LECTURE 11- AUSCULTATION OF THE HEART . HEART MURMURS.

Introduction
 Diseases of the cardiac valves and other cardiac structures frequently result in abnormal
turbulent blood flow within the heart causing murmurs. Careful auscultation of heart
murmurs is an extremely tool in the diagnosis of many cardiac conditions.
 When normal laminar blood flow within the heart is disrupted, an audible sound is created
by turbulent blood flow.
 Outside of the heart audible turbulence is referred to as a bruit, while inside the heart it is
called a murmur.

There are four major causes of cardiac murmurs:

1. First, if blood is forced through a tight area, turbulent blood flow ensues.
 This is the case in valvular stenosis. As a general rule, the worse the stenosis, the
louder the murmur, however if heart failure develops, adequate pressures to create
turbulent blood flow may not be able to be achieved and the murmur may lessen or
even disappear.
2. A second cause of a murmur is valvular insufficiency in which blood abnormally travels
backward through an incompetent valve causing turbulence when it meets normal, forward
blood flow.
3. If blood is forced through a congenital anomaly from one chamber to another, as in an atrial
septal defect (ASD) or ventricular septal defect (VSD), a murmur is produced again due to
turbulence.
4. Another cause of cardiac murmurs is increased flow of blood through a normal valve.
 In high output states such as anemia, thyrotoxicosis, or sepsis, a large amount of
volume is passing through the cardiac valves and the normal laminar blood flow may
be disturbed.

Physical and hemodynamic bases of originating of cardiac murmurs

Cardiac murmurs are endo- and exocardiac
Endocardial murmurs
 Endocardiac murmurs occur most frequently. These occur in anatomical changes of the
structure of the heart (organic murmurs) or in dysfunction of the intact valves (functional
murmurs).
 Functional murmurs may be heard with increased rate of blood flow or decreased blood
viscosity.
 The mechanism of endocardiac murmurs can be easier understood if one remembers the
laws of physics concerning the flow of liquids in tubes.
 If a tube has a point where its otherwise even lumen is narrowed, the passing liquid
produces noise.
 This noise is associated with turbulent flow of liquid above the narrowed portion of the tube,
which causes vibration of the tube.
 The intensity of noise depends on two factors, - the liquid velocity and the extent of
narrowing.

Extracardial murmurs
 Although synchronous with the heart work, they arise outside the heart. These are
pericardial and pleuropericardial friction sounds.
 Pericardial friction murmurs are connected with the changes in the visceral and parietal
pericardial layers in which fibrin is deposited (in pericarditis), cancer nodes develop, etc.
 The mechanism by which pericardial friction sounds are generated is similar to that of the
pleural friction sounds, except that they depend not on- the respiratory movements but on
the movements of the heart during systole and diastole.
 Pericardial friction murmurs vary.
  Sometimes they resemble pleural friction and sometimes they are very soft, as if produced
by rattling of paper or scratching.

Murmurs characteristics they are described by their timing in the cardiac cycle,
 intensity,
 shape,
 pitch,
 location,
 radiation,
 response to dynamic maneuvers.
 Using the above, a clinician can accurately characterize the nature of a murmur and
communicate their findings in a precise manner.

Criterion of classification Classification groups

Cause Endocardiac and exocardiac murmurs

(pleuropericardial/ cardiopulmonary and
pericardial friction murmurs)

Changes of the structure of the heart Organic and functional murmurs

Time of appearance - Systolic murmurs

- Diastolic murmurs (protodiastolic
mesodiastolic, presystolic murmurs)

Relation to course of blood flow Ejection and regurgitation (regurgitant)

murmurs

Amplitude of the murmur High and low amplitude murmurs

Oscillation frequency of the murmur High-pitched and low-pitched murmurs

noise
Character of the murmur noise Faint (weak), soft, blowing, coarse, rough,
grating or grazing sounds; musical murmurs

Changes of the intensity of the noise Decrescendo (decreasing), crescendo

with the phase of the heart activity. (increasing, growing), and crescendo-
decrescendo (diamond-shaped) murmurs

Properties of murmurs
The following characteristics of murmurs should be determined during auscultation:
1. the relation of the murmur to the phase of the heart activity (to systole or diastole);
2. the features, character, strength, and length of murmur;
3. localization of the murmur, i.e. the area where this murmur is heard best;
4. direction of transmission (radiation).

