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Heart Sounds

Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from mitral and tricuspid valve Tricuspid valve The valve consisting of three cusps situated between the right atrium and right ventricle of the heart. Heart: Anatomy closure (S1), as well as aortic and pulmonary valve Pulmonary valve A valve situated at the entrance to the pulmonary trunk from the right ventricle. Heart: Anatomy closure (S2). The third heart sound (S3) may be physiologic (e.g., athletes) or pathologic (e.g., congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure), and is related to abnormally rapid deceleration Deceleration A decrease in the rate of speed. Blunt Chest Trauma of early diastolic left ventricular inflow. The fourth heart sound (S4) is associated with contraction of the atria into partially-filled and non-compliant (stiff) ventricles. S4 is a pathologic sign in the young, but may be found in older individuals due to an age-related decrease in ventricular compliance Compliance Distensibility measure of a chamber such as the lungs (lung compliance) or bladder. Compliance is expressed as a change in volume per unit change in pressure. Veins: Histology. Additional sounds include murmurs (physiologic and pathologic), clicks, and snaps. These sounds are heard in individuals with structural abnormalities of the heart such as septal defects, valvular stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS), and mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation.

Last updated: Sep 15, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Heart sounds

  • Heart sounds are produced by:
    • Valve opening and closure
    • Movement of blood in the heart
  • The more turbulent the flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure, the more audible the created vibrations.
  • On auscultation, 2 heart sounds heard from a normal heart are reflective of the cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle.
    • The cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle is a sequence of pressure changes in the heart, resulting in:
      • Systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle (ventricular contraction and ejection of blood) and
      • Diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle (ventricular relaxation and filling)
    • S1 and S2 mark the beginning and end, respectively, of the cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle phases: systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle and diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle; they are high-frequency sounds.
    • Colloquially referred to as the “lub-dub” sound of the heart
  • S3 and S4 are low-frequency sounds which may be heard in various conditions.
Table: Heart sounds
Sound Timing Association
S1 Isovolumetric contraction Isovolumetric contraction Cardiac Cycle (beginning of systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle) Closure of atrioventricular valves
S2 Isovolumetric relaxation Isovolumetric relaxation Cardiac Cycle (beginning of diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle) Closure of semilunar valves
S3 Rapid filling of ventricles (early diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle)
  • Normal in pregnant women, children, athletes
  • Ventricular dilation (e.g., congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure)
S4 Late filling of ventricles by atrial contraction (late diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle)
  • Noncompliant or stiff ventricles
  • Pathologic in children and young people
  • May be seen in older people with age-related stiff ventricles

S1 and S2

S1

S1

S1:
Closure of the atrioventricular valves (tricuspid and mitral) at the beginning of systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle. In the systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle phase of the cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle, the right and left ventricles develop pressure, leading to ventricular contraction and ejection of blood into the pulmonary artery Pulmonary artery The short wide vessel arising from the conus arteriosus of the right ventricle and conveying unaerated blood to the lungs. Lungs: Anatomy and aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy, respectively. Thus, the pulmonary and aortic valves are open. The closed atrioventricular valves prevent the backflow of blood into the atria during ventricular contraction.

Image: “2013 Blood Flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure Contracted Ventricles” by OpenStax College. License: CC BY 3.0

S2

  • Closure of the semilunar valves (pulmonary and aortic)
  • Indicates the start of diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle
  • Occurs just after the T-wave and coincides with isovolumetric relaxation Isovolumetric relaxation Cardiac Cycle (beginning of diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle)
  • The aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy (A2 component of S2) closes before the pulmonic valve (P2 component of S2).
  • Loudest at left upper sternal border

Audio:

Normal S1 and S2: In this audio clip, normal S1 and S2 heart sounds can be heard. S1 corresponds to the closure of the AV valves, marking the beginning of systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle. S2 corresponds to the closure of the semilunar valves, marking the beginning of diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

S3 and S4

S3 and S4 sounds are heard in certain clinical situations and are produced by turbulent blood entering the ventricle at different points during diastole. S3 and S4 are the so-called “extra heart sounds.” They are low-frequency sounds.

