Murmurs

1. Murmur: new, transient, paradoxical S2 during pain

Origin: apex, Left Lower Sternal Border (LUSB) , 2nd ICS
Possible associated diagnosis: coronary ischemia, left ventricular dysfunction,
chronic heart failure or left bundle-brunch block. (Carabello et al, 2006).

2. Murmur: transient S3 (ventricular gallop) with mitral regurgitation

Origin: apex.
Possible associated diagnosis: myocardial ischemia or congestive heart failure,
usually with an increase in filling pressurer within the affected ventricle. (Carabello et
al, 2006).

3. Murmur: Third sound (S3 physiological gallop)

Origin: apex
Possible associated diagnosis: is heard in healthy young adults in 30 - 50%.
(Carabello et al, 2006).

4. Murmur: S4 (atrial gallop)

Origin: apex (5th ICS), using bell, patient in lateral position; and LLSB.
Possible associated diagnosis: stressed heart as a result of HTN, MI or CAD
causing heart failure. S4 is also present in most patients with a complete AV block,
HCM, and chronic ischemic heart disease. (Carabello et al, 2006).

5. Murmur: S3, S4 (summation gallop, "quadruple rhythm")

Origin: apex
Possible associated diagnosis: heart failure, DCM and ventricular aneurysm.
(Carabello et al, 2006).

6. Murmur: murmur with thrill

Origin: upper right or left sternal border (URSB)
Possible associated diagnosis: congenital heart defect. (Carabello et al, 2006).

7. Murmur: aortic diastolic murmur

Origin: upper right or left sternal border
Possible associated diagnosis: dissecting aorta. (Carabello et al, 2006).

8. Murmur: midsystolic click/late systolic murmur (honk)

Origin: apex, 5th ICS
Possible associated diagnosis: mitral valve prolase. (Carabello et al, 2006).

9. Murmur: S2 is louder than S1

Origin: apex
Possible associated diagnosis: diastolic hypertension. In normal individual, S2 is
louder than S1 at the aortic and pulmonic area. (Carabello et al, 2006).

10. Murmur: The pulmonary ejection sound (click)

 Origin: pulmonic area
Possible associated diagnosis: idiopathic dilatation of the pulmonary artery.
(Carabello et al, 2006).

11.Murmur: Mid-late nonejection systolic clicks

Origin: apex, 5th ICS
Possible associated diagnosis: MVP, ventricular and atrial septal aneurysms,
ventricular free wall aneurysm, ventricular and atrial tumors. (Carabello et al, 2006).

12. Murmur: fixed splitting of S2 (no respiratory effect).

Origin: pulmonic area.
Possible associated diagnosis: ASD (60-70%). Occasionally, normal subjects
appear to have fixed splitting of S2 in the supine position that becomes single in the
upright position. (Carabello et al, 2006).

13.Murmur: wide splitting of S2

Origin: pulmonic area
Possible associated diagnosis: CRBBB (complete right bundle branch block)
(Carabello et al, 2006).

14.Murmur: both components of S2 (aortic A2, pulmonic P2) are heard at the apex,
implying an increased of S2
Origin: apex
Possible associated diagnosis: ASD, pulmonary hypertension. (Carabello et al,
2006).

15.Murmur: systolic ejection murmur.

Origin: RUSB, 2nd ICS
Possible associated diagnosis: AS, PS, ASD and HCM, innocent murmur.
(Carabello et al, 2006).

16.Murmur: innocent (functional) murmur

Origin: pulmonic area, in early systole, with short and soft S3. (Carabello et al,
2006).

17.Murmur: mid-diastolic rumbling murmur start with OS lasts to S1.

Origin: apex
Possible associated diagnosis: MS, AR. Laud murmur with increased pressure
gradient across the valve. (Carabello et al, 2006).

18. Murmur: early systolic ejection murmur

Origin: pulmonic valve
Possible associated diagnosis: ASD. (Carabello et al, 2006).

19. Murmur: pansystolic murmur

Origin: apex, 5 th ICS; and LLSB, 4th ICS.
 Possible associated diagnosis: VSD, MR, TR. Pansystolic murmur of VSD should
be differentiated from TR and MR. (Carabello et al, 2006).

20.Murmur: Venous hums.

Origin: female breasts in postpartum period should be differentiated from AR.
(Carabello et al, 2006).

21. Murmur: continuous murmur

Origin: loudest in the posterior thorax
Possible associated diagnosis: coactation of the aorta, pulmonary arterio-venous
fistula, peripheral pulmonary stenosis. (Carabello et al, 2006).

