Heart murmurs & Dynamic Auscultation

Dr Nithin P G

Outlay of Seminar
Definition What to look for/ how to describe a murmur Classification of murmurs Types of murmurs Dynamic Auscultation

Definition of murmur
elati!ely prolon"ed series of audible !ibrations# Characteri$ed by the timin" in cardiac cycle% intensity &loudness'% fre(uency &pitch'% (uality% confi"uration% duration and direction of radiation)

How is a murmur produced and heard?

How is a murmur produced?

*ound is produced by !ibration Turbulence "enerated in the blood column !ibrations set up in the !essel wall + cardiac structures murmurs

How is a murmur produced?

/ e 12333 turbulent flow0

L , linear dimension &internal diameter -n pipes' Q = V1 A1= V! A! V , mean fluid !elocity Q , !olumetric flow rate Q = "#$ A , pipe cross.sectional area = dynamic !iscosity of the fluid e ,1 Turbulence , kinematic !iscosity // 0 murmur , density of the fluid

,1

Auscultation of murmur
4ther factors affectin" auscultation of murmur Distance from chest wall% position of patient 5nderlyin" soft tissue% lun"% fluid 6uality of apparatus

Auscultation of murmur

Upper 3rd L St-C Jn 4th L cos. cart. in L St. border

4 RICS
th

How to descri%e a murmur?

Description of a &urmur
Position in the cardiac cycle *ite of murmur /ma7) intensity0 -ntensity 6uality + Pitch Conduction Dynamic chan"es

"osition in the cardiac cycle

early systolic mid systolic *ystolic murmur systolic late systolic pan/holo

Diastolic murmur

early diastolic mid diastolic pre systolic

Continuous murmur

Site of murmur
*ystolic Ape7 ::*; 8 T % <*D Diastolic 8*% 9low mur) T*% 9low mur) *4< to <% :*;. *4< to A% Cor A<9 PDA. = + > :-C*% APW. ? :-C* Continuous

5:*;

P*

P % A

5 *; 4thers

A*

'ntensity( )radin*
9 @@8AN + :@<-N@ G AD-NG
G AD@ =. faintest murmur which can be heard only with special effort) G AD@ >. soft but readily audible G AD@ ?. loud without thrill G AD@ 2. loud with thrill G AD@ A. heard with steth partially off the chest G AD@ B. heard with steth held off the chest wall)

Quality & "itch

Depends on two factors =) Pressure difference or "radient. Gr pitch >) Amount of 9low. 9low pitch
P-TCC :4W C$ 9low Pr Gr 65A:-T D rumblin" harsh blowin" @)")E 8D8. 8* A* 8 %A

>A. =>A 8@D-58 =>A. ?33 C-GC 1?33

+onduction of murmur
*ite to which conducted aids in dia"nosis 8* locali$ed to ape7 8 conducted to a7illa and backF ::*; in 8<P.8

A* conducted to Carotids

+lassification & types of murmurs

+lassification & types of murmurs

early systolic mid systolic *ystolic murmur systolic late systolic pan/holo

Diastolic murmur

early diastolic mid diastolic pre systolic

Continuous murmur

Systolic &urmurs

&idsystolic murmur
8ost common murmur heard in e!eryday practice) *tarts at an inter!al after *= and ends before *>) -t could be PATC4:4G-CA:

-NN4C@NT/PCD*-4:4G-CA: A settin"s
=) <entricular outflow obstruction >) Dilation of aorta and pulmonary trunk ?) Accelerated systolic flow into aorta or pulmonary trunk 2) -nnocent midsystolic murmur& includin" those due to morpholo"ical chan"es of !al!e with no obstruction' A) *ome forms of 8

Ventricular outflow o%struction

Phasic flow across left and ri"ht outflow tract
-so!olumic contraction &b' 8a7imal eGection &c' *tart of rela7ation and reduced eGection &d' -so!olumic rela7ation &e' :< fillin"% rapid phase &f' *low :< fillin" &diastasis' &"' Atrial systole or booster &a'

AS
-<C *= !entricular pressure increases openin" of Aorta and pulmonary !al!e eGection commences and murmur be"ins @Gection increases murmur becomes crescendo @Gection declines murmur in decrescendo 8urmur ends before !entricular pressure drops below aortic pressure at which aortic !al!e and pulmonary !al!e closes "eneratin" a> and p>

