From the Guidelines
The Graham Steele murmur is best heard during expiration, as it is a high-pitched, blowing diastolic murmur associated with pulmonary hypertension, and expiration increases pulmonary vascular resistance, making the murmur more audible. This murmur represents pulmonary regurgitation due to pulmonary hypertension causing dilation of the pulmonary artery and subsequent incompetence of the pulmonary valve. According to the guidelines provided by the American College of Cardiology/American Heart Association Task Force on Practice Guidelines 1, the timing and characteristics of cardiac murmurs can be influenced by various factors, including respiration. The guidelines state that "Right-sided murmurs generally increase with inspiration. Left-sided murmurs usually are louder during expiration" 1.
When auscultating for the Graham Steele murmur, it is essential to have the patient take a deep breath and then exhale fully, listening carefully during the expiratory phase with the diaphragm of the stethoscope placed at the left second intercostal space. The murmur begins immediately after the second heart sound (P2) and decreases in intensity throughout diastole. It's crucial to differentiate this from an aortic regurgitation murmur, which is typically heard best at the right sternal border and with the patient leaning forward. The characteristics of early diastolic murmurs, such as the Graham Steele murmur, are further described in the guidelines, highlighting their association with pulmonary hypertension and the importance of accurate diagnosis 1.
Key points to consider when diagnosing the Graham Steele murmur include:
- The murmur is best heard during expiration
- It is a high-pitched, blowing diastolic murmur
- It is associated with pulmonary hypertension
- It represents pulmonary regurgitation due to pulmonary hypertension
- Accurate diagnosis requires careful auscultation and differentiation from other murmurs, such as aortic regurgitation.
From the Research
Timing of Graham Steell Murmur
- The Graham Steell murmur is an early diastolic murmur of pulmonary incompetence caused by pulmonary hypertension 2.
- The timing of the Graham Steell murmur is related to the phase of diastole, specifically early diastole 2.
- The murmur is a result of long-continued excess of blood pressure in the pulmonary artery, leading to pulmonary regurgitation 2.
- The Graham Steell murmur is associated with conditions such as aortic regurgitation, which can lead to pulmonary hypertension 3, 4.
- The management of aortic regurgitation, including the treatment of pulmonary hypertension, can affect the timing and presence of the Graham Steell murmur 3, 4, 5, 6.
- However, there is no direct information available on the timing of the Graham Steell murmur in relation to the provided studies.