Updated: 1/19/2019

Heart Murmurs

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Auscultation Rules of Thumb
  • "All Physicians Take Money" (rule of thumb/mnemonic) 
    • aortic valve
      • upper right sternal border
        • aortic stenosis
        • flow murmur
        • aortic valve sclerosis
    • left ventricular outflow tract obstruction
      • lateral displacement of maximal impulse
      • S4 gallop
      • upper left sternal border (ULSB) harsh, crescendo-decrescendo systolic murmur
        • hypertrophic obstructive cardiomyopathy
    • pulmonic valve
      • ULSB
        • pulmonic stenosis
        • flow murmur (e.g., ASD)
    • tricuspid valve
      • lower left sternal border (LLSB)
        • pansystolic murmur (tricuspid regurgitation and VSD)
        • diastolic murmur (tricuspid stenosis and ASD)
    • mitral valve
      • apex 
        • systolic murmur (mitral regurgitation) 
        • diastolic murmur (mitral stenosis) 
Murmur Cheat Sheet
Crescendo/Decrescendo
Holosystolic
Systolic
  • AS (to neck)
  • MVP (click)
  • HOCM
  • MR (to axilla)
  • TR (inspiration increases)
  • VSD (harsh)
Diastolic
  • Aortic regurgitation
  • MS (opening snap)
  • NOTE: See chart below for abbreviations
Murmur Identification
 
Lesion
Shape
Location Heard
Altered by Characteristics
Systolic
Aortic stenosis (AS)
  • Crescendo-decrescendo
  • Radiates to neck (carotids) and apex 

--

  • "Parvus et tardus" (pulses weak compared to heart sounds)
  • Follows ejection click (due to halting of valve leaflets)  
Hypertrophic cardiomyopathy (HOCM)
  • Crescendo-decrescendo
--
  • ↓ venous return (e.g., Valsalva) - increases murmur
--
Mitral valve prolapse (MVP) 
  • Late crescendo
--
  • ↑ TPR (e.g., squatting, hand grip) - decreases murmur
  • ↓ venous return (e.g., Valsalva) - increases murmur
  • Mid-systolic click (tensing of chordae tendinae)
  • Loudest at S2
  • Later with ↑ afterload (e.g., hand grip).
Mitral regurgitation (MR) 
  • Holosystolic
  • Radiates to axilla
  • ↑ TPR (e.g., squatting, hand grip)
  • ↑ LA return (e.g., expiration)  
  • High-pitched, blowing
Tricuspid regurgitation (TR) 
  • Holosystolic
  • Radiates to right sternal border
  • ↑ RA return (e.g., inspiration)
  • High-pitched, blowing
Ventricular septal defect (VSD) 
  • Holosystolic
-- --
  • Harsh-sounding
Diastolic
Aortic regurgitation (AR)
  • Early decrescendo
  • Left sternal border with patient leaning forward
--
  • High-pitched blowing heard at end of expiration
Mitral stenosis (MS)
  • Late rumble 
  • Heard in lateral left decubitus position
  • ↑ LA return (e.g., expiration)
  • Opening snap (tensing of chordae tendinae) in early diastole after A2
Other
Patent ductus arteriosus (PDA)
  • Continuous
  • ULSB
--
  • Machine-like, continuous/constant murmur heard through systole and diastole
Atrial septal defect (ASD)
  • Systolic and diastolic
  • Systolic: ULSB (pulmonic valve)
  • Diastolic: LLSB (tricuspid valve)
-- --
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Questions (13)
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(M1.CV.15.75) A 65-year-old male with a history of coronary artery disease and myocardial infarction status post coronary artery bypass graft (CABG) surgery presents to his cardiologist for a routine appointment. On physical exam, the cardiologist appreciates a holosystolic, high-pitched blowing murmur heard loudest at the apex and radiating towards the axilla. Which of the following is the best predictor of the severity of this patient's murmur? Tested Concept

QID: 106799
1

Enhancement with hand grip maneuver

24%

(51/211)

2

Enhancement with expiration

9%

(18/211)

3

Presence of audible S3

48%

(101/211)

4

Enhancement with inspiration

8%

(17/211)

5

Presence of audible S4

8%

(17/211)

M 2 D

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(M1.CV.14.141) A 73-year-old man presents to your clinic for a routine checkup. His medical history is notable for a previous myocardial infarction. He states that he has not seen a doctor in "many years". He has no complaints. When you auscultate over the cardiac apex with the bell of your stethoscope, you notice an additional sound immediately preceding S1. This extra heart sound is most likely indicative of which of the following processes? Tested Concept

QID: 100657
1

Increased left ventricular compliance

2%

(2/94)

2

Decreased left ventricular compliance

83%

(78/94)

3

Increased left ventricular filling volume

7%

(7/94)