S3

  • Rapid filling phase of ventricular diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle
  • ↑ Left ventricular filling Ventricular filling Cardiac Cycle pressure → ↑ cardiac output Cardiac output The volume of blood passing through the heart per unit of time. It is usually expressed as liters (volume) per minute so as not to be confused with stroke volume (volume per beat). Cardiac Mechanics
  • Best heard at the apex (left lateral decubitus position)
  • Can be normal in children, pregnant women, and athletes
  • Associated pathologic conditions:
    • Dilated cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types
    • Congestive heart failure Congestive heart failure Congestive heart failure refers to the inability of the heart to supply the body with normal cardiac output to meet metabolic needs. Echocardiography can confirm the diagnosis and give information about the ejection fraction. Congestive Heart Failure
    • Chronic mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation ( MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status)
    • Chronic aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation ( AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation)
    • Thyrotoxicosis Thyrotoxicosis A hypermetabolic syndrome caused by excess thyroid hormones which may come from endogenous or exogenous sources. The endogenous source of hormone may be thyroid hyperplasia; thyroid neoplasms; or hormone-producing extrathyroidal tissue. Thyrotoxicosis is characterized by nervousness; tachycardia; fatigue; weight loss; heat intolerance; and excessive sweating. Thyrotoxicosis and Hyperthyroidism
Timing and amplitude of s3

Timing and amplitude of S3 when inaudible and audible

Image by Lecturio.

Audio:

S3: In this audio clip, the S3 gallop S3 gallop Congestive Heart Failure can be heard (left decubitus, heard with the bell of the stethoscope). S3 occurs after S2 during the rapid filling phase of ventricular diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

S4

  • Atrial contraction or “kick” during ventricular diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle
  • Due to ventricular noncompliance Noncompliance Clinician–Patient Relationship or stiffness
  • May be auscultated in older adults due to loss of ventricular compliance Compliance Distensibility measure of a chamber such as the lungs (lung compliance) or bladder. Compliance is expressed as a change in volume per unit change in pressure. Veins: Histology with age
  • Best heard at the apex (left lateral decubitus position)
  • Associated conditions:
    • Hypertrophic cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types
    • AS
Timing and amplitude of s4

Timing and amplitude of S4 when inaudible and audible

Image by Lecturio.

Audio:

S4 gallop: In this audio clip, the S4 gallop can be heard (left decubitus, heard with the bell of the stethoscope). S4 occurs before S1 during the atrial filling phase. S4 is heard in conditions where there is stiffness or low compliance Compliance Distensibility measure of a chamber such as the lungs (lung compliance) or bladder. Compliance is expressed as a change in volume per unit change in pressure. Veins: Histology in the ventricle.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Respiratory Variation

An increase in right ventricular (RV) volume (occurring with inspiration Inspiration Ventilation: Mechanics of Breathing) affects the right side of the heart and is heard as splitting Splitting Defense Mechanisms of S2 (A2 and P2).

Physiologic splitting Splitting Defense Mechanisms

Widening of the components of s2

Diagram showing widening of the S2 components (A2 and P2) during increased preload Preload Cardiac Mechanics conditions such as inspiration Inspiration Ventilation: Mechanics of Breathing, which produces the physiologic splitting Splitting Defense Mechanisms of S2

Image by Lecturio.

Widened or persistent splitting Splitting Defense Mechanisms

Persistent splitting of s2

Diagram showing persistent S2 splitting Splitting Defense Mechanisms in which closure of the pulmonic valve is further delayed by inspiration Inspiration Ventilation: Mechanics of Breathing (right). This splitting Splitting Defense Mechanisms can occur in a right bundle branch block Bundle branch block A form of heart block in which the electrical stimulation of heart ventricles is interrupted at either one of the branches of bundle of His thus preventing the simultaneous depolarization of the two ventricles. Bundle Branch and Fascicular Blocks.

Image by Lecturio.

