A

• Aortic Stenosis (AS)

  • Type: Systolic, crescendo-decrescendo ejection murmur

  • Best Heard: Right upper sternal border, radiates to carotids

  • Clinical Scenario: Elderly patient with exertional syncope, angina, and heart failure symptoms

  • Murmur Maneuvers: Heard louder with patient leaning forward and during expiration

• Aortic Regurgitation (AR)

  • Type: Early diastolic, high-pitched decrescendo murmur

  • Best Heard: Left sternal border (3rd-4th intercostal space) with diaphragm

  • Clinical Scenario: Patient with Marfan syndrome or rheumatic heart disease, presenting with dyspnea and bounding pulses

  • Murmur Maneuvers: Loudest with patient sitting up, leaning forward, during expiration

B

• Blowing Murmur

  • Description: Soft, high-pitched murmur typical of valve regurgitation (e.g., mitral or aortic regurgitation)

  • Clinical Tip: Helps distinguish regurgitant murmurs from stenotic ones

C

• Continuous Murmur

  • Example: Patent ductus arteriosus (PDA) producing a “machinery” murmur

  • Best Heard: Left infraclavicular area

  • Clinical Scenario: Infant or young child with signs of volume overload and failure to thrive

• Crescendo-Decrescendo Murmur

  • Characteristic of AS; intensity rises then falls during systole

D

• Diastolic Murmur

  • Always abnormal; includes murmurs from mitral stenosis, aortic regurgitation, and pulmonary regurgitation

  • Clinical Note: Any diastolic murmur requires further evaluation with echocardiography

H

• Holosystolic (Pansystolic) Murmur

  • Examples: Mitral regurgitation, tricuspid regurgitation, ventricular septal defect

  • Best Heard: MR – apex radiating to axilla; TR – lower left sternal border; VSD – lower left sternal border with loud harsh sound

  • Clinical Scenario: Patient with previous MI may develop MR due to papillary muscle dysfunction

L

• Loudness (Grade of Murmur)

  • Graded I (barely audible) to VI (heard without stethoscope, with thrill)

  • Thrills correlate with grade IV or higher murmurs

• Late Systolic Murmur

  • Often due to mitral valve prolapse

  • Clinical Clue: Usually preceded by a mid-systolic click

M

• Mitral Stenosis (MS)

  • Type: Low-pitched, rumbling diastolic murmur with an opening snap

  • Best Heard: Apex with bell, patient in left lateral decubitus position

  • Clinical Scenario: History of rheumatic fever, presenting with exertional dyspnea and atrial fibrillation

• Mitral Regurgitation (MR)

  • Type: Holosystolic, blowing murmur

  • Best Heard: Apex, radiating to axilla

  • Clinical Scenario: Patient post-MI or with dilated cardiomyopathy presenting with pulmonary edema

P

• Pulmonary Stenosis (PS)

  • Type: Harsh systolic ejection murmur

  • Best Heard: Left upper sternal border with possible thrill

  • Clinical Scenario: Congenital heart disease in children or young adults

• Pulmonary Regurgitation (PR)

  • Type: Early diastolic decrescendo murmur

  • Best Heard: Left upper sternal border, increases with inspiration

  • Clinical Scenario: May occur post-pulmonary hypertension or after repair of tetralogy of Fallot

R

• Rumbling Murmur

  • Low-frequency murmur typical of mitral stenosis

  • Requires bell of stethoscope for best detection

S

• Systolic Murmur

  • May be benign (e.g., innocent murmur) or pathological (e.g., AS, MR)

  • Timing and quality important for diagnosis

• Systolic Ejection Murmur

  • Common in AS and pulmonary stenosis

T

• Thrill

  • Palpable vibration on chest wall indicating significant turbulent flow, often in severe AS or VSD

  • Helps grade murmur severity

• Tricuspid Regurgitation (TR)

  • Type: Holosystolic murmur

  • Best Heard: Lower left sternal border

  • Clinical Clue: Increases with inspiration (Carvallo’s sign)

  • Clinical Scenario: Seen in right heart failure or endocarditis

• Tricuspid Stenosis (TS)

  • Diastolic rumbling murmur at lower left sternal border

  • Often with prominent “a” waves in JVP

V

• Valve Insufficiency (Regurgitation)

  • Leads to backward blood flow producing blowing murmurs

  • Examples: MR, AR, TR, PR

• Valve Stenosis

  • Narrowing of valve opening causing turbulent flow and characteristic murmurs

  • Examples: AS, MS, PS, TS

Murmur Maneuvers (Helpful to Differentiate Murmurs)