Heart murmur
? H M is abnormal sound
? Produce by vibration
? Within the heart or large arteries,
? Mechanism
– Blood velocity?
– Blood vascosity?
– Valve,narrowed or incompetent; organic
or relative
– Abnormal connection
– Vibration of loose structure
– Diameter of vessel ?or ?
? character of murmur
? Location,
– Murmur of valvular origin are usually
best heard over their respective valve area
? Timing,
– Murmurs are timed according to the
phase of cardiac cycle during which they
occur,
– SM,DM,CM,
– Early,middle,late
? Quality
– Depend on,frequency and intensity of
sound wave
– Related to,pathology and hemodynamic
changes of the heart
– Soft harsh,musical,
– SM,blowing,harsh,musical (seagull)
– DM,blowing,sigh-like,rumbling,
– CM,machine-like,hum
? Radiation,transmitted direction
– With the bloodstream by which they are
produced or propagated from their point
of origin in many directions
– AS
– MR
– MS
? Intensity,
– Related to,
? The severity of abnormal
? The velocity of blood flow
? The pressure gradient of valve
? The myocardial contraction
? Six-point scale of for grading the intensity of
heart murmur
– Grade Ⅰ, basely audible
– Grade Ⅱ, usually readily heard
– Grade Ⅲ, loud
– Grade Ⅳ, quite loud
– Grade Ⅴ, even most pronounced
– Grade Ⅵ, may be heard with the stethoscope
removed from the chest wall,
? PCG
– Crescendo type
– Decrescendo type
– Crescendo-decrescendo type
– Continuous
– Regular
? Physiological maneuver
1) Change the body position
- Left recumbent,MS
- Sitting,leaning forward,AI
- Squatting from standing,supine position,
raising two legs may increase venous
return,SV? CO?
- Murmur of MI,AI?
- Murmur of IHSS?
2) Respiration
- Deep inspiration,thorax pressure?
venous return?,pulmonary circulation?
clockwise rotation of heart make murmur
of TI,TS,PI?
- Expiration,
- Valsalva maneuver,thorax pressure?
venous return? M of IHSS?
3) Exercise,
- HR?
- Blood volume?
- Blood velocity?
make the murmur of MS?
The clinical value of heart murmur
1,Important in diagnosis
2,Organic M, MS
Relative M,valve,supporting tissues
of the valve abnormal
Functional M,increased flow across
a normal valve
? 1,Systolic murmur
? 1) MV area, produced by MI
– Organic,RHD,MVP
Character,pan systolic
Harsh,Loud >3/6
Radiate to the left axilla
Maneuver insp? exp?
– Relative murmur,Dilated LV
BP?
Acute rheumatic fever
Severe anemia
Character,
– Functional M,Valve(-) blood flow fastter
Fever
Anemia
Hyperthyroidism
Character,
? 2) AV area—AS
– Organic,RHD
Character,Harsh,crescendo-decrescendo,
radiate?neck,Thrill,S2?
– Relative,Arteriosclerosis,Dilation of aorta,
HP
? 3) PV area
– Most are functional,
– Relative,ASD,PA dilation
– Organic,congenital PS
? 4) TV area—TI
– Most are relative,duo to dilate of RV
Character like MI,but increased in
inspiration organic SM are rare
? 5) Other position
– VSD,harsh and loud
Third-forth intercostal space
Left to the sternal border
Thrill
? 2,Diastolic murmur
1) MV area
– Organic,RHD—MS,Apex
Mid-late diastolic
Rumbling,decrescendo-crescendo
Thrill,S1?,OS
3) PV area
– Most are produced by relative PI
– Relative,LVH
AI
Austin-Flint murmur
2) AV area – AI rheumatic
– decrescendo,sigh-like
– best heard at aortic second area
– radiate to the left side of the lower part of
sternal
4) TV area
– It is rare in clinical
? continuous murmur
– In patent ductus Arteriosus
– Begins after S1,crescendo,peak intensity
at S2,envelop S2,decreased at early-
middle diastole producing a large
diamond sharp,
– Harsh,mimic the sound of machine
rotating
– Best heart at second intercostal space,
left to sternal artery-vein fistula,
Pericardial friction sound
? It is produced by the rubbing on each other
of the parietal and visceral surfaces of the
roughened pericardium,
? During pericarditis
? In both systolic and diastolic
? Systolic component predominates
? Sometime only in systole
? Harsh,
