(HOCM)
Crescendo-decrescendo murmur

Maneuvers

Standing Squatting
Valsalva

↑ Intensity of ↓ Intensity of
murmur murmur

Heard best at left sternal border

A 43 year old man presents to the GP with with a three week

history of dyspnea especially during exercise. QUICKFIRE

QUESTION
On examination, he is very tall and has a high arched palate.

He also has a protruding chest as well as very long fingers.

He is comfortable at rest. Auscultation of his chest reveals a late

systolic murmur preceded by a mid-systolic click.

What is the likely diagnosis?

 Mitral Valve Prolapse
Causes
• Idiopathic degeneration
• Ma fan nd ome
• Rheumatic heart disease
• Infective Endocarditis
If prolapse occurs:
Without rupture of chordae tendinae no or mild MR

With rupture of chordae tendinae severe MR

Most patients are asymptomatic

Can lead to severe MR

 Mitral Valve Prolapse

SYSTOLE DIASTOLE

S1 Midsystolic Mitral
Click regurgitation S2 S1
(due to tensing of
chordae tendinae)
 Mitral Regurgitation
Causes
ACUTE:
• Papillary muscle rupture secondary Complications
to MI
• Ruptured Chordae tendinae • Heart failure
• MV prolapse
• Infective Endocarditis • Atrial Fibrillation
• Trauma

CHRONIC: • Infective Endocarditis

• Dilated MV annulus
• LV failure
• Dilated Cardiomyopathy
• Rheumatic Heart Disease
• Ma fan S nd ome
 Mitral Regurgitation
SYSTOLE DIASTOLE

S1 Pansystolic S2 S1
murmur

PANSYSTOLIC MURMUR Other signs Maneuvers

RADIATING TO THE AXILLA
• Soft S1 Standing
Made louder by held Squatting,
Valsalva
expiration with the patient lying • Signs of heart failure
on their left side
↓ Intensity of ↑ Intensity of
HEARD LOUDEST IN MITRAL AREA murmur murmur
A 24 year old man brought to the emergency department

because of reduced consciousness. On examination, he has

QUICKFIRE
finger clubbing, a fever and a loud pansystolic murmur at the

lo e lef e nal edge. Hi il a e in oin and he e a e

QUESTION
also needle marks on his forearms.

What is the diagnosis?

During a newborn examination, a baby QUICKFIRE
is found to have fixed splitting of the
second heart sound. She also has a QUESTION
systolic murmur heard at the upper left
sternal edge which radiates to the back.
What is the diagnosis?
 Pansystolic murmur heard in tricuspid area
Louder on inspiration
Causes: RV dilation, IE (IV drug use), Rheumatic Heart Disease

TRICUSPID REGURGITATION

ATRIAL FUNCTIONAL
SEPTAL MURMURS
DEFECT Normal heart structure
Soft ≤ 3/6
Fixed S2 splitting Position dependent
Very common in infants
Flow murmur head in
pulmonary area Can occur in hyperdynamic states

VENTRICULAR PULMONIC STENOSIS

Crescendo-decrescendo ejection systolic murmur
SEPTAL DEFECT heard in pulmonary area
Pansystolic murmur heard in tricuspid area Wide S2 Splitting
Does not radiate Causes: Tetralog of Fallot, Noonan s S ndrome
 Break time!
LET'S TAKE A 2 MINUTE BREAK TO
RECHARGE...
Any questions? Drop them in the Q and A!
Coming Up Diastolic Murmurs!!!
 DIASTOLIC MURMURS

AORTIC PULMONIC AUSTIN FLINT MITRAL TRICUSPID

REGURGITATION REGURGITATION MURMUR STENOSIS STENOSIS

HEARD BEST
HEARD BEST HEARD BEST
AT LEFT
AT MITRAL AT TRICUSPID
STERNAL
AREA AREA
BORDER
 Aortic Regurgitation
Causes
VALVULAR: Complications
• Infective Endocarditis • Heart failure
• Rheumatic Heart Disease
• Ma fan nd ome • Infective Endocarditis
• Congenital Bicuspid Valve

