Heart Sound

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

Pansystolic Murmurs of MR
• Timing: no gap between S1 & the onset of these
murmurs
• Intensity: does not change with respiration
• Location: heard best at the apex  radiates toward the
left axilla
• Pitch: high pitched & “blowing” in quality
• Clench the fists  SVR ↑  severity of MR & its murmur
will intensify (AS not)

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

Pansystolic Murmurs of TR

• Location: best heard  left lower sternal border 

radiates to the right of the sternum
• Pitch: high pitched & blowing in quality.
• Inspiration  negative intrathoracic pressure  ↑
intensity

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

Pansystolic Murmurs of VSD

• Location: heard best  fourth to sixth left

intercostal spaces  does not radiate to the axilla
• Pitch: high pitched & thrill
• Intensity: does not increase with inspiration. the
smaller the VSD  louder the murmur

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

Late systolic murmurs
• Begin in mid-to-late systole & continue to the end of
systole (mitral valve prolapse)
• Usually preceded by a midsystolic click
• Maneuvers:
• maneuvers that increase the volume of the LV (e.g.,
sudden squatting/ ↑ venous return) delay the
occurrence of prolapse & cause the click and murmur
• volume of blood in the LV ↓ (e.g., on sudden standing),
prolapse occurs more readily & the click and murmur
occur earlier in systole (closer to S1)

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

Diastolic Murmurs
• Early decrescendo murmurs & mid-to-late rumbling
murmurs
• Early diastolic murmurs  AR/ PR
• Mid-to-late diastolic murmurs  MS/ TS or less commonly
 abnormally increased flow across a normal mitral or
tricuspid valve

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

 Early Diastolic Murmurs of AR
• Decrescendo
• Rapid diastolic relaxation of the left ventricle 
pressure gradient develops immediately  maximum
intensity at its onset
• As the aortic pressure falls the LV pressure increases 
the gradient between the two chambers diminishes 
murmur decreases in intensity
• High-pitched murmur,
• Best heard  left sternal border  patient sitting, leaning
forward, and exhaling

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

Early Diastolic Murmurs of PR
• Usually because of PAH
• Early diastolic decrescendo murmur
• Best heard  the pulmonic area  may increase with inspiration.

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

 Mid-to-late diastolic murmurs of MS
• After S2 & preceded by OS
• The murmur is at its loudest  then decrescendos or disappears
• Whether the stenosis is mild or severe, the murmur intensifies at the end of diastole in patients in
normal sinus rhythm
• The more severe the stenosis, the longer murmur
• Low pitched
• Best heard best at the apex  lies in the left lateral decubitus

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

Mid-to-late diastolic murmurs of TR
• Rare
• Lower sternum, near the xiphoid processuss

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

Continuous Murmurs
• PDA  persistent pressure gradient between two structures during
both systole & diastole

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

The Differences of Continous and
To-and-Fro Murmur

A to-and-fro murmur is not continuous;

rather, there is a systolic component and a distinct diastolic
component, separated by S2
Lilly Leonard S. Pathophysiology of heart disease. 6 th ed. Wolters Kluwer. 2016
MATUR NUWUN