The timing of a murmur - the relation of the murmur to the phase of the heart activity (to
systole or diastole)
The timing of a murmur is crucial to accurate diagnosis. A murmur is either systolic, diastolic, or
continuous throughout systole and diastole.
 Stenosis of the aortic or pulmonic valves will result in a systolic murmur as blood is ejected
through the narrowed orifice.
 Regurgitation of the same valves will result in a diastolic murmur as blood flows backward
through the diseased valve when ventricular pressures drop during relaxation.
  Regarding the mitral and tricuspid valves, stenosis would result in a diastolic murmur and
regurgitation a systolic murmur.

Systolic murmurs
 Systolic murmurs can be classified as either midsystolic (a.k.a. systolic e jection murmurs
or SEM), holosystolic (pansystolic), or late systolic.
 A midsystolic murmur begins just after the S1 heart sound and terminates just before the
P2 heart sound, so S1 and S2 will be distinctly audible.
 A holosystolic murmur begins with or immediately after the S1 heart sound and extends up
to the S2 making them difficult, if not impossible to hear.
 A mid-late systolic murmur begins significantly after S1 and may or may not extend up to
the S2.

Character of murmur
 By their character, murmurs may be soft, blowing, or on the contrary rough, grating or
grazing sounds; musical murmurs can also be heard.
 By duration, heart murmurs are classified as short and long, and by their intensity as soft
and loud.

Grading
 Systolic murmurs are graded on a scale of 6. This grading is for the most part subjective.
 Grade I murmurs may not be audible to the inexperienced examiner, however grade 6
murmurs are heard even without the stethoscope on the chest and may actually be visible.
 Diastolic murmurs are graded on a scale of 4. This a completely subjective grading scale.
Once again, grade I murmurs may not be audible to some, however grade IV murmurs are
audible very easily.

The intensity of a murmur

 The intensity of a murmur is determined by the volume of blood flowing through a defect
and the distance between the stethoscope and the lesion.
 A very thin patient with severe aortic stenosis with a high pressure gradient across the
valve (thus high velocity of blood flow) will have a loud murmur.
 The exact same valvular lesion in a morbidly obese person or a person with severe COPD
and a widened anterior-posterior chest diameter may be inaudible.
 The intensity of the noise may change with the phase of the heart activity.
 Murmurs become weaker (decrescendo) or louder (crescendo), and crescendo-
decrescendo (diamond-shaped).
 Decrescendo murmurs occur more frequently. This can be explained as follows: as blood
begins flowing from one heart chamber to another or from the heart to the main vessel, the
difference in pressures in two chambers is high and the blood flow rate is therefore high as
well.
 Presystolic murmur has an increasing character and occurs mostly in stenosis of the
anterior left atrioventricular orifice, at the very end of ventricular diastole, when atrial systole
begins to increase the blood outflow from the left atrium to the left ventricle.
 Systolic crescendo-decrescendo (diamond-shaped) murmur presents in aortic stenosis.

Shape
 The shape of a murmur describes the change of intensity throughout the cardiac cycle.
 Murmurs are either crescendo, decrescendo, crescendo- decrescendo, or uniform.

Pitch
 A murmur will be high pitched if there is a large pressure gradient across the pathologic
lesion and low pitched if the pressure gradient is low.
  The murmur of aortic stenosis is high pitched since there is usually a large pressure
gradient between the LV and the aorta.
 The murmur of mitral stenosis is low pitched since there is a lower pressure gradient
between the LA and the LV during diastole.
 High pitched sounds are heard with the diaphragm of the stethoscope while low pitched
sounds are heard with the bell.

Location
 The anatomic location that the murmur is best heard is an important factor in determining
the etiology of the lesion. There are four main "listening posts" on the chest (see picture
below).
 A = aortic valve post (right upper sternal border )
P = pulmonic valve post (left upper sternal border )
T = tricuspid valve post (left lower sternal border )
M = mitral valve post (apex)
E = "Erb's point"
Note: Both the aortic and pulmonic listening posts are considered to be near the "base" of
the heart.
 Corresponds to the best listening post of that particular valve where this murmur is
generated.
 Murmurs are well transmitted in the direction of the blood flow. They are better heard in
areas where the heart is close to the chest wall and where it is not covered by the lungs.
 Systolic murmur due to mitral valve incompetence is best heard at the heart apex. It can be
transmitted by the firm muscle of the left ventricle to the axillary area or by the course of the
backward blood flow from the left ventricle to the left atrium.
 Diastolic murmur generated in a narrowed left atrioventricular orifice is usually heard over a
limited area at the heart apex.
 Systolic murmur due to stenosed aortic orifice is heard in the second interspace, to the right
of the sternum. As a rule, it is well transmitted by the course of the blood flow into the
carotid arteries.
 Diastolic murmur due to aortic valve regurgitation is better heard not over the aortic valve
but rather at the Botkin-Erb point, where it is transmitted by the back flow of blood from the
aorta to the left ventricle.
 Systolic murmur associated with tricuspid insufficiency is best heard at the base of the
xiphoid process, since the right ventricle is the closest to the chest wall at this point, from
which the sound can be transmitted upwards and to the right, in the direction of the right
atrium.