AS
Carsh% crescendo. decrescendo 8*8 @arly sys peak short duration !s) :ate systolic peak lon" duration Always *ymmetrical /!s) P*0 @* absent in calcific !al!es% sub and supra !al!ular A* :en"th and loudness do not necessarily corresponds to se!erity but len"th more su""esti!e of se!erity than other murmurs

S4

Reverse splitting S2

AS
Galla!erdin phenomenon/ hour"lass phenomenon
:ower &aortic' !s) Ci"her &mitral' periodic !ibrations of stiffened non calcific aortic !al!e

Differentiatin" from 8
8
Apical mid sys/ Colosystolic A> buried in late sys !ibrations P/P<C unchan"ed @nd of :on" cycles in A9 unchan"ed

A* / Galla!erdin0
Apical mid sys Clear *> heard P/P<C mur , @nd of :on" cycles in A9 ,

AS
Poste7trasystolic enhancement results from the variable interaction of three factors: =' -ncrease in the contractile state &inotropism' of the !entricular muscle which is more e!ident if there is hypertrophy and/or depressed !entricular function) >' The pause pro!ides lon"er fillin" time for the !entricle% which is more conse(uential in hypertrophic !entricles &e)")% aortic stenosis' than in !entricular !olume o!erload states &e)")% mitral re"ur"itation') ?' :astly% there is more time for arterial runoff% and in the case of aortic re"ur"itation% more backflow into the !entricle) This effect lowers the arterial diastolic pressure and the impedance to forward flow &afterload' in the beat followin" the pause)

AS
<al!ular A* ;P difference Thrill @Gection sound 8urmur 8a7imum Assoc A
nil 8a7 > -C*F *upra sternal + carotids Present > -C*

*upra !al!ular
5: 1 :5: 8a7 i"ht carotid Absent = -C*

*ub !al!ular
Nil 8id :*;

Absent 8id :*; H/.

H/.

rare

HO+&
Dynamic :<4T obstruction 9actors increasin" "radient :< Contractility
@7ercise Cathecolamines Di"italis

<entricular <olume

Aortic impedance and pressure

*ustained Cand"rip Passi!e :e" aise

<alsal!a *tandin" Nitro"lycerine/ Amyl nitrate Tachycardia

"S
8urmur brou"ht on by a phasic eGection clickF radiates up + left As se!erity increases len"th increases and P> becomes soft &abruptness of closure reduced'% *> split widens% *2 :oses symmetry becomes kite shaped 8ay en"ulf A> and P> may be inaudibleF may be confused with <*D

"S

Other causes of &S&

Dilation of Aorta + Pulmonary trunk *hort soft midsystolic murmur :eft sided murmurs in marfanIs syndrome% syphilis i"ht sided murmurs in idiopathic dilation of pulmonary artery% pulmonary hypertension 8*8 of Cyperdynamic circulation Normal aorta or pulmonary trunk but increased flow Anaemia% pre"nancy% fe!er% thyroto7icosis

Other causes of &S&

4*.A*D apid flow across pulmonary !al!e to dilated pulmonary trunk

Pure A Due to Accelerated :< eGection

"hysiolo*ical causes
-nnocent systolic murmur
*tillIs murmur Pulmonary mid systolic murmur Peripheral pulmonary systolic murmur *upracla!icular or brachiocephalic systolic murmur Aortic sclerosis *ystolic mammary soufflJ

"hysiolo*ical murmurs
*tillIs murmur *hort bu$$in" murmur Ktwan"in" of a rubber bandI Pure medium fre(uency by periodic !ibrations of pulmonic leaflets at their attachment

"hysiolo*ical murmurs
Pulmonary mid systolic murmur + Peripheral pulmonary systolic murmur An"ulation and disparity between pulmonary trunk and its branches turbulent flow Normally disappears with maturity of pulmonary bed

"hysiolo*ical murmurs
*upracla!icular or brachiocephalic systolic murmur Aortic ori"ins of maGor normal brachiocephalic arteries Crescendo.decrescendo% abrupt onset% short% sometimes radiatin" below cla!icle !s) supra !al!ular A* L these murmur are softer below cla!icle and decreases with shoulder abduction

"hysiolo*ical murmurs
8ammary *oufflJ
:ate Pre"nancy or puerperium *ometimes continuous louder in systole% distinct "ap from *= / time for eGected blood to reach mammary arteries0 > or ? -C*/ :-C* :i"ht Pressure au"ments murmur becomes continuousF firm Pr abolishes murmur