4

Decreased left ventricular filling volume

4%

(4/94)

5

Increased pulmonary compliance

1%

(1/94)

M 1 E

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(M1.CV.13.130) A 79-year-old man presents to the emergency room after a syncopal event. The patient has a history of hyperlipidemia for which he is taking atorvastatin. On physical examination, his vital signs are stable, but on cardiac auscultation, you detect a crescendo-decrescendo systolic murmur loudest on the right upper sternal border radiating to the neck. On physical exam, one would also expect: Tested Concept

QID: 100646
1

That the murmur would best be heard in the lateral left decubitus position

4%

(3/85)

2

The character of the murmur would be machine-like

5%

(4/85)

3

The murmur would also have a mid-systolic click loudest before S2

9%

(8/85)

4

The murmur would also have an opening snap

11%

(9/85)

5

Palpation of the carotid pulse would be weak and late relative to the patient’s heart sounds

71%

(60/85)

M 2 E

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(M1.CV.13.26) A 65-year-old male presents to his cardiologist to discuss increasing episodes of dyspnea after climbing stairs. He also now needs three pillows at night to sleep. Physical examination reveals an early diastolic murmur best appreciated at the left sternal border with bounding peripheral pulses. The cardiologist is very concerned and immediately refers the patient for a surgical workup. What is the most likely diagnosis? Tested Concept

QID: 100542
1

Mitral valve insufficiency

5%

(14/270)

2

Aortic regurgitation

73%

(198/270)

3

Mitral stenosis

12%

(32/270)

4

Aortic stenosis

6%

(15/270)

5

Atrial myxoma

1%

(4/270)

M 2 E

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(M1.CV.13.121) A 33-year-old Honduran woman presents to your clinic with shortness of breath. She reports that her symptoms have progressed over the past several months and are now impacting her quality of life because she cannot complete her usual exercise routine. She recalls "normal" childhood illnesses, including sore throats and fevers, but never required hospitalization. Vital signs are temperature 37 degrees Celsius, blood pressure 110/70 mm Hg, heart rate 109/min, respiratory rate 22/min, and oxygen saturation 98% on room air. Physical exam reveals a holosystolic, high-pitched, blowing murmur at the cardiac apex. One would expect that this murmur would also: Tested Concept

QID: 100637
1

Radiate to the neck

4%

(11/262)

2

Increase with squatting or handgrip

60%

(157/262)

3

Increase with inspiration

15%

(38/262)

4

Also have a mid-systolic click loudest at S2

16%

(42/262)

5

Have a characteristic machine-like sound

3%

(9/262)

M 2 E

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(M1.CV.13.117) A 37-year-old woman presents to clinic for routine checkup. She has no complaints with the exception of occasional "shortness of breath." Her physical examination is unremarkable with the exception of a "snap"-like sound after S2, followed by a rumbling murmur. You notice that this murmur is heard best at the cardiac apex. A history of which of the following are you most likely to elicit upon further questioning of this patient? Tested Concept

QID: 100633
1

Family history of aortic valve replacement at a young age

6%

(5/81)

2

Hyperflexibility, vision problems, and pneumothorax

4%

(3/81)

3

Systolic click auscultated on physical exam 10 years prior

6%

(5/81)

4

Repeated episodes of streptococcal pharyngitis as a child

78%

(63/81)

5

Cutaneous flushing, diarrhea, and bronchospasm

0%

(0/81)

M 2 B

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(M1.CV.13.142) A 48-year-old homeless man presents to clinic complaining of fatigue and fevers that "began recently." Cardiac exam reveals a holosystolic murmur, heard best over the left lower sternal border. The murmur increases on inspiration. He also has track marks on his arms bilaterally. This presentation is consistent with which defect? Tested Concept

QID: 100658
1

Ventricular septal defect

3%

(2/75)

2

Tricuspid regurgitation

75%

(56/75)

3

Mitral regurgitation

17%

(13/75)

4

Aortic stenosis

3%

(2/75)

5

Pulmonary stenosis

1%

(1/75)

M 2 C

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(M1.CV.13.28) A 64-year-old woman with a history of rheumatic fever presents to her primary care clinician complaining of excessive fatigue with walking and difficulty lying flat. She had no prior physical limitations, but recently has been unable to walk more than 3 blocks without needing to stop and rest. Her cardiac exam is notable for a late diastolic murmur heard best at the apex in the left lateral decubitus position with no radiation. What is the most likely diagnosis? Tested Concept

QID: 100544
1

Mitral Regurgitation

20%

(28/142)

2

Aortic Stenosis

1%

(2/142)

3

MItral Stenosis

70%

(99/142)

4

Aortic Regurgitation

5%

(7/142)

5

Tricuspid Regurgitation

1%

(1/142)

M 2 B

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