Radiation
 While murmurs are usually most intense at one specific listening post, they often radiate to
other listening posts or areas of the body.
 The murmur of aortic stenosis frequently radiates to the carotid arteries and the murmur of
mitral regurgitation radiates to the left axillary region. It is often difficult to distinguish if one
murmur is radiating to multiple sites or if there are multiple murmurs present from many
different causes. Dynamic auscultation and echocardiography is helpful in determining the
exact lesion present.

Systolic Heart Murmurs

Midsystolic murmurs
 Midsystolic murmurs include the murmurs of
a. aortic stenosis (AS),
b. pulmonic stenosis (PS),
c. hypertrophic obstructive cardiomyopathy (HOCM).
A midsystolic murmur begins just after the S1 heart sound and terminates just before the P2 heart
sound, so S1 and S2 will be distinctly audible.

Aortic stenosis (AS)

 The classic murmur of aortic stenosis is a high pitched, crescendo-decrescendo ("diamond
shaped"), midsystolic murmur located at the aortic listening post and radiating toward the
neck.
 The radiation of the aortic stenosis murmur is often mistaken for a carotid bruit.
 The aortic stenosis murmur is also well known to radiate to the cardiac apex on occasion,
making it difficult to distinguish if mitral regurgitation is also present. This radiation of the
aortic stenosis murmur to the apex is known as "Gallavardin dissociation".

Mitral regurgitation (MR)

 The murmur of mitral regurgitation is described as a high-pitched, "blowing" holosystolic
murmur best heard at the apex.
 The direction of radiation of the murmur depends on the nature of the mitral valve disease,
however it usually radiates to the axilla. The intensity of the murmur of MR does not
increase with inspiration helping to distinguish it from the murmur of tricuspid regurgitation.
 Holotsystolic murmurs are also known as pansystolic and include the murmurs of mitral
regurgitation (MR), tricuspid regurgitation (TR), and ventricular septal defects (VSD).
 Since the intensity of these murmurs is high immediately after the onset of S1 and it
extends to just before the S2, often the S1 and S2 sounds are overwhelmed by the murmur
and may be difficult to hear.

Mitral valve prolapse (MVP)

 Mitral valve prolapse produces a mid-systolic click usually followed by a uniform, high-
pitched murmur. The murmur is actually due to mitral regurgitation that accompanies the
mitral valve prolapse, thus it is heard best at the cardiac apex. Mitral valve prolapse
responds to dynamic auscultation.

Diastolic Heart Murmurs

 Diastolic murmurs include aortic and pulmonic regurgitation (early diastolic), and mitral or
tricuspid stenosis (mid-late diastolic).
 Tricuspid stenosis is very rare and is discussed further in the valvular heart disease section.

Aortic regurgitation (AR)

 The murmur of aortic regurgitation is a soft, high-pitched, early diastolic decrescendo
murmur usually heard best at the 3rd intercostal space on the left (Erb's point) at end
expiration with the patient sitting up and leaning forward.
 If the aortic regurgitation is due to aortic root disease, the murmur will be best heard at the
right upper sternal border and not at Erb's point. As aortic regurgitation worsens in severity,
the pressure between the left ventricle and the aorta equalize much faster, thus the murmur
becomes significantly shorter.

Pulmonic regurgitation (PR)

 Pulmonic regurgitation produces a soft, high-pitched, early diastolic decrescendo murmur
heard best at the pulmonic listening post .
 The murmur of pulmonic regurgitation increases in intensity during inspiration, unlike that of
aortic regurgitation. The murmur of pulmonic regurgitation is classically referred to as the
"Graham-Steell murmur" after it's initial describers.