"an Systolic# Holo Systolic &urmur

9low from a chamber or !essel whose pressure or resistance throu"hout systole is hi"her than pressure or resistance of the chamber recei!in" the flow 8itral e"ur"itation Tricuspid e"ur"itation <entricular *eptal Defect Aorto Pulmonary Window Patent Ductus Arteriosus with PAC

&itral $e*ur*itation
*= to *> pro!ided 8< remains incompetent and "radient remains Colosystolic @arly systolic :ate systolic *ometimes 8*8 adiates to a7illa and back becos Get directed posterolaterally in :A ::*; when Get directed a"ainst atrial septum near base of aorta

,ricuspid $e*ur*itation
::*;. A i!ero Car!alloIs si"n. -ncreased < % increased < !olume -ncreased *< !elocity of re"ur"itant flow *ometimes T heard only durin" inspiration Car!alloIs si"n disappears in < failure Diff from or"anic T P*8 !s) @*8 Ci"h !s) 8edium 9eatures of PAC present

Ventricular Septal Defect

Depends on site% si$e and "radient
<ery restricti!e <*D. @*8 decrescendo pattern 8od and N <*D. P*8 *ub arterial <*D. = or > :-C* similar to P* murmur *eptal aneurysms. click with :*8 or P*8 with late *ys Accentuation :ar"e shunt L 8D8 N <*D with PAC. @*8 P*8 absent in @issenmen"er *yndrome

Other "S&
Aorto Pulmonary Window with PAC
4therwise continuous murmur Diastolic component reduced with increasin" PAC

PDA with PAC

*imilar mechanism

-S&
Acute 8itral e"ur"itation
Decrescendo murmur Non distensible :A % lar"e ! wa!e approachin" :< pressure in late systole 8a7imum flow early systole and minimum to nil flow in late systole

Other -S&
Normal pressure T % 4r"anic T
Tall A ! wa!es reach the le!el of normal < pressure in late systole% so lower rate of re"ur"itant flow 8oderate to low fre(uency as compared to hi"h fre(uency in hi"h pressure T

<*D with P< or small muscular <*D .@(uali$ation of pressures in cases of PAC
.*mall <*D closes in late systole

LS&
8<P
:eaflets remains competent durin" early !entricular contraction but o!ershoot in late systole /critical <) dimensions0 4ne or more mid systolic clicks precede murmur /sudden deceleration of the column of blood a"ainst the prolapsed leaflet or scallops0 :on"er and softer Prompt standin" after s(uattin" <alsal!a -*hort + louder s(uattin" *ustained hand "rip Amyl nitrate

;arlowIs syndrome refers to the spectrum of symptoms caused by 8<P /click or murmur alone to palpitations% chest pain% or syncope0

4ther :*8. papillary muscle dysfunction Post Pap 8uscle ) :ate systolic cresendo to

Diastolic &urmurs

-arly diastolic murmur

A murmur

.*oft hi"h fre(uency early diastolic murmur with pt sittin" + leanin" forward in full held e7piration .? :-C* / > + ? dil0 -C* in root

.musical (uality in e!ersion .Austin 9lint murmur .Cole. Cecil murmur. A murmur in left a7illa due to

A$
Difference between acute and chronic A Austin 9lint 8urmur to be discussed

A/C A

C/C A

*hort mur) :on" mur) .early e(uali$ation of diastolic pressures 8edium L Ci"h !elocity less rapid and pressure "radient lower Associated *2

Hi*h "ressure "$

Ci"h pitched soft blowin" decrescendo murmur usually lasts throu"hout diastole heard in the left upper sternal border Associated with loud P> and other features of PAC P !s) A :oud P>% murmur be"ins after P> Normal pulse pressure Clinical settin" *(uattin" and sustained hand "rip increases A

Hi*h "ressure .s/ 0ormal "ressure

Ci"h Pressure
Decrescendo Ci"h fre(uency 4nset immediately with p> 5su e7tends throu"hout diastole 9eatures of PAC present
Crescendo decrescendo

Normal pressure

8edium to low pitched Delayed in onset

*hort duration

5sually absent

&id Diastolic &urmur

.;e"in At Clear -nter!al After *> apid 9illin" Phase
A! !al!e obstruction *tenotic A< !al!es% tumors 9unctional obstruction Abnormal patterns of A< flow increased flow !olume increased flow !elocity

-- -ncompetent Pulmonary <al!e /P with normal PA Pressure0 --- Atherosclerotic e7tramural coronary arteries

&id Diastolic &urmur

<
. T* . T . A*D

:<
. 8* - Austin 9lint murmur
.

