Cardiac (heart) murmurs are pathological sounds usually

produced in an affected heart.

The main mechanism of the heart murmurs is the
turbulent flow of the blood, caused by the obstacles in the
blood flow.
So, the causes of the heart murmurs are:

An obstacle in the blood flow because of a
narrowed lumen (narrowed vessel or narrowed
valve orifices);
An enlarged passage (a dilated vessel aneurism)
Sometimes murmurs can be caused by the
changed properties of the blood decreased
viscosity of the blood or increased speed of the
blood flow so-called functional murmurs.
According to the origin there could be 2
types of cardiac murmurs:
Endocardiac - arise inside the heart; occur more
frequently;
Extracardiac- arise outside the heart

Endocardiac murmurs may be organic or
functional.
Organic murmurs :
- due to anatomical changes in the structure of the heart
valves (stenosis, incompetence);
Functional murmurs are produced:
- due to dysfunction of the intact valves. For example:
due to the dilatation of the left ventricle the mitral
orifice will be dilated and the mitral valve will not close
completely the mitral orifice;
- due to increased speed of the blood flow (for ex. - in
hyperthyroidism)
- due to decreased blood viscosity (for ex.. in anemia).
According to timing of appearance cardiac
murmurs can be:
1. Systolic
2. Diastolic
Systolic murmur appears during cardiac
systole:
Stenosis of the aortic orifice
Stenosis of pulmonary trunk
Regurgitation of blood through an incompletely
closed orifice during ventricular systole (mitral
regurgitation and tricuspid regurgitation.)
Diastolic murmur occurs during diastole.
In stenosed left or right atrioventricular orifice,
since blood meets a narrow passage in its flow from
atria to ventricle.
Aortic or pulmonary valve regurgitation when the
blood flows back from the vessels to the ventricles
through the slit formed by incomplete closure of the
cusps of the affected valves.
Systolic murmurs occur with the
S1, during the short pause of
the heart; they are synchronized
with the heart beat and carotid
pulse.
Diastolic murmurs occur during
the long pause of the heart and
follow S2
Three types of systolic murmurs are
distinguished:
1. protosystolic (early systolic)- appears at the
beginning of systole, after the S1
2. midsystolic - occurs soon after the S1
3. late systolic - at the end of systole
Three types of diastolic murmurs are
distinguished:
1. protodiastolic (early diastolic) - appears at the
beginning of diastole, after the S2
2. middiastolic - occurs soon after the S2
3. presystolic (late diastolic)- at the end of diastole
To characterize the cardiac murmur, during
auscultation the following should be determined:
Localization of the murmur
The relation of the murmur to the phase of the heart
activity (to systole or diastole) to appreciate it is a
Systolic or a Diastolic murmur;
The features, character, the length and strength of
the murmur
Irradiation of the murmur
Properties of the murmurs.
By their character, murmurs can be - soft, blowing or
rough, grating or grazing sounds, musical murmurs.
By duration short or long;
By intensity - low or loud.
Configuration of murmur may be:
Crescendo
Descrescendo
Crescendo Descrescendo (diamond-shaped)
Plateau
Murmur may become weaker (descrescendo) and
louder (crescendo).
Murmur Patterns
Common systolic
Crescendo-decrescendo
Holosystolic
Common diastolic
Decrescendo
Holodiastolic
Systole Diastole
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Common Murmurs and
Timing
Common Murmurs and
Timing
Systolic Murmurs
Aortic stenosis
Mitral insufficiency
Mitral valve prolapse
Tricuspid insufficiency
Diastolic Murmurs
Aortic insufficiency
Mitral stenosis
S1 S2 S1
Descrescendo murmurs occur
when blood begins to flow from
one chamber to another and the
pressure is high and the noise is
high. When the blood is expelled,
the pressure decreased and the
noise becomes weaker.
Presystolic murmur occurs mostly in
stenosis of the left atrioventricle orifice
and has an increasing character.
Murmurs are well transmitted in the
direction of the blood flow. They are
better heard in areas where heart is
close to the chest and not covered with
the lungs.
Systolic murmur due to mitral
regurgitation is best heard at the
heart apex and transmitted to the
axillary area and by the course of
the backward of the blood flow
from LV to LA - to the 2nd or 3rd
intercostal space, to the left of
sternum.
Plateau-like, Pan-Systolic, Quiet S1, Blowing,
High-Pitched, Heard at Apex, Radiates to Axilla,
Diastolic murmur due to mitral stenosis is
usually heard in limited apex area.
Auscultative picture mitral stenosis, Diastolic, Low-Pitched,
Heard over Apex.
Systolic murmur due to stenosed aortic
orifice is better heard in 2nd
intercostal space, to the right of
sternum and transmitted by the course
of blood flow to carotid areas. Noise is
characterized like rough and loud. Can
be auscultated over the entire heart
region and transmitted into
interscapular area.
Auscultative picure of aortic stenosis. Crescendo-
Decrescendo, Ejection systolic, Loud, Rough, Medium
Pitched, Heard over Aortic Area, Radiates to Carotids

Diastolic murmur due to aortic
insufficiency is better heard in
the Erb's point, where it is
transmitted by the back flow
from aorta to LV.
Auscultative picture of aortic regurgitation. Early-
Diastolic, Low-pitched, Heard over Apex.
Systolic murmur associated with tricuspid insufficiency is
best heard at base of xiphoid process and can be
transmitted to the right atrium. In right atrioventricular
orifice stenosis, diastolic murmur is heard over a limited
area at the base of the xiphoid process.
Systolic murmurs associated with AV valves regurgitation
or stenosis of aortic or pulmonary orifices, is better heard
when the patient is in the recumbent posture. Diastolic
murmurs due to stenosis of AV orifices or aortic or
pulmonary trunk insufficiency are better heard in upright
posture.
Differentiation of murmurs
Systolic and diastolic murmurs over the same valve
indicate its associated affection, i.e. insufficiency of
the valve and stenosis of the orifice.
If systolic murmur is heard over one valve and diastolic
murmur over the other, a combined affection of two
valves can be diagnosed.
During heart auscultation, it is
necessary to differentiate
between functional and
organic, and between
endocardiac and extracardiac
murmurs
. The following properties of functional
murmurs help to differentiate them from
organic murmurs:
Most cases functional murmurs are systolic
2. Functional murmurs are not permanent and may arise and
disappear when the person changes its posture, after exercise and
during respiratory phases.
3. They are mostly heard over the pulmonary trunk and less
frequently over the heart apex
4. Functional murmurs are transient and are rarely heard during
the entire systole, they are soft and blowing sounds
5. Functional murmurs are normally heard over limited area and are
not transmitted to long distances from the place of formation
6. Functional murmurs are not accompanied by other signs of valve
affections, i.e. changes of the sound