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heart murmur
Classification:
1) grade 1: faint murmur, heard with difficulty
2) grade 2: faint murmer, easily identified
3) grade 3: moderately loud murmur
4) grade 4: loud murmur associated with palpable thrill
5) grade 5: very loud murmur, cannot be heard without stethocope
6) grade 6: loudest murmurs, can be heard without stethocope [3]
Etiology:
1) systolic murmurs
2) diastolic murmurs:
3) continuous murmur
4) innocent murmurs
Clinical manifestations:
1) systolic murmurs
a) graded I to VI
b) differential response to maneuvers (see systolic murmur)
c) holosystolic murmur engulfs heart sounds S1 & S2
2) Diastolic murmurs:
a) graded I to IV
b) early diastolic murmur
- begin immediately following S2
- high-pitched
- aortic regurgitation
- pulmonic regurgitation
c) mid-to-late diastolic murmur
- low-pitched
- heard best with bell of stethoscope
3) Continuous murmur
- present in systole & diastole (envelops S2)
- patent ductus arteriosus
4) innocent murmurs:
a) patient is asymptomatic
b) typically midsystolic, located at base of heart, grade 1-2/6 without radiation, normal splitting of S2, soft S3 may be present [3]
c) heart murmurs of pregnancy
- may mimic valvular heart disease
- increased P2, S3
- early peaking systolic murmur over the left sternal border
d) S4 >= 3/6 in intensity, fixed S2, diastolic murmur, continuous murmur are signs of serious cardiac disease
5) right-sided murmur increases with inspiration
Special laboratory:
1) transthoracic echocardiogram
- indications:
- systolic murmur grade 3/6 or greater
- late or holosystolic murmurs
- diastolic murmur
- continuous murmur
- murmur with accompanying symptoms [3]
- contraindications: innocent murmurs
2) transesophageal echocardiogram
- improved imaging quality, especially for mitral valve
Specific
continuous murmur
diastolic murmur
innocent murmur
systolic murmur
General
abnormal heart sound
murmur
References
- Harrison's Principles of Internal Medicine, 13th ed.
Companion Handbook, Isselbacher et al (eds), McGraw-Hill
Inc. NY, 1995, pg 327-28
- Harrison's Principles of Internal Medicine, 14th ed.
Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 199
- Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 18.
American College of Physicians, Philadelphia 2006, 2012, 2015, 2018.
- Etchells E, Bell C, Robb K.
Does this patient have an abnormal systolic murmur?
JAMA. 1997 Feb 19;277(7):564-71.
PMID: 9032164
- Premkumar P.
Utility of Echocardiogram in the Evaluation of Heart Murmurs.
Med Clin North Am. 2016 Sep;100(5):991-1001. Review.
PMID: 27542419
- What Is a Heart Murmur?
http://www.nhlbi.nih.gov/health/dci/Diseases/heartmurmur/hmurmur_what.html
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