Heart Murmurs

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Introduction
A heart murmur is a sound produced due to turbulent blood flow within the heart.

Heart murmurs are heard by auscultation with a stethoscope as part of the cardiovascular
examination.

The cardiac cycle

The cardiac cycle refers to a series of physiological events making up a single heartbeat.
The cycle involves contraction (systole) and relaxation (diastole) of the atria and ventricles to
effectively pump blood.

The cardiac cycle starts with the atria and ventricles in diastole. Blood enters the right atrium
(from the vena cava) and the left atrium (from the pulmonary vein). At this point, the mitral
and tricuspid valves are open. This allows blood to flow freely into the right ventricle and left
ventricle from the atria. The aortic and pulmonary valves are shut, which prevents an
abnormal backflow of blood into the ventricles from the aorta and pulmonary artery.

The next stage of the cycle is atrial systole, contraction of the atria to finish “filling” the
ventricles with blood.

Ventricular systole occurs as the ventricles contract, increasing the pressure within the
ventricles. The increased pressure causes the closure of the mitral and tricuspid valves, this
prevents regurgitation of blood from the ventricles into the atria.

At this point, the volume of blood within the ventricles remains constant as the aortic and
pulmonary valves have not yet opened. This phase of ventricular systole is
called isovolumetric contraction.

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Eventually, the pressure within the ventricles exceeds the pressure in the pulmonary artery
and aorta causing the pulmonary and aortic valves to open. Blood is ejected from the
ventricles during ventricular ejection phase.

The ventricles then begin to relax following contraction (ventricular diastole). The drop in
pressure within the ventricle causes the aortic and pulmonary valves to close, to prevent
backflow (regurgitation) of blood into the ventricles.

Figure 1. An overview of the cardiac cycle.1

For more information, see the Geeky Medics guide to the electrical conduction system of the
heart.

Normal heart sounds

Normal heart sounds are caused by the closure of heart valves.

First heart sound (S1)

The first heart sound (S1) is caused by the closure of the mitral and tricuspid valves. It
marks the start of ventricular systole, and a peripheral pulse is felt at the same time (or
shortly after) S1.

Second heart sound (S2)

The second heart sound (S2) is caused by the closure of aortic and pulmonary valves. It
marks the end of ventricular systole, and the start of diastole.

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The pulmonary valve may close just after the aortic valve. Closure of the pulmonary valve
just after the aortic valve is prolonged during inspiration, or in defects which cause more
blood to be pumped out of the right ventricle.

Therefore, S2 may not always be heard as one discrete sound but may be muffled or have
two discrete sounds (split S2).

Heart sounds and the cardiac cycle

Figure 2. A Wiggers diagram showing the events of

the cardiac cycle.2

How to approach heart murmurs

It is important to have a structured approach to interpreting heart murmurs. See the Geeky
Medics guide to cardiovascular examination for more information on how to perform
auscultation.

If a murmur is heard during auscultation, consider the following questions:

When during the cardiac cycle is the murmur heard?

What are the characteristics of the murmur? What is the intensity (Table 1)?
Is the murmur heard loudest using the bell or the diaphragm of the stethoscope?
Where is the murmur heard the loudest?
Do any manoeuvres exaggerate the murmur?
Heard loudest on inspiration or expiration?
Does the murmur radiate?

Table 1. The Levine scale for grading cardiac murmurs according to intensity.3

Grade Description

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 One Very faint. Heard by an expert in optimum conditions

Two Heard by a non-expert in optimum conditions

Three Easily audible, no thrill

Four A loud murmur, with a thrill

Five Very loud, often heard over a wide area, with thrill

Six Extremely loud, heard without a stethoscope

A thrill is a palpable vibration caused by turbulent blood flow through a heart valve. Thrills
may be felt when palpating the anterior chest wall during a cardiovascular examination.

Aortic stenosis
Aortic stenosis (AS) refers to a tightening of the aortic valve at the origin of the aorta.

