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CARDIOLOGY · FREE NOTE
Heart murmurs
| Murmur | Timing | Best heard | Key clue |
|---|---|---|---|
| Aortic stenosis | Crescendo–decrescendo systolic | Right upper sternal border → carotids | Syncope, angina, dyspnea; pulsus parvus et tardus |
| Mitral regurgitation | Holosystolic, blowing | Apex → axilla | Post-MI papillary muscle rupture, MVP |
| Mitral valve prolapse | Mid-systolic click ± late murmur | Apex | Young woman, Marfan, Ehlers-Danlos |
| VSD | Holosystolic, harsh | Left lower sternal border | Most common congenital heart defect |
| Aortic regurgitation | Early diastolic, decrescendo | Left sternal border | Wide pulse pressure, bounding pulses |
| Mitral stenosis | Opening snap → mid-diastolic rumble | Apex | Rheumatic fever history |
Maneuvers
- ↑ Preload (squatting, leg raise): most murmurs get louder. HCM gets softer; MVP click comes later.
- ↓ Preload (Valsalva, standing): most murmurs get softer. HCM gets louder; MVP click comes earlier.
- Handgrip (↑ afterload): MR, VSD and AR louder; AS and HCM softer.
Pearl: only HCM and MVP move the "wrong" way with preload.
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