? Resemble massage the ear using the finger
? Best heard at 3th-4th in intercostal space
? Left to the sternal border
? Common cause is pericarditis (TB,non-
specific,rheumatic)
? Also can been heard in AMI,uremia,SLE
The blood vessels
? I,Pulse
The palpation of artery is important in
clinical diagnosis
– Content,rate
rhythm
tension
intensity
wave form
condition of arterial wall
? Tention,
– Depends on the level of BP (systolic)
? Intensity
– Depends on, arterial filling degree
resistance of peripheral vessel
cardiac output
pulse pressure
– Bounding pulse,high fever,AI
– Small pulse,AS,heart failure,shock
? Wave form
? 1,Normal wave form
– Composed,
? 1) ascending limb,during the heart
contract,the aortic valve is opened,
LV ejection begining,results in a
abrupt sharp rise in aortic pressure,
? 2) peak,rounded,smooth
? 3) descending limb,as the LV relaxes,
the aortic pressure continuous to
decrease,blood flow continues to the
peripheral vessels,The descending
limb is more gradual and less steep
than the upstroke,
there is a dicrotic notch in it,it is
due to the close of AV,a part of
blood flow goes back to the valve,
? 2,Water hammer pulse
– Strong bounding pulse
– Tall rapid ascending limb
– Equal rapid descending limb
– Associated with a wide pulse
pressure
– Causes,AI,PDA,hyperthyroidism,
severe anemia.,
? 3,Tardu pulse
– Ascending and descending limb both
gradual up and down usually in AS,
? 4,Dicrotic pulse
– there are two impulses be palpable
during diastole,It is due to the
abnormal of dicrotic notch in
descending limb,usually in high
fever,When the tension of
peripheral vessel decreased,
? 5,Pulses alternate
– A regularly alternating pulse in intensity-
strong and weak indicates LV failure,in
HP,AMI,AI,
? 6,Paradoxical pulse,
– In inspiration,the pulse is decreased in
amplitude or disappear,It is due to the
decreased of out put of LV,
In normal condition in inspiration,
– Blood return?,blood flow of pulmonary
circulation?,the blood volume from
pulmonary vein?LA?LV,as same as in
respiration,
– In some disease(pericardium effusion,
constractive pericarditis),the ventricle
dilate was limited during inspiration the
blood return no?,but pulmonary
circulative still?,so LV output?
? The condition of arterial wall
– Method,expressing the radial artery to
occlud the blood flow,
the distal segment of the artery can be
palpated
– Normal,soft,pliable
– Arteriosclerosis,―pipe stem‖,Easy to
roll,snake like pulsating,
The murmur of vessel
? 1,Neck venous hum
– It is due to the blood flow rapid goes to SVC
from the nick,
different from hyperthyroidism,
? 2,Murmur of peripheral artery
– Hyperthyroidism,continuous M
– Multiarteritis SM
– A-V fistula CM
– Duroziez M,in AI- Brachial A,
? 3,Pistol shot sound in AI- femoral A,
? 4,Capillary pulsation
– Press the nail of P,it changes in red
and while regularly follow the heart
beat,
Major symptom and sign of common
diseases in circulatory system
? Mitral Stenosis (MS)
– Rheumatic
? Commissural thickening,adherent fusion
? Orifice of MV stenosis,blood flow from LA?
LV was limited,
? LAP?,LAH,Pulmonary V and capillary
pressure ? dilatation,stasis,PAP? ? RV over
load ? RV failure
? LV filling ? CO?
– Symptoms,
? Exertional dyspnea,cough,hemoptysis
? Paroxysmal noctunnal dyspnea
– Signs,
? Mitral face,apical pulse left side
? Diastolic thrill at apex
? Cardiac waist prominence
? Diastolic murmur at apex
? OS S1 ? P2 ? splitting
Graham-Steel murmur,
? Mitral Insufficiency(MI)
– Etiology,Rheumatic
Non-rheumatic
– Organic
– Relative,duo to the LV enlargement,
in systolic period,blood flow from
LV?LA LA filling degree? P?
In diastolic period,LV accepts
more blood→dilation
CO?
– Symptom,fatigue,palpitation,dyspnea
– Sign,
? Apical pulse?left,lower
? Apical beat heavy
? Cardiac dullness enlarged?left
? Pausystolic,murmur at apex
? Radiate to left axilla,subscapular
? P2? spitting S1?
