Heart Murmurs

1 Systolic Murmurs

Mitral Regurgitation

• high pitched, pansystolic murmur at the apex, radiates to LLSB
• pressure gradient between LV and LA
• increases during squatting (SQUAMR), decreases on standing
  
• DDx:
  1. HOCM: squatting decreases
  2. AS (Gallavardin Phenomenon): hand grip doesn't increase
  

Aortic Stenosis

• harsh, systolic murmur at the 2nd R ICS, (sitting up and leaning forward)
• stops before S2; increases with squatting (SQUAS), decreases on standing
  
• pressure gradient between LV and Aorta during systole
  
• severity: duration of murmur and delay in peak
  - the greater the delay of peak, the more severe
• carotid upstroke is delayed and decreased (vs. innocent systolic murmur)
• sometimes heard at apex with a change in pitch: Gallavardin Phenomenon
• ejection type, crescendo-decrescendo type, diamond-shaped
• DDx:
  
  1. MR (due to Gallavardin Phenomenon of AS): sustained hand grip x 20 seconds = increase LV volume, increases MR murmur
     
  2. Innocent murmur: normal carotid pulse
  3. HOCM: standing increases, squatting decreases
     

Innocent Murmur

• increase blood flow along normal AV or PV
• 2nd R or L ICS
• no structural pathology
• 50% of population (most common murmur in general population)
• DDx
  1. AS:
  
  • peaks late in systole
  • more harsh
  • carotid upstroke is delayed and increased (Innocent murmurs has normal carotid pulse)
  2. PS
  3. ASD: fixed split S2
  

2 Diastolic Murmurs

Aortic Regurgitation

• diastolic, decrescendo, high pitched, 3rd-4th L ICS
• leaning forward, end of inspiration
  
• the longer the more severe
• if heard also at RLSB: significant aortic root disease, wide pulse pressure

Mitral Stenosis

• most difficult to recognize; may ask the patient to make a few sit-ups
  
• opening snap: clue to use bell
• opening snap: high pitched sound caused by LA pressure snapping open the valve (like wind suddenly catching sails); heard only when valve is mobile and pliable, not if calcified
  
• diastolic, low pitched, rumbling, at the apex left lateral decubitus
  
• DDx
  1. Atrial Myxoma: changes from supine to left lateral position
  2. Tricuspid Stenosis: if loudest in LLSB, changes with inspiration, prominent a wave if NSR; TS frequently occurs with MV lesions
  

Heart Sounds
S4:

• apex at Left lateral position; heard just before S1 (Tennesse), drup-dup
  
• bell; late diastole
  
• not a sign of CHF
  - decrease ventricular compliance (more stiff) needing more forceful atrial contraction for adequate filling
  
• Hypertension (most common), AS, CMP, IHD especially after MI
• ?normal after 50 yo (if also palpable which is a double impulse at the apex, always abnormal)

S3:

• apex at left lateral position; heard just after S2, (Kentucky), dup-drup
  
• bell; early diastole
• maybe normal for the kids and adults below 40 yo
  
• if >40 yo; LV failure is suspected
• usually decreased EF; maybe the only clue in early CHF
• dilated CMP, end-stage IHD, VHD (MR, VSD) - if VHD is the cause, not necessarily CHF

MVP:

• midsystolic click: squatting/hand grip increases distance of S1 and click
• late systolic murmur
• DDx
  1. MR

HOCM

• Systolic murmur of HCM:
  - 4th L ICS, widely radiates at precordium
  - summation of 2 murmurs:
  1) Ejection murmur: muscular obstruction of LV outflow tract
  - LSB
  2) Regurgitation murmur: systolic anterior motion of the MV
  - Apex
• standing: decrease in preload, decrease LV volume, increase obstruction in LVOT
  = increase murmur (ejection murmur)
  prompt squatting: increase in preload, increase in LV volume, decrease obstruction on LVOT
  = decrease in murmur
• S4
• vs purely MR: SQUAMR
  squatting: increases afterload, = increase in murmur

Acute Aortic Regurgitation (4th L ICS)

• 1.Soft S1: elevated filling pressure closes MV in diastole rather in systole
• 2. systolic flow murmur
• 3. diastolic
  
• tachycardia, presents with acute heart failure, pulmonary edema, cardiogenic shock
• MEDICAL EMERGENCY!
• causes: Endocarditis, Trauma, Aortic Dissection, Dehiscence of Prosthetic AV
  
• apex: S3, diastolic rumble (Austin Flint Murmur)

Atrial Myxoma

• early diastolic sound = TUMOR PLOP, vs opening snap of MS
• hallmark: change in left lateral position (more delay between S2 to Tumor flop interval), diastolic murmur also changes (longer)
  
• tumor obstruction: syncope or sudden death
• DDx:
  1. MS

ASD

• systolic murmur at 2nd LICS: increase flow at pulmonic valve
  
• fixed Split S2: increase R SV vs L SV

TR

• pansystolic murmur at 4th LICS, increases on respiration
• if in adult + RAE + RBBB = Ebstein's anomaly of TV
  

Precordium parts:
1. Apex: MR, MS (left lateral)
2. 2nd LICS: ASD/innocent murmur/PDA/VSD
3. 2nd RICS: AS/innocent murmur
4. 4th LICS: AR/Ebstein Anomaly/TR/TS/HOCM