Aortic stenosis is associated with an ejection systolic murmur heard loudest over the aortic
valve. The murmur is described as having a ‘crescendo-decrescendo’ quality (it appears
as diamond-shaped on a phonogram). The murmur of aortic stenosis commonly radiates to
the carotid arteries.

Aetiology
Causes of aortic stenosis include:

Calcification of the aortic valves: this is the most common cause of AS in developed
countries, typically occurring in elderly adults.
Congenital abnormality of the aortic valve: the aortic valve is normally composed of
three cusps (known as a tricuspid valve), but in some cases, individuals have only two
cusps (known as a bicuspid valve) which predisposes them to the development of AS
as well as aortic regurgitation.
Rheumatic heart disease: a rare cause of AS in developed countries.

Clinical features

Typical features of an aortic stenosis murmur include:

Ejection systolic murmur heard loudest over the aortic area

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 Radiates to the carotid arteries
Loudest on expiration and when the patient is sitting forwards

Other clinical features of aortic stenosis may include:

Slow rising pulse with narrow pulse pressure

Non-displaced, heaving apex beat (if present indicates left ventricular hypertrophy)
Reduced or absent S2 (a sign of moderate-severe aortic stenosis)
Reverse splitting of S2: aortic valve closes after pulmonary valve (due to the longer
time required for blood to exit the left ventricle)

For more information, see the Geeky Medics guide to aortic stenosis examination.

Mitral regurgitation
Mitral regurgitation (MR) occurs when there is backflow (regurgitation) of blood from the left
ventricle into the left atria (through the mitral valve) during ventricular systole.

Mitral regurgitation is associated with a pansystolic murmur heart loudest over the mitral
area and radiating to the axilla.

Aetiology
Mitral regurgitation can be either acute or chronic.

Causes of mitral regurgitation include:

Infective endocarditis
Acute myocardial infarction with rupture of papillary muscles
Rheumatic heart disease
Congenital defects of the mitral valve
Cardiomyopathy

Clinical features

Typical features of mitral regurgitation murmur include:

A pansystolic murmur heard loudest over mitral area

Radiation of the murmur to the axilla
Heard loudest using the bell of the stethoscope
Loudest on expiration in the left lateral decubitus position

Other clinical features may include:

Displaced, hyperdynamic apex beat

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Aortic regurgitation
Aortic regurgitation (AR) occurs when there is backflow of blood from the aorta into the left
ventricle during ventricular diastole.

Aortic regurgitation is associated with an early diastolic murmur heard loudest at the left
sternal edge

Aetiology
Aortic regurgitation can be either acute or chronic. Chronic AR is often asymptomatic.

AR can occur due to a disease process affecting the valve itself, or due to dilatation of the
aortic root.

Diseases affecting the valve include:

Congenital bicuspid aortic valve

Rheumatic heart disease
Infective endocarditis

Causes of aortic root dilatation include:

Aortic dissection: can result in acute aortic regurgitation

Connective tissue diseases (e.g. Marfan’s)
Aortitis

Typical clinical features

Typical features of an aortic regurgitation murmur include:

Decrescendo early diastolic murmur

Heard loudest at left sternal edge (the direction that the turbulent blood flows)
sometimes heard loudest over the aortic area
Austin Flint murmur: a low pitched rumbling mid-diastolic murmur heard best at the
apex. This is caused by the regurgitated blood through the aortic valve mixing with
blood from the left atrium, during atrial contraction. An Austin Flint murmur is a sign of
severe aortic regurgitation.

