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1971;59;443-445ChestB. Argano and Aldo A. LuisadaInnocent Diastolic Murmurs

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T H E S O U N D OF T H E H E A R TInnocent Diastolic Murmurs*B . Argano, M.D., nd Aldo A. Luisada, M.D. , F.C.C.P.

About 10 percent of children, a dolescents, or adults withan innocent systolic murmur also have an "innocent*diastolic murmur, which may be either low pitched andapical, or high-pitched and basal. Tentative explanationsare advanced .

D as to l ic mur m ur s hav e been cons ide r ed ev idence oforganic valvula r les ions for a long t ime. How ever , inthe l a s t 30 years , numerous cl inical and phonocardio-grap hic s tudies revealed t he poss ibil i ty of dias tol ic rum-bles not caused by mitral s tenosis . Following demonstra-t ion of such murmurs in congenital hear t disease, ourgr oup desc r ibed them in cor onar y , hyper tens ive , andanemic hea r t d i s ease , a s w e l l as in cases of myocardi-t is .l -3 More recently a funct io nal mid-diastol ic rumb le'From the Division of Cardiology (M ed ici ne ) of Th e Chica oMedical School, University of H ealth Sciences, and B ehloun t Sinai Hospital Medical Center.

This stud y was aided by a G rant of the H enry Davis 400Foundation and was made during tenure of U ndergrad uateTraining grant HE-5002 of the National Heart and LungInstitute, USPHS.

w as desc r ibed in a few normal subjects .4 High f requen-cy dias tol ic murmurs , not associated with hear t disease,were recently descr ibed in a fe w normal chi ldren.5We though t tha t a s ta t i st i cal s tudy w as ind ica ted an d

r ev iew ed the phonocar d iogr aphic t r ac ings r ecor dedwithin th e las t ten years in th e Divis ion of Cardiology.

The phonocardiograms of this Division were recorded withthe subjects in the supine position. Equipment used was:first, routine Sanborn recorder with high pass filters; second,Sanborn recorder modified in this 1aboratory;s third, GeneralElectric microphone and preamplifier with Sanborn amplifiersand galvanometers and band pass filters.?All tracing recorded in patients subsequently diagnosed ashaving "innocent" murmurs were reviewed. These subjectshad normal chest x-ray films and normal electrocardiograms.Their total number was 320. Excluded were cases withhistory of h eart disease or abno rmal electrocardiograms.Seventeen children (ages 3 to 1 5) and 13 adults (ages 15

to 40) presented a diastolic murmur in addition to a systolic

FIGURE . Tracings from a 33-year-old woman with an innocent systolic murmur. At left: lowfrequency tracing disclosing a low frequency mid-diastolic murmur at the apex. At right: highfrequency tracing disclosing a prolonged second sound and a high frequency diastolic murmurboth at base and apex.

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ARGANO AND LUISADA

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FIGURE. At left: tracings from a 66-year-old pa tient with an innocent systolic murmu r and a highfrequency, small diastolic murmur. At right: tracings from a 9-year-old child with a vibratory,innocent systolic murmur and a low frequency, mid-diastolic murmur, best recorded over themidprecordium (low er tracing ).murmur, which was often midsystolic and vibratory in nature. or adults. All cases ha d an "innocent" systolic mu rmu r atThis represen ts a total of 30cases or 9.6 percent. the base.

Amy1 nitrite by inhalation increased the systolic mur-RESULTS mur, decreased the early-diastolic murmur in most cases,T~~ types of murmurs were recognized, a mid-diastol- and tended to increase the mid-diastolic murmur; thisic, rumbling apical or midprecordial murmur an d an often beca me diastolic-presystolic becau se of th e fast-

early-diastolic, high frequency murmur at the second- er heart rate caused by the drug.third left intercostal spaces. D~ s c u s s ~ o ~( 1 Apical mid-diasto lic murmur Low frequency functional diastolic murmu rs in hearts

