Can pulmonary hypertension cause a heart murmur?

Pulmonary Hypertension and Heart Murmurs

Yes, pulmonary hypertension can cause heart murmurs, specifically a midsystolic ejection murmur due to turbulent transvalvular pulmonary flow, and in more advanced disease, diastolic murmurs of pulmonary regurgitation and holosystolic murmurs of tricuspid regurgitation. 1

Murmurs Associated with Pulmonary Hypertension

Pulmonary hypertension (PH) produces several characteristic cardiac auscultatory findings:

Early/Mild PH:

• Midsystolic ejection murmur caused by turbulent transvalvular pulmonary flow 1
• Accentuated pulmonary component of the second heart sound (P2) - present in 90% of patients with idiopathic PAH 1
• Early systolic ejection click due to sudden interruption of pulmonary valve opening 1

Advanced PH:

• Diastolic murmur of pulmonary regurgitation 1
• Holosystolic murmur of tricuspid regurgitation - heard at the lower left sternal border and augmented with inspiration 1
• Right ventricular S3 gallop (audible in 23% of patients) 1
• Right ventricular S4 gallop (audible in 38% of patients) 1

Physical Examination Findings in Pulmonary Hypertension

Beyond murmurs, other key physical examination findings in PH include:

• Palpable left parasternal lift (RV heave) 1
• Prominent jugular "a" wave 1
• Elevated jugular venous pressure with accentuated V waves 1
• Hepatojugular reflux and pulsatile liver 1
• Peripheral edema (32% of patients) 1
• Ascites in advanced right ventricular failure 1

Diagnostic Significance of Murmurs in PH

The murmurs associated with PH have varying diagnostic value:

• The presence of a holosystolic murmur at the lower left sternal border that increases with inspiration strongly suggests tricuspid regurgitation due to PH 2
• However, the sensitivity and specificity of auscultatory findings for diagnosing PH are limited 3
• In a study of patients with interstitial lung disease, clinical signs suggestive of PH showed low sensitivity (50-68%) and specificity (22-56%) 3

Special Considerations

1. Changing Murmur Characteristics: In severe PH with equalization of pressures between pulmonary and systemic circulation, the typical murmurs may change or disappear 4

2. Diagnostic Challenges: The presence of hyperinflation or abnormal breath sounds in patients with underlying lung disease may mask the auscultatory findings of PH 1

3. Pediatric Considerations: In children, a loud second heart sound may indicate PH but can also be present in congenital heart conditions like congenitally corrected transposition 5

Diagnostic Approach

When PH is suspected based on auscultatory findings:

1. ECG evaluation: Look for right axis deviation, right ventricular hypertrophy, and right ventricular strain 1

2. Echocardiography: Essential for confirming the diagnosis, assessing severity, and identifying underlying causes 1

3. Response to maneuvers: Tricuspid regurgitation murmurs typically increase with inspiration (Carvallo's sign), helping distinguish them from mitral regurgitation murmurs 2

The presence of these murmurs, particularly when accompanied by other signs of right ventricular pressure or volume overload, should prompt further evaluation for pulmonary hypertension to reduce morbidity and mortality associated with delayed diagnosis.