Cardiac murmurs – systolic

Clinical examination > Cardiorespiratory

Aortic stenosis

Aortic stenosis causes increased resistance between the left ventricle and systemic circulation. This results in limited cardiac output and subsequent LV hypertrophy.

• Character: ejection systolic
• Best heard: upper right sternal edge; loudest on expiration
• Radiation: carotids and apex
• Symptoms:
  • Exertional dyspnoea
  • Syncope
  • Angina (coronary perfusion impaired)
• Signs:
  • Slow-rising pulse
  • Narrow pulse pressure
  • Heaving apex beat (pressure-loaded)
  • Soft or absent S2 (depending on AS severity)
  • May be signs of LVF (S3, pulmonary oedema)

Aortic sclerosis

Aortic sclerosis is a hard and inflexible aortic valve (thickened, NOT narrowed) due to age-related calcification. This causes turbulence and a local sound only.

• Character: ejection systolic
• Best heard: upper right sternal edge
• Radiation: does not radiate
• Symptoms: none
• Signs:
  • No abnormal signs
  • Differentiate from AS by normal pulse, apex and S2

Mitral regurgitation

Mitral regurgitation causes backflow of blood from left ventricle to left atrium during systole. This causes LV and left atrial dilation, which ultimately results in pulmonary hypertension.

• Character: pansystolic
• Best heard: apex; loudest on expiration
• Radiation: left axilla
• Symptoms:
  • Dyspnoea
  • Orthopnoea
  • Paroxysmal nocturnal dyspnoea

• Signs:
  • AF
  • Displaced thrusting apex (volume-loaded)
  • Soft S1
  • Signs of pulmonary hypertension (RV heave, loud P2)
  • May be signs of LVF (S3, pulmonary oedema)

A patient presents to ED with chest pain and this trace. What would you do?

Interpretation management

Covered in OSCE Stations

Mitral valve prolapse

Mitral valve prolapse is when a mitral valve leaflet prolapses into the left atrium during ventricular systole.

• Character: mid-systolic click and/or late systolic murmur
  • Differentiate from MR by normal S1 then gap before murmur
• Best heard: apex; loudest on expiration
• Radiation: left axilla and back
• Symptoms: atypical chest pain
• Signs:
  • Murmur only
  • Can develop significant MR

Ventricular septal defect

A ventricular septal defect results in some blood from the left ventricle leaking into the right ventricle during systole. It is usually congenital (chronic), or due to a myocardial infarction (acute).

• Character: pansystolic loud machinery-like murmur
• Best heard: lover left sternal edge
• Radiation: whole precordium
• Symptoms: often none if small
• Signs:
  • Signs of pulmonary hypertension (RV heave, loud P2)
  • If acute, may cause cardiogenic shock

Tricuspid regurgitation

Tricuspid regurgitation results in the backflow of blood from the right ventricle to the right atrium during systole. This causes increased right atrial and venous pressure.

• Character: pansystolic
  • Differentiate from MR by…
    • louder on inspiration because it’s on the right
    • Giant JVP
    • Non-displaced apex
• Best heard: lower left sternal edge; loudest on inspiration
• Radiation: none
• Symptoms:
  • Fatigue
  • Ascites
  • Peripheral oedema

• Signs:
  • Giant ‘v’ waves in JVP (giant JVP waves without RVF = TR)
  • Backflow signs (peripheral oedema, ascites, pulsatile hepatomegaly)
  • Signs of lung disease and pulmonary hypertension (RV heave, loud P2) if that is the cause

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