1. Or, Between the Lubs and the Dubs
Adult Heart Murmurs
Or, Between the Lubs and the Dubs
Paul D. Simmons, MD, FAAFP
Faculty Physician
St. Mary’s Family Medicine Residency Program
Grand Junction, Colorado

2. Learning Objectives
At the end of this presentation, you should be able to:
1. Distinguish innocent and abnormal heart murmurs in patients and classify them as systolic, diastolic or continuous.
2. Formulate a differential diagnosis of specific cardiac sounds and explain the pathology of heart murmurs to patients.
3. Evaluate diagnostic factors in patients with suspected heart murmurs using cost-effective cardiac testing.

3. Question 1 Who invented the stethoscope? William Osler Robert Koch
Rene Laennec
Edward Jenner
Moses Maimonides
Answer: C

4. Question 2
Which of the following murmurs would be heard during diastole?
Aortic stenosis (AS)
Pulmonic stenosis (PS)
Tricuspid regurgitation (TR)
Mitral stenosis (MS)
Mitral regurgitation (MR)
Answer: D

5. Question 3
You are examining a 30 year old woman, a new patient to your practice. You do not have medical records for her yet, but she states she has no history of a murmur. On auscultation, you hear a murmur. Which of the following would NOT be suggestive of a benign, functional murmur?
Systolic murmur of short duration (i.e., not holosystolic)
Intensity less than or equal to 2/6
Early to mid-systolic
Decreased intensity when the patient stands or Valsalvas
Diastolic murmur
Answer: E

6. Why Should We Care?
“Auscultation has a reported sensitivity of 70% and a specificity of 98% for detection of valvular heart disease.”
Orient JM (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th edition. Philadelphia, PA: Wolters Kluwer Health.
Image public domain, copyright expired, WikiCommons

7. Image from Wikicommons user CFCF, Creative Commons

8. AS / PS
MR / TR
MVP
Image from Wikicommons user CFCF, Creative Commons

9. AR / PR
MS / TS
Image from Wikicommons user CFCF, Creative Commons

10. Another Way to Remember
Valve
Stenosis
Regurgitation
Aortic
Systolic “Manly”
HOOOT Dub
Diastolic
Lub hoot
Pulmonic
Tricuspid
Systolic “Blowing”
Hoot Dub
Mitral

11. Valve Stenosis Regurgitation Aortic Systolic “Manly” Diastolic
HOOOT Dub
Heard at A,  carotid
Diastolic
Lub hoot
Pulmonic
Heard at P, no  carotid
Tricuspid
Holosystolic, T area, no rad
Systolic “Blowing”
Hoot Dub
Mitral
Holosystolic, M area,  axilla

12. Valve Stenosis Regurgitation Aortic Systolic “Manly” Diastolic
HOOOT Dub
Heard at A,  carotid
Diastolic
Lub hoot
Heard at LLSB, decrescendo
Pulmonic
Heard at P, no  carotid
Heard at LUSB, decrescendo
Tricuspid
Lub K-hoot
Opening snap, heard at T area, presystolic “rumble”
Systolic “Blowing”
Hooot Dub
Holosystolic, T area, no 
Mitral
Opening snap, heard at M area, presystolic “rumble”
Holosystolic, M area,  axilla

13. Phonocardiograms AS may have ejection “click” at onset of murmur
A “continuous” murmur…
Image from Wikicommons user Madhero88, creative commons license

14. Systolic Murmur Pathophysiology
Flow across an obstruction: AS, PS or idiopathic hypertrophic subaortic stenosis
Increased flow across a normal valve: ASD – not from flow across the defect, but rather from increased ejection volume
Regurgitation from high pressure to low pressure: MR, TR or VSD

15. Diastolic Murmur Pathophysiology
Generally, diastolic murmurs are softer and lower pitch because of lower pressure during diastole
Regurgitant flow across an aortic or pulmonic (semilunar) valve
Abnormal flow across tricuspid or mitral valves, or “rumble” from increased volume across a normal A-V valve

16. How Good Are Murmurs at Detecting Valve Disease?
“Typical” murmur
+ LR
- LR
Aortic stenosis
5.9
0.1
Sev aortic stenosis
3.6
0.06
Mitral regurg
5.4
0.3
Tricuspid regurg
14.6
VSD
24.9
MVP
12.1 AR
9.9 PR
17.4
From McGee S. (2012), p. 361

