1. Heart Disease Braunwald
Chapter Physical Examination (II)
--- Heart Murmur
Presenter: R4 劉嚴文

2. Cardiac Auscultation Heart Murmur
Characteristics of heart murmur
Timing in the cardiac cycle
Intensity (loudness)
Frequency (pitch) --- from high to low
Configuration (shape) --- crescendo, decrescendo, crescendo-decrescendo (diamond-shaped), plateau (even) or variable (uneven)
Quality
Duration
Direction of radiation

3. Cardiac Auscultation Heart Murmur

4. Cardiac Auscultation Heart Murmur
Heart murmurs broad categories
Systolic: begin with / after S1
end at / before S2
2 terms out of time
Regurgitant systolic murmur (holosystolic murmur)
Ejection systolic murmur (midsystolic murmur)
Diastolic: begin with / after S2
end at / before the subsequent S1
Continuous: begin in systole and continue without interruption through the S2 into all / part of diastole

5. Midsystolic Murmurs Etiologies Obstruction to ventricular outflow
Dilatation of the aortic root or pulmonary trunk
Accelerated flow into the normal aorta or pulmonary trunk, as during pregnancy, fever, thyrotoxicosis, or anemia
Innocent (normal) midsystolic murmurs
Some forms of MR

6. Aortic Valve Stenosis Symmetrical diamond shape
High-velocity jet within the aortic root
 radiation of the murmur upward to the right 2nd intercostal space and the neck

7. Aortic Valve Stenosis
In old adults, aortic valve with sclerotic or stenotic change resulted from fibrocalcific change :
R’t 2nd ICS: impure, noisy, harsh (jet turbulence)
LV impulse: pure, musical (from periodic high-frequency vibrations of the fibrocalcific aortic cusps)
( Gallavardin dissociation --- Noisy right basal and musical apical )

8. Aortic Valve Stenosis D/D from high-pitch apical murmur of MR
VPC followed by pauses longer than the dominant cycle length
Intensity of AS: increase
Intensity of MR: unchange

9. Pulmonary Valve Stenosis
Location: Right side of the heart
Length and configuration: signs of severity

10. Still Murmur Normal vibratory midsystolic murmur
Short, buzzing, pure and medium in frequency
Generated by low-frequency periodic vibrations of normal pulmonary leaflets or a left LV false tendon
Typically heard between LLSB and apex

11. Innocent Midsystolic Murmur
Location: second left intercostal space
Aortic sclerotic murmur (most common)
Exaggeration of normal ejection vibrations within the pulmonary trunk: relatively impure, best heard in the left 2nd ICS.
In patients with diminished anteroposterior chest dimension

12. Midsystolic Murmur from MR
Usually in ischemic heart disease associated with LV regional wall motion abnormalities.
Impaired integrity of the muscular component of the mitral apparatus
Early systolic competence of the mitral valve
Midsystolic incompetence
Late systolic decline in regurgitant flow

13. Holosystolic Murmurs
A persistent high pressure / resistance systolic flow to a low pressure / resistance vascular bed
Left heart: MR
Right heart: TR
Between the ventricles:
a restrictive VSD
Between the great arteries:
Aortopulmonary connection
(pulmonary vascular resistance rise to abolish the diastolic portion of the continuous murmur)

14. Holosystolic Murmurs Direction of radiation of MR
Jet forward and medial against the atrial septum near the origin of the aorta: murmur radiation to the left sternal edge, base and neck
Jet posterolateral with the LA: murmur radiation to the axilla, left scapula angle and the vertebral column with bone conduction from the C spine to L spine

15. Holosystolic Murmurs Diagnostic feature of TR
Carvallo sign --- inspiratory increase in loudness
Due to increase RV volume during inspiration
 Stroke volume ↑
 Regurgitant flow velocity ↑

16. Early Systolic Murmurs
Begins with S1, diminish in decrescendo and end well before S2, generally at or before midsystole
Certain types of acute severe MR, TR and VSD

17. Early Systolic Murmurs
A feature of TR with normal RV systolic pressure, ex. TR caused by IE
VSD
A small VSD (constrictive): a soft, pure, high-frequency, early systolic murmur localized to the mid- or lower left sternal edge
A non-constrictive VSD with elevated pulm. vascular resistance

18. Late Systolic Murmurs
Begin in mid- to late systole and proceed up to S2
Prototype: Mitral valve prolapse
Response to postural maneuvers / amyl nitrite
Prompt standing after squatting / valsalva maneuver: longer and softer
Squatting / handgrip (LV volume↑): shorter and louder
An intermittent, striking systolic whoop or honk -- spontaneously or in response to maneuvers: from mitral leaflets and chordae tendineae

19. Heart Murmur Diastolic murmur
Early diastolic murmur  AR, PR
Mid-diastolic murmur  MS, TS and atrial tumors, increase flow through non-obstructive AV valve
Late diastolic murmur  Austin-Flint murmur

20. Early Diastolic Murmurs --- AR
Left side of the heart, esp. with the diaphragm of the stethoscope
From primary valvular disease: best heard along the left sternal border in the 3rd and 4th intercostal space
From ascending aorta dilatation: along the right sternal border
Esp. leaning forward and during a held, deep exhalation
Beginning immediately after A2, high frequency

21. Early Diastolic Murmurs --- AR
Chronic AR
Moderate: murmur throughout diastole
Severe: more obvious decrescendo
Radiation to the right sternal edge: aortic root dilatation, as in Marfan syndrome

