Memorising what Murmurs Mean

It is often difficult to remember which valve and which type of lesion produce which murmur. Here is a framework of thinking about valve and other lesions that may help you.

Systolic Murmurs
1. What is the most important thing that all systolic murmurs hold in common? a. If you have trouble with this subtle but obvious question, look at the following list and pick what is in common Ejection systolic Mid systolic Late systolic Early systolic Pan systolic Holo systolic Innocent systolic 2. Thats it, they all share a common timing in the cardiac cycle the one beginning with s. Why is that important? Well, what normally happens in the pumping chambers, the ventricles, during this s period? To prompt you, pick one a. Blood enters the ventricles b. Blood leaves the ventricles c. Blood is created within the ventricles d. Blood mysteriously vanishes from the ventricles e. Blood is motionless in the ventricles 3. You got it. So, in which of the following directions can the blood possibly go across the aortic and pulmonic valves during this s period? a. From great arteries to ventricles b. From ventricles to great arteries 4. If that is the case, which pathological change in these valves would most likely cause a murmur during this s period? a. Narrowing (stenosis) b. Leaking (incompetence) 5. Bearing in mind the pressure changes in the ventricle and great arteries during the cardiac cycle, what would the shape of the murmur be? a. Constant i.e. pansystolic b. Peaking and falling i.e. ejection systolic or diamondshaped

6. What about the AV valves the tricuspid and mitral valves. Which direction could blood possibly go during the s period? a. Ventricles to atria b. Atria to ventricles 7. And what pathology would cause the blood so flowing to murmur? a. Narrowing b. Leaking 8. What shape would the murmur be? a. Ejection systolic b. Pansystolic 9. What about across the IV septum or a patent ductus. If they were patent in which direction would blood floow? a. Right to left shunt b. Left to right shunt 10. What shape would the murmurs be? a. Pansystolic b. Ejection systolic

Diastolic murmurs
Go through the same exercise in your head What is in common with all diastolic murmurs? What is blood doing in the ventricles during this period? Which direction would blood flow across the semilunar valves during this period? What pathology would cause a murmur from such blood flow? What happens to the pressure gradient between great arteries and ventricles during diastole? (increases, decreases, both, none?) What shape of murmur would you expect? Which direction would blood flow across the A-V valves during this period? What pathology would cause this blood flow to murmur? What happens to the pressure gradient between atria and ventricles during diastole? What shape of murmur would you expect?

Systolic murmurs
To sum up, systolic murmurs are caused by 1. Blood leaving the ventricles, forward to the great arteries through narrow aortic or pulmonic valves (ejection systolic murmurs, as the gradient from ventricle-arteries increases to a peak then decreases) or 2. Blood leaking backward from the ventricles to the atria through leaky mitral or tricuspid valves (pansystolic murmurs as there is a continous gradient from ventricles to atria through systole), or 3. Blood crossing the IV septum or a PDA (most commonly left-to right) . These tend to be pansystolic when mild (the hole is small and L-R pressures dont equalize so flow continues throughout systole); they get progressively shorter and ejection shaped when severe (with a big defect the L-R pressures equalize more quickly). In addition the PDA murmur can go through the second heart sound into diastole as blood can continue flowing L-R during this period. 4. Blood being noisy during systole for obscure but nonpathological reasons (innocent murmurs).

Diastolic murmurs
To sum up, diastolic murmurs occur when blood is entering and filling the ventricles, through leaky aortic and pulmonic valves (decrescendo murmur due to decreasing artery-ventricle gradient), or through narrow AV valves (rumbling mid-diastolic with pre-systolic accentuation due to atrial contraction). Diastolic murmurs are in general softer and more difficult to hear than systolic murmurs, as the diastolic pressures are lower, and blood is flowing away from the chest wall. As a consequence, it is usual to apply some manouevres to increase the murmur or the transmission of the murmur to the chest wall. For aortic and pulmonic valves, this means listening at the end of a forced expiration with the subject leaning forward, listening at the 2nd left or right interspaces. For mitral stenosis it means a short burst of exercise (5-10 sit-ups) to increase flow, and lying on the left side, listening over the apex.