Murmurs and Myocardial Murmurs and Myocardial Sounds…Making Sense of Sounds…Making Sense of

the Madnessthe Madness

Sara G. Tariq, M.D.Sara G. Tariq, M.D.

August, 2012August, 2012

GoalsGoals Know how we classify murmursKnow how we classify murmurs

• SystolicSystolic Crescendo-decrescendoCrescendo-decrescendo

• Aortic stenosis, pulmonic stenosis, or “innocent” Aortic stenosis, pulmonic stenosis, or “innocent” murmurmurmur

HolosystolicHolosystolic• Mitral regurg, tricuspid regurg or VSDMitral regurg, tricuspid regurg or VSD

Late Systolic - MVPLate Systolic - MVP• DiastolicDiastolic

Aortic regurgitation, pulmonic regurgitationAortic regurgitation, pulmonic regurgitation Stenosis of mitral or tricuspidStenosis of mitral or tricuspid

• BothBoth Patent Ductus ArteriosusPatent Ductus Arteriosus

GoalsGoals

Know the significance of rubsKnow the significance of rubs Know the significance of extra Know the significance of extra

soundssounds• Split S2 (varies vs split)Split S2 (varies vs split)• S3S3• S4S4

What are murmurs?What are murmurs?

SoundsSounds Murmurs exist because of turbulent Murmurs exist because of turbulent

blood flow or increased velocity of blood flow or increased velocity of blood flow across an orifice (a blood flow across an orifice (a valve)valve)

Usually 3 different kinds of soundsUsually 3 different kinds of sounds• Holosystolic, crescendo-decrescendo Holosystolic, crescendo-decrescendo

or decrescendo,or decrescendo,

Does sound matter?Does sound matter?

Most murmurs will worsen with smaller Most murmurs will worsen with smaller orifice size—so a very large VSD may have orifice size—so a very large VSD may have almost no pressure gradient across its almost no pressure gradient across its mouth and thus little murmur but very mouth and thus little murmur but very large physiologic consequences.large physiologic consequences.

Conversely, a small VSD may have a very Conversely, a small VSD may have a very turbulent jet with high velocity and a high turbulent jet with high velocity and a high pressure gradient across its mouth and be pressure gradient across its mouth and be associated with a loud murmur, but have a associated with a loud murmur, but have a much lower hemodynamic significance. much lower hemodynamic significance.

Grading the SoundGrading the Sound

II-faintest murmur that can be heard (with -faintest murmur that can be heard (with difficulty)difficulty)

II- II- murmur is also a faint murmur but can murmur is also a faint murmur but can be identified immediatelybe identified immediately

III- III- moderately loudmoderately loud IV- IV- loud with a palpable thrillloud with a palpable thrill V- V- very loud, but still need stethoscopevery loud, but still need stethoscope VI- VI- loudest and can be heard without loudest and can be heard without

stethoscopestethoscope

S1 and S2S1 and S2

Closing of the mitral (tricuspid, too) Closing of the mitral (tricuspid, too) and aortic (pulmonic, too) valvesand aortic (pulmonic, too) valves

Usually very crispUsually very crisp You should hear S1 loudest at mitral You should hear S1 loudest at mitral

areaarea You should hear S2 loudest at aortic You should hear S2 loudest at aortic

areaarea

Where do you hear murmurs?Where do you hear murmurs?

• RUSB= (may radiate to RUSB= (may radiate to neckneck))• LUSB=Pulmonic (may radiate to back)LUSB=Pulmonic (may radiate to back)• LLSB=Tricuspid (usually doesn’t radiate)LLSB=Tricuspid (usually doesn’t radiate)• Apex=Mitral (may radiate to Apex=Mitral (may radiate to axilla)axilla)

Systolic murmurs Systolic murmurs

““swooshing” soundsswooshing” sounds Occur right after S1 (closing of mitral Occur right after S1 (closing of mitral

valve) and before S2 (closing aortic v)valve) and before S2 (closing aortic v) Causes:Causes:

• having trouble getting out of the ventricle having trouble getting out of the ventricle through a tight door (aortic stenosis)through a tight door (aortic stenosis)

• You fall out through a door which should be You fall out through a door which should be closed tight but isn’t (mitral reg)closed tight but isn’t (mitral reg)

• A hole exists where it shouldn’t in the A hole exists where it shouldn’t in the ventricular septum and blood crosses from ventricular septum and blood crosses from high pressure side to low pressure side (VSD)high pressure side to low pressure side (VSD)

Mitral regurgitation

Mitral regurgitationMitral regurgitation

Mitral valve is incompetent and does Mitral valve is incompetent and does not close properly (door won’t close)not close properly (door won’t close)

