Common Murmurs:

Systolic

Diastolic

Aortic Stenosis

Aortic Regurgitation

Mitral Regurgitation

Mitral Stenosis

MVP
HOCM
An important concept to keep in mind is that maneuvers affect the volume of blood entering the heart chambers.

Right-sided murmurs are increased with inhalation

Left-sided murmurs are increased with exhalation

VENOUS RETURN / PRELOAD:
What increases venous return to the heart / Preload?

Squatting

Lifting the legs

What decreases venous return to the heart / Preload?

Valsalva

Standing up

Squatting Squeezes blood up into the heart Blood return to the heart.
Valsalva Intrathoracic pressure Blood return to the heart. We can clearly observe in the table that MS, AS,
MR, AR and VSD become louder with leg raising and squatting, except HOCM and MVP, which become softer with
these maneuvers. On the other hand, MS, AS, MR, AR and VSD become softer with valsalva and standing, except
HOCM and MVP, which become louder with such maneuvers.
AFTERLOAD:
What increases afterload?

Handgrip
What decreases afterload?

Amyl Nitrate

Handgrip Contract arms muscle Compresses arteries of the arm

Amyl Nitrate (Vasodilator) Dilate peripheral arteries
As we can see in the table, handgrip softens the aortic stenosis murmur by preventing blood leaving the ventricles.
In other words, if the afterload goes up, blood cannot be ejected from the left ventricles, and the aortic stenosis
murmur will soften.
In Amyl nitrate, if the afterload goes down, blood can be easily ejected from the left ventricles, and finally worsening
or making it louder.
An important point to mention is that handgrip and Amyl nitrate have a negligible effect on mitral stenosis since both
maneuvers do not affect ventricular filling which is important in such murmurs.
Aortic and mitral regurgitation are worsen or louder by handgrip because this pushes blood backward into the heart.
The same rule apply for VSD, since more blood goes from the left to the right and making it louder.But since Amyl
nitrate has the opposite result of hangrip, then this improves both aortic and mitral regurgitation.
On the other hand, while handgrip improves or soften the MVP and HOCM murmurs due to a large left ventricle
caused by the increased afterload, Amyl Nitrate will result in an opposite effect which appear as an increased
ventricular emptying due to a decreased afterload that ultimately worsen the obstruction and makes the murmur
louder.
DRUGS:
Based on the table above, we can observe that mitral and aortic regurgitation can be treated with vasodilators, like
ACEi, and ARBs.
ACE inhibitors basically functions as the opposite of handgrip, by decreasing afterload which at the same time
increases the forward flow of blood out of the left ventricle. In some cases when the medical therapy is not enough,
then valve replacement is the best option.
On the other hand, mitral and aortic stenosis are appropriately treated with surgery. Whereas mitral stenosis is
treated with balloon valvuloplasty (or valve replacement when valvuloplasty is not an option depending on certain
valve characteristics), aortic stenosis is best treated with valve replacement.
Note: Even though diuretics can decrease pulmonary vascular congestion in either mitral or aortic stenosis, they are
not as effective as balloon valvuloplasty or valvular replacement. Also important to mention, is that ACE inhibitors
have scant effect on mitral stenosis.
An important concept that can help us to remember the uses of diuretics and ACEIs is as follows:

If valsalva improves the murmur, diuretics can be used.

If Amyl nitrate improves the murmurs, ACEIs can be used.