.Atrial 8y7oma

4TC@ *

Carey.CombMs

. <*D . PDA . 8

&S
:ow rou"h rumblin" /sound of distant thunder0 8D8 :ocali$ed to ape7% better heard in left lateral position with bell :en"th se!erity :on" murmurs up to *= e!en in lon" cycles of A9. se!ere 8* :ate diastolic or Pre systolic accentuation usually seen in pliable !al!es and in N* / sometimes in A90

,S
*imilar to 8* 8urmur usually seen associated with A9 Diff) from 8* -ncreases durin" inspiration
!olume% !al!e0 < Diastolic Pr)%

/Au"mentation of < 9low rate and "radient across

::*;

"$ with normal "A pressures

P assoc with Con" P*% P< -@% repair of <4T

Ne"li"ible "radient at the start of diastole% "radient increases especially durin" the -< phase of < when murmur reaches ma7imum intensity)
> + ? :-C* 8edium to low pitched Delayed in onset *hort duration @ndin" before *=

Austin 1lint &urmur

*e!ere A re"ur"itant Get directed toward the A8: pre!ent the latter from openin" well durin" diastole "eneratin" turbulent flow :ow 8D8 or late diastolic% best heard at the ape7) To differentiate from 8*
No 4* Amyl nitrate inhalation A % Austin flint murmur

Other &id Diastolic &urmur

Carey CoombIs murmurs
Acute rheumatic fe!er% mitral !al!e structures acutely inflamed with some thickenin" and edema turbulence of flow durin" the rapid fillin" phase)

H moderate 8 /increased mitral inflow in diastole0

:ow pitched short 8D8) "ood e!idence of acti!e carditis

1low &urmurs
-ncreased A< flow T % A*D% 8 % <*D% PDA% hyperdynamic circulation To differentiate from 8* + T* *hort 8D8 8edium Pitch. increased flow Preceded by *? Absence of 4penin" *nap Thrill less common

Late Diastolic# "re(systolic &urmurs

8* Ci"her fre(uency than 8D8 *ometimes only P*A heard. mild 8* Generally absent in calcified !al!es and most of A9 / may be present durin" short cycle len"ths in A90 Cause. -ncreased flow durin" atrial contraction in late systole -ncreased dp/dt of :< contraction increases turbulence / esp) in A9 short cycles0

Other diastolic murmurs

CabotL :ocke 8urmur.
/Diastolic 9low murmur0 The CabotL:ocke murmur is a diastolic murmur that sounds similar to aortic insufficiency but does not ha!e a decrescendoF it is heard best at the left sternal border) /Ci"h flow thru coronary !essels% :8CA% :AD0 The murmur resol!es with treatment of anaemia)

DockIs murmur
diastolic crescendo.decrescendo% with late accentuation% /consistent with blood flow throu"h the coronary0 in a sharply locali$ed area% 2 cm left of the sternum in the ?:-C*% detectable only when the patient was sittin" upri"ht) Due to stenosis of :AD

Other diastolic murmurs

NeyLCod"kin murmur
@D8 of A F it has a raspy (uality% /sound of a saw cuttin" throu"h wood0) Cod"kin correlated the murmur with retro!ersion of the aortic !al!e leaflets in syphilitic disease)

ytandIs murmur in complete heart block

8D8 or :ate diastolic murmur Atrial contraction coincides with the phase of rapid diastolic fillin" increased flow short 8D8 /intermittent0) Another theory. Delayed <) contraction followin" A) contraction may lead to diastolic 8 + T % because A< !al!e closure does not occur /unless <) systole super!enes0) When hi"her < than A pressure durin" atrial rela7ation% an incompletely closed A< !al!e may lead to a re!erse "radient with a considerable re"ur"itation !olume)

+ontinuous murmur

+ontinuous murmur
;e"in in systolic and continues without interruption throu"h the timin" of *> into all or part of diastole 9low from $one of hi"her resistance into lower resistance without phasic interruption b/w systole + diastole

=) Connection b/w hi"h pressure chamber/!essel + low pressure chamber/!essel >) Disturbance in flow patterns in arteries ?) Disturbances in flow patterns in !eins

