Heart murmur

Clinical Examination

Location

• Valves have characteristic locations at which their murmurs are usually heard best
• Murmurs may radiate

Location	Valve
Right upper sternal border at second intercostal space	aortic valve
Left upper sternal border at second intercostal space	pulmonary valve
Left lower sternal border at fourth intercostal space	tricuspid valve
point of maximal impulse of apex, left midclavicular line at the fifth intercostal space	mitral valve

Intensity

Grade	Description
Grade 1	faint murmur, barely audible after waiting and focusing
Grade 2	quiet murmur but readily heard
Grade 3	easily audible but without a palpable thrill
Grade 4	easily audible and with a palpable thrill
Grade 5	loud murmur, audible with stethoscope lightly touching the chest
Grade 6	loudest murmur, audible with stethoscope not touching the chest

Pitch

• High or low frequency
• Blowing, harsh, musical, rumbling, squeaky

Profile

• Crescendo, decrescendo, crescendo-decrescendo, plateau

Timing

• Systolic or diastolic
• Early, mid, late, holosystolic, or continuous

Characteristic Murmurs

Murmur	Location	Profile	Timing	Pitch	Notes
Aortic stenosis	RUSB, may radiate to carotid arteries	crescendo-decrescendo	systolic
Aortic regurgitation	LLSB	descrescendo	diastolic	blowing
Aortic regurgitation, Austin-Flint murmur	PMI		mid-diastolic	rumbling	may be mistaken for mitral stenosis
Flow murmur			mid-systolic
Pulmonary stenosis	LUSB		systolic
Tricuspid stenosis	LLSB		diastolic
Tricuspid regurgitation	LLSB		systolic
Mitral stenosis	PMI		diastolic
Mitral regurgitation	PMI, may radiate to left axilla		systolic
Pulmonic stenosis	LUSB	crescendo-decrescendo	systolic ejection
Atrial septal defect					wide fixed split S2 at LUSB
Ventricular septal defect	PMI		holosystolic
HOCM	between PMI and LLSB		systolic
PDA	LUSB		continuous