Other clinical features of aortic regurgitation may include:

Collapsing pulse (a ‘water hammer pulse’ with wide pulse pressure)

Displaced, hyperdynamic apex beat

Eponymous clinical signs of aortic regurgitation

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There are many eponymous clinical signs associated with aortic regurgitation. These
include:

Corrigan’s sign: visible distention and collapse of carotid arteries in the neck
De Musset’s sign: head bobbing with each heartbeat
Quincke’s sign: pulsations are seen in the nail bed with each heartbeat when the nail
bed is lightly compressed
Traube’s sign: ‘pistol shot’ sound heard when stethoscope placed over the femoral
artery during systole and diastole
Muller’s sign: uvula pulsations are seen with each heartbeat

Mitral stenosis
Mitral stenosis (MS) is narrowing of the mitral valve, which results in decreased filling of the
left ventricle during systole and increased left atrial pressure (due to incomplete left atrial
emptying).

Mitral stenosis is associated with a low-pitched, rumbling, mid-diastolic murmur heard

loudest over the apex.

Aetiology
Rheumatic heart disease is the most common cause of mitral stenosis.

Other rarer causes include:

Congenital
Left atrial myxoma
Connective tissue disorders
Mucopolysaccharidosis

Clinical features
Typical features of a mitral stenosis murmur include:

Low-pitched, rumbling mid-diastolic murmur with an opening click (click heard in mid-
diastole when the mitral valve opens)
Murmur is heard loudest over the apex
Loudest in left lateral decubitus position on expiration

Other clinical features of mitral stenosis may include:

A low-volume pulse which may be irregularly, irregular (atrial fibrillation is common in

mitral stenosis)

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 Loud first heart sound with tapping apex beat (due to a palpable closing of the mitral
valve)
A malar flush (plum-red discolouration of the cheeks)

Mitral valve prolapse

A mitral valve prolapse occurs when the mitral valve leaflets prolapse into the left atrium
during systole.

Mitral valve prolapse is associated with a combination of a mid-systolic click and mid to late-
systolic murmur.

Aetiology
Mitral valve prolapse is the most common valvular abnormality with a prevalence of
approximately 5%.

The exact underlying cause of mitral valve prolapse is unknown. Primary mitral valve
prolapse is caused by myxomatous degeneration of the mitral valve and is associated with
connective tisuse diseases. Secondary mitral valve prolapse occurs when a ‘normal’ valve
prolapses.

Typical clinical features

Typical features of a mitral valve prolapse murmur include:

Mid-systolic click (prolapse of the mitral valve into left atrium)

Followed by a mid or late-systolic murmur
Heard loudest at the apex
Loudest in expiration

Tricuspid regurgitation
Tricuspid regurgitation occurs when there is backflow of blood from the right ventricle into
the right atrium during ventricular systole. This causes an increase in right atrial pressure
and elevated venous pressures.

Tricuspid regurgitation is associated with a pansystolic murmur heard loudest over the
tricuspid region.

Aetiology
Causes of tricuspid regurgitation include:

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 Right ventricular dilatation (e.g. secondary to pulmonary stenosis or pulmonary
hypertension)
Rheumatic fever
Infective endocarditis (intravenous drug users are at high risk of endocarditis affecting
the tricuspid valve)
Carcinoid syndrome
Congenital (e.g. atrial septal defect, AV canal, Ebstein anomaly)

The Ebstein anomaly (i.e. congenital isolated tricuspid regurgitation) is abnormal attachment
of tricuspid valve leaflets causes the tricuspid valve to displace downwards into the right
ventricle.

Typical clinical features

Typical features of a tricuspid regurgitation murmur include:

Pansystolic murmur
Heard loudest over the tricuspid region
Loudest during inspiration

Other clinical features of tricuspid regurgitation may include:

Large ‘v-waves’ visible in the jugular veins: caused by the right atrial filling of blood
against a closed tricuspid valve
Visible/palpable hepatic pulsations
Signs of right-sided heart failure: right ventricular heave, peripheral oedema,
hepatomegaly, ascites

Pulmonary stenosis
Pulmonary stenosis (PS) refers to narrowing of the pulmonary valve. It is commonly
associated with other congenital heart defects.