22. Early Diastolic Murmurs --- Acute AR
D/D from chronic AR
Often loud, Grade 4
Quite soft, Grade 2

23. Early Diastolic Murmurs
Graham Steell murmur (of pulmonary hypertensive pulmonary regurgitation)
Begin with loud P2
High pulmonary pressure on the incomplete P valve
 High diastolic pressure gradient between the pulmonary artery and the RV
 High-velocity regurgitant flow
 High-frequency blowing murmur, throughout diastole
 Amplitude of the murmur: uniform throughout most of diastole

24. Mid-Diastolic Murmurs
Mitral stenosis
Following the mitral opening snap, originating within the LV, transmission to the chest wall, maximal over the LV impulse
Left lateral decubitus position
Vigorous voluntary cough or a few sit-ups
 HR and mitral valve flow ↑
 Murmur reinforced

25. Mitral stenosis
In Af, duration of the murmur is a sign of the degree of obstruction at the mitral orifice
In sinus rhythm

26. Mid-Diastolic Murmurs
Tricuspid stenosis
D/D from MS:
Loudness of tricuspid murmur ↑with inspiration
Tricuspid murmur confined to a localized area along the left lower sternal edge

27. Late Diastolic Murmurs
Occur immediately before S1
Usually originate at the mitral or tricuspid orifice because of obstruction (MS, TS)
Tricuspid stenosis: crescendo-decrescendo. Fading before S1
Austin-Flint murmur in AR

28. Continuous Murmurs PDA (loudest in left 2nd ICS)
Coronary AV fistula (loudest in lower sternal border)
Ruptured sinus of Valsalva aneurysm (loudest in right upper sternal border)

29. Continuous Murmurs Arteriovenous continuous murmurs
Arterial continuous murmurs
Continuous venous murmur
Innocent cervical venous hum: the most common type of normal continuous murmur, in healthy children and healthy young adults, esp. pregnancy
Thyrotoxicosis and anemia

30. Heart Murmur Approach

31. Approach to the Patient with a Heart Murmur
Cardiac echo is indicated as follows:
Loud murmur (>= grade 3)
Holosystolic or late systolic murmur
Systolic murmur becomes louder or longer during Valsava maneuver (susp. HOCM or MVP)
Systolic murmur with clinical findings suggesting IE, thromboembolism or syncope
Systolic murmur associated with abnormal EKG

32. Heart Murmur Pericardial Rubs
Triple phases midsystolic, middiastolic and late diastolic
Detected in Acute pericarditis

33. Dynamic Auscultation Respiration
Diastolic sounds and ejection sounds
S3, S4, opening snap
From right heart: augmented during inspiration
From left heart: diminished during inspiration
Ejection sounds intensity
Right heart, ex. PS: ↓ during inspiration
Left heart: not effected, except tetralogy of Fallot
Murmur: more pronounced on the right side murmur
( Venous return increase during inspiration )
↑during inspiration: TS, PR (diastolic murmur), TR and Ebstein anomaly (presystolic murmur), MVP

34. Dynamic Auscultation Valsalva Maneuver

35. Dynamic Auscultation Valsalva maneuver reduced LV filling
Standing—reduce venous return
Squatting—increase venous return and systemic resistence
Lying—increase venous return
Hand grip—increase cardiac output and BP
Amyl nitritevasodilationBP drop reflex tachycardiaincrease cardiac output
Phenylephrine opposite effect of amyl nitite

36. Dynamic Auscultation

37. Thanks for Your Attention

38. Systolic Arterial Murmurs
Normal anatomical arteries with normal or increased flow
Abnormal arteries with tortuosity or luminal narrowing
Systolic and crescendo-decrescendo configuration
In old adults: atherosclerotic narrowing of a carotid, subclavian or iliofemeral artery
A rare pulmonary arterial systolic murmur: by luminal narrowing after a pulmonary embolus

39. Supraclavicular Systolic Murmurs
Often heard in children and aldolescents
Originate at the aortic origins of normal major branchiocephalic arteries
Crescendo-decrescendo, abrupt onset, loud and radiation below the clavicles
Murmur decrease in response to hyperextension of the shoulders

40. Systolic Mammary Souffle
Over the breast because of increase flow through normal arteries during late pregnancy or in lactating
Begin after S1

41. Mid-Diastolic Murmurs
Appreciable aortic valve incompetence or large left-to-right shunts, preceded by S3
Short, mid-diastolic aortic valve flow murmur in complete AV block
Pulmonary valve regurgitation

42. Dynamic Auscultation Muller Maneuver
Close the nose and seal the mouth
then forcibly inspire for 10 seconds
 Widen the split S2 and augment murmurs originating in the right heart

43. Heart Murmur

44. Dynamic Ausculation Lesion Murmur Valsalva Hand Grip Squat Stand AS
mid-systolic ↓ ↑ MR
holosystolic
VSD
MVP
Late systolic
HOCM
Amyl nitrite ↑ ↓

45. Heart Murmur Systolic murmur
Early Systolic Murmuracute MR(giant V)
TR with normal RV systolic pressure
Midsystolic murmur(ejection murmur) AS, PS,VSD,ASD
Late systolic murmurMVP
Holosystolic murmur(regurgitant murmur) MR,TR(Carvallo sign selective inspiratory increase murmur),VSD