Audio:

Persistent S2 splitting Splitting Defense Mechanisms: heard in right bundle branch block Bundle branch block A form of heart block in which the electrical stimulation of heart ventricles is interrupted at either one of the branches of bundle of His thus preventing the simultaneous depolarization of the two ventricles. Bundle Branch and Fascicular Blocks (listening with the diaphragm Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm: Anatomy of the stethoscope)

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Fixed splitting Splitting Defense Mechanisms

  • Description:
    • ↑ Right atrial (RA) and RV volume (due to left-to-right shunt)
    • Blood flow Blood flow Blood flow refers to the movement of a certain volume of blood through the vasculature over a given unit of time (e.g., mL per minute). Vascular Resistance, Flow, and Mean Arterial Pressure through the pulmonic valve
    • Delays closure of the pulmonic valve
  • Associated condition: atrial septal defect Atrial Septal Defect Atrial septal defects (ASDs) are benign acyanotic congenital heart defects characterized by an opening in the interatrial septum that causes blood to flow from the left atrium (LA) to the right atrium (RA) (left-to-right shunt). Atrial Septal Defect (ASD) ( ASD ASD Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder)
Fixed splitting

Diagram showing fixed splitting Splitting Defense Mechanisms, in which closure of P2 is NOT delayed by inspiration Inspiration Ventilation: Mechanics of Breathing (right)

Image by Lecturio.

Paradoxical splitting Splitting Defense Mechanisms

  • Description:
    • Delayed aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy closure
    • Pulmonic valve closure (P2) occurs before delayed aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy closure (A2).
  • Associated conditions:
    • Delayed aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy closure due to obstruction:
      • Aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis (AS)
      • Hypertrophic obstructive cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types (HOCM)
    • Delayed aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy closure due to conduction disease: left bundle branch block Bundle branch block A form of heart block in which the electrical stimulation of heart ventricles is interrupted at either one of the branches of bundle of His thus preventing the simultaneous depolarization of the two ventricles. Bundle Branch and Fascicular Blocks
Paradoxical splitting of s2

Diagram showing paradoxical splitting Splitting Defense Mechanisms in which closure of the aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy is delayed: The name “paradoxical” is because the split narrows the inspiration Inspiration Ventilation: Mechanics of Breathing (right). The split can be heard in some individuals with a left bundle branch block Bundle branch block A form of heart block in which the electrical stimulation of heart ventricles is interrupted at either one of the branches of bundle of His thus preventing the simultaneous depolarization of the two ventricles. Bundle Branch and Fascicular Blocks.

Image by Lecturio.

Clicks and Snaps

Clicks

  • A high-pitched sound occurring at the point of maximal opening of the valves
  • Occurs after S1 (systolic)
  • Can be ejection or nonejection clicks:
Diagram depicting the the mid-systolic click

Schematic diagram depicting the mid-systolic click (MSC): MSC occurs after S1.

Image by Lecturio.

Audio:

Mid-systolic click (MSC): This audio clip is an example of an MSC heard in mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse. An MSC is a crisp sound occurring between S1 and S2 (no murmur follows).

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Snap

  • A high-frequency diastolic sound made by the opening of a stenotic mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy (most common)
  • Leaflets swell out into the ventricle and suddenly stop, producing a mid-to-high–frequency sound.
Diastolic filling and rumbling murmur of mild and severe mitral stenosis

Diastolic filling and rumbling murmur in mild and severe mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis:
The mid-diastolic murmur starts after the opening snap Opening snap Mitral Stenosis (O.S.). The presystolic murmur is due to atrial contraction (absent in atrial fibrillation Atrial fibrillation Atrial fibrillation (AF or Afib) is a supraventricular tachyarrhythmia and the most common kind of arrhythmia. It is caused by rapid, uncontrolled atrial contractions and uncoordinated ventricular responses. Atrial Fibrillation) and is best heard over the apex with the bell of a stethoscope.

Image by Lecturio.

