Cardiac murmers, mnemonics

1. Cardiac Murmers
Lejay Jacob
Presentation during Pediatric Rotation w/
Dr. Luis F. Santiago, M.D.
October 21st, 2014
by

2. Thought process
• Timing,
- Is it Systolic/Diastolic
• Location
• Specific Description of murmer
-Shape, Pitch, Quality, Radiation, Grading
5th ICS
In MCL
Image Source- http://www.aafp.org/afp/2011/1001/p793.html
Note: Orange text , following , describes terms indicating Quality

3. Overview
Murmers
Systolic Diastolic
M St
T St
A R
P R
M R
T R
A St
P St
ASD
VSD
Septal Defect
Flow Murmer
=Anemia
HOCM
Continuous
= PDA
MVP
Mnemonic
MR ASS(ystolic)
MS ARD(iastolic)
Think of Aortic/Pulm Valves
Together, time of Closing
Mitral/ Tricuspid Valves
Mnemonic source- Fernando Catalan

4. Physiology , Variations of Murmers
• Increased velocity of Blood
-Through morphologically Normal Structures
-Through narrowed structures, velocity
increases with square of radius
• Decreased Viscosity of Blood
-Notable in Anemic p/ts
• Variation of Heart Murmer
- AKA Bruits in Veins , in the carotid Arteries ,
Abdominal Aortic Aneurysm

5. Innocent heart Murmer criteria*,
PEDs >1 y.o.
• absence of abnormal physical examination findings
(except for the murmur);
• a negative review of systems (i.e., child is
asymptomatic, parents report of time Child plays);
• a history that is negative for features that increase the
risk of structural heart disease;
• characteristic auscultatory features of a specific
innocent heart murmur.
> If above criteria not met, refer to EKG And OR pediatric
cardiologist.
>Other orders suggested- CBC, Chest Xray
Note-In this presentation, the term Innocent is Synonymous with term, Benign
* According to criteria in Article Evaluation and Management of Heart Murmers in Children , See Source Slide

6. Benign
Pediatrics Related Murmers
Stills Early systolic
Grade 1-3
Tricuspid and mitral V
Twang sound , increase with supine
Decrease with sitting up
Rarely in infants, most likely 2-6 y.o
Pulm flow Grade 2-3
Systolic Ej murmer
Pulm V
Harsh, intensity increase with supine
Young children to young adulthood
Peripheral Pulm
artery
Sten
Grade 1-2
Mid Syst
Medium pitch, increase w/ supine
Back and axilla
Newborn , and <1y.o + recovering viral resp infxn
Supraclavicular
Or
Brachiocephalic
Syst
Med pitch
Clavicles,radiate to neck
Rapid shoulder extension can dec Intensit
Any Age child
Aortic Syst
Non harsh
Aortic V
In p/t with High Heart Output Volume
Systolic
Venous Hum Grade 1-6
Diastole
Continuous
Loud on right side , supra /infra clavicular
area, increase when sitting up and
looking away from you
Decrease when Supine
Compression of internal jugular may
decrease it
3-6 y.o
Mammary souffle murmer Continuous murmer
High pitch, intensity varies daily
Over Anterior Breast
In lactating Mothers
PDA Physiologicin newborns, pathologic if
persist
Continuous machine like murmer,
diamond shape
Continuous

7. “Knowing appearance(s)of Normal is First step of
Finding what’s wrong” - Anon
Image Source- University of Utah, http://library.med.utah.edu/kw/pharm/hyper_heart1.html

8. Systolic
T R
VSD
Valve defect Specific Descriptions
ASD Wide fixed Splitting
L->R Shunt
VSD Harsh Holosystolic
MR
M V
Prolapse
Holosystolic
Blowing/ Musical
Radiation to Axilla
Pronounced with Increase in After Load
Midsystolic Click, follow by crescendo decresc
At Apex
Enhanced by Valsalva, decreased by Squatting
Contrary to other murmers , also seen HOCM
TR Holosystolic
Present on Left; Radiation to Rt Sternal Border
Inpiration Increases Right side murmers
ASt Pulsus Parvus et Tardus
Early Systolic Click
Harsh sound
Seen in old age OR Bicuspid Aortic Valve
PSt
HOCM
Related to Tetrology of Fallot
Decreased intensity with sustained Squat
PSt
Image- Master the boards,
USMLE Step 2 CK, 2nd ed
Note- Pay attention
To Clicks and Snaps shown in
Red
Overview