? Aortic Stenosis (AS)
– Rheumatic,atherosclerosis,congenital
Narrowed orifice of AV,the resistence of
LV to output the blood?
LV contractility?,LVH
Aorta P? blood flow in coronary A and
peripheral A?
– Symptom,palpitation,fatigue,angina,
syncope
– Sign,
? Apical impulse?,to left
? Systolic thrill in AV area,pulse?
? Cardiac dullness?left
? Ejection SM in AV area,radiate to neck
? A2? splitting paradoxically
? Aortic insufficiency(AI)
– Rheumatic,arteriosclerosis,infective
endocarditis,syphilis,
– In AI,LV receives both blood from LA,
AO?volume overload?LV
dilation?relative MI,relative MS
Diastolic pressure?,pulse pressure?
– Symptom,palpitation,angina
– Sign,
? Apical impulse?left,inferiorly
? Cardiac dullness enlarged?left,inferiorly
? Boot-shaped shadow –cardiac waist?
? DM in AV2 area ?apex
? S1?,A2?
? Relative MI—SM at apex
? Relative MS—Austin Flint,DM
? Peripheral vascular sign,
pulse pressure? water hammer pulse,
carotic pulsation?,Musset sign(moving
head with each heart beat),capillary
pulsation,pistol shot sound,Duroziez M,
Pericardial Effusion
? Inflammatory (TB,purulent) non inflammatory
(rheumatism,uremia)
? Pericardial cavity P?,limit the dilation of heart,
blood flow from systemic venous to the RV?,
RV filling ? output ?
– Symptom,
? Depends on the volume and the
velocity of effusion producing,
? Pericardial compression,dyspnea,
? Infection,fever,fatigue
? Cough,dysphagia
– Sign,
? Cardiac impulse?
? Apical pulsation?
? Cardiac dullness enlarged,
coincide with position
? Pericardial friction rub
? Heart sound?
? In massive effusion,neck vein
engagement,inspiration?
? Paradoxical pulse,venous pressure?
? Ewart sign,the lung was pressed by
the effusion,
? in the area of left scapula inferior
angle with dullness,vocal fremitue,
bronchovesicular breath sound
Thank you!
? H M is abnormal sound
? Produce by vibration
? Within the heart or large arteries,
? Mechanism
– Blood velocity?
– Blood vascosity?
– Valve,narrowed or incompetent; organic
or relative
– Abnormal connection
– Vibration of loose structure
– Diameter of vessel ?or ?
? character of murmur
? Location,
– Murmur of valvular origin are usually
best heard over their respective valve area
? Timing,
– Murmurs are timed according to the
phase of cardiac cycle during which they
occur,
– SM,DM,CM,
– Early,middle,late
? Quality
– Depend on,frequency and intensity of
sound wave
– Related to,pathology and hemodynamic
changes of the heart
– Soft harsh,musical,
– SM,blowing,harsh,musical (seagull)
– DM,blowing,sigh-like,rumbling,
– CM,machine-like,hum
? Radiation,transmitted direction
– With the bloodstream by which they are
produced or propagated from their point
of origin in many directions
– AS
– MR
– MS
? Intensity,
– Related to,
? The severity of abnormal
? The velocity of blood flow
? The pressure gradient of valve
? The myocardial contraction
? Six-point scale of for grading the intensity of
heart murmur
– Grade Ⅰ, basely audible
– Grade Ⅱ, usually readily heard
– Grade Ⅲ, loud
– Grade Ⅳ, quite loud
– Grade Ⅴ, even most pronounced
– Grade Ⅵ, may be heard with the stethoscope
removed from the chest wall,
? PCG
– Crescendo type
– Decrescendo type
– Crescendo-decrescendo type
– Continuous
– Regular
? Physiological maneuver
1) Change the body position
- Left recumbent,MS
- Sitting,leaning forward,AI
- Squatting from standing,supine position,
raising two legs may increase venous
return,SV? CO?
- Murmur of MI,AI?
- Murmur of IHSS?
2) Respiration
- Deep inspiration,thorax pressure?
venous return?,pulmonary circulation?
clockwise rotation of heart make murmur
of TI,TS,PI?
- Expiration,
- Valsalva maneuver,thorax pressure?
venous return? M of IHSS?
3) Exercise,
- HR?
- Blood volume?
- Blood velocity?
make the murmur of MS?
