How should I describe a heart murmur on a chart using a structured, concise format?

How to Document Heart Murmurs on a Chart

Document heart murmurs using a structured format that includes: timing in the cardiac cycle, intensity grade (1-6 for systolic, 1-4 for diastolic), configuration, location, radiation, pitch, and response to dynamic maneuvers. 1, 2

Essential Components to Document

Timing Classification

• Systolic murmurs occur between S1 and S2 and are subdivided into:

  • Holosystolic (pansystolic): throughout systole 1
  • Midsystolic (ejection): starting after S1, crescendo-decrescendo pattern 1
  • Early systolic: immediately after S1 1
  • Late systolic: ending at S2 1, 2

• Diastolic murmurs occur between S2 and S1 and include:

  • Early high-pitched diastolic 1
  • Middiastolic 1
  • Presystolic 1

• Continuous murmurs extend through both systole and diastole 1, 2

Intensity Grading

• Systolic murmurs: Grade on a 1-6 scale 1, 3

  • Grade 1: Very faint, barely audible 3
  • Grade 2: Soft but readily heard 3
  • Grade 3: Moderately loud (warrants echocardiography) 3
  • Grade 4: Loud 3
  • Grade 5: Very loud 3
  • Grade 6: Extremely loud, audible with stethoscope off chest 3

• Diastolic murmurs: Grade on a 1-4 scale 3

Configuration

Document the shape of the murmur 1, 2:

• Crescendo (increasing intensity) 1, 2
• Decrescendo (decreasing intensity) 1, 2
• Crescendo-decrescendo (diamond-shaped, typical of ejection murmurs) 1, 2
• Plateau (constant intensity, typical of holosystolic murmurs) 1, 2

Location and Radiation

• Specify the primary location where the murmur is loudest (e.g., apex, left lower sternal border, left upper sternal border, right upper sternal border) 1
• Document any radiation patterns (e.g., to axilla, carotids, back) 1

Pitch

• High-pitched 1
• Medium-pitched 1
• Low-pitched 1

Response to Dynamic Maneuvers

Document changes with specific maneuvers, as these provide critical diagnostic information 1, 2, 4:

• Respiration: Right-sided murmurs increase with inspiration 1, 4
• Valsalva maneuver: Hypertrophic cardiomyopathy murmurs increase (65% sensitivity, 96% specificity) 3, 4
• Position changes:
  • Standing increases hypertrophic cardiomyopathy and mitral valve prolapse murmurs (95% sensitivity, 84% specificity) 3, 4
  • Squatting decreases hypertrophic cardiomyopathy murmurs (95% sensitivity, 85% specificity) 3, 4
• Handgrip exercise: Increases mitral regurgitation and ventricular septal defect murmurs (68% sensitivity, 92% specificity) 3, 4

Example Documentation Format

"Grade 3/6 midsystolic, crescendo-decrescendo murmur heard best at the right upper sternal border, radiating to the carotids, high-pitched, increases with squatting, normal S2 splitting." 1, 2

Or for an innocent murmur: "Grade 2/6 midsystolic, vibratory murmur at left lower sternal border, no radiation, disappears when standing, normal S2." 1, 3

Critical Documentation Pitfalls to Avoid

• Never dismiss diastolic murmurs regardless of intensity—they virtually always represent pathology and require documentation of plans for echocardiographic evaluation 1, 3, 2
• Always document associated findings: presence or absence of abnormal S2 splitting, ejection clicks, other heart sounds 3
• Document symptoms: syncope, angina, heart failure, or thromboembolism override murmur characteristics and mandate immediate workup 3, 2
• Grade 3 or louder systolic murmurs are not innocent and require documentation of echocardiography plans 3, 2
• Holosystolic or late systolic murmurs require echocardiography even if soft, as they indicate regurgitant lesions 3, 2