Author:

Editor(s):

Updated:

ULY CLINIC

12 Septemba 2025, 00:47:51

Murmurs

Murmurs are auscultatory sounds originating from the heart chambers or major arteries. They are classified by timing, duration, location, loudness, configuration, pitch, and quality.

Timing: Systolic (between S1 and S2), holosystolic (throughout systole), diastolic (between S2 and S1), or continuous. Systolic and diastolic murmurs can be early, mid, or late.
Location: Area of maximum loudness (e.g., apex, lower left sternal border, intercostal spaces).
Loudness: Graded 1–6 (1 = faint, 6 = audible with stethoscope lifted; thrill may be present in grades 4–6).
Configuration: Crescendo, decrescendo, crescendo-decrescendo, decrescendo-crescendo, plateau, variable.
Pitch: High or low.
Quality: Harsh, rumbling, blowing, scratching, buzzing, musical, or squeaking.

Pathophysiology

Murmurs can indicate accelerated blood flow, forward flow through a narrowed/irregular valve or dilated vessel, backflow through an incompetent valve, septal defect, patent ductus arteriosus, or decreased blood viscosity. They may result from organic heart disease or surgical prosthetic valves. Some murmurs are innocent (functional), e.g., Still’s murmur in children or mammary souffle during late pregnancy/postpartum.

History and Physical Examination

History:
- Determine if the murmur is new or known since birth.
- Assess associated symptoms: palpitations, dizziness, syncope, chest pain, dyspnea, fatigue.
- Review medical history: rheumatic fever, heart disease, heart surgery, prosthetic valves.
Examination:
- Auscultate using bell for low-pitched and diaphragm for high-pitched murmurs.
- Check for arrhythmias, jugular vein distention, pulmonary signs, hepatomegaly, peripheral edema.

Emergency interventions

Acute MI: Loud holosystolic murmur may indicate papillary muscle rupture or ventricular septal defect.
Bacterial endocarditis: New murmurs plus crackles, jugular vein distention, dyspnea, orthopnea may indicate heart failure.

Medical causes

Cause	Murmur Characteristics	Associated Findings
Aortic insufficiency (acute)	Soft, short diastolic murmur over left sternal border; best heard sitting, leaning forward	Tachycardia, dyspnea, JVD, crackles, fatigue, cool extremities
Aortic insufficiency (chronic)	High-pitched, blowing, decrescendo diastolic murmur; Austin Flint murmur possible	Palpitations, tachycardia, angina, fatigue, dyspnea, orthopnea
Aortic stenosis	Systolic, harsh, medium-pitched, crescendo-decrescendo; loudest at 2nd right intercostal	Dizziness, syncope, exertional dyspnea, fatigue, angina
Hypertrophic cardiomyopathy	Harsh late systolic murmur ending at S2	Dyspnea, chest pain, palpitations, dizziness, syncope
Mitral insufficiency (acute)	Medium-pitched blowing, early systolic or holosystolic decrescendo at apex; S2 split, S4	Tachycardia, acute pulmonary edema
Mitral prolapse	Midsystolic to late-systolic click, high-pitched late-systolic crescendo murmur	Palpitations, chest pain, dyspnea, syncope, migraines, anxiety
Mitral stenosis	Soft, low-pitched, rumbling, diastolic; loud S1, opening snap	Dyspnea, fatigue, hemoptysis, pulmonary edema
Myxomas (atrial/ventricular)	Left atrial: middiastolic + holosystolic at apex; S4, tumor plop	Dyspnea, orthopnea, chest pain, syncope, fatigue
Papillary muscle rupture	Loud holosystolic murmur at apex	Severe dyspnea, chest pain, hypotension, tachycardia
Rheumatic fever with pericarditis	Systolic mitral regurgitation, midsystolic mitral leaflet swelling, diastolic aortic regurgitation	Fever, joint/sternal pain, edema, tachypnea
Tricuspid insufficiency	Soft, high-pitched holosystolic, louder with inspiration (Carvallo’s sign)	JVD, ascites, peripheral edema, fatigue
Tricuspid stenosis	Diastolic, louder with inspiration, softer with exhalation/Valsalva	Fatigue, peripheral edema, hepatomegaly, ascites, dyspnea

Other causes

Prosthetic valves: Variable murmurs depending on location, composition, and function.

Special considerations

Prepare patients for ECG, echocardiography, angiography.
Administer antibiotics or anticoagulants if indicated.
Provide emotional support, as cardiac findings can be distressing.

Patient counseling

Explain signs and symptoms that require prompt reporting.
Discuss prophylactic antibiotics if appropriate.

Pediatric pointers

Innocent murmurs (e.g., Still’s murmur) common in children; usually resolve by puberty.
Pathological murmurs may indicate congenital heart disease: atrial or ventricular septal defects, rheumatic heart disease.

Summary Table: Common Murmur Types

Murmur	Key Features	Best Heard	Associated Signs
Aortic stenosis	Systolic, harsh, crescendo-decrescendo	2nd right intercostal	Syncope, angina, dyspnea
Aortic regurgitation	Diastolic, high-pitched, decrescendo	Left sternal border	Palpitations, fatigue, dyspnea
Mitral stenosis	Diastolic, low-pitched, rumbling, opening snap	Apex, left lateral	Dyspnea, hemoptysis, fatigue
Mitral regurgitation	Holosystolic, blowing	Apex	Pulmonary edema, tachycardia
Tricuspid regurgitation	Holosystolic, high-pitched, increases with inspiration	Lower left sternal border	JVD, ascites, edema
Mitral prolapse	Mid-to-late systolic click, late-systolic crescendo	Apex	Palpitations, chest pain, anxiety

References

Geliki KA, Sotirios F, Sotirios T, Alexandra M, Gabriel D, Stefanos M. Accuracy of cardiac auscultation in asymptomatic neonates with heart murmurs: Comparison between pediatric trainees and neonatologists. Pediatr Cardiol. 2011;32:473–477.
Gokman Z, Tunaoglu FS, Kula S, Ergenekon E, Ozkiraz S, Olgunturk R. Comparison of initial evaluation of neonatal murmurs by pediatrician and pediatric cardiologist. J Fetal Neonatal Med. 2009;22:1086–1091.