The clinical value of heart murmur
1,Important in diagnosis
2,Organic M, MS
Relative M,valve,supporting tissues
of the valve abnormal
Functional M,increased flow across
a normal valve
? 1,Systolic murmur
? 1) MV area, produced by MI
– Organic,RHD,MVP
Character,pan systolic
Harsh,Loud >3/6
Radiate to the left axilla
Maneuver insp? exp?
– Relative murmur,Dilated LV
BP?
Acute rheumatic fever
Severe anemia
Character,
– Functional M,Valve(-) blood flow fastter
Fever
Anemia
Hyperthyroidism
Character,
? 2) AV area—AS
– Organic,RHD
Character,Harsh,crescendo-decrescendo,
radiate?neck,Thrill,S2?
– Relative,Arteriosclerosis,Dilation of aorta,
HP
? 3) PV area
– Most are functional,
– Relative,ASD,PA dilation
– Organic,congenital PS
? 4) TV area—TI
– Most are relative,duo to dilate of RV
Character like MI,but increased in
inspiration organic SM are rare
? 5) Other position
– VSD,harsh and loud
Third-forth intercostal space
Left to the sternal border
Thrill
? 2,Diastolic murmur
1) MV area
– Organic,RHD—MS,Apex
Mid-late diastolic
Rumbling,decrescendo-crescendo
Thrill,S1?,OS
3) PV area
– Most are produced by relative PI
– Relative,LVH
AI
Austin-Flint murmur
2) AV area – AI rheumatic
– decrescendo,sigh-like
– best heard at aortic second area
– radiate to the left side of the lower part of
sternal
4) TV area
– It is rare in clinical
? continuous murmur
– In patent ductus Arteriosus
– Begins after S1,crescendo,peak intensity
at S2,envelop S2,decreased at early-
middle diastole producing a large
diamond sharp,
– Harsh,mimic the sound of machine
rotating
– Best heart at second intercostal space,
left to sternal artery-vein fistula,
Pericardial friction sound
? It is produced by the rubbing on each other
of the parietal and visceral surfaces of the
roughened pericardium,
? During pericarditis
? In both systolic and diastolic
? Systolic component predominates
? Sometime only in systole
? Harsh,
? Resemble massage the ear using the finger
? Best heard at 3th-4th in intercostal space
? Left to the sternal border
? Common cause is pericarditis (TB,non-
specific,rheumatic)
? Also can been heard in AMI,uremia,SLE
The blood vessels
? I,Pulse
The palpation of artery is important in
clinical diagnosis
– Content,rate
rhythm
tension
intensity
wave form
condition of arterial wall
? Tention,
– Depends on the level of BP (systolic)
? Intensity
– Depends on, arterial filling degree
resistance of peripheral vessel
cardiac output
pulse pressure
– Bounding pulse,high fever,AI
– Small pulse,AS,heart failure,shock
? Wave form
? 1,Normal wave form
– Composed,
? 1) ascending limb,during the heart
contract,the aortic valve is opened,
LV ejection begining,results in a
abrupt sharp rise in aortic pressure,
? 2) peak,rounded,smooth
? 3) descending limb,as the LV relaxes,
the aortic pressure continuous to
decrease,blood flow continues to the
peripheral vessels,The descending
limb is more gradual and less steep
than the upstroke,
there is a dicrotic notch in it,it is
due to the close of AV,a part of
blood flow goes back to the valve,
? 2,Water hammer pulse
– Strong bounding pulse
– Tall rapid ascending limb
– Equal rapid descending limb
– Associated with a wide pulse
pressure
– Causes,AI,PDA,hyperthyroidism,
severe anemia.,
? 3,Tardu pulse
– Ascending and descending limb both
gradual up and down usually in AS,
? 4,Dicrotic pulse
– there are two impulses be palpable
during diastole,It is due to the
abnormal of dicrotic notch in
descending limb,usually in high
fever,When the tension of
peripheral vessel decreased,
? 5,Pulses alternate
– A regularly alternating pulse in intensity-
strong and weak indicates LV failure,in
HP,AMI,AI,
? 6,Paradoxical pulse,
– In inspiration,the pulse is decreased in
amplitude or disappear,It is due to the
decreased of out put of LV,
In normal condition in inspiration,
– Blood return?,blood flow of pulmonary
circulation?,the blood volume from
pulmonary vein?LA?LV,as same as in
respiration,
– In some disease(pericardium effusion,
constractive pericarditis),the ventricle
dilate was limited during inspiration the
blood return no?,but pulmonary
circulative still?,so LV output?
