Murmurs

• Systolic murmurs


  Murmurs that occur during any part of systole
• Types of systolic murmurs

  • Ejection systolic (e.g. aortic stenosis)
  • Pansystolic (e.g. mitral regurgitation)
• Systolic murmurs may not be exactly the same amongst different patients with the same pathology
• Murmurs


  • Dependent on the severity of the pathology and presence of associated pathologies or changes
• Aortic stenosis


  A common valvular pathology affecting 2-7% over the age of 65, characterised by an ejection systolic 'woosh'
• Causes of aortic stenosis

  • Calcific (most common)
  • Bicuspid (congenital)
  • Rheumatic heart disease (common in the developing world)
• Aortic stenosis murmur


  Ejection systolic, described as crescendo-decrescendo, radiates to the carotids
• Best heard aortic stenosis murmur


  On expiration in the aortic area
• Additional signs of aortic stenosis

  • Sustained apex
  • Slow rising pulse
  • Narrow pulse pressure
• Heart sounds in aortic stenosis

  • Soft S2 (sign of severe disease)
  • S4
  • Reversed splitting of S2
• Pulmonary stenosis


  Often seen as a component of congenital syndromes but may also be acquired later in life, similar to aortic stenosis it results in an ejection systolic murmur
• Congenital associations of pulmonary stenosis

  • Noonan syndrome
  • Tetralogy of Fallot
  • Congenital rubella syndrome
• Acquired causes of pulmonary stenosis

  • Carcinoid syndrome
  • Rheumatic fever
• Pulmonary stenosis murmur


  Ejection systolic, described as crescendo-decrescendo, often associated with a thrill
• Best heard pulmonary stenosis murmur


  On inspiration at the pulmonary area
• Additional signs of pulmonary stenosis

  • Right ventricular heave
  • S4
  • Prominent a waves
• Hypertrophic cardiomyopathy (HOCM)


  A collection of inherited conditions that result in myocardial hypertrophy, may be picked up incidentally, on family screening, symptomatically or present with sudden cardiac death
• Causes of HOCM


  • Mutation of β-myosin heavy chain
  • Mutation of myosin-binding protein C
• HOCM murmurs


  Ejection systolic murmur, mid-late systolic murmur
• Best heard HOCM murmurs

  Ejection systolic murmur at the lower left sternal edge, mid-late systolic murmur often best heard at the apex and may radiate to the axilla
• Dynamic manoeuvres that increase HOCM ejection systolic murmur intensity

  • Valsalva
  • Standing
• Additional signs of HOCM

  • Jerky carotid pulse
  • Double apical pulsation
  • S4
  • Arrhythmia (e.g. AF)
• Mitral regurgitation


  Incompetence of the mitral valve that may occur due to abnormalities to the valve leaflets, subvalvular apparatus or left ventricle, may be acute or chronic
• Causes of mitral regurgitation

  • Degenerative
  • Infective endocarditis
  • Rheumatic heart disease
  • Congenital abnormalities
  • Medications (e.g. ergotamine)
• Mitral regurgitation murmur


  Pansystolic murmur
• Best heard mitral regurgitation murmur

  Over the apex, may radiate to the axilla depending on the direction of the regurgitant jet
• Additional signs of mitral regurgitation


  • Soft S1
  • S3
  • Mid-systolic click (in valve prolapse due to tensing of chordae tendineae)
• Tricuspid regurgitation


  Incompetence of the tricuspid valve, may be primary (disease directly affects the valve) or secondary (caused by dilatation of the right ventricle)
• Causes of primary tricuspid regurgitation

  • Rheumatic heart disease
  • Carcinoid syndrome
  • Infective endocarditis
  • Ebstein's anomaly
• Causes of secondary tricuspid regurgitation

  • Any cause of pulmonary hypertension and secondary dilation of the right ventricle
• Best heard tricuspid regurgitation murmur


  On inspiration at the lower left sternal edge, may be more lateral if right ventricle very enlarged
• Additional signs of tricuspid regurgitation

  • Prominent, pulsatile JVP
  • Large cv wave in JVP
  • S3/S4
  • Liver may be enlarged and pulsatile
• Ventricular septal defect (VSD)


  Common congenital cardiac malformation affecting around 1 in 500 births, causes a pansystolic murmur due to blood shunting from left to right during systole
• Causes of VSD


  • Largely unknown, some cases associated with chromosomal abnormalities (trisomy 13, 18 and 21)
• Best heard VSD murmur

  Depends on age and size of defect, generally the left sternal edge
• There is a wide range of additional signs that may be present in VSD, highly dependent on the size of the defect, direction of the shunt and other cardiac abnormalities
• Physiological murmur


  Ejection type systolic murmurs common in otherwise healthy individuals, thought to be caused by vibration of the pulmonary trunks
• Physiological murmurs can be hard to distinguish from other causes of systolic murmurs, but the remainder of the examination should be entirely unremarkable
• Transthoracic echocardiogram may be used to exclude cardiac pathology in cases of physiological murmur
• Diastolic murmurs


  Murmurs that occur in diastole, often described as early diastolic or mid-diastolic