AORTIC ROOT:
• Aortic Dissection
• Tertiary Syphilis
• Ankylosing Spondylitis
• Rheumatoid Arthritis
 Aortic Regurgitation
SYSTOLE DIASTOLE

S1 S2 Early
Diastolic S1
Decrescendo
murmur

Blo ing earl diastolic Other signs Maneuvers

decrescendo murmur • WIDE PULSE PRESSURE
Made louder by held Standing, Squatting,
expiration with the patient sitting • Waterhammer pulse Valsalva handgrip
forward
• Austin Flint Murmur
HEARD LOUDEST IN LEFT STERNAL ↓ Intensity of ↑ Intensity of
BORDER • Signs of heart failure murmur murmur
 Other signs of AR

A B C D E

To-and-fro bruit over

Head nodding with Pulsation of nail Pistol shot bruits Visible pulsation
femoral artery with
the heartbeat beds of femoral pulse light pressure of carotids

de Musset s Sign Quincke s Sign Traube s Sign Duro ie s Sign Corrigan s Sign
 Mitral Stenosis
Main Cause
=
Rheumatic heart disease Complications
• Heart failure
Complications
Symptoms
• Dyspnoea • Infective Endocarditis
• Symptoms of Right • Recurrent laryngeal
Heart Failure nerve palsy

• Malar flush • Oesophageal

compression
 Mitral Stenosis
SYSTOLE
DIASTOLE

S1 S2 Opening Mid Atria S1

snap Diastolic Contract
rumble - louder

Opening snap followed by Other signs Maneuvers

diastolic murmur
Made louder by held
• Loud S1 Standing Squatting
expiration with the patient lying on Valsalva
their left side • P-mitrale on ECG
HEAD LOUDEST IN MITRAL AREA ↓ Intensity of ↑ Intensity of
WITH BELL • Signs of right heart failure murmur murmur
 Pulmonary Tricuspid
Regurgitation Stenosis
Causes: Causes:
Pulmonary Hypertension Rheumatic Heart Disease
Carcinoid Syndrome

Early diastolic decrescendo Ejection click + Diastolic

murmur rumble

Best heard in pulmonary area Best heard in tricuspid area

 Apex beat algorithm

No Is it forceful? Yes

S1not S1 Not
palpable sustained Sustained
palpable

Normal if not Tapping Apex Volume Pressure

beat e.g. MS overloaded overloaded
displaced
ventricle e.g. AR, ventricle e.g. AS
MR
A 2 day old baby is noted to have a systolic
and diastolic continuous murmur at the right
QUICKFIRE
upper sternal border. He is breathing very QUESTION
fast and has a very strong pulse.
What is the immediate management of this
condition?
 Patent Ductus Arteriosus
SYSTOLE
DIASTOLE

S1 S2 S1

Continuous machine-like murmur

Often due to congenital rubella or prematurity
 Valve Replacements
Mechanical valve Biological valve

Longer life span Shorter life span

Requires lifelong anticoagulation No lifelong anticoagulation

Metallic Heart Sound (click) No Metallic Heart Sound

Complications: Valve failure, paravalvular leak, valve thrombosis, IE,

Haemolysis
 Manouver Physiology Murmurs that increase in Murmurs that decrease in
intensity intensity

Standing valsalva venous return HOCM ( LV volume) Most murmurs

( flow through stenotic or
regurgitant valve)

Squatting ↑ venous return Most murmurs HOCM (↑ LV volume)

(↑ flow through stenotic or
regurgitant valve)

Handgrip ↑ afterload reverse flow across AR,MR,VSD AS ( transaortic valve

aortic valve (↑ LV volume) pressure gradient)
HOCM (↑ LV volume)

Inspiration ↑ venous return to right heart Most right-sided murmurs Most left-sided murmurs
venous return to left heart

Expiration venous return to right heart Most left-sided murmurs Most right-sided murmurs
↑ venous return to left heart
SUBSCRIBE FOR MORE VIDEOS
 Go to
menti.com!!!