Audio:

Opening snap Opening snap Mitral Stenosis: A mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis murmur can be heard in this audio clip. The low-pitched, rumbling murmur starts after the opening snap Opening snap Mitral Stenosis of the mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy (after S2) and finishes with a short crescendo up to S1.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Murmurs

Heart murmurs

  • Murmurs are audible vibrations that can be produced by the following:
  • Not all murmurs indicate structural heart disease.
  • Determine characteristics by:
    • Timing ( cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle)
    • Intensity
    • Pattern or configuration
    • Pitch and quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement
    • Location or auscultation area
    • Maneuvers, position, and exercise

Classification according to cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle

  • Systolic (occurs at or after S1 and ends before or at S2)
    • Early systolic: heard in acute mitral or tricuspid regurgitation Tricuspid regurgitation Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Tricuspid Regurgitation (TR)
    • Midsystolic: aortic or pulmonary stenosis Pulmonary stenosis Valvular disorders can arise from the pulmonary valve, located between the right ventricle (RV) and the pulmonary artery (PA). Valvular disorders are diagnosed by echocardiography. Pulmonary stenosis (PS) is valvular narrowing causing RV outflow tract obstruction. Pulmonary Stenosis
    • Holosystolic:
    • Late systolic: mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse
  • Diastolic (occurs at or after S2 and ends before or at S1)
    • Early diastolic: aortic or pulmonary regurgitation Pulmonary regurgitation Backflow of blood from the pulmonary artery into the right ventricle due to imperfect closure of the pulmonary valve. Pulmonary Regurgitation
    • Mid diastolic: mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis, tricuspid stenosis Tricuspid stenosis Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Tricuspid Stenosis (TS)
    • Late diastolic (or presystolic):
      • Moderate-to-severe AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation ( Austin Flint murmur Austin Flint murmur Aortic Regurgitation)
      • Mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis
  • Continuous (not confined to either systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle or diastole Diastole Post-systolic relaxation of the heart, especially the heart ventricles. Cardiac Cycle):
Patterns of heart murmurs

Patterns of heart murmurs (with examples):
A: presystolic or late diastolic, crescendo murmur ( tricuspid stenosis Tricuspid stenosis Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Tricuspid Stenosis)
B: holosystolic murmur Holosystolic Murmur Tricuspid Valve Atresia (TVA) ( mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation)
C: midsystolic, crescendo-decrescendo murmur ( aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis)
D: long systolic, crescendo-decrescendo murmur (pulmonic stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS))
E: early diastolic, decrescendo murmur ( aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation)
F: mid-diastolic murmur ( mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis)
G: short mid-diastolic murmur
H: continuous murmur (patent ductus arteriosus Ductus arteriosus A fetal blood vessel connecting the pulmonary artery with the descending aorta. Patent Ductus Arteriosus (PDA))

Image by Lecturio.
Ar murmur simplification

Diastolic murmur: Chronic aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation ( AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation) results in an early diastolic murmur (high pitched). The murmur becomes holodiastolic in severe AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation.

Image by Lecturio.

Audio:

Early diastolic murmur: Aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation, a high-pitched decrescendo murmur, can be heard in this audio clip.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0
Holosystolic murmur

Holosystolic murmur Holosystolic Murmur Tricuspid Valve Atresia (TVA): Chronic mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation can be heard as a holosystolic murmur Holosystolic Murmur Tricuspid Valve Atresia (TVA) at the apex, radiating to the axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy.

Image by Lecturio.

Audio:

Holosystolic murmur Holosystolic Murmur Tricuspid Valve Atresia (TVA): This audio clip presents an example of a holosystolic murmur Holosystolic Murmur Tricuspid Valve Atresia (TVA) from MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status. The murmur results in a high-pitched “blowing” sound through the entirety of the systole Systole Period of contraction of the heart, especially of the heart ventricles. Cardiac Cycle.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Classification according to intensity

Using the Levine system, murmurs can be graded on a scale Scale Dermatologic Examination from I to VI, which reflects the intensity of the murmur. 

  • I: very soft, may only be heard by experienced cardiologists
  • II: faint but readily audible
  • III: readily audible, louder than grade 2, no thrill
  • IV: loud and accompanied by a palpable thrill
  • V: loud enough to be heard with a stethoscope lightly touching the chest
  • VI: loud enough to be heard with a stethoscope off the chest

Classification according to pattern

  • Crescendo-decrescendo murmur:
    • Ascending then descending systolic ejection murmur
    • Diamond shaped
    • Example: AS
  • Crescendo:
    • Ascending intensity from faint to loud
    • Example: can be heard in mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse
  • Decrescendo:
    • Descending intensity from loud to faint
    • Example: AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
  • Uniform/ plateau Plateau Cardiac Physiology: mitral/TR murmur
Crescendo-decrescendo murmurs

Crescendo-decrescendo murmurs: ascending then descending systolic murmur (diamond shaped) heard in aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis

Image by Lecturio.

