What is the typical location of each heart murmur?

Typical Auscultation Locations for Heart Murmurs

Each cardiac murmur has a characteristic location where it is best heard, determined by the anatomic origin of the turbulent flow and the direction of blood flow propagation.

Systolic Murmurs

Aortic Stenosis

• Best heard at the right upper sternal border (2nd right intercostal space) 1
• May radiate to the carotids bilaterally 1
• Midsystolic, crescendo-decrescendo character 2

Mitral Regurgitation

• Best heard at the cardiac apex (left ventricular apex) 1, 3
• Radiation to the axilla is pathognomonic for mitral regurgitation 3
• Pansystolic (holosystolic) murmur extending from S1 to S2 3, 2
• Note: Functional mitral regurgitation produces a midsystolic murmur, not pansystolic 3

Mitral Valve Prolapse

• Best heard at the left ventricular apex 1, 3
• Late systolic murmur with characteristic midsystolic click 3, 2
• Can become holosystolic when regurgitation is severe 3

Tricuspid Regurgitation

• Best heard at the left lower sternal border 1
• Pansystolic murmur 2
• Increases with inspiration (Carvallo's sign) 2

Ventricular Septal Defect

• Best heard at the left lower sternal border 1
• Pansystolic murmur in small to moderate defects 2
• Early systolic only in large defects with pulmonary hypertension due to pressure equalization 2

Hypertrophic Cardiomyopathy (with LVOT obstruction)

• Best heard at the left sternal border and apex 4
• Midsystolic, crescendo-decrescendo murmur 4
• Grade 2-3/6 or higher depending on obstruction severity 4

Pulmonic Stenosis

• Best heard at the left upper sternal border (2nd left intercostal space) 1
• Midsystolic murmur 1

Diastolic Murmurs

Aortic Regurgitation

• Best heard at the left sternal border (3rd-4th intercostal space) 1
• Early diastolic, high-pitched, decrescendo murmur beginning with or shortly after S2 1, 2
• Patient should be sitting up, leaning forward, in full expiration 1

Mitral Stenosis

• Best heard at the cardiac apex 1
• Middiastolic or presystolic murmur (presystolic requires sinus rhythm) 1, 2
• Low-pitched, rumbling quality 1
• Best heard with patient in left lateral decubitus position 1

Tricuspid Stenosis

• Best heard at the left lower sternal border 1
• Middiastolic or presystolic murmur 2
• Increases with inspiration 2

Pulmonic Regurgitation

• With pulmonary hypertension: Best heard at left upper sternal border, high-pitched, early diastolic 1, 2
• Without pulmonary hypertension: Low to medium pitched with slightly delayed onset (common after tetralogy of Fallot repair) 1

Austin-Flint Murmur (severe chronic AR)

• Best heard at the left ventricular apex 1
• Low-pitched, rumbling middiastolic or presystolic murmur 1
• No opening snap (distinguishes from mitral stenosis) 1

Key Clinical Pearls

Dynamic Auscultation for Localization

• Right-sided murmurs increase with inspiration due to increased venous return 1, 2
• Left-sided murmurs are louder during expiration 1, 2
• Standing causes most murmurs to diminish except HCM and MVP, which become louder 1, 2
• Squatting increases most murmurs but softens HCM and MVP murmurs 1, 3, 4

Common Pitfalls

• Combined valvular lesions (present in 35% of organic murmurs) are frequently missed on physical examination, particularly combined aortic and mitral disease 5
• Aortic stenosis severity may be underestimated when left ventricular ejection fraction is severely reduced 5
• Echocardiography should be performed in all patients with systolic murmurs of unknown cause suspected of having significant heart disease, as physical examination alone has limited accuracy for determining exact etiology 5