22.Murmur: Pan/holosystolic: inspiration accentuates, thrill

Origin: LLSB, 4th and 5th ICS, xiphoid
Possible associated diagnosis: tricuspid valve insufficiency, tricuspid
regurgitation. (Carabello et al, 2006).

23. Murmur: crescendo-decrescendo, ejection-click, split S2

Origin: left upper sternal border, 2nd ICS
Possible associated diagnosis: pulmonic valve stenosis. (Carabello et al, 2006).

24. Murmur: mid-systolic: crescendo-decrescendo, soft S2, ejection-click,

paradoxical split S2
Origin: Right upper SB, 2nd ICS, R neck; lying flat or sitting up
Possible associated diagnosis: aortic stenosis. (Carabello et al, 2006).
Innocent pulmonary ejection murmur - soft, midsystolic murmur
that was second-degree at the most. Auscultation area: left third
intercostal space (LIC3).
Innocent vibratory murmur - On auscultation, the typical early and
midsystolic low-vibrating murmur is best heard at the left fourth intercostal
space and the apex
Venous hum - Auscultation revealed a systolic-diastolic second-degree
murmur that was loudest in early diastole. Venous hum is sometimes a
misleadingly loud murmur. It is caused by flow in the jugular veins under the
clavicle into the superior vena cava. This sound is intensified when the head
is turned left and disappears when lying supine. The hum is heard best at the
right second intercostal space and medially up behind the sternum. The hum
is not necessarily heard on every auscultation.
Aortic stenosis A third-degree coarse, stenosis-type murmur that does not
last until the end of systole is heard in the aortic area. Auscultation area: left
third intercostal space (LIC3).
Pulmonary stenosis. On auscultation a second-degree coarse, low-
frequency systolic ejection murmur was heard. Flow velocity is highest at the
beginning of systole, and the peak frequencies also occur in early systole,
with a descending frequency contour. The findings resemble ASD, the main
difference being that P2 is quieter than normal. Because the stenosis is mild,
however, P2 can be heard. Area of auscultation: left second ic space (LIC2).
Ductus arteriosus On auscultation, a fourth-degree continuous murmur
with throbbing pulses, a consistent (systolic-diastolic) murmur that becomes
louder towards endsystole and is quieter in diastole. left second ic space
(LIC2)
Fairly large perimembranous VSD in a 7-month-old. On auscultation a
fourth-degree systolic murmur was heard, and on palpation a small thrill was
felt in the left third intercostal space, pansystolic murmur, but S1 and S2 are
distinguishable. P2 is not enhanced and is split normally. This also suggests
that pulmonary resistance is normal. Area of auscultation: left third ic space
(LIC3).
ASD On auscultation a quiet systolic ejection murmur was heard in the
pulmonary area. It resembled the physiological sound but was longer. The
second heart sound was clearly and constantly split. Because the ASD
secundum murmur is caused by increased pulmonary artery flow, the sound
is sometimes difficult to distinguish from the physiological sound. In such
cases, attention should be given to the possible splitting of the second heart
sound. Area of auscultation: left second ic space (LIC2).
Features of pathological murmurs

All diastolic murmurs

All pansystolic murmurs
Late systolic murmurs
Loud murmurs > 3/6
Continuous murmurs
Associated cardiac abnormalities
􀁺Still’s Murmur
􀂄Timing: Systolic Ejection
􀂄Intensity: 1-3/6
􀂄Location: Several cm lateral to LLSB

􀂄Pitch: Low

􀂄Character: Vibratory, Musical

􀂄Helpful Maneuvers: Standing vs. Supine

􀁺Pulmonary Flow Murmur

􀂄Timing: Systolic ejection

􀂄Intensity: 1-3/6

􀂄Location: LUSB

􀂄Pitch: Low to medium

􀂄Character: Blowing

􀂄Helpful Maneuvers: Inspiration, Standing

􀁺Pulmonary Branch Murmur of Infancy*

􀂄Timing: Systolic ejection

􀂄Intensity: 1-3/6

􀂄Location: LUSB, RUSB, to axillae and back

􀂄Pitch: Medium
􀂄Character: Blowing
􀂄Helpful Maneuvers: None

*Also known as Peripheral Pulmonary Stenosis

(PPS) or Benign Pulmonary Stenosis (BPS)
􀁺Venous Hum
􀂄Timing: Continuous

􀂄Intensity: 1-3/6

􀂄Location: RUSB, occasionally LUSB

􀂄Pitch: Medium

􀂄Character: Machinery-like

􀂄Helpful Maneuvers: Supine to sitting, Head position, Compress jugular vein

When to Refer to a Pediatric Cardiologist

􀁺Diagnostic Criteria for Innocent Murmur
􀂄Classic physical findings for a specific innocent murmur
􀁺Grade 1 or 2, changes with position, LLSB
􀂄No history/complaints to suggest disease