+onnection %#w hi*h pressure cham%er#.essel & low pressure cham%er#.essel

=) 9rom the aorta
a) Persistent ductus arteriosus b) Aorto.pulmonary window c) *4< =) Coronary arterio!enous fistulae drainin" into >) A:CAPA A% <% PA

>) 9rom the coronary arteryE

?) 4ther arterio!enous communications

=) ;roncho.pulmonary collaterals >) Chest wall arteriesLpulmonary !essels ?) Peripheral A.< 9istula

2) 4thers =) :utembacher syndrome with restricted A*D

"DA
GibsonIs murmur At = or > :-C* N . hi"h fre(uency soft murmur peaks around *> 8od . loud coarse machinery murmur with PDA with no continuous murmur eddy sounds
Neonates. due to hi"h P< <ery small ductus <ery lar"e ductus + lar"e <*D. due to e(uali$ation of pulm and sys Pr PAC. first dia component "oes% then sys A*% CoA. due to low

* @ < @ T D

+ontinuous murmurs
APW
> or ? :-C* 5sually associated with early de!p of eissenmen"er

*4<
No peakin" at *> seen /peaks in sys or dia)0 To A. :*; <. ::*; <4T. ? :-C*

:utembacher syndrome with restricted A*D

::*; /body of A0

+ontinuous murmurs
C.A<9
-:A. 5:*; rad to :t ant a7 A. :*; or 5*; C*. back b/w spine + :t scapula line . :t *<C. upper to mid :*; < inflow. ::*; <4T. 5pper to 8id :*; /beat to beat chan"e in murmur may
be present% < systolic compression% !alsal!a softens murmur0

PA. 5:*; /no eddy sounds0

A:CAPA
8urmur louder in diastole /:< contr) Do not peak at *> 5su :5*; or 5*; -/C flow0

Distur%ance in flow patterns in arteries

A< 9istula Due to rapid blood flow.
8urmur heard in the !enous side cer!ical !enous hum% mammary soufflJ% hyperthyroidism% heman"ioma% hyperemia of neoplasm &CCC% CC% Pa"etIs disease ' aortic arch !essel occlusions% atherosclerotic carotids% coarctation of aorta% main pulmonary artery stenosis and periph pulmonary artery stenosis

*tenosed arteries with inade(uate distal collaterals

Distur%ances in flow patterns in .eins

<enous hum
Cealthy children% youn" healthy adults% pre"nancy *ittin"% ;ell% medial aspect of t *Cl fossa% with face pulled leftwards + upwards disappears when returned to normal position :ouder in diastole% H/. hi"h pitched whine adiation to infra cla!icular areas confuse with other mur) Check by obliteration

Dynamic Auscultation

Dynamic Auscultation
-t refers to the techni(ue of alterin" circulatory dynamics by a !ariety of physiolo"ical and pharmacolo"ical maneu!ers and determinin" the effects of these maneu!ers on heart sounds and murmurs )

'nter.ention
Position

Physical maneu!ers

Pharmacolo"ical

"osition
A) :t :ateral Decubitus
:< impulse /apical sounds% murmurs better heard0 Act of turnin" increases C / 8D8 + P*A of 8* 0% induces P<C /A* murmur !s) 8 &n/c'0 A + P @D8 murmur

A) *ittin" leanin" forward full held e7piration A) *ittin" with le"s dan"lin"
9urther reduces !enous return -f *> fails to fuse on sittin"

D) @lbow Nnee Position

Pericardial friction rub

"osition
@) *tandin" to s(uattin" and !ice !ersa
=) *tandin"/ !enous return% ;P 0F /opp) in s(uattin"0 All murmurs /e7cept C4C8 % 8<P earlier0 C4C8 / :< contractility% after load% preload0 8<P / preload% afterload 0 =) A>. P> % A>.4* % A>.*? &n/c'

9) Cypere7tension of shoulders
supracla!icular *ystolic murmurs

G) *tretchin" of Neck
<enous hum

C) Passi!e ele!ation of both le"s

Transiently increases !enous return% increase *?

