APPROACH TO

HEART
MURMURS

CHARISMAY B. BANWA, MD
OBJECTIVES
• To be able to present the basic physiology of
murmurs

• To be able to describe the different

characteristics of a cardiac murmur

• To be able to differentiate the types of heart

murmurs
 64 years old
CM widow

female

Filipino
Roman
Catholic
Cordon
Isabela

Cc: CHEST PAIN

HPI
• Patient was admitted for chest pain on exertion
that started about 6months ago.
• During interim, chest pain became
progressively worse, initially graded 5-7/10 dull
in character.

• Patient also had dyspnea on exertion and

recalled syncopal episodes.
HPI
• Patient denies palpitations, orthopnea, PND.

• No consult done and no medications taken.

• Few hours prior to admission, patient had

progressive chest pain, shortness f breath hence
admitted.
Past Medical History
• No hypertension
• No diabetes
• No asthma
• No heart disease
• No PTB
• No cancer
Family Medical History
• No hypertension
• No diabetes
• No asthma
• No heart disease
• No PTB
• No cancer
Personal and Social History
• Occasional alcoholic beverage drinker
• Non smoker
• Farmer, driver
• No known allegies
REVIEW OF SYSTEMS
• Integumentary: (-) pruritus
• CNS: (-) seizure, (+) loss of consciousness, (-)
dizziness
• Cardio-respiratory: (-) non-productive cough, (-)
colds, (+) DOB (-) palpitations (+) chest pain
(+) easy fatigability, (-) orthopnea
• GIT: (-) abdominal pain, (-) diarrhea, (-)
constipation, (-) N/V
REVIEW OF SYSTEMS

• GUT: (-) hematuria, (-) dysuria, (-) oliguria

• Musculoskeletal: (-) myalgia, (-) arthralgia (+)
body weakness
• Hematologic: (-) epistaxis, (-) gum bleeding
• Endocrine: (-) chills, (-) loss of appetite, (-)
weight loss
PHYSICAL EXAMINATION

GENERAL APPEARANCE
awake, conscious coherent not in respiratory distress

VITAL SIGNS
BP: 140/80 mmHg RR: 22 cpm
HR:93 bpm Temp: 36.7°C

No pallor no jaundice
Anicteric sclera, pink palpebral conjunctiva
PHYSICAL EXAMINATION

CHEST
symmetric chest expansion, no retractions, no
wheezes on both lung fields, no crackles or rhonchi

HEART
Adynamic precordium, PMI at 5th ICS MCL,
normal rate, regular rhythm, with 3/6 midsystolic
murmur at second ICS at right parasternal
border
PHYSICAL EXAMINATION

ABDOMEN
normoactive bowel sounds, soft, no
organomegaly, no tenderness

EXTREMITIES
Weak pulse, no cyanosis, no deformities
 QUESTIONS:
WHAT IS THE MOST LIKELY DIAGNOSIS:
AORTIC STENOSIS

WHAT ARE THE CARDINAL ANGINA,

SYMPTOMS OF THIS SYNCOPE,
CONDITION:
DYSPNEA
WHAT IS THE BEST INITIAL TRANSTHORACIC
TEST: ECHOCARDIOGRA
M
 Cardiac cycle

• 7phases
• 1. Atrial systole
• 2. Isovolumetric ventricular contraction
• 3. Rapid ventricular ejection
• 4. Reduced ventricular ejection
• 5. Isovolumetric ventricular relaxation
• 6. Rapid ventricular filling
• 7. Diastasis
Normal heart sounds
The bell and diaphragm of the stethoscope
accentuate sounds of different pitches
BELL- low pitch sound such as normal
heart sound and diastolic murmur of mitral
stenosis
DIAPHRAGM- high pitch sounds such as
early diastolic murmur of aortic
regurgitation or pericardial friction rub
seen in acute pericarditis
Normal heart sounds

S1 S2
S3 S4
Systole- period of contraction of the
ventricles of the heart that occurs
between the first and second heart
sounds of the cardiac cycle

Diastole- period of heart muscle

relaxation that occurs between S2 and
S1
•tricuspid valve: located between the right
atrium and the right ventricle
•pulmonary valve: located between the
right ventricle and the pulmonary artery
•mitral valve: located between the left
atrium and the left ventricle
•aortic valve: located between the left
ventricle and the aorta
Always Pray To Mary
Acute severe MR
a normal-sized, relatively
noncompliant left atrium
results in an early, decrescendo
systolic murmur best heard at
or just medial to the apical
impulse.

It often is signaled by chest pain,

hypotension, and pulmonary
edema, but a murmur may be
absent in up to 50% of cases.
Acute severe MR
Clinical settings in which acute,
severe MR occur include
(1) papillary muscle rupture
complicating acute myocardial
infarction
(2) rupture of chordae tendineae
in the setting of myxomatous
mitral valve disease
(3) infective endocarditis
(4) blunt chest wall trauma.
 A congenital, small muscular VSD may be associated
with an early systolic murmur.
It is localized to the left sternal border and is usually of
grade 4 or 5 intensity.

left-to-right
shunt
Anatomically large
and uncorrected
VSDs, which usually
involve the
membranous portion
of the septum, may
lead to pulmonary
hypertension

signs of pulmonary hypertension : right ventricular lift,

loud and single or closely split S2.
The murmur is best heard along the left sternal border
but is softer
Tricuspid regurgitation with normal pulmonary artery
pressure

The murmur is soft (grade 1 or 2), is best heard at the

lower left sternal border and may increase in intensity
with inspiration – CARVALLO’s sign
• Most common cause of a midsystolic murmur in an
adult.
• usually loudest to the right of the sternum in the
second intercostal space (aortic area) and radiates into
the carotids

• AORTIC
STENOS
IS
HOCM
is associated with a midsystolic murmur that is
usually loudest along the left sternal border or
between the left lower sternal border and the
apex
 the bulging of one or both of the
mitral valve flaps (leaflets) into the
left atrium during the contraction of
the heart.

MITRAL
VALVE
PROLAPSE
Although the systolic murmur associated with
MVP behaves similarly to that due to HOCM
in response to the Valsalva maneuver and to
standing/squatting

LVH in HOCM
a nonejection click in MVP
Not all continuous murmurs are pathologic.

The continuous mammary souffle/murmur of

pregnancy is created by enhanced arterial flow
through engorged breasts and usually appears
during the late third trimester or early puerperium
STRATEGY IN EVALUATING HEART MURMURS
 THANK YOU
DOCTORS! 
GODBLESS! 