This was fo un d in nine &Idren and six or with an abnormal myocardium are often of high voltage.adults. It was usually associated with a low-pitched, 0" the contrary, those that we found in cases with aprominent third sound, which it seemed to prolong. It normal myocardium were of low voltage. High frequen-was of low frequency as it disappeared with filters above CY functional diastolic murmurs in hearts with a normal200 hz having a -24 db/octave slope (Fig 1 , 2 ) . myocardium were also of low voltage. This may explainwhy, contrary to the experience of others,S these mur-(2 Basal earlu-dia stolic murm ur murs w ere not disclosed by auscultation.. , While the low frequency rumbling murmur can beThis was found in ten children an d nine adolescents or explained by the modality of left ventricular filling,adults. It was a small amplitude, diastolic series of

possibly more tumultuous on a-unt of tachycardia,vibrations with a crescendo-decrescendo configuration; several alternative explanations can be advanced for theit was often (but not always) well separated from the high frequency murmur: minimal causedsecond sound. Exceptions were represented by a decre- b y uinnocentn fenestration of fie aortic or pulmonicscendo murmur star t ing with the semnd sound. This Ieageu;. minimalegurgitation on account of a bicuspidmurmur was of high f requency and was of ten well aortic valve; or minimal b y incorn-even with a ' hz "ter having a -30 db/oc- plete closure of the aortic or pulmonary valve. We havetave slope ( Fig 1 ,2 ) . no way to decide among them.( 3 ) Both

'Fenestrations of either the aortic or pulmonary leaflets wereThis occurred in two children and in two adolescents found by Foxes in 82 percent of a series of 300 hearts.CHEST, VOL. 59, NO. 4, APRIL 1971



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INNOCENT DIASTOLIC MURMURSThese murmurs should be known because otherwise

they may be accepted as evidence of a significant valvu-lar lesion when reading a phonocardiogram. Unfortu-nately such murmurs may also occur in pathologichearts. We had the experience of recording them inpatients with aortic or mitral valve lesions in whombiplane angiocardiography and cineangiocardiographyfailed to disclose any regurgitation.

1 Luisada AA, Perez Montbs L: A phonocardiographic studyof apical diastolic murmurs simulating those of mitralstenosis. Ann Intern Med 33:56-71, 1950

2 Luisada AA, Haring OM, Zilli AB: Apical diastolic mur-murs simulating mitral stenosis. 11. Graphic differentiation.Ann Intern Med 42:644-653, 1955

3 Luisada AA, Szatkowski J , Testelli MR, et al: Apicaldiastolic and presystolic murmurs of proved functionalnature. Amer J Cardiol4:501-507, 1959

4 Ferinelli A, Sbrighi V : I1 rumore mesodiastolico. Studiosemeiologico con fonocardiografia filtrata e ad alta ve1ocit.A.Cardiol Prat-Arch 5:276,310, 1964

5 Liebman J , Sood S: Diastolic murmurs in apparently nor-mal children. Circulation 38:755-762, 1968

6 Luisada AA , Bernstein JG: Better resolution and quantita-tion in clinical phonocardiography. Cardiologia 47:113-126,1965

7 Luisada AA, MacCanon DM, Feigen LP, et al: Design andfirst results of a new phonocardiograph. Amer J Cardiol ( inpress ) .8 Foxe AN: Fenestrations of the semilunar valves. Amer JPath 5 : 179-182,1929

Reprint requests: Dr. Luisada, 2020 West Ogden, Chicago60612.

Comments on Prevention of Myocardial lschem aAutoptic findings reveal severe narrowing of the coro- body requires for a given physical performance a smallernary arteries in uncomplicated angina pectoris in 92 to myocardial energy expenditure. These combined meta-100 percent of the cases. Th e same is true of massive bolic and dynamic effects of train ing, together with antransmural myocardial infarction. The "coronary re- improved development of collaterals, protect the hear t

serve" ranges between the coronary flow and oxygen against myocardial ischemia even in the presence ofco nsum ~t io n t rest. on the one hand and their com- some degree of coronary atherosclerosis.bined Aaximal au&nentation to the ~ o i n twhich still"permits an adequate oxygen availability to myocardialtissue, on the other. The trained, efficient heart with itslower sympathetic and higher vagal tone (augmentedcoronary reserve) requires less oxygen for a givenamount of work than t he inefficient faster beat ing heartof the sedenta ry individual. In addition, the trained

-Schimmert, G C and Schwalb, H : Functional and

Metabolic Factors in the Origin and Preventionof Myocardial Ischemia, in Raab, W :

Prevention of Ischemic Hear t Disease,C. C Thomas, Springfield, 1966

CHEST, VOL. 59, NO. 4, APRIL 19711971, by the American College of Chest Physicians

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1971;59; 443-445ChestB. Argano and Aldo A. LuisadaInnocent Diastolic Murmurs

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