Advanced Physical Diagnosis
  • Techniques
• 1st & 2nd Heart Sounds
• 2nd & 3rd Heart Sounds
• Clicks and Snaps
• Murmurs
• Rubs
  • Demonstrations
Associated Evaluations
  • Patient HX
  • Physical Exam
  • Laboratory & Imaging
Differential Dx
Evidence Base
• Accuracy in Diagnosis of Systolic Murmurs
• Accuracy in Diagnosis of Diastolic Murmurs
• Accuracy in Diagnosis of CHF
Teaching Tips
[Skill Modules >> Heart Sounds & Murmurs >> Techniques ]

Techniques: Heart Sounds & Murmurs

Murmurs (general) | Systolic | Diastolic

Diastolic Murmurs

valvular murmurs
Click this button to hear AI murmur.
nonvalvular murmurs

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Due to structural cardiac abnormality
  • Aortic regurgitation
  • Pulmonic regurgitation
  • mitral stenosis
  • tricuspid stenosis
Due to structural cardiac abnormality and increased flow
  • ventricular septal defect
  • atrial septal defect
  • mitral regurgitation
Due to increased flow
  • renal failure
  • thyrotoxicosis
  • anemia
  • sepsis/SIRS

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Analyze the murmur for

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Where murmurs occur in diastole
Diastolic murmurs are classified as:
  • Early or high or low pitched
  • Mid-diastolic murmurs
  • Presystolic murmurs

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Early diastolic murmur
Timing: Peaks at beginning of diastole when aortic or pulmonary pressure is highest and rapidly becomes quieter (decrescendo) as pressure falls.
Cause: Usually due to incompetence of aortic or pulmonary valve.
Examples: Aortic insufficiency; pulmonic regurgitation
Sound: Described as like a whispered letter "r".

diagram showing timing of aortic regurgitation from S2 to S1

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Timing: Begins after opening snap (50-100 msec after A2)
Cause: Usually caused by blood flow through narrowed mitral or tricuspid valve; related to abrupt deceleration of valve leaflets.
Examples: Mitral stenosis; tricuspid stenosis

diagram showing timing of diastolic murmur of mitral stenosis

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Presystolic murmur
Timing: Begins before systole
Cause: Found in 60% of moderate to severe AI, related to strong regurgitant flow
Examples: Austin Flint Murmur of aortic insufficiency

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Where it is best heard and where it radiates to
Location of Maximal Intensity Radiation Typical for:
Left 2nd ICS Down left sternal border Aortic insufficiency
2nd & 3rd ICS little Pulmonic regurgitation
Apex none Mitral stenosis
Lower left sternal edge little Tricuspid stenosis

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What it sounds like
Aortic insufficiency

High pitched, often faint, puffing, blowing quality

Pulmonic regurgitation

Can be high-pitched or low-pitched, often faint, blowing decrescendo.

Mitral stenosis

Low-pitched, rumbling murmur heard throughout diastole: a whispered letter "r".Best heard if the patient is rolled onto left side with stethoscope bell at apex.

Tricuspid stenosis

Rumbling murmur, increases with inspiration

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What happens during special maneuvers/positioning?
Pulmonary regurgitation

Increases with inspiration

Aortic insufficiency

Sometimes best heard if the patient is made to site up, lean forward and breathe out fully while the stethoscope at the left side of the lower part of the sternum.

Mitral stenosis

Best heard as the patient is rolled onto left side with stethoscope bell at apex. Better heard after exercise.

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Aortic regurgitation (aortic insufficiency)

Defective closure of the aortic valve with blood return from the aorta to the LV during diastole

Chronic aortic regurgitation

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Characterized by:
  • Diastolic murmur
  • Dilated apical impulse
  • Abnormal and collapsing arterial pulses
  1. Early diastolic
  2. Systolic flow murmur
  3. Diastolic rumble (Austin Flint)

    A. Most important murmur is early diastolic murmur

    • Early diastolic
    • Blowing high frequency
    • Decrescendo
    • Sounds like: Lub Pewwwwww
    • Best heard with diaphragm left 3-4 ICS
    • Augmented sitting up, leaning forward, exhaling

    B. Short systolic murmur

    • To-and-fro murmur
    • Sounds like: Lub shshs Pewww

    C. Apical diastolic rumble

    • 50% are Pre-systolic only, 50% have both mid-diastolic and pre-systolic component

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