What are the causes and management of a pan systolic murmur?

Pansystolic Murmur: Causes and Management

Primary Causes

Pansystolic (holosystolic) murmurs are generated when there is continuous flow between chambers with widely different pressures throughout systole, most commonly representing mitral regurgitation, tricuspid regurgitation, or ventricular septal defect. 1

The Three Cardinal Causes:

• Mitral Regurgitation (MR): The most common cause, occurring when the pressure gradient between left ventricle and left atrium persists throughout systole, creating continuous regurgitant flow from S1 through S2 1, 2

• Ventricular Septal Defect (VSD): Creates flow from left ventricle to right ventricle throughout systole due to persistent pressure difference between ventricles 1

• Tricuspid Regurgitation (TR): Produces pansystolic murmur when pulmonary hypertension is present, maintaining pressure gradient between right ventricle and right atrium throughout systole 1

Critical Diagnostic Distinctions

Acute vs. Chronic Presentation:

• Chronic MR produces a true holosystolic murmur beginning with S1 and continuing through systole until S2, representing established pressure gradient 2

• Acute MR (papillary muscle rupture, chordal rupture) produces an early systolic murmur that begins with S1 but ends in midsystole, not a true pansystolic pattern 2, 3

• Left ventricular dilation can transform early systolic murmurs into pansystolic variants in papillary muscle dysfunction 4

Bedside Diagnostic Maneuvers

To Confirm Left-Sided Regurgitant Lesions (MR, VSD):

• Isometric handgrip exercise increases murmur intensity by increasing afterload and regurgitant volume 1, 5

• Transient arterial occlusion (bilateral arm cuff inflation to 20 mm Hg above systolic pressure for 20 seconds) augments MR, VSD, and AR murmurs but not other causes 1, 5

• Left-sided murmurs are louder during expiration 1, 2

To Identify Tricuspid Regurgitation:

• Right-sided murmurs increase with inspiration due to increased venous return 1, 6

• TR without pulmonary hypertension produces early systolic, not pansystolic murmur 1

Management Algorithm

Immediate Assessment Required:

Urgent echocardiography is mandatory for any new pansystolic murmur with acute heart failure, hypotension, or shock, as this suggests mechanical complications like papillary muscle rupture or acute VSD 2, 3

For Stable Patients:

• Echocardiography should be performed in all patients with pansystolic murmurs of unknown cause to determine exact etiology, severity, and presence of multiple lesions 7

• Physical examination alone has limited accuracy (sensitivity 88% for isolated MR, 100% for VSD, but only 55% for combined lesions), making echocardiography essential 7

Common Pitfalls:

• Combined aortic and mitral valve disease is frequently missed on examination (sensitivity only 55%), as multiple lesions obscure individual findings 7

• Aortic stenosis severity can be misjudged when left ventricular ejection fraction is severely reduced, as decreased flow reduces murmur intensity 7

• Do not administer thrombolytics if mechanical complications are suspected (papillary muscle rupture, VSD) without echocardiographic confirmation, as surgery is the definitive treatment 3

Rare but Important Causes:

• Left ventricular-right atrial communication can occur after cardiac surgery, producing harsh pansystolic murmur 8

• Atrial myxoma rarely produces systolic murmurs but should be considered in appropriate clinical context 1