UpToDate’ rinse tor ohn aout, adoring Resend Wolters Kluwer Effects of physiologic maneuvers on heart murmurs Respiration Rightsided murmurs (eg, tricuspid regurgltation) Increase with Inspiration due to increased venous return to the right heart Abrupt standing ‘Most murmurs diminish in intensity with standing due to reduced venous return to the heart and subsequently reduced right and left ventricular diastolic volumes. In contrast, the murmur of hypertrophic cardiomyopathy becomes louder, and the murmur of mitral valve prolapse lengthens and often is intensified. Squatting ‘Most murmurs become louder with squatting (or passive leg raising). In contrast, the murmur of hypertrophic cardiomyopathy becomes softer. The murmur of mitral valve prolapse may shorten with squatting, although as mitral regurgitation becomes more severe, the murmur may increase in intensity with squatting due to increase in afterload. Valsalva maneuver ‘Most murmurs decrease in intensity during the Valsalva manewver. Two exceptions are the systolic murmur of hypertrophic cardiomyopathy, which becomes louder, and the systolic murmur of mitral valve prolapse, which becomes longer and often louder. Sustained hand grip Hand grip (sustaines for 20 to 30 seconds) Is most useful in differentiating the election systolic murmur of aortic stenosis from the ‘murmur of mitral requrgjtation: The intensity of the murmur of aortic stenosis tends to decrease, while the murmur of mitral regurgitation increases. Postextrasystolic potentiation During the cardiac cycle following a premature beat or in the beat after a long cycle length in atrial fibrilation), the murmur of aortic stenosis increases in intensity, as does the ejection systolic murmur in hypertrophic cardiomyopathy. Carotid pulse volume increases inthe former and decreases or remains unchanged inthe latter. The murmur of mitral regurgitation does not usually change. However, the murmur of mitra regurgitation associated with mitral valve prolapse s prolonged since the click and onset of murmur occur earler.