Audio:

Crescendo-decrescendo murmur: In this audio clip, the sound of severe AS, a harsh, crescendo-decrescendo murmur occurring between S1 and S2, can be heard. The S2 heart sound is inaudible due to the severity of AS.

Heart sound by The Regents of the University of Michigan. License: CC BY-SA 3.0

Classification according to pitch and quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement

  • Pitch:
    • Frequency of the murmur
    • High pitch:
      • TR
      • MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status
      • AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
    • Low pitch: mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis
  • Quality Quality Activities and programs intended to assure or improve the quality of care in either a defined medical setting or a program. The concept includes the assessment or evaluation of the quality of care; identification of problems or shortcomings in the delivery of care; designing activities to overcome these deficiencies; and follow-up monitoring to ensure effectiveness of corrective steps. Quality Measurement and Improvement: can be blowing, harsh, rumbling, scratchy, vibratory, squeaky, or musical

Auscultation areas

The 5 areas of auscultation can be recalled using the mnemonic, “All People Enjoy Time Magazine.”

  1. Aortic area: right 2nd intercostal space adjacent to the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy
    • AS
    • Aortic valve Aortic valve The valve between the left ventricle and the ascending aorta which prevents backflow into the left ventricle. Heart: Anatomy sclerosis Sclerosis A pathological process consisting of hardening or fibrosis of an anatomical structure, often a vessel or a nerve. Wilms Tumor
    • Systolic flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure murmurs
  2. Pulmonic area: left 2nd intercostal space adjacent to the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy
    • PS PS Invasive Mechanical Ventilation
    • Systolic flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure murmurs
  3. E rb RB Chlamydia’s (auscultation) point (left sternal border): left 3rd intercostal space
    • Systolic murmurs: HOCM
    • Diastolic murmurs:
      • AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
      • Pulmonic regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD) (PR)
  4. Tricuspid area: left 4th–5th intercostal space adjacent to the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy
    • Systolic murmurs:
      • TR
      • VSD
    • Diastolic murmurs:
      • TS
      • ASD ASD Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder
  5. Mitral area (apex): left 4th intercostal space, midclavicular line
    • Systolic murmurs:
      • MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status (holosystolic)
      • Mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse
    • Diastolic murmurs: mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis ( MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis)
Auscultation areas

Auscultation areas and associated murmurs that are heard: aortic, pulmonic, Erb’s point, tricuspid, and mitral areas (APETM)
TR: tricuspid regurgitation Tricuspid regurgitation Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Tricuspid Regurgitation
VSD: ventricular septal defect Ventricular Septal Defect Tetralogy of Fallot
TS: tricuspid stenosis Tricuspid stenosis Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Tricuspid Stenosis
ASD ASD Autism spectrum disorder (ASD) is a neurodevelopmental disorder marked by poor social skills, restricted interests/social interactions, and repetitive/stereotyped behaviors. The condition is termed a “spectrum” because of the wide variability in the severity of symptoms exhibited. Autism Spectrum Disorder: atrial septal defect Atrial Septal Defect Atrial septal defects (ASDs) are benign acyanotic congenital heart defects characterized by an opening in the interatrial septum that causes blood to flow from the left atrium (LA) to the right atrium (RA) (left-to-right shunt). Atrial Septal Defect (ASD)
MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status: mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation
MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis: mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis

Image by Lecturio.

