Cardiac murmurs – diasystolic

Aortic regurgitation

Aortic regurgitation results in regurgitation of blood from the aorta back into the left ventricle during diastole. This results in increased left ventricular end-diastolic volume.

• Character: Early diastolic (sounds like a breath)
• Best heard: upper right sternal edge (or lower left sternal edge sitting forwards); loudest on expiration
• Radiation: none
• Symptoms:
  • Fatigue
  • SOB
  • Palpitations
• Signs:
  • Collapsing pulse
  • Wide pulse pressure
  • Very displaced thrusting apex (volume-loaded)
  • Backflow signs:
    • Corrigan’s (visible carotid pulsation)
    • de Musset’s (head-nodding pulse)
    • Quincke’s (red-coloured pulsation in nails)
  • ±Austin Flint murmur (apical diastolic rumble)

Causes of… Aortic regurgitation

Acute causes

• Infective endocarditis
• Aortic dissection

Chronic causes

• Aortic root dilatation
  • Longstanding hypertension
  • Syphilitic aortitis
  • Aortic vasculitis (giant cell arteritis, Takayasu arteritis)
• Connective tissue disorders (e.g. Marfan syndrome, ankylosing spondylitis, Ehlers–Danlos syndrome) – may also cause aortic root dilatation
• Rheumatic heart disease
• Congenital/bicuspid aortic valve

Mitral stenosis

Mitral stenosis causes increased resistance between left atrium and left ventricle. This results in high left atrial pressure and subsequent pulmonary hypertension.

• Character: low rumbling mid-diastolic with opening snap
• Best heard: apex in left lateral position; loudest on expiration using bell of stethoscope
• Radiation: none
• Symptoms:
  • Dyspnoea
  • Fatigue
  • Haemoptysis
  • Chest pain
• Signs:
  • Malar flush (due to low cardiac output)
  • AF
  • Tapping apex (palpable S1)
  • Loud S1
  • Signs of pulmonary hypertension (RV heave, loud P2)

Causes of… Mitral stenosis

• Rheumatic heart disease
• Others causes rare (e.g. congenital, carcinoid)

Why don’t you test your knowledge?

Try some OSCE stations!

1. Cardiovascular examination
2. Cardiovascular examination pansystolic murmur
3. Cardiovascular examination valve replacement
4. Aortic Stenosis
5. Chest Pain 1
6. And there’s lots more here!