How do you describe a heart murmur?

How to Describe a Heart Murmur

Heart murmurs should be described based on their timing in the cardiac cycle, configuration, location and radiation, pitch, intensity (grades 1 through 6), and duration, as these characteristics provide critical information for determining the underlying cardiac pathology. 1

Essential Components of Murmur Description

1. Timing in the Cardiac Cycle

• Systolic Murmurs:

  • Holosystolic/Pansystolic: Occur throughout systole (e.g., mitral regurgitation, tricuspid regurgitation)
  • Midsystolic/Ejection: Start after S1 and end before S2 (e.g., aortic stenosis)
  • Early systolic: Occur at the beginning of systole
  • Mid-to-late systolic: Begin in mid-systole and continue to S2

• Diastolic Murmurs:

  • Early high-pitched diastolic: Begin with S2 (e.g., aortic regurgitation)
  • Middiastolic: Occur during mid-diastole (e.g., mitral stenosis)
  • Presystolic: Occur during late diastole after atrial contraction

• Continuous Murmurs: Begin in systole and continue through S2 into diastole 1

2. Configuration/Shape

• Crescendo: Increasing intensity
• Decrescendo: Decreasing intensity
• Crescendo-decrescendo (diamond-shaped): Increases then decreases in intensity
• Plateau: Constant intensity throughout 1

3. Location and Radiation

• Specify the area of maximal intensity:
  • Mitral area (apex): Mitral valve pathology
  • Tricuspid area (lower left sternal border): Tricuspid valve pathology
  • Aortic area (right upper sternal border): Aortic valve pathology
  • Pulmonic area (left upper sternal border): Pulmonic valve pathology
• Describe radiation pattern (e.g., to axilla, neck, back) 2

4. Intensity/Grade

• Grade 1: Very faint, heard only with special effort
• Grade 2: Quiet but clearly audible
• Grade 3: Moderately loud
• Grade 4: Loud with palpable thrill
• Grade 5: Very loud, audible with stethoscope partly off chest
• Grade 6: Audible with stethoscope entirely off chest 1

5. Pitch

• High-pitched: Best heard with diaphragm of stethoscope
• Medium-pitched
• Low-pitched: Best heard with bell of stethoscope 1

6. Quality

• Harsh
• Blowing
• Musical
• Rumbling 3

Dynamic Auscultation

Document changes in murmur characteristics with the following maneuvers:

• Respiration: Right-sided murmurs increase with inspiration; left-sided murmurs are louder during expiration
• Valsalva maneuver: Most murmurs decrease in intensity except HCM (increases) and MVP (becomes longer/louder)
• Exercise: Murmurs across normal or obstructed valves become louder
• Positional changes:
  • Standing: Most murmurs diminish except HCM and MVP (become louder)
  • Squatting: Most murmurs become louder except HCM and MVP (soften)
• Post-premature beat: Semilunar valve murmurs increase in intensity after a premature beat 1, 2

Associated Findings

Document associated cardiac findings that provide context:

• Presence of extra heart sounds (S3, S4)
• Splitting of S2 (normal, fixed, paradoxical)
• Presence of clicks
• Signs of cardiac failure
• Peripheral pulse characteristics 1

Pathological vs. Innocent Murmurs

When describing a murmur, note features suggesting pathology:

• Diastolic or continuous murmurs (almost always pathological)
• Holosystolic murmurs
• Grade 3 or higher intensity
• Harsh quality
• Abnormal S2
• Maximal intensity at upper left sternal border
• Presence of systolic click 4

Common Pitfalls to Avoid

• Failing to time the murmur properly in relation to S1 and S2
• Not using dynamic auscultation to clarify murmur characteristics
• Overlooking associated findings that provide diagnostic context
• Confusing innocent flow murmurs with pathological ones 5

By systematically describing these characteristics, you provide a comprehensive assessment that helps determine the underlying cardiac pathology and guides further diagnostic evaluation.