Dynamic Auscultation

Cardiac physiology Cardiac Physiology A complex system of coordinated electrical circuitry within the heart governs cardiac muscle activity. The heart generates its own electrical impulses within its pacemaker cells. The signal then travels through specialized myocytes, which act as electrical wiring, distributing the signal throughout the heart. Cardiac Physiology and maneuvers

  • Preload Preload Cardiac Mechanics:
    • Stretching of cardiac muscles prior to contraction ( ventricular filling Ventricular filling Cardiac Cycle)
    • Preload Preload Cardiac Mechanics: increase in venous return into the right ventricle and decrease in venous return to the left ventricle:
      • Deep inspiration Inspiration Ventilation: Mechanics of Breathing
      • Supine position
      • Squatting (seen in tetralogy of Fallot Tetralogy of Fallot Tetralogy of Fallot is the most common cyanotic congenital heart disease. The disease is the confluence of 4 pathologic cardiac features: overriding aorta, ventricular septal defect, right ventricular outflow obstruction, and right ventricular hypertrophy. Tetralogy of Fallot)
      • Passive leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy raise (increased venous return due to gravity)
    • Preload Preload Cardiac Mechanics: decrease in venous return → ↓ LV volume
  • Afterload Afterload Afterload is the resistance in the aorta that prevents blood from leaving the heart. Afterload represents the pressure the LV needs to overcome to eject blood into the aorta. Cardiac Mechanics:
    • Effective pressure against which the heart ejects blood during ventricular contraction
    • Afterload Afterload Afterload is the resistance in the aorta that prevents blood from leaving the heart. Afterload represents the pressure the LV needs to overcome to eject blood into the aorta. Cardiac Mechanics: handgrip

Effects on the intensity of heart murmurs

  • Respiration Respiration The act of breathing with the lungs, consisting of inhalation, or the taking into the lungs of the ambient air, and of exhalation, or the expelling of the modified air which contains more carbon dioxide than the air taken in. Nose and Nasal Cavity: Anatomy ( preload Preload Cardiac Mechanics):
  • While standing and with the Valsalva maneuver Valsalva maneuver Forced expiratory effort against a closed glottis. Rectal Prolapse ( preload Preload Cardiac Mechanics), most murmurs decrease, EXCEPT the following:
    • HOCM (becomes louder)
    • Mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse (becomes longer and louder)
  • While squatting and with passive leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy raise (↑ preload Preload Cardiac Mechanics), most murmurs become louder, EXCEPT:
    • HOCM (becomes softer)
    • Mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse (becomes shorter, except in severe MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status)
  • With isotonic Isotonic Solutions having the same osmotic pressure as blood serum, or another solution with which they are compared. Renal Sodium and Water Regulation and isometric (sustained handgrip) exercise ( afterload Afterload Afterload is the resistance in the aorta that prevents blood from leaving the heart. Afterload represents the pressure the LV needs to overcome to eject blood into the aorta. Cardiac Mechanics), most murmurs increase, EXCEPT:
    • HOCM (decreases in intensity)
    • AS (decreases in intensity, helping to differentiate AS from MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status)
Table: Maneuvers that change the intensity of murmurs
Physiologic changes Maneuver Murmurs that increase with maneuver Murmurs that decrease with maneuver
Increased preload Preload Cardiac Mechanics (on the right) Inspiration Inspiration Ventilation: Mechanics of Breathing Most right-sided murmurs Most left-sided murmurs
Increased preload Preload Cardiac Mechanics
  • Lying supine
  • Passive leg Leg The lower leg, or just “leg” in anatomical terms, is the part of the lower limb between the knee and the ankle joint. The bony structure is composed of the tibia and fibula bones, and the muscles of the leg are grouped into the anterior, lateral, and posterior compartments by extensions of fascia. Leg: Anatomy raise
  • Squatting
Most murmurs
Decreased preload Preload Cardiac Mechanics
  • Valsalva (straining)
  • Abrupt standing
Most murmurs
Increased afterload Afterload Afterload is the resistance in the aorta that prevents blood from leaving the heart. Afterload represents the pressure the LV needs to overcome to eject blood into the aorta. Cardiac Mechanics Handgrip Most murmurs, especially AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation, MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status, VSD
  • AS
  • HOCM
HOCM: hypertrophic obstructive cardiomyopathy Cardiomyopathy Cardiomyopathy refers to a group of myocardial diseases associated with structural changes of the heart muscles (myocardium) and impaired systolic and/or diastolic function in the absence of other heart disorders (coronary artery disease, hypertension, valvular disease, and congenital heart disease). Cardiomyopathy: Overview and Types
AS: aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis
AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation: aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
MR MR Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status: mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation
VSD: ventricular septal defect Ventricular Septal Defect Tetralogy of Fallot

Mnemonics

  • rIght-sided murmurs: increase with Inspiration
  • lEft-sided murmurs: increase with Expiration

Specific Murmurs

The table below lists cardiac abnormalities with their corresponding murmurs.

