Heart murmurs

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Clinical Features

Differential Diagnosis

Valvular Emergencies



  • Aortic Stenosis
    • Systolic murmur heard best in the aortic area; rarely at apex
    • Crescendo-decrescendo, radiates to carotids
    • A2 decreased
    • Paradoxical splitting of S2; narrow pulse pressure
    • Pulsus parvus et tardus
  • Aortic Insufficiency
    • Diastolic blowing murmur heard at left sternal border in 3rd and 4th interspace
    • Wide pulse pressure
    • Quincke's sign (capillary pulsations at fingertips), DeMusset's sign (bobbing head), Muller's sign (pulsing uvula), and Corrigan's pulse (water hammer)
    • Pistol shot sounds
  • Pulmonic stenosis
    • Systolic murmur heard in pulmonic area, transmitted to back and neck
    • A2 is decreased, P2 is delayed, and RVH with parasternal lift
  • Pulmonic insufficiency
    • High pitched diastolic murmur; heard in pulmonic area; decrescendo; RVH
  • Mitral Stenosis
    • Low rumbling diastolic murmur heard best at apex with bell
    • Opening snap sometimes present worse with closer to S2
    • Loud S1
    • Associated with left atrial dilation
    • Can hear presystolic sound confused with systolic murmur
  • Mitral Insufficiency
    • Loud, holosystolic, high-pitched, heard best at apex and transmitted to axilla
    • Soft S1
    • Severity gauged by s3, rumble.
    • Paradoxical splitting


  • Gallavardin Effect
    • AS sounds like MR - high frequency vibrations to the apex through a calcific AV
  • Austin-Flint
    • MS sounds like AR - Soft, rumbling murmur, likely due to functional mitral valve stenosis as the backflow of blood from the aorta presses on anterior leaflet of MV
  • Parodoxical S2
    • Splittin during expiration and goes away during inspiration
    • Secondary to inc left sided volume; AS, HOCM
  • Wide S2
    • secondary to Inc right sided volume; PE, ASD, VSD, Pulmonic stenosis
  • S3
    • AKA ventricular gallop produced during passive LV filling when blood strikes a compliant LV; CHF, Inc Vol, CAD, benign in youth, train athletes
  • S4
    • AKA atrial gallop produced when blood is forced into a stiff/hypertrophic ventricle ;MI, hypertension, restrictive cardiomyopathy


  • Valsalva
    • Increases thoracic pressure and lowers preload; then then decreased CO and afterload
    • Increases murmur in MP & HOCM
    • With release: right heart murmurs return first
  • Hand grip
    • Increases HR + CO
    • Increases murmur in MR, MS, AR
    • Decreases murmur in AS and HOCM
  • Squatting
    • Increased venous return
    • Delays MP click
  • Standing
    • Dec in both right & left venous return & SV
    • Decreases murmur of PS, AS, AR, TR, VSD
    • Increases murmur of HOCM
  • Inspiration
    • Increases right sided venous return while decreasing left sided return
    • Increases S2 splitting with P2 further from A2
    • Increases in right sided S3 & S4
    • Increases TS opening snap & murmur, PR, TR
    • Decreases MS opening snap, MVP murmur

See Also