"hysical &aneu.ers
-nspiration i"ht sided e!ents become more prominent @7piration :eft sided e!ents become more prominent Diff A + P

*> split appreciable <s? <s2 prominent

Pericardial friction rub /e7halation + supine0 -nnocent pulm mid sys murmur becomes more prominent becos of reduced AP diameter

Tricuspid sys + dia 8ur increased Pulm eGection sound reduced

Valsal.a &aneu.er
-nspiration followed by forced e7halation a"ainst a closed "lottis for =3 to >3 seconds Physician has to keep flat of the hand on the abdomen to pro!ide the patient a force to breathe a"ainst Not attempted in patients with -CD Normal response has four phases

Valsal.a &aneu.er

initial pulm < , *< -/T Pr directly transmitted to aorta) -/T Pr , ;P <

sudden return of peripherally pooled blood to the !aso.constricted arterial system &>3 to the increased sympathetic tone' *udden , -/T Pr , ;P

sympathetic tone C

Valsal.a &aneu.er
Phase -- L Decrease in systemic !enous return % systolic pressure and pulse pressure *? + *2 attenuated A>.P> inter!al narrows All murmurs e7cept 8<P / C4C8 decrease Phase ---. increased :eft murmurs + Phase -<. increased i"ht murmurs

Valsal.a &aneu.er

PCA*@ -/T Pr , -;P

<

sympathetic tone C 8AO-8A: *D8PATC@T-C ACT-<AT-4N 9:AT PA T 49 *TA :-NGI* C5 <@

sudden return of peripherally pooled blood to the !aso.constricted arterial system &>3 to the increased sympathetic tone'

PCA*@ -<

C@A T 9A-:5 @ A*D 8*

'sometric -2ercise
Calibrated Cand"rip de!ice or a handball) ;etter to carryout bilaterally% sustained for >3.?3 secs Not to be done in arrhythmia / -schemia Transient but si"nificant increase in *< % ;P% C fillin" pressure % Ceart si$e % C4 % :<

=) :<*? + :<*2 increases >) *ystolic 8urmur of A* reduced L reduced "radient across aortic !al!e ?) A % 8 % <*D L increased 2) 8D8 of 8* L increased A) *yst 8urmur of C4C8 reduced B) 8<P murmur H click delayed

'sotonic -2ercise
9ew minutes of brisk walkin" sufficient 8ust be auscultated (uickly before effect wears off -ncreases 8s murmur in low output states Wide *plit of *> in e7ercise <9 further widens after

"harmacolo*ical &aneu.ers
-nhalation of Amyl Nitrate /Crush
breaths o!er =3L=A s0 ampoule in towel% ?.2 deep

9irst ?3 secs Decreased *ys Art Pressure :asts > minutes

?3 to B3 secs efle7 Tachycardia

1 B3 secs -ncreased C4% C

No reduction in stroke !olume as seen in NTG

Amyl 0itrate inhalation

A* T P* 8* P C4C8 /n/c0 !s) !s) !s) !s) !s) !s) 8 8 T49 Austin 9 A 8<P

Lon* cycle len*th

:on" cycle len"th after P<C or in lon" cycles of A9 -ncreases murmur of A*% C4C8% P* 8urmurs of 8 % T has no chan"e

Thank you

Anatomy
,he pulmonary orifice is situated in the upper an*le of the third left sternocostal articulation3 the aortic orifice is a little %elow and medial to this4 close to the articulation/ ,he left atrio.entricular openin* is opposite the fourth costal cartila*e4 and rather to the left of the midsternal line3 the ri*ht atrio.entricular openin* is a little lower4 opposite the fourth interspace of the ri*ht side/ ,he lines indicatin* the atrio.entricular openin*s are sli*htly %elow and parallel to the line of the coronary sulcus/ The coronary sulcus can be indicated by a line from the third left, to the sixth right, sternocostal joint

A$ "ressure ,racin*
9emoral artery pr =23/2A :< Pr ==P/?Q Pp, =33 / n ,230 @nd Diastolic Diff between Aorta and l! is A.B mm / n , R30

Wide PP% apidly risin" slope% ele!ated :<@DP% near end diastolic e(uali$ation of pressures between aorta and :< , A

"harmacolo*ical &aneu.ers
Inhalation of Amyl Nitrate [Crush ampoule in towel, 3-4 eep !reaths over "#$"% s& 'irst 3# se(s +e(rease Sys Art ,ressure 3# to )# se(s Refle- .a(hy(ar ia * )# se(s In(rease C/, 0R

S" $ Augmente A2 $ +iminishe /S $ 1e(omes lou er A2-/S interval shortens S3- 2ither ventri(les $ augmente AS , ,S , 0/C3 , .R , 'un(tional murmurs All augmente