Mitral stenosis
 Mitral stenosis results in a uniquely shaped, low-pitched diastolic murmur best heard at the
cardiac apex.
  The opening of the mitral valve produces an "opening snap" due to the high left atrial
pressures, which is immediately followed by a decrescendo murmur as blood flows
passively from the left atrium to the left ventricle through the stenosed mitral valve creating
turbulence.
 As mitral stenosis worsens, left atrial pressure increases forcing the mitral valve open
earlier in diastole.
 In severe mitral stenosis, the opening snap occurs earlier as does the initial decrescendo
part of the murmur. The opening snap and murmur of mitral stenosis also respond to
dynamic auscultation.

Dynamic Auscultation of Heart Murmurs

 Dynamic auscultation refers to using maneuvers to alter haemodynamic parameters during
cardiac auscultation in order to diagnose the etiology of a heart sound or murmur.
 Valsalva maneuver: The Valsalva maneuver is performed by having a patient “bear down”
like they are going to have a bowel movement and exhaling forcefully with the airway
closed.
 The hemodynamic changes that occur are complex, however the ultimate result is a
decrease in left ventricular preload.
 The most important use of the Valsalva maneuver is to distinguish the murmur of aortic
stenosis from hypertrophic obstructive cardiomyopathy .
 Aortic stenosis will soften or not change while the murmur of hypertrophic obstructive
cardiomyopathy becomes quite loud with Valsalva.

Squatting from a standing position:

 Squatting forces the blood volume that was stored in the legs to return to the heart
increasing preload and thus increasing left ventricular filling.
 This maneuver will decrease the murmur of hypertrophic obstructive cardiomyopathy has
the increased left ventricular volume helps displace the hypertrophied interventricular
septum causing less outflow tract obstruction.
 This maneuver causes the click of mitral valve prolapse to move later in systole.

Standing from a squatting position:

 Standing quickly from a squatting position causes blood to move from the central body to
the legs resulting in less blood returning to the heart decreasing left ventricular preload
similar to that seen with the Valsalva maneuver.
 This maneuver will increase the murmur of hypertrophic obstructive cardiomyopathy and
decrease that of aortic stenosis.
 This maneuver causes the click of mitral valve prolapse to move earlier in systole.

Leg raising:
 Passive leg raising is permed simply by raising the legs high in a patient lying supine. This
results in blood that was pooled in the legs returning to the heart increase left ventricular
filling and preload similar to squatting from a standing position.
 This maneuver will decrease the murmur of hypertrophic obstructive cardiomyopathy has
the increased left ventricular volume helps displace the hypertrophied interventricular
septum causing less outflow tract obstruction.

Handgrip exercise:
 Isometric handgrip exercises are performed by having a patient squeeze hart repetitively.
 This results in increased blood pressure (similar to exercise) and thus increased afterload.
 Elderly individuals may have a hard time with this maneuver and thus transient arterial
occlusion can be used instead.
 This maneuver will increase the intensity of left-sided regurgitant murmurs including mitral
regurgitation and aortic regurgitation.
  Handgrip exercises will have no effect on the murmur of aortic stenosis which helps
distinguish the presence of coexistent mitral regurgitation from that of the Galliveridin
phenomenon.

Transient arterial occlusion:

 This maneuver is performed by placing a blood pressure cuff on both arms and inflating it to
20 to 40 mmHg above the systolic blood pressure for 20 seconds. This results effectively in
increased afterload.
 This maneuver will increase the intensity of left-sided regurgitant murmurs including mitral
regurgitation and aortic regurgitation and is especially useful in elderly individuals who are
not able to perform adequate handgrip exercises.

Amyl nitrate inhalation:

 Amyl nitrate decreases left ventricular afterload by dilating the peripheral arteries. and
would decrease the murmur of mitral regurgitation.
 When the afterload is decreased, there is less resistance to blood flow from the left ventricle
through the aortic valve and thus less blood regurgitates through the mitral valve,
decreasing the intensity of the murmur.
 Amyl nitrate can be given via inhalation to reduce afterload for diagnostic purposes in the
cardiac catheterization laboratory

Differentiation of murmurs
 If several murmurs are heard simultaneously over different valves, it is necessary to
determine the affected valves and the character of their affections. Systolic and diastolic
murmurs over one valve indicate its composite affection, i.e. incompetence of the valve and
stenosis of the orifice.
 If systolic murmur is heard over one valve and diastolic murmur over the other, a combined
affection of two valves can be diagnosed.
 During auscultation of the heart, it is necessary to differentiate between functional and
organic, and between endocardial and exocardial murmurs.