Aetiology

Causes of pulmonary stenosis include:

Congenital: Turner’s, Noonan’s and Williams syndromes. Tetralogy of Fallot (pulmonary

stenosis, right ventricular hypertrophy, ventricular septal defect and an overriding
aorta).
Rheumatic fever
Carcinoid syndrome

Typical clinical features

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Typical features of a pulmonary stenosis murmur include:

Ejection systolic murmur heard loudest over pulmonary area

Loudest during inspiration
Radiates to left shoulder/left infraclavicular region
In severe pulmonary stenosis, the murmur is longer and may obscure the sound of A2

Other clinical features of pulmonary stenosis may include:

Prominent ‘a waves’ in the jugular veins

Widely split S2: blood from the ventricles takes longer to pass through a narrow
pulmonary valve, so pulmonary valve closure occurs much later than aortic valve
closure
P2 may be soft and inaudible
Right ventricular dilatation can lead to a right ventricular heave, tricuspid regurgitation
and peripheral signs of right-sided heart failure (e.g. peripheral oedema, ascites etc)

Pulmonary regurgitation
Pulmonary regurgitation (PR) occurs when there is backflow of blood from the pulmonary
artery into the right ventricle during ventricular diastole. Pulmonary regurgitation is rare.

Aetiology
Causes of pulmonary regurgitation include:

Pulmonary hypertension
Infective endocarditis
Congenital valvular heart disease

Typical clinical features

Pulmonary regurgitation is usually asymptomatic.

Typical features of a pulmonary regurgitation murmur include:

Early decrescendo murmur heard loudest over the left sternal edge
Loudest during inspiration
Usually due to pulmonary hypertension: known as a Graham Steell murmur when
associated with mitral stenosis

Tricuspid stenosis
Tricuspid stenosis (TS) refers to narrowing of the tricuspid valve.

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Tricuspid stenosis is associated with a soft diastolic murmur loudest at 3rd – 4th intercostal
space at the left sternal edge

Aetiology
Causes of tricuspid stenosis include:

Rheumatic fever (most common)

Congenital disease
Infective endocarditis

Clinical features
Typical features of a tricuspid stenosis murmur include:

Mid-diastolic murmur (rarely audible)

Loudest at 3rd-4th intercostal space at the left sternal edge
Loudest during inspiration

Other clinical features of tricuspid stenosis may include:

Raised JVP with giant ‘a waves’

Peripheral oedema, ascites

Summary

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 Figure 3. An overview of heart murmurs using a
phonogram.4

Table 2. A table summarising the key differences between different heart murmurs.

Lesion Cardiac Character Breathing Location Radiation

cycle

Aortic Systolic Ejection Expiration 2nd intercostal Carotid

stenosis systolic space right arteries
sternal edge

Pulmonary Systolic Ejection Inspiration 2nd intercostal Left

stenosis systolic space left shoulder/infra-
sternal edge clavicular

Mitral Systolic Pansystolic Expiration Apex Axilla

regurgitation

Tricuspid Systolic Pansystolic Inspiration Left sternal

regurgitation edge

Mitral valve Mid Expiration Apex

prolapse systolic +
opening
click

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 Aortic Early Decrescendo Expiration Left sternal Left sternal
regurgitation diastolic edge (or 2nd edge
intercostal
space right
sternal edge)

Pulmonary Early Decrescendo Inspiration 2nd intercostal

regurgitation diastolic space left
sternal edge

Mitral Mid/late Expiration Apex

stenosis diastolic

Tricuspid Mid/late Inspiration Left sternal

stenosis diastolic edge

Editor

Dr Chris Jefferies

References
1. OpenStax College. Diagram describing the phases of the human cardiac cycle.
License: [CC-BY]. Available from: [LINK]
2. adh30/DanielChangMD/DestinyQx. Wiggers diagram. License: [CC-BY-SA]. Available
from: [LINK]
3. Innes, A, Dover, A, Fairhurst, K. Macleod’s Clinical Examination – 14th Edition.
Published in 2013.
4. Madhero88. Phonocardiograms from normal and abnormal heart sounds. License:
[CC-BY-SA]. Available from: [LINK]

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