􀂄No additional physical findings to suggest disease

􀁺When to Refer?
􀂄When these criteria are not met
􀂄When patient or family persists in belief of disease
􀁺Assess anxiety level of family and patient
Small VSD (23%)
􀁺High-pitched Holosystolic murmur @ LMSB to LLSB
􀁺May or may not have a thrill
􀁺Generally no LV heave or RV lift
􀁺Normal S2
􀁺No diastolic murmur
􀁺Normal EKG and chest x-ray
Small VSD
􀁺Most common form of CHD
􀁺75-90% close by 1 year of age
􀁺Incidence is inversely correlated to newborns age
􀁺No SBE Prophylaxis
Pulmonary Stenosis (14%)
􀁺Systolic Ejection Murmur @ LUSB with radiation to back
􀁺May have systolic thrill
􀁺May have increased RV impulse
􀁺Usually with ejection click
􀁺May have RVH on EKG
􀁺May have prominent MPA on X-ray
Pulmonary Stenosis
􀁺Often confused w/ innocent pulmonary flow murmur or ASD
􀁺Systolic gradient across valve >25mmHG
􀁺Mildly thickened valve in a neonate can resolve with time
􀁺No SBE prophylaxis
Aortic Stenosis (13%)
􀁺Systolic ejection murmur @ RUSB to Neck
􀁺May have thrill @ RUSB or SSN
􀁺Usually with ejection click
􀁺May have LV heave
􀁺May have assoc diastolic murmur if valve leaks
􀁺May have LVH on EKG
􀁺May have cardiomegaly, or prominent aortic shadow on x-ray
Aortic Stenosis
􀁺Easy to diagnose when moderate to severe
􀁺Bicuspid Aortic Valve
􀂄1% of population??

􀂄Can be asymptomatic

􀂄Late complications

􀁺Stenosis or Insufficiency
􀁺No SBE prophylaxis
Large VSD (8%)
􀁺Low pitched Holosystolic murmur @ LMSB to LLSB
􀁺Diastolic flow rumble @ apex
􀁺Increased precordial activity
􀁺Increased P2 intensity
􀁺May have RVH +/- LVH on EKG
􀁺May have cardiomegaly and pulmonary plethora on x-ray
Large VSD
􀁺Perimembranous or membranous
􀂄can also be muscular

􀁺Pulmonary overcirculation
􀂄LA/LV enlargement

􀂄Late complication of Pulmonary HTN

􀁺Often require surgical closure @ 4-6 months

ASD (8%)
􀁺Systolic ejection murmur @ LUSB
􀁺Diastolic flow rumble @ LLSB
􀁺No palpable thrill
􀁺RV heave
􀁺Fixed Split S2
􀁺May have RVH on EKG
􀁺May have cardiomegaly and pulmonary plethora on x-ray
ASD
􀁺Usually asymptomatic
􀂄No murmur

􀂄May present as teen or young adult

􀁺rSR’ pattern on EKG

􀁺ASD vs. PFO
􀁺Recommend closure when large and evidence of RA and RV enlargement
􀁺No SBE prophylaxis
PDA (5%)
􀁺Continuous murmur @ LUSB to left infraclavicular region
􀁺Wide pulse pressure, bounding pulses
􀁺May have increased LV impulse
􀁺Largest may have diastolic thrill @ LUSB
􀁺May have LVH on EKG
􀁺May have cardiomegaly and pulmonary plethora on x-ray
PDA
􀁺Very Common
􀂄“Silent PDA”