Functional murmurs
 Functional heart murmurs are sounds made by the blood circulating through the heart's
chambers and valves or through blood vessels near the heart.
 They are sometimes called other names such as "innocent" or "physiologic" murmurs.
Many heart murmurs are considered to be “innocent” or harmless.

Causes
 Murmurs also can be caused by certain congenital defects and other conditions such as
pregnancy, fever, thyrotoxicosis (a diseased condition resulting from an overactive thyroid
gland) or anemia.

The properties of functional murmurs help differentiate them from organic murmurs
In most cases of functional murmurs are systolic;
 functional murmurs are not permanent and may arise and disappear when the person
changes his posture, after exercise and during various respiratory phases;
 they are mostly heard over the pulmonary trunk and less frequently over the heart apex;
 functional murmurs are transient and are rarely heard during the entire systole; these are
soft and blowing sounds;
 the murmurs are normally heard over a limited area and are not transmitted to long
distances from their source;
 functional murmurs are not accompanied by other signs of valve affections (e.g.
enlargement of the heart chambers or changes in the heart sounds).
Functional diastolic heart murmurs
Austin Flint murmur
 The Austin Flint murmur is named after the 19th century American physician, Austin Flint
(1812–1886).
 Austin Flint murmur is a low- pitched rumbling heart murmur which is best heard at the
cardiac apex.It can be a mid- diastolicor presystolic murmur
 It is associated with severe aortic regurgitation, although the role of this sign in clinical
practice has been questioned.

Graham Steell murmur

 A Graham Steell murmur is a heart murmur associated with pulmonary regurgitation.
 It is a high pitched early diastolic murmur heard best at the left sternal edge in the second
intercostal space with the patient in full inspiration.
 The murmur is heard due to a high velocity flow back across the pulmonary valve; this is
usually a consequence of pulmonary hypertension secondary to mitral valve stenosis.
 The Graham Steell murmur is often heard in patients with chronic cor pulmonale as a result
of chronic obstructive pulmonary disease.

The Carey-Coombs murmur or Coombs murmur

 The Carey Coombs murmur or Coombs murmur is a clinical sign which occurs in patients
with mitral valvulitis due to acute rheumatic fever.
 It is described as a short, mid-diastolic rumble best heard at the apex, which disappears as
the valvulitis improves.
 It is often associated with an S3 gallop rhythm, and can be distinguished from the diastolic
murmur of mitral stenosis by the absence of an opening snap before the murmur. The
murmur is caused by increased blood flow across a thickened mitral valve

Extracardial murmurs
 Although synchronous with the heart work, they arise outside the heart. These are
pericardial and pleuropericardial friction sounds.
 Pericardial friction murmurs are connected with the changes in the visceral and parietal
pericardial layers in which fibrin is deposited (in pericarditis), cancer nodes develop, etc.

The following signs can be used for differentiation between pericardial friction sounds and
intracardiac sounds:
 there is no complete synchronism of pericardial friction sounds with systole and diastole;
friction sounds are often continuous, their intensity increasing during systole or diastole;
 friction sounds can be heard for short periods during various phases of the heart work,
either during systole or during diastole;
 pericardial friction sounds are not permanent and can reappear at intervals;
 friction sounds are heard at sites other than the best auscultative points; they are best
heard in the areas of absolute cardiac dullness, at the heart base, at the left edge of the
sternum in the 3rd and 4th intercostal spaces; their localization is inconstant and migrates
even during the course of one day;
 friction sounds are very poorly transmitted from the site of their generation;
 the sounds are heard nearer the examiner's ear than endocardial murmurs;
 friction sounds are intensified if the stethoscope is pressed tighter to the chest and when
the patient leans forward, because the pericardium layers come in closer contact with one
another.

Pleuropericardial friction murmurs

 arise in inflammation of the pleura adjacent to the heart and are the result of friction of the
pleural layers (synchronous with the heart work).
  As distinct from pericardial friction sounds, pleuropericardial friction is always heard at the
left side of relative cardiac dullness.
 It usually combines with pleural friction sound and changes its intensity during the
respiratory phases: the sound increases during deep inspiration when the lung edge comes
in a closer contact with the heart and decreases markedly during expiration, when the lung
edge collapses.

IS there Prevention of heart murmur

 In most cases heart murmurs can not be prevent.
 The exception is that if underlying conditions, such as high blood pressure or heart valve
infections are treated, heart murmurs are stopped before they start.