9. Diastolic and
Continuous
Valve Defect Specific Description
MSt Opening Snap
Rumbling
Note- for immigrants with a
delayed or unverified vaccination
Hx= Could have had Rh Heart Dis
TSt A Rt sided Heart Defect
Affected In IV Drug abusers and
Rheumatic Heart Disease
AR
AKA
Aortic
Insufficiency
Blowing Murmer
Wide pulse pressure, Lower
diastolic pressure
PR A Rt sided Heart Defect
Affected In IV Drug abusers and
Rheumatic Heart Disease
PDA Continuous Machine Like murmerPDA
T St
P R
A R
Aortic Insufficiency
Blue Images-
http://www.stritch.luc.edu/lumen/MedEd/MEDICINE/PULMONAR/PD/heart%20murmurs.ppt
Overview

10. General Details
• Radiations
- Bruits and murmers radiate In the Direction of Blood Flow
- Aortic Valve defects radiate to Carotid Arteries
- Tricuspid V Defects radiate to Ant Thorax sternal borders
- Mitral V Defects radiate to mid clavicular Line
• Order of Preference of Valves affected in Rheumatic Heart Disease
1) Mitral V 2) Aortic V 3) Tricuspid V
• Diastolic Murmers are generally pathologic*
• Grading
– graded on a 6 point scale
• Grade 1 = very faint
• Grade 2 = quiet but heard immediately
• Grade 3 = moderately loud
• Grade 4 = loud
• Grade 5 = heard with stethoscope partly off the chest
• Grade 6 = no stethoscope needed
*Note: Thrills are assoc. with murmurs of grades 4 – 6
* Article: Approach to Cardiac Murmers - see Sources Slide

11. Maneuvers Change in Afterload
Pressure in Pulmonic Circulation is seen with Pulmonary HT, sign of SOB, Increase HR
Pressure in Aortic/Systemic Circulation is increased
with Hand Fist, Sustained Squat(30 Sec)
 Change in Preload
Inspiration , causes increase in Preload , blood to Right side of heart, pronounced
RH murmers
Fast Squat, Increase Venous Return and Diastolic Filling
Another way to increase RH murmers is to make p/t Lie down Supine
Expiration, increases Lt heart murmers
 Valsalva Maneuver/ standing
Done by asking p/t to close nose and mouth and blow like blowing balloon
Increases Vasovagal Rxn , Increases PSNS tone, decrease HR and BP
Decrease Volume of Left Ventricle
 Lateral Decubitis Position
Accentuates Mitral Murmers
 Sitting Forward and Exhaling Completely
Accentuates Aortic Murmers , decrease HR , Increase Stroke Volume
 Carotid massage, decrease HR, PSNS
Simultaneous Carotid massage, can cause Syncope

12. Named Murmers,
Wards and Clinical Importance
Eponym Description
Austin Flint murmer Mid to Diastolic rumble , heard in AR
Can mimic MS
Graham Steel murmer PR occurring with Pulm HT
High pitch and Blowing
Carey Coombs murmer Mid diastolic , at Apex,
During Acute Rheumatic Fever
Gallavardin Phenomonen Highest frequencies of AS murmer , radiate to apex,
Mimic MR
Dock’s Murmer Diastolic, heard w/ stenosis of LAD

13. Case 1
• A 1 mth old female infant born at full term is noted to
have a harsh holosystolic 3/6 heart murmer heard best
at lower sternal border . The child is not cyanotic and
does not have hepatomegaly or tachypnea at rest . The
child feeds without tachypnea or diaphoresis, and
weight gain is appropriate. There is no cardiomegaly on
chest Xray , Which of the following is most likely Dx?
• A) VSD
• B)ASD
• C) PDA
• D) P St
• F) A St
Sound

14. Ans. 1

15. Source
• Evaluation and Management of Heart Murmers in Children by Frank, Jennifer E,
MD and Jacobe, Kathyryn M. MD, accessed on October 10th, 2014.
http://www.aafp.org/afp/2011/1001/p793.html
• Approach To Cardiac Murmers by Nabi, Shahin M . Ed by Bishop, Jeff. Accessed on
October 15th, 2014
http://learnpediatrics.com/body-systems/cardiology/approach-to-cardiac-murmurs/
• Kaplan Step 1 Lecture CD ,2007 set, Cardiology, Murmers video- Dr Wasir Kudrath,
MD
• Heart murmers for USMLE step 1 video, Youtube –Joseph Benidict, Eric strong,MD
• Blueprints for Pediatrics , 3rd edition.
• Master the Boards, USMLE Step 2 CK, 2nd edition.
• Heart murmer Library accessed on October 10th ,2014
- http://www.med.umich.edu/lrc/psb/heartsounds/index.htm
Question 1 Sound -http://www.easyauscultation.com/holosystolic-murmur
• Background image-
http://www.aubmc.org/patientcare/spe_cli_pro_ser/Pages/chc.aspx

16. Thank You