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systolic murmur

Classification: - graded I to VI Etiology: 1) aortic stenosis best heard at right upper sternal border 2) mitral regurgitation best heard at cardiac apex 3) ventricular septal defect 4) mitral valve prolapse 5) hypertrophic obstructive cardiomyopathy best heard at left lower sternal border 6) bicuspid aortic valve (without aortic stenosis) - most common congenital heart defect - systolic ejection click - early diastolic murmur due to aortic regurgitation common [5] - murmur does not vary with respiration or valsalva maneuver 7) right-sided systolic murmurs a) tricuspid regurgitation - jugular venous distension increases with Valsalva maneuver - pansystolic murmur at the left lower sternal border - murmur increases during inspiration b) pulmonic stenosis (valvular, sub- & supravalvular) 8) innocent murmurs may appear to be systolic murmurs* - heart murmurs of pregnancy - mammary souffle - result from increased intravascular volume 9) other - atrial septal defect: pulmonary mid-systolic flow murmur [3] - coarctation of the aorta: systolic murmur over the left chest [3] * patent ductus arteriosus causes a continuous murmur that envelops S2 [3] Clinical manifestations: 1) response to maneuvers: (Decrease (D) or Increase (I) in murmur) quality etiology valsalva hand grip squat stand cres-decres* AS* D D I D holosystolic MR* D I I D holosystolic VSD* D I I D after-late-click* MVP* D* D D I ?? h-cres-decres-h@a* HOC* I D D I * cres-decres: crescendo-decrescendo * AS: aortic stenosis * MR: mitral regurgitation * VSD: ventricular septal defect * MVP: mitral valve prolapse * after-late-click: late systolic murmur follows click * h-cres-decres-h@a: harsh, crescendo-decrescendo @ left sternal border, holosystolic @ apex * HOC: hypertrophic obstructive cardiomyopathy * ref [5] indicates murmur of mitral valve prolapse increases with valsalva maneuver 2) response to inspiration - pulmonary stenosis: murmur increases during inspiration 3) holosystolic murmur engulfs heart sounds S1 & S2 * innocent murmurs: - patient is asymptomatic - typically midsystolic, located at base of heart, grade 1-3/6 without radiation, normal splitting of S2, soft S3 may be present [3] - a Still murmur is a short, vibratory, grade 1-3, midsystolic murmur of low-pitch - best heard at the left sternal border - occasionally radiates to the cardiac apex - loudest with the patient supine - diminished in intensity when the patient sits or stands up (supine -> sitting or standing diminishes venous return to the heart) - no further testing indicated - heart murmurs of pregnancy (mammary souffle) a) continuous murmur b) may mimic valvular heart disease c) increased P2, S3 d) early peaking systolic murmur over the left sternal border e) S4 >= 3/6 in intensity & fixed S2 are signs of serious cardiac disease Special laboratory: 1) transthoracic echocardiogram - indications: - grade 3/6 or greater - late or holosystolic murmur [3] - symtomatic patients - not indicated for innocent murmur [3] 2) transesophageal echocardiogram - improved imaging quality, especially for mitral valve Management: - mild midsystolic murmurs are usually benign & warrant no further testing [3]

Related

handgrip Valsalva maneuver

Specific

innocent murmur

General

heart murmur

References

  1. Harrison's Principles of Internal Medicine, 13th ed. Companion Handbook, Isselbacher et al (eds), McGraw-Hill Inc. NY, 1995, pg 327-28
  2. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 199
  3. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2012, 2015, 2018, 2022.
  4. Salazar SA, Borrero JL, Harris DM. On systolic murmurs and cardiovascular physiological maneuvers. Adv Physiol Educ. 2012 Dec;36(4):251-6 PMID: 23209004
  5. NEJM Knowledge+. Question of the Week. Nov 29, 2016 http://knowledgeplus.nejm.org/question-of-week/3067/
  6. What Is a Heart Murmur? http://www.nhlbi.nih.gov/health/dci/Diseases/heartmurmur/hmurmur_what.html

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