Table: Systolic murmurs
Type Cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle Pattern Location Additional description
Aortic stenosis Aortic stenosis Aortic stenosis (AS), or the narrowing of the aortic valve aperture, is the most common valvular heart disease. Aortic stenosis gradually progresses to heart failure, producing exertional dyspnea, angina, and/or syncope. A crescendo-decrescendo systolic murmur is audible in the right upper sternal border. Aortic Stenosis Systolic Crescendo-decrescendo murmur Right 2nd ICS (aortic)
Pulmonic stenosis Stenosis Hypoplastic Left Heart Syndrome (HLHS) Systolic Crescendo-decrescendo murmur Left 2nd ICS (pulmonic)
Mitral valve Mitral valve The valve between the left atrium and left ventricle of the heart. Heart: Anatomy prolapse Systolic Click, crescendo into S2 (can vary with severity) Left 4th ICS (mitral) Mid-to-late systolic click
Mitral regurgitation Mitral regurgitation Mitral regurgitation (MR) is the backflow of blood from the left ventricle (LV) to the left atrium (LA) during systole. Mitral regurgitation may be acute (myocardial infarction) or chronic (myxomatous degeneration). Acute and decompensated chronic MR can lead to pulmonary venous congestion, resulting in symptoms of dyspnea, orthopnea, and fatigue. Mitral Regurgitation Systolic Uniform (holosystolic) Left 4th ICS (mitral)
  • Holosystolic,
high pitched
  • Radiates to axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy
Tricuspid regurgitation Tricuspid regurgitation Tricuspid regurgitation (TR) is a valvular defect that allows backflow of blood from the right ventricle to the right atrium during systole. Tricuspid regurgitation can develop through a number of cardiac conditions that cause dilation of the right ventricle and tricuspid annulus. A blowing holosystolic murmur is best heard at the left lower sternal border. Tricuspid Regurgitation Systolic Uniform (holosystolic) LLSB (tricuspid)
VSD Systolic Uniform (holosystolic) LLSB (tricuspid)
Harsh, loud murmur
ICS: intercostal
LLSB: left lower sternal border
VSD: ventricular septal defect Ventricular Septal Defect Tetralogy of Fallot
Table: Diastolic murmurs
Type Cardiac cycle Cardiac cycle The cardiac cycle describes a complete contraction and relaxation of all 4 chambers of the heart during a standard heartbeat. The cardiac cycle includes 7 phases, which together describe the cycle of ventricular filling, isovolumetric contraction, ventricular ejection, and isovolumetric relaxation. Cardiac Cycle Pattern Location Additional description
AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation Diastolic Decrescendo Erb’s point
  • S3 in acute AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
  • High pitched
Pulmonary regurgitation Pulmonary regurgitation Backflow of blood from the pulmonary artery into the right ventricle due to imperfect closure of the pulmonary valve. Pulmonary Regurgitation Diastolic Decrescendo Erb’s point ↑ With inspiration Inspiration Ventilation: Mechanics of Breathing
Mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis Diastolic Opening snap Opening snap Mitral Stenosis followed by decrescendo-crescendo murmur Left 4th ICS (mitral)
Tricuspid stenosis Tricuspid stenosis Tricuspid stenosis (TS) is a valvular defect that obstructs blood flow from the right atrium to the right ventricle during diastole. This condition most commonly results from rheumatic heart disease or a congenital defect, and is usually found in conjunction with other valvular disease. A mid-diastolic murmur is best heard at the lower left sternal border. Tricuspid Stenosis Diastolic Frequently with MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis (but softer and shorter than MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis) LLSB (tricuspid)
Patent ductus arteriosus Ductus arteriosus A fetal blood vessel connecting the pulmonary artery with the descending aorta. Patent Ductus Arteriosus (PDA) Continuous Crescendo-decrescendo murmur Left 1st and 2nd ICS Continuous machinery-like murmur
AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation: aortic regurgitation Aortic regurgitation Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation
ICS: intercostal
LLSB: left lower sternal border
MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis: mitral stenosis Mitral stenosis Mitral stenosis (MS) is the narrowing of the mitral valve (MV) orifice, leading to obstructed blood flow from the left atrium (LA) to the left ventricle (LV). Mitral stenosis is most commonly due to rheumatic heart disease. Mitral stenosis leads to impaired LV diastolic filling, increased LA pressure, and LA dilation. Mitral Stenosis