? The condition of arterial wall
– Method,expressing the radial artery to
occlud the blood flow,
the distal segment of the artery can be
palpated
– Normal,soft,pliable
– Arteriosclerosis,―pipe stem‖,Easy to
roll,snake like pulsating,
The murmur of vessel
? 1,Neck venous hum
– It is due to the blood flow rapid goes to SVC
from the nick,
different from hyperthyroidism,
? 2,Murmur of peripheral artery
– Hyperthyroidism,continuous M
– Multiarteritis SM
– A-V fistula CM
– Duroziez M,in AI- Brachial A,
? 3,Pistol shot sound in AI- femoral A,
? 4,Capillary pulsation
– Press the nail of P,it changes in red
and while regularly follow the heart
beat,
Major symptom and sign of common
diseases in circulatory system
? Mitral Stenosis (MS)
– Rheumatic
? Commissural thickening,adherent fusion
? Orifice of MV stenosis,blood flow from LA?
LV was limited,
? LAP?,LAH,Pulmonary V and capillary
pressure ? dilatation,stasis,PAP? ? RV over
load ? RV failure
? LV filling ? CO?
– Symptoms,
? Exertional dyspnea,cough,hemoptysis
? Paroxysmal noctunnal dyspnea
– Signs,
? Mitral face,apical pulse left side
? Diastolic thrill at apex
? Cardiac waist prominence
? Diastolic murmur at apex
? OS S1 ? P2 ? splitting
Graham-Steel murmur,
? Mitral Insufficiency(MI)
– Etiology,Rheumatic
Non-rheumatic
– Organic
– Relative,duo to the LV enlargement,
in systolic period,blood flow from
LV?LA LA filling degree? P?
In diastolic period,LV accepts
more blood→dilation
CO?
– Symptom,fatigue,palpitation,dyspnea
– Sign,
? Apical pulse?left,lower
? Apical beat heavy
? Cardiac dullness enlarged?left
? Pausystolic,murmur at apex
? Radiate to left axilla,subscapular
? P2? spitting S1?
? Aortic Stenosis (AS)
– Rheumatic,atherosclerosis,congenital
Narrowed orifice of AV,the resistence of
LV to output the blood?
LV contractility?,LVH
Aorta P? blood flow in coronary A and
peripheral A?
– Symptom,palpitation,fatigue,angina,
syncope
– Sign,
? Apical impulse?,to left
? Systolic thrill in AV area,pulse?
? Cardiac dullness?left
? Ejection SM in AV area,radiate to neck
? A2? splitting paradoxically
? Aortic insufficiency(AI)
– Rheumatic,arteriosclerosis,infective
endocarditis,syphilis,
– In AI,LV receives both blood from LA,
AO?volume overload?LV
dilation?relative MI,relative MS
Diastolic pressure?,pulse pressure?
– Symptom,palpitation,angina
– Sign,
? Apical impulse?left,inferiorly
? Cardiac dullness enlarged?left,inferiorly
? Boot-shaped shadow –cardiac waist?
? DM in AV2 area ?apex
? S1?,A2?
? Relative MI—SM at apex
? Relative MS—Austin Flint,DM
? Peripheral vascular sign,
pulse pressure? water hammer pulse,
carotic pulsation?,Musset sign(moving
head with each heart beat),capillary
pulsation,pistol shot sound,Duroziez M,
Pericardial Effusion
? Inflammatory (TB,purulent) non inflammatory
(rheumatism,uremia)
? Pericardial cavity P?,limit the dilation of heart,
blood flow from systemic venous to the RV?,
RV filling ? output ?
– Symptom,
? Depends on the volume and the
velocity of effusion producing,
? Pericardial compression,dyspnea,
? Infection,fever,fatigue
? Cough,dysphagia
– Sign,
? Cardiac impulse?
? Apical pulsation?
? Cardiac dullness enlarged,
coincide with position
? Pericardial friction rub
? Heart sound?
? In massive effusion,neck vein
engagement,inspiration?
? Paradoxical pulse,venous pressure?
? Ewart sign,the lung was pressed by
the effusion,
? in the area of left scapula inferior
angle with dullness,vocal fremitue,
bronchovesicular breath sound
Thank you!
