Heart Sound

Murmur
 Turbulence blod flow
• Mechanism :
• Partial obstruction. Ex: AS
• Increase flow through normal structure. Ex:
Severe anemia
• Ejection into dilated chamber. Aneurismal
dilatation of aorta
• Regurgitant flow across incompetent valve. Ex:
MR
• Abnormal shunting of blood from one vascular
chamber to low pressure chamber. Ex: VSD

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

 Common Murmurs

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

 Murmur
Murmur Description

Example : a grade III-IV high pitch, cresendo-decrescendo systolic murmur, best

heard at the upper right sternal border, radiating toward the neck, not vary with
inspiration.
Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016
 Intensity

Grading system of systolic murmurs

Grading System of diastolic murmurs

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

Location

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

Systolic Murmur

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

Systolic Ejection Murmur

• AS/ PS
• Crescendo–decrescendo
• May be immediately preceded by an ejection click

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

The Ejection Murmur
of Aortic Stenosis
• Timing: begins after S1, separated by a short audible gap.
• The more severe the stenosis  the longer it takes to force blood across the valve  later the
murmur peaks in systole
• The severity of stenosis increases  the aortic component of S2 softens
• Frequency: high-frequency murmur
• Location: best  the second & third right intercostal spaces close to the sternum
• Radiation: the neck

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

Effect of Maneuvers on Murmurs of
Aortic Stenosis and Hypertrophic
Cardiomyopathy
• Valsalva maneuver  increases intrathoracic pressure  decreases venous return
to the heart & transiently reduces LV size
• HCM  brings the hypertrophied septum & anterior leaflet of the mitral valve
into closer proximity  greater obstruction  increases in intensity
• AS reduced flow across the stenotic valve  decreases in intensity

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

The Ejection Murmur
of Pulmonic Stenosis
• Timing: begins after S1, may be preceded by an
ejection click
• Location: loudest  second to third left intercostal
spaces close to the sternum transmitted to the
neck or left shoulder

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

Pansystolic Murmurs

• Holosystolic murmurs
• mitral or tricuspid valve regurgitation or Ventricular septal
defect (VSD)

Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016

MATUR NUWUN