Mnemonics for valvular murmurs

  • Systolic murmurs: MR. PV TR-APS
    • MR (Mitral Regurgitation)
    • P (mitral valve Prolapse)
    • V (VSD)
    • TR (Tricuspid Regurgitation)
    • A (Aortic stenosis)
    • PS (Pulmonic Stenosis)
  • Diastolic murmurs: MS. PAR-TS
    • MS MS Multiple sclerosis (MS) is a chronic inflammatory autoimmune disease that leads to demyelination of the nerves in the CNS. Young women are more predominantly affected by this most common demyelinating condition. Multiple Sclerosis (Mitral Stenosis)
    • P (Pulmonary regurgitation Regurgitation Gastroesophageal Reflux Disease (GERD))
    • AR AR Aortic regurgitation (AR) is a cardiac condition characterized by the backflow of blood from the aorta to the left ventricle during diastole. Aortic regurgitation is associated with an abnormal aortic valve and/or aortic root stemming from multiple causes, commonly rheumatic heart disease as well as congenital and degenerative valvular disorders. Aortic Regurgitation (Aortic Regurgitation)
    • TS (Tricuspid Stenosis)

References

  1. Alpert, M.A. (1990). Systolic Murmurs. In Walker, H.K., et al. (Ed). Clinical Methods: The History, Physical, and Laboratory Examinations. (3rd ed.) https://www.ncbi.nlm.nih.gov/books/NBK345/
  2. Gersh, B. (2021). Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds. UpToDate. Retrieved Sept 4, 2021, from https://www.uptodate.com/contents/physiologic-and-pharmacologic-maneuvers-in-the-differential-diagnosis-of-heart-murmurs-and-sounds
  3. Gomella, L.G., Haist, S.A. (2007). History and physical examination. In Gomella, L.G., Haist, S.A. (Eds.), Clinician’s Pocket Reference: The Scut Monkey (11th ed.) https://accessmedicine.mhmedical.com/content.aspx?bookid=365&sectionid=43074910
  4. Jacobs, W.R. (1990). Ejection Clicks. In Walker, H.K., et al. (Ed.), Clinical Methods: The History, Physical, and Laboratory Examinations. (3rd ed.) https://www.ncbi.nlm.nih.gov/books/NBK347/
  5. McGee, S. (2018). Miscellaneous heart sounds. In S. McGee MD (Ed.), Evidence-based physical diagnosis (1st ed., pp. 355–360) http://dx.doi.org/10.1016/B978-0-323-39276-1.00042-1
  6. Meyer, T. (2021). Auscultation of cardiac murmurs. UpToDate. Retrieved Sept 5, 2021, from https://www.uptodate.com/contents/auscultation-of-cardiac-murmurs-in-adults#H2
  7. Mohrman, D.E., Heller, L.J. (2018). The heart pump. In Mohrman, D.E., Heller, L.J. (Eds.), Cardiovascular Physiology (9th ed.). accessmedicine.mhmedical.com/content.aspx?aid=1153946347
  8. O’Gara, P.T., Loscalzo, J. (2018). Approach to the patient with a heart murmur. In J.L. Jameson, et al. (Ed.), Harrison’s Principles of Internal Medicine (20th ed.). https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&sectionid=192012631
  9. Williams, E.S. (1990). The Fourth Heart Sound. In Walker H.K., et al. (Ed.), Clinical Methods: The History, Physical, and Laboratory Examinations (3rd ed.) https://www.ncbi.nlm.nih.gov/books/NBK344/

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