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MURMURS

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Introduction

Def:

prolonged series of sounds or vibrations

of varying loudness , frequency , character ,

duration , configuration .

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Physics of murmurs:

Any fluid that crosses reynolds number morethan 2000 causes murmur because of turbulence

R=density of fluid *velocity * diameter divided byviscosity

There are two theories for production ofturbulence , turbulence theory and eddie or

vortex theory Turbulence is produced by high velocity ,

abnormal valve , narrow orifice , post stenoticdilatation

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some important points

1)all murmurs are not pathological

2)absence of murmur cant exclude pathology

of heart

3)murmurs can also be due to extra cardiacorigin

4)murmurs have different properties intensity, location ,pitch ,quality , radiation , shape ,timing of the murmur.

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continued

5)High and medium pitched sounds are bestheard with diaphragm

6)Low pitched heart sounds are best heard

with the bell 7)We cannot identify properly a murmur if the

heart is beating rapidly and irregularly

8)diastolic murmurs are always pathological

9) grade 3 or more systolic murmurs are canbe pathological

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Timing

Murmurs can be divided into systolic or

diastolic by inspection or palpation of the

carotid artery and apical impulse

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1)Systolic based on timing divided into

Early systolic

Mid systolic

Late systolic

Pan systolic or holosystolic 2)diastolic divided into

Early diastolic

Mid diastolic

Late diastolic or pre systolic 3)continous murmurs

4)double murmurs

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EARLY SYSTOLIC MURMUR

Due to acute severe mitral regurgitation

Tricuspid regurgitation

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Mid systolic murmur

Can be innocent or pathological

Most common

sometimes present in children and adults

without pathology Will be present high output states such as

anaemia , fever , pregnancy

Aortic stenosis

Pulmonary stenosis Hypertrophic cardiomyopathy (due to septal

enlargement)

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Late systolic

Mitral valve prolapse

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Pan systolic murmur

Mitral regurgitation

Tricuspid regurgitation

Ventricular septal defect

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Mid or Late diastolic

Mitral stenosis

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Double murmurs

Aortic stenosis with aortic regurgitation

Pulmonary stenosis with pulmonary

regurgitation

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Continuous murmurs

Venous hum

Patent ductus arteriosis

Mammary souffle

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Timing of the murmurs

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Shape of the murmur

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Shape of the murmur

It can be crescendo ascending

Decrescendo- descending

Crescendo-decresendo uniform

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Location of the murmur

Normally method of auscultation should be

inch to inch

Main areas of auscultation are mitral area or

apex , tricuspid area , aortic area and

pulmonary area

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Mitral area 5th intercostal space half inch medialto the mid clavicular line

Tricuspid area 5th intercostal space in the leftparasternal area

Pulmonary area 2nd intercostal space leftparasternal area

Aortic area 2nd intercostal space right parasternalarea

Neo aortic or erbs area 3rd and 4th intercostal leftparasternal areas

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Character or Quality

Can be described as blowing , musical,

rumbling or rolling , grating etc

Rumbling or rolling commonly used for mitral

stenosis

Blowing is soft murmurs for regurgitant

lesions

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Radation

To the axilla and back-mitral regurgitation

To carotids -aortic stenosis

Gallaverdin effect

to apex in aortic stenosis To the right parasternal area-vsd

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intensity

Grading of murmurs of systolic origin

Grade 1 heard with difficulty

Grade 2 faint but can be heard easily

Grade 3 moderately loud

Grade 4 loud with thrill

Grade 5 very loud

Grade 6 loud can be heard without astethascope

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Diastolic murmurs graded upto 4 only

Thrill always associated with pathological heartonly

Murmur grade 3 or more is always pathological Mitral stenosis , aortic stenosis and ventricular

septal defect as they progress the intensity oftheir murmur decreases

Heart failure as it progress decreases theintensity of murmur

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Pitch

High frequencies normally produce highpitched sounds

Low frequencies low pitched sounds

High pitch is normally due to high velocity offlow which can be due to high pressuregradient and a narrow orifice eg ( small aortic

regurgitation and a small vsd) Low pitch is normally due to low pressure

gradient and large orifice eg(mitral stenosis)

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Other procedures

Valsalva and standing decreases the flow to

the heart so they decrease the intensity of the

murmur

Squatting and exercise increases the flow so

increases the intensity of the murmur

There are two exceptions hocm and mvp

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location pitch quality radiatio

n

shape timing others

Mitral

regurgitation

Apical

Leftlateral

position

High

pitched

blowing To the

axillaand

back

From s1

to s2

Soft s1

bestheard

with

diaphgr

am

Mitral

stenosis

apex low Rumblin

g or

rolling

cresend

o

decresc

endo

and

From s2

to s1

Presysto

lic

accentu

ation

Loud s1

Opening

snap

Aorticstenosis

Aorticarea

low rough To thecarotids

Crescendo-

decresc

endo

Midsystolic

Diamond

shaped

EjectionClick,gall

avedin

effect

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location pitch quality radiation Shape timing others

Tricuspid

regurgita

tion

Tricuspi

d area

Low

pitch

blowing nil uniform pansyst

olic

May be

associat

ed with

diastolic

rumble

Raised

jvp

Pulmon

ary

stenosis

Pulmon

ary area

Low

pitch

rough Diamon

d

shaped

systolic Wide

split s2

Aortic

regurgit

ation

2nd and

3rd ics

and left

sternal

border

blowing decresc

endo

Early

diastolic

Can be

Associat

ed

With

ESM

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SOME EPONYMS

Stills murmur-innocent murmur in childhood

Graham steels murmur-pulmonary regurgitation

Austin flint murmur-aortic regurgitation

Rogers murmur-ventricular septal defect Machinary murmur-patent ductus arteriosus

Carey coombs murmur-mitral valve inflammationdue rheumatic fever mid diastoloic

Cabot locke murmur-anaemia diastolic Docks murmur-left anterior descending branch

stenosis (continuous)

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THANK YOU