17. Maneuvers and Murmurs
Inspiration: decreases intrathoracic pressure, increases venous return to the R heart, and thus increasing TR murmur (Carvallo sign)
Valsalva: increases intrathoracic pressure, decreases venous return to the heart, decreases MVP murmur due to decreased afterload
Squat-to-stand: decreased venous return, moving mitral leaflet closer to the septum, and increases IHSS murmur and MVP murmur
Stand-to-squat: increases venous return, so softens IHSS murmur

18. Continuous Murmurs
“Continuous” murmurs aren’t necessarily continuous, but they don’t obey systolic / diastolic boundaries.
Partial DDx of continuous murmurs:
note that most of these are external to the heart itself
Patent ductus arteriosus
L to R shunt from ASD
A-V fistula
Coarctation of the aorta
Partial obstruction of the pulmonary artery by PE
Venous hum
“Mammary souffle” of pregnancy

19. Question 4
You are seeing a 62 year old man with an apparently new systolic murmur. Which of the following would NOT be an indication for immediate echocardiography?
Systolic murmur with new chest pain and dyspnea
Asymptomatic patient with a 2/6 systolic murmur
Asymptomatic patient with a 4/6 systolic murmur
Asymptomatic patient with a 2/6 systolic murmur and decreased carotid upstroke
All of the above are indications for echocardiography
Answer: B

20. When to Get an Echo Any murmur with cardiac symptoms
Asymptomatic patients with a diastolic murmur
Asymptomatic with a loud (3+/6) systolic murmur
Systolic murmur with other abnormal cardiovascular findings (e.g., systolic click, decreased carotid upstroke)
Figure 3 from Shipton B, Wahba H. (2001), AFP 63 (11): 2201 ff.

21. From Choosing Wisely: Cardiology
Don’t perform echocardiography as routine follow-up for mild, asymptomatic native valve disease in adult patients with no change in signs or symptoms.

22. Question 5
You are examining a 72 year old woman with a history of COPD, ischemic and hypertensive cardiomyopathy, and DVT without PE. You hear an extra heart sound beyond S1 and S2. Which of the following statements is TRUE?
S3 and S4 are best heard with the patient supine while holding a deep breath.
S3 is caused by the atrial jet hitting a volume-overloaded ventricle.
S4 is caused by sudden tensing of mitral valve chordae tendinae.
S3 is always abnormal.
All of the above are true.
Answer: B

23. Some Pearls About S3 and S4
S3 and S4 are heard best in the L lateral decubitus position, and both are more “felt” with the eardrums than heard – very low frequency
S3 is caused by atrial filling into a volume overloaded ventricle
S4 is caused by atrial jet hitting a stiff, hypertrophic ventricle (pressure overload)
S3 can be normal in children

24. Excellent Physical Exam Resources
McGee S. (2012). Evidence-Based Physical Diagnosis, 3rd edition.
Orient JM. (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th edition.
Stanford Medicine 25 Website: stanfordmedicine25.stanford.edu
Heart Sounds & Murmurs app (Android)
Heart Murmur Pro (iOS, $2.99)

25. References
Orient JM. (2010). Sapira’s Art & Science of Bedside Diagnosis, 4th ed. Philadelphia, PA: Wolters Kluwer Health.
McGee S. (2012). Evidence-Based Physical Diagnosis, 3rd ed. (Chapter 41 – Heart Murmurs, General Principles, p. 351ff.)
Nishimura RA, Otto CM, Bonow RO, Carabello BA, Erwin JP 3rd, Guyton RA, O’Gara PT, Ruiz CE, Skubas NJ, Sorayja P, Sundt TM 3rd, Thomas JD. (2014). AHA/ACC Guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology / American Heart Association task force on practice guidelines. J Am Coll Cardiol 2014; 63(22):e57ff.
Mineo K, Cummings J, Josephson R, Nanda NC. (2001). Acquired left ventricular outflow tract obstruction during acute myocardial infarction: Diagnosis of a new cardiac murmur. Am J Geriatr Cardiol., 10(5):

26. Thank you!