Result: abnormal leaking of blood Result: abnormal leaking of blood from the LV, through the mitral from the LV, through the mitral valve, and into the left atriumvalve, and into the left atrium

Causes: myxomatous degeneration, Causes: myxomatous degeneration, MI, dilated LVMI, dilated LV

Sound: holosystolic (swoosh lasts Sound: holosystolic (swoosh lasts throughout systole) radiates to axillathroughout systole) radiates to axilla

Mitral and tricuspid valves – like a Mitral and tricuspid valves – like a parachuteparachute

Systolic MurmursSystolic Murmurs Mitral Regurgitation (apex)Mitral Regurgitation (apex)

• Systolic murmur Systolic murmur • Radiates to axillaRadiates to axilla

S1 S1S2

Mitral valve prolapse

displacement of an abnormally thickened mitral valve leaflet that gets displaced into the atrium in systole

Mid-systolic click with late systolic murmur

You can get mitral regurg if severe

Aortic StenosisAortic Stenosis

Aortic stenosisAortic stenosis

The aortic valve narrowsThe aortic valve narrows Creates turbulent blood flow across the Creates turbulent blood flow across the

narrowed valvenarrowed valve Result- the heart has to work hard by Result- the heart has to work hard by

creating pressure to get blood across the creating pressure to get blood across the stenotic valvestenotic valve

Causes: congenitally bicuspid valve, wear Causes: congenitally bicuspid valve, wear and tear from age, Rheumatic fever and tear from age, Rheumatic fever

Sound: crescendo-decrescendo murmur in Sound: crescendo-decrescendo murmur in systole, radiates to carotidssystole, radiates to carotids

Physical Exam: CardiacPhysical Exam: Cardiac RUSB with diaphragm; radiates to RUSB with diaphragm; radiates to

carotids bilaterallycarotids bilaterally

S1 S1S2

VSDVSD

VSDVSD

Congenital – hole in septumCongenital – hole in septum Left heart pressures>right heart Left heart pressures>right heart So in systole, when heart contracts, So in systole, when heart contracts,

the blood in the left goes across the the blood in the left goes across the “window” into the right side“window” into the right side

Holosystolic murmur, just like mitral Holosystolic murmur, just like mitral regurgitationregurgitation

Only difference is that it is usually over Only difference is that it is usually over the sternal borderthe sternal border

SystolicSystolic• Ventricular Septal Defect Ventricular Septal Defect

ContinuousContinuous• Arteriovenous connections (PDA)Arteriovenous connections (PDA)

““Innocent murmur”Innocent murmur”

AKA “physiologic murmur”AKA “physiologic murmur” Doesn’t radiateDoesn’t radiate Occurs NOT from a structural Occurs NOT from a structural

problem in the heart but from problem in the heart but from something outside the heartsomething outside the heart

Hyperthyroidism, anemiaHyperthyroidism, anemia

Systolic MurmursSystolic Murmurs Innocent murmursInnocent murmurs

• Usually ‘diamond shaped’, brief, little Usually ‘diamond shaped’, brief, little radiationradiation

• Common in children and young adultsCommon in children and young adults• ALWAYS: systolic, < III/VI intensity, ALWAYS: systolic, < III/VI intensity,

other other heart sounds and pulses heart sounds and pulses are normalare normal

S1 S1S2

Diastolic murmurs= really badDiastolic murmurs= really bad

Same “swoosh” but at a different Same “swoosh” but at a different timetime

You hear it right after S2 and before You hear it right after S2 and before S1S1

Blood is having trouble leaving the Blood is having trouble leaving the atrium to the ventricle b/c door is atrium to the ventricle b/c door is partly shut (mitral stenosis) partly shut (mitral stenosis)

Ventricular outflow tract can not stay Ventricular outflow tract can not stay shut (aortic regurg)shut (aortic regurg)

Aortic RegurgitationAortic Regurgitation

Aortic regurgAortic regurg

Aortic valve can not close fullyAortic valve can not close fully Some blood that should go forward Some blood that should go forward

to the body now comes back into the to the body now comes back into the heartheart

Causes:congenitally bicuspid valveCauses:congenitally bicuspid valve You hear the turbulence in diastole You hear the turbulence in diastole

after aortic valve should have fully after aortic valve should have fully closed (after S2)closed (after S2)

Diastolic MurmursDiastolic Murmurs Aortic Regurgitation (Upper Sternal)Aortic Regurgitation (Upper Sternal)

• radiates inferiorly radiates inferiorly • best heard with patient sitting up and best heard with patient sitting up and

leaning forward (in expiration)leaning forward (in expiration)

