Murmurs and Valve Lesions

OVERVIEW

• Description of a murmur

DESCRIPTION OF A MURMUR

(1) Timing

• systole/diastole/continuous
• early/mid/late/pan

(2) Area of greatest intensity

(3) Loudness

• grade 1 (very soft/consultants)
• grade 4 (thrill)
• grade 6 (no stethoscope required)

(4) Pitch

• low (low pressure)
• high (high pressure)

(5) Changes with Dynamic Manoeuvres

• respiration (RILE)
• squatting (makes most murmurs louder, except HOCM and MVP)
• isometric exercise (AS, HOCM and MVP softer, other murmurs louder)
• Valsalva:
  • -> straining -> HOCM and MVP softer
  • -> release -> first R sided murmurs increase then left sided

PAN-SYSTOLIC

• MR
• TR
• VSD
• Aorto-pulmonary shunts

MID-SYSTOLIC

• AS
• PS
• HOCM
• Pulmonary flow murmur of an ASD

LATE SYSTOLIC

• MVP
• Papillary muscle dysfunction (due to ischaemia or HOCM)

EARLY DIASTOLIC

• AR
• PR

MID-DIASTOLIC

• MS
• TS
• Atrial myoxoma
• AR (Austin Flint murmur – low pitched rumbling mid-diastolic and presystolic murmur @ apex -> shuddering of anterior leaflet of mitral valve)
• Carey Coombs murmur of acute rheumatic fever

PRESYSTOLIC

• MS
• TS
• Atrial myxoma

CONTINUOUS

• PDA
• Arteriovenous fistula (coronary artery, pulmonary, systemic)
• Aorto-pulmonary connection (e.g. congenital, Blalock shunt)
• Venous hum
• Rupture of sinus of Valsavla into right ventricle or atrium
• ‘Mammary souffle’ – late in pregnancy or early post partum period

PAN-SYSTOLIC MURMUR DISTINGUISHING FEATURES