􀁺Increased incidence w/ prematurity

􀁺Surgical Ligation, Device, Coil
􀁺No SBE prophylaxis
Mitral Disease (3%)
􀁺Non-ejection Click, Late Systolic Murmur
􀁺May have Diastolic Rumble @ Apex
􀁺May have of Palpitations, Arrhythmias, Chest Pain
􀁺May have Nonspecific ST-T Wave Changes
􀁺May have Cardiomegaly on CXR
􀁺May have LVH or LAE on EKG
􀁺Marfan, Ehlers-Danlos, Stickler’s, Fragile X, Connective Tissue Syndromes
Mitral Disease
􀁺Rare to occur isolated in children
􀁺Prognosis varies
􀁺Often require ACE inhibitor and possibly anti-arrhythmic
􀁺No SBE prophylaxis
Coarctation of Aorta (2%)
􀁺Systolic ejection murmur in midback, also LUSB
􀁺May have continuous murmur in back (older)
􀁺Increased BP in arms
􀁺Lower BP with weak to absent pulses in legs
􀁺LV heave
􀁺RVH (infant) or LVH (older) on EKG
􀁺May have cardiomegaly, abnormal aortic contour, or rib notching on CXR
http://web1.aapa.org/aapaconf2009/syllabus/9255DolphensPEDMurmurs.pdf

The first heart sound (S1) is associated with closure of the mitral and tricuspid valves. It
is best heard at the apex or the left lower sternal border. Occasionally, an ejection
click may closely follow S1, sounding like a split. This is most audible at the upper
sternal borders, and is normal. The second heart sound (S2) is associated with closure
of the aortic and pulmonic valves. It is best heard at the left upper sternal border. The
first component of a normal S2 is A2 (aortic), followed by P2 (pulmonic). A2 is
louder than P2. The spacing between these two sounds can vary with respiration
(increasing with inspiration and decreasing with expiration). S3 is a low-frequency
sound that can be heard in early diastole, and is associated with rapid ventricular
filling. S4 is heard in late diastole and is associated with decreased ventricular
compliance or congestive heart failure – it is always pathologic.

The characterization of a cardiac murmur consists of several components: intensity,

timing, location, transmission, and quality.
Intensity:
Grade I: Barely audible
Grade II: Soft, but easily audible
Grade III: Moderately loud, but not accompanied by a thrill
Grade IV: Louder and associated with a thrill
Grade V: Audible with the stethoscope barely on the chest
Grade VI: Audible with the stethoscope off the chest

Evaluation of Cardiac Murmurs in the Clinic Setting

Timing: Cardiac murmurs can be described as systolic, diastolic, or continuous. First,
identify S1 and S2, and place the murmur that you hear relative to those heart sounds.
a. Systolic Murmurs Systolic murmurs are heard between S1 and S2. They can be
classified as: Early systolic Mid-systolic (systolic ejection) Mid to late systolic
Holosystolic
b. b. Diastolic Murmurs Diastolic murmurs are heard between S2 and S1. They can be
classified as:
Early diastolic
Mid-diastolic
Late diastolic (pre-systolic)
Note: Diastolic murmurs are always pathological and suggestive of valvular
abnormalities.
c. Continuous Murmurs. These murmurs begin in systole and continue through S2
into diastole. The differential diagnosis for continuous murmurs includes
aortopulmonary or arteriovenous connections (e. g. PDA, AV fistula, or s/p systemic-
to-PA surgery), disturbances in venous flow (e. g. venous hum), and disturbances in
arterial flow (e. g. coarctation or PA stenosis).
Location: Determine the point at which the murmur is loudest. Most common locations are:
the right upper sternal border (RUSB - aortic area),
left upper sternal border (LUSB - pulmonic area),
left lower sternal border (LLSB - tricuspid area),
and apex (mitral area).
Transmission: Determine whether the murmur radiates to other locations, including the
back, neck, axilla, and right side of the chest.
Quality: The quality of the sound can be useful in differentiating between murmurs.
Possibilities include high-pitched (blowing), rough (harsh), mechanical, or vibratory
(humming).

9. Abnormal heart sounds other than the murmur Common innocent murmurs:

Type Description Age Group

Still’s Murmur Intensity: II-III/VI Timing: 3-6 years, occasionally infant
Systolic ejection Location:
MLSB or between the LLSB
and apex Quality: Low-
frequency, vibratory
Maneuvers: Frequently
decreases or disappears when
sitting or standing.
Peripheral Pulmonic Stenosis (pulmonary flow Intensity: I-II/VI Timing: Newborns, usually disappearing
murmur of the newborn) Systolic ejection Location: by 3-6 months
LUSB Quality: Musical
Transmission: Both sides of
the chest, axilla, and back

Evaluation of Cardiac Murmurs in the Clinic Setting Page 5 of 9

Pulmonary Ejection Intensity: I-III/VI Timing: 8-14 years
Early to midsystolic
Location: LUSB Quality:
Blowing
Venous Hum Intensity: I-III/VI Timing: 3-6 years
Continuous, diastolic louder
than systolic Location:
Supra/infraclavicular
Maneuvers: Disappears
when supine; intensity
varies with head rotation