In cardiology, heart murmurs are the "heart sounds caused by vibrations resulting from the flow of blood through the heart. Heart murmurs can be examined by heart auscultation, and analyzed by their intensity (6 grades), duration, timing (systolic, diastolic, or continuous), location, transmission, and quality (musical, vibratory, blowing, etc)."
|Aortic stenosis||Valve velocity > 2.0 m/s||2||1|
More discussion is available online.
A systematic review by the Rational Clinical Examination addresses the diagnosis of systolic murmurs. A blinded, cross-sectional study addresses provocative maneuvers to help distinguish systolic murmurs.
Mitral valve insufficiency
- Holosystolic (pansystolic) murmur. Loudest at apex with radiation to the axilla
- Third heart sound
- Abnormal apical impulse
Aortic valve stenosis
More discussion is available online.
Mitral valve stenosis
- Mid-diastolic rumbling murmur
- Loud first heart sound
- Opening snap after the second heart sound
- Low pitched diastolic murmur following the opening snap with accentuation before the first heart sound
- Narrow pulse pressure
Aortic valve insufficiency
- Aortic ejection sound after the first heart sound
- Decrescendo diastolic murmur
- Mid-diastolic murmur (Austin Flint murmur)
- Wide pulse pressure
Indications for echocardiography
- "Echocardiography is recommended for asymptomatic patients with diastolic murmurs, continuous murmurs, holosystolic murmurs, late systolic murmurs, murmurs associated with ejection clicks or murmurs that radiate to the neck or back."
- "Echocardiography is recommended for patients with heart murmurs and symptoms or signs of heart failure, myocardial ischemia/infarction, syncope, thromboembolism, infective endocarditis, or other clinical evidence of structural heart disease."
- "Echocardiography is recommended for asymptomatic patients who have grade 3 or louder midpeaking systolic murmurs."
Class IIa recommendations
- "Echocardiography can be useful for the evaluation of asymptomatic patients with murmurs associated with other abnormal cardiac physical findings or murmurs associated with an abnormal ECG or chest X-ray."
- "Echocardiography can be useful for patients whose symptoms and/or signs are likely noncardiac in origin but in whom a cardiac basis cannot be excluded by standard evaluation."
Class III recommendations
- "Echocardiography is not recommended for patients who have a grade 2 or softer midsystolic murmur identified as innocent or functional."
Murmurs may be graded by their loudness:
- Grade I - not heard immediately
- Grade II - heard immediately
- Grade III - hear immediately, but louder
- Grade IV - associated with palpable thrill
- Grade V - may be heard with stethoscope partially off the chest
- Grade VI - may be heard with stethoscope off the chest
- Anonymous (2015), Heart murmur (English). Medical Subject Headings. U.S. National Library of Medicine.
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- Drummond Rennie; David Simel (2008). THE RATIONAL CLINICAL EXAMINATION: EVIDENCE-BASED CLINICAL DIAGNOSIS (Jama & Archives Journals). McGraw-Hill Professional. ISBN 0-07-159030-7.
- McGee, Steven R. (2007). Evidence-Based Physical Diagnosis. Philadelphia: Saunders. ISBN 1-4160-2898-6.
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