S1 S1S2

Mitral stenosisMitral stenosis

Mitral stenosisMitral stenosis Mitral valve is tight so blood can not get out of Mitral valve is tight so blood can not get out of

the atriumthe atrium When the mitral valve area goes below 2 cm, When the mitral valve area goes below 2 cm,

the valve causes an impediment to the flow of the valve causes an impediment to the flow of blood into the left ventricle, creating a pressure blood into the left ventricle, creating a pressure gradient across the mitral valve. gradient across the mitral valve. Pressure=turbulence=murmurPressure=turbulence=murmur

Causes: Rheumatic heart dz, damage from Causes: Rheumatic heart dz, damage from endocarditisendocarditis

Sound: A mid-diastolic rumbling Sound: A mid-diastolic rumbling murmur will be will be heard after an opening snap. The murmur is heard after an opening snap. The murmur is best heard at the apical region and doesn’t best heard at the apical region and doesn’t radiate radiate

Patent Ductus Arteriosis (PDA)Patent Ductus Arteriosis (PDA)

In some babies the ductus arteriosus In some babies the ductus arteriosus remains patent (connects pulm a and remains patent (connects pulm a and aorta)aorta)

This opening allows oxygen-rich blood This opening allows oxygen-rich blood from the aorta to mix with oxygen-poor from the aorta to mix with oxygen-poor blood from the pulmonary artery. blood from the pulmonary artery.

This can put strain on the heart and This can put strain on the heart and increase blood pressure in the lung increase blood pressure in the lung arteries. arteries.

PDAPDA

Sounds like continuous machinery Sounds like continuous machinery murmur throughout systole and murmur throughout systole and diastolediastole

SystolicSystolic• Ventricular Septal Defect Ventricular Septal Defect

ContinuousContinuous• Arteriovenous connections (PDA)Arteriovenous connections (PDA)

Split S2Split S2 Physiologically split S2Physiologically split S2

• Natural delay in closure of pulmonic valveNatural delay in closure of pulmonic valve• Why? increase in pulmonary blood flow that occurs with Why? increase in pulmonary blood flow that occurs with

inspiration when increased venous return to the right inspiration when increased venous return to the right side of the heart delays the closure of the pulmonic side of the heart delays the closure of the pulmonic valvevalve

Fixed Split S2= ASDFixed Split S2= ASD• Increase pulmonary blood flow from increased preload Increase pulmonary blood flow from increased preload

from L->R shunt of blood across ASD delays closure of from L->R shunt of blood across ASD delays closure of pulmonic valvepulmonic valve

• This split doesn’t change with respiration b/c ASD is This split doesn’t change with respiration b/c ASD is more hemodynamically significant than the small more hemodynamically significant than the small increase in volume of blood that results from inspirationincrease in volume of blood that results from inspiration

Split S2Split S2

Paradoxically Split S2Paradoxically Split S2• You have split S2 in EXPIRATIONYou have split S2 in EXPIRATION• This can only happen when the aortic This can only happen when the aortic

valve is delayed in closing.valve is delayed in closing.• A LBBB will cause delayed A LBBB will cause delayed

depolarization of the left ventricle and a depolarization of the left ventricle and a slightly delayed closing of the aortic slightly delayed closing of the aortic valve!!valve!!

S3S3 Only be heard with the bell, never with Only be heard with the bell, never with

the diaphragm .This helps distinguish it the diaphragm .This helps distinguish it clinically from a widely split S2. clinically from a widely split S2.

Is heard after S2 Is heard after S2 It can be normal in children and young It can be normal in children and young

people if no other abnormalities are people if no other abnormalities are reported on exam.reported on exam.

If other abnormalities are reported or the If other abnormalities are reported or the person is over 40, interpret this sound as person is over 40, interpret this sound as caused by the blood entering a ventricle caused by the blood entering a ventricle that is already volume and pressure that is already volume and pressure overloaded (like CHF) overloaded (like CHF)

S4S4

Caused by blood entering a thickened, Caused by blood entering a thickened, stiffened ventricle.stiffened ventricle.

Comes just before S1 in the cardiac cycleComes just before S1 in the cardiac cycle Can be left or right sidedCan be left or right sided Can occasionally be heard in athletes but Can occasionally be heard in athletes but

more commonly found in ventricular more commonly found in ventricular hypertrophy states or infiltrative hypertrophy states or infiltrative cardiomyopathies (amyloid etc) cardiomyopathies (amyloid etc)

RubsRubs

Pericardial rub= pericarditisPericardial rub= pericarditis This is a velcro sound that you can This is a velcro sound that you can

hear throughout the cardiac cyclehear throughout the cardiac cycle PericarditisPericarditis

• Recent upper resp tract infectionRecent upper resp tract infection• Chest pain that is better with leaning Chest pain that is better with leaning

forward and worse with lying downforward and worse with lying down