CHARACTERIZATION OF CARDIAC MURMURS

Dr. Roberto Roldan Guzman

1. LOUDNESS OR INTENSITY

Levine scale: Grade no./ 6-→ Roman numerals are also acceptable

Grade 1/6= very faint; heard only in a very quiet room without distractions

Grade 2/6= fairly audible

Grade 3/6= definitely and unequivocally audible, but NOT associated with a palpable thrill

Grade 4/6=definitely and unequivocally audible ALWAYS ASSOCIATED WITH PALPABLE THRILLS

Grade 5/6= can be heard even with only the stethoscope rim applied on the chest wall

Grade 6/6= audible even with the stethoscope off the chest (occasionally even with bare ears)

2. TIMING= Use the carotid impulse to time; peripheral pulse may not be reliable.

SYSTOLIC= early, mid, late, pan/ holo-

Crescendo, decrescendo, crescendo-decrescendo
Harsh, soft blowing, cooing

DIASTOLIC= rumbling, soft, musical

TO & FRO

3. LOCATION= heard best where? Auscultatory areas:

- by assigned cardiac areas: mitral, primary aortic, secondary aortic, tricuspid, pulmonic OR
- by exact location (preferred method; do not abbreviate): 3rd Left Parasternal, 3rd Right Parasternal, 5th
intercostal left midclavicular line, etc.
4. RADIATION OF SOUNDS

5. RELATION TO MANEUVERS

RESPIRATION = Murmurs originating from the right heart usually become louder with inhalation. Left sided
murmurs usually become louder on exhalation.

BODY POSITION= Most murmurs (especially the physiologic murmurs) become softer on assuming the upright
or seated up position, except murmurs of hypertrophic cardiomyopathy & mitral valve
prolapse which becomes louder & longer in the upright position.
With squatting & passive leg raising, most murmurs become louder, except again murmurs of
hypertrophic cardiomyopathy & mitral valve prolapse which may even disappear with
squatting.

HANDGRIP= murmurs arising from stenotic valves, mitral regurgitation, ventricular septal defects, and aortic
regurgitation become louder with handgrip exercise. Murmurs of hypertrophic cardiomyopathy
usually become softer.

VALSALVA MANEUVER= most murmurs become softer & shorter with Valsalva maneuver, except murmurs of
hypertrophic cardiomyopathy & mitral prolapse which become louder.

God gave us two ears but only one mouth. We should listen twice as much as we talk.
- Yiddish proverb