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
