Overview of Heart Murmurs

Original article by Tom Leach | Last updated on 24/12/2011
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Murmur	Type	Where Heard	Radiates	Symptoms	Associations	Info Aortic stenosis	Ejection systolic	2nd right intercostal space, left sternal edge	Carotids	Hypotension, cold peripheries, left ventricular enlargement, dyspnoea, angina, syncope, sudden death, slow rising carotid pulse, can cause an aortic thrill	Ejection click, Heaving apex beat, JVP – slow rising with plateau	More clinically severe than mitral regurg. The stenosis can be very severe, even when no murmur is present (or the murmur is very quiet). Can be caused by a congenital defect of the valve (where it only has two cusps), or by calcification of a normal three cusp valve. Can also be caused by rheumatic heart disease, and rarely, a large atheroma when there is sever hypercholesterolaemia. Mitral Regurgitation	Pan-systolic	Apex	Axilla	Often caused by left ventricular dilatation – thus the apex beat is displaced, and signs of heart failure may be present, also AF		Generally quieter, and longer duration than aortic stenosis. The second heart sound may be absent. The murmur is generally uniform and lasts the whole of systole. The sound is likely to be low pitched, and thus, best heard with the bell, but you should listen with the diaphragm as welll Mitral Prolapse	Late-systolic	Apex	Axilla		Mid-systolic click	Similar to mitral regurg. However, the murmur will first be audible half way through systole (not at the start), and will be preceded by the characteristic click of a prolapsing valve.  Aortic regurgitation	Early diastolic	Left sternal edge, 4th IC space	?	JVP – this may be fast rising and fast falling – ‘water-hammer pulse’, displaced apex beat, nailbed pulsations, collapsing pulse, head nodding in time with heartbeat, Corrigan’s sign – prominent carotid pulsation, BP higher in legs than in arms	Sometimes S3 – when there is associated LV hypertrophy	It will often initially sound high pitched, then will die away. Best heard with the patient sat upright in bed at the left sternal angle, with the patient holding their breath at the end of full expiration. This brings the valve closest to the stethoscope.   Best heard with the bell   Mitral stenosis	Mid- diastolic	Mitral area		Often associated with AF. 	Opening snap	It is rare to hear this anywhere other than the mitral area. It can be heard better if you get the patient to lie on their left hand side as this brings the valve closer to the stethoscope Acute pericarditis	‘to and fro’, or triple	Left sternal edge, sat upright, full expiration	-----------	Symptoms of pericarditis; sharp retrosternal pain (may radiate to the shoulders and neck), fever,	Pericardial friction rub	Can vary from hour to hour, like the pain of pericarditis, thought to be caused by the inflamed surfaces of the visceral and parietal pericardium rubbing together when they are inflamed. In severe effusion (tamponade) the sound may be absent due to the amount of fluid present Innocent flow murmurs	Pan systolic	?	?	These are normal sounds in children and young adults	-	Caused by the flow of blood over the valves, they often have a musical tone Split S2	-	-	-	-	-	When there is a wide fixed splitting of S2 that is not altered by respiration, this is likely to be caused by a atrial septal defect. Also, splitting of S2 is a normal finding; especially during inspiration. This is becausein inspiration, the diaphragm contracts, and the venous return to the heart is increased. Thus, the right side of the heart takes longer to fill, and so the sound  is split Atrial Plop	Diastolic	?	?	This is a sign of atrial myxoma. There may be signs of cerebrovascular damage (stroke)		Atrial myxoma is a non-cancerous tumour that can occur in the left or right atria. It grows on the atrial septum. it can embolise and cause strokes. A myxoma is a primary tumour of the heart. About 75% of them occur on the left side. They are rare. They are more common in families, and there is a genetic component.  S3	-	Mitral area	-	Normal finding in fit young people, and pregnant women. Thought to be caused by rapid filling of the heart. Also present in left ventricular failure – because even though filling is slow, the ventricle is non-compliant. 	Mitral and aortic regurg	This is a low pitched sound, and thus best heard with the bell. It occurs right after S2, and may sound like a double S2. It is often present in mitral and aortic regurgitation, because the stroke volume (and thus filling speed) is very high to cope with the regurgitation.  S4	-	Mitral area		Found in aortic stenosis, hypertension, CCF, hypertrophic obstructive cardiomyopathy	Aortic stenosis	This is also low pitched, and best heard with the bell. This is never a normal finding. It results from atrial contraction pushing the last bit of blood into the ventricle – thus is present when there is a non-compliant ventricle. Machinery murmur	Systolic 			Usually asymptomatic		Can also be heard quietly in diastole. Caused by a patent ductus arteriosus. This is a congenital anastomosis between the pulmonary and aortic circulation, that normally closes off at birth.    						   						  Systolic murmurs are easiest to hear, but it is more difficult to decide what type they are	 Don’t forget to feel for the carotid to know whether they are systolic or diastolic!  -	Systole – between S1 and S2 -	Diastole – between S2 and S3   Left sided murmurs are best heard on Expiration Right sided heart murmurs are best heard on Inspiration Left sided murmurs are the ones you are more bothered about!  Infective Endocarditis can cause any murmur, but is most likely to cause regurgitation.


Eponymous signs of aortic regurgitation
Austin Flint Murmur
Mid-diastolic murmur in the absence of mitral stenosis
Becker Sign
Accentuated Retinal Artery Pulsation
Corrigan’s Sign
Collapsing pulse (aka ‘Water Hammer pulse’)
De Musset sign
Head bobbing in time with the heart beat
Duroziez sign
Femoral artery sounds under compression
Gerhard Sign
Pulsatile spleen
Hill Sign
Higher systolic BP in the legs than in the arms
Mayne Sign
Drop in systolic BP >15mmHg when arm is raised
Mueller sign
Pulsatile uvula
Quincke sign
Exaggerated nail bed pulsations
Rosenback sign
Pulsatile Liver
Traube Sign
Loud sounds heard in systole and diastole over the femoral artery. Sometimes described as a pistol shot – heard with light compression
Grading Murmurs
If you hear a murmur you should be able to describe:
-          Systolic / Pansystolic
-          Duration – e.g. pan-systolic, ejection systolic
-          Site best heard at – e.g. Mitral area
-          Radiation – e.g. axilla
-          Grade
Murmurs can be graded on a scale of 1 – 6:
Very faint, can only be heard with stethoscope under optimal conditions
Only heard with stethoscope, but easily audible
Still only heard through the stethoscope, but loud
Similar to Grade 3, but also palpable
Louder than grade 4, and palpable thrill
Audible without the use of a stethoscope, and palpable thrill

Whats the difference between a thrill and a heave? 

  • A thrill - is a palpable murmur
  • A heave - is the result of LVH (Left ventricular hypertrophy) and feels like something pushing your hand off the chest