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My approach to heart murmurs

February 17, 2024 Andrew To

3D echo image of mitral valve prolapse with flail of P2 scallop

Murmurs could be benign, up to 10% of adults, 30% of children, and could be exacerbated by conditions such as anaemia, pregnancy, fever, hyperthyroidism. Murmurs could also pathological, including valvular lesions and structural abnormalities.

Here is my approach:

  • Describing the heart murmur

    • Timing

      • Murmurs are longer than heart sounds

      • Murmurs are systolic, diastolic or continuous

      • S1 vs. S2 could be distinguished by simultaneous carotid arterial pulse palpation

    • Shape

      • Crescendo (grows louder), decrescendo, crescendo-decrescendo, plateau

    • Location - determined by where the murmur originates

      • A, P, T, M listening areas

    • Radiation

      • reflects direction of blood flow and murmur intensity

    • Intensity grades

      • 1 = very faint

      • 2 = quiet but heard immediately

      • 3 = moderately loud

      • 4 = loud

      • 5 = heard with stethoscope partly off chest

      • 6 = no stethoscope needed

    • Pitch - high, medium, low

    • Quality - blowing, harsh, rumbling, musical

    • Others

      • variation with respiration

      • variation with patient position

      • variation with manoeuvres (e.g. standing, Valsalva make murmurs less intense and shorter, except HCM and mitral valve prolapse

  • What to look for, apart from the murmur?

    • BP - high, low, narrow pulse pressure, wide pulse pressure

    • Pulse - SR, AF, slow rising, collapsing

    • Heart failure - left, right, left+right

  • What to ask

    • Cardiac symptoms

    • Physical capacity

    • Congenital heart disease

    • Orthopnoea, PND

    • Rheumatic fever history

  • Remember other causes of murmurs

    • PDA

    • HCM

    • ASD

    • VSD

  • Tips

    • Time your murmur (systolic vs diastolic) by palpating radial/brachial artery when auscultating.

    • Inspiration accentuates right sided murmurs.

    • Expiration accentuates left sided murmurs.

    • Aortic regurgitation is best heard sitting forward in expiration.

    • Use bell of stethoscope to listen for mitral stenosis (low pitched murmur).

    • Loudness does not always correlate with severity.

    • If young + slim + pectus deformity + AR, think Marfan’s.

    • Management of valvular disease is primarily driven by symptoms

Dr Gary Lau

In Valvular heart disease, Cardiac Investigations Tags echocardiography, Aort, mitral regurgitation, aortic regurgitation, mitral stenosis, murmur
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Copyright @2024 Cardiology Institute; All photos copyright @2024 Andrew To