A p p ro a c h t o t h e Pa t i e n t w i t h

a M u rm u r
John Landefeld, MD, MS*, Melody Tran-Reina, MD, Mark Henderson, MD, MACP

KEYWORDS

Cardiac auscultation
Valvular heart disease
Murmurs
Physical examination

KEY POINTS

The cardiac examination consists of auscultation, visualization, palpation, and special ma-
neuvers, all of which can reveal abnormalities suggestive of valvular heart disease.

Likelihood ratios, calculated from the sensitivity and specificity of a physical finding (or test
result), are useful to adjust one’s clinical impression or likelihood of a given diagnosis,
providing practical information regarding the need for further evaluation or management.

The most robust likelihood ratios for the cardiac examination pertain to systolic murmurs,
the primary focus of this review.

Video content accompanies this article at http://www.medical.theclinics.com.

INTRODUCTION

As average life expectancy approaches 80 years in the United States, and exceeds
80 years in many other wealthy countries, the prevalence of valvular heart disease
is growing, impacting patient quality of life, functional status, and mortality. Recently,
advances in valve replacement and repair for patients with valvular heart disease have
led to improvements in outcomes for patients with conditions such as mitral regurgi-
tation and aortic stenosis.1 The identification of patients who might benefit from these
and other treatments often depends on a clinician’s ability to evaluate for valvular pa-
thologies through the physical examination. Murmurs are initially classified according
to their timing in the cardiac cycle, specifically, systolic or diastolic. As they are most
common, systolic murmurs will be the focus of this article. Diastolic murmurs generally
indicate important underlying valvular pathology, but there is less evidence supporting
the diagnostic utility of the accompanying physical examination findings.
Likelihood Ratios
Interpreting the physical examination findings for valvular heart disease requires a
basic understanding of likelihood ratios. Likelihood ratios serve to define the relative

Department of Internal Medicine, UC Davis School of Medicine, 4150 V Street, Suite 2400,
Sacramento, CA 95817, USA
* Corresponding author.
E-mail address: jclandefeld@ucdavis.edu

Med Clin N Am 106 (2022) 545–555

https://doi.org/10.1016/j.mcna.2021.12.011 medical.theclinics.com
0025-7125/22/ª 2022 Elsevier Inc. All rights reserved.

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546 Landefeld et al

utility of a given physical examination maneuver (or test result) and can be applied in
clinical scenarios to determine the likelihood that a patient has (or does not have) a
particular valvular pathology.
Likelihood ratios are a function of test sensitivity and specificity. A positive likelihood
ratio (1LR) can be calculated as follows:

Sensitivity
1LR 5
1  Specificity

A 1 LR can also be articulated as:*

The probability that a person with Condition A 0 tested 02 positive for Condition A
1LR 5
The probability that a person without Condition A 0 tested 0 positive for ConditionA

The probability of a true positive

ie: 1 LR 5
The probability of a false positive

A negative likelihood ratio can be calculated as follows:

1  Sensitivity
LR 5
Specificity

A LR can also be read as:

The probability that a person with ConditionA tested negative for ConditionA
LR 5
The probability that a person without ConditionA tested negative for ConditionA

The probability of a false negative

ie:  LR 5
The probability of a true negative

An LR close to 1 means that the test result or clinical finding does not appreciably
change the likelihood of disease. A 1LR informs the clinician how much a positive
test result (or the presence of a given clinical finding) changes the probability of a
disease. A LR suggests how much a negative test result (or the absence of a
given clinical finding) changes the probability of a disease. In this review, we
include physical examination findings with LRs greater than 5 or less than 0.2,
because such findings sufficiently impact post-test probabilities as to be clinically
useful.
Clinicians can apply physical examination findings with a known likelihood ratio to
their pretest probability of disease by using a Fagan nomogram, to thus arrive at a
post-test probability (Fig. 1).2 The post-test probability informs further diagnostic
and therapeutic planning.

AUSCULTATION IN VALVULAR HEART DISEASE

Auscultation of the heart in a patient with suspected valvular heart disease centers
around 4 core components: timing, intensity, onomatopoeia, and location. A precise
description of murmurs is fundamental to identifying valvular pathology and informing
appropriate next steps.

* In the case of a physical exam finding, ‘tested’ refers to the probability that a person with Condition
A has a particular characteristic physical exam finding associated with Condition A.

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 Approach to the Patient with a Murmur 547

Fig. 1. Fagan nomogram. (Adapted from Fagan TJ. Nomogram for Bayes’s theorem. N Engl J
Med Jul 31, 1975; 293(5):257.)

Timing in the Cardiac Cycle

The first step in classifying a murmur is to characterize its timing. Murmurs may occur
in either part of the cardiac cycle (systole or diastole), or in some instances, may be
continuous throughout the cycle.

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548 Landefeld et al

Systolic murmurs, which occur in between the closing of the atrioventricular valves
(S1) and the closing of the semilunar valves (S2), are the most common. Diastolic mur-
murs occur at any time in the longer interval between S2 and S1. One can first identify
S1 and S2 by palpating the carotid pulse while auscultating the heart. The heart sound
that nearly coincides with the pulse is S1. Systolic murmurs, by far the most common
murmurs, should further be described according to when in systole they occur.3
Early systolic murmurs: Murmurs with indistinct or obliterated S1 but distinct S2.
Midsystolic murmurs: Murmurs with distinct S1 and S2.
Late systolic murmurs: Murmurs with distinct S1 but indistinct or obliterated S2.
Holosystolic murmurs: Murmurs with indistinct or obliterated S1 and S2.
Diastolic murmurs tend to occur either immediately after S2, in mid-diastole, or late
in diastole (also termed “presystolic”). Early murmurs may obscure S2 and mid-
diastolic murmurs (eg, mitral stenosis) often follow an opening snap (more on
onomatopoeia below).

Murmur Intensity
Once the timing of the murmur is established, the examiner should describe its inten-
sity. By convention, intensity is categorized into 6 levels according to the Levine
grading system.
Grade 1: Murmurs only audible by listening carefully through the stethoscope for a
period of time.
Grade 2: Murmurs audible as soon as the stethoscope is placed on the chest wall.
Grade 3: Murmurs which are loud with the stethoscope but without a palpable thrill.
Grade 4: Murmurs which are loud, still require a stethoscope to be heard, and are
associated with a thrill.
Grade 5: Murmurs which are very loud, associated with a thrill, but only require the
edge of the stethoscope to contact the chest in order to be heard.
Grade 6: An unusually loud murmur, associated with a thrill, and audible with the
stethoscope even when the stethoscope is just off the surface of the chest wall.
The intensity of a murmur alone is not particularly predictive of the underlying cause,
but may be useful when considered in context with other findings.

Nature of the Sounds—Onomatopoeia

After determining the timing and intensity of the murmur, the clinician should describe
the nature of the murmur. Phonetically imitating aloud the sounds auscultated is a
practical way to differentiate various murmurs and to accurately communicate the
findings to colleagues and learners.4
The clinician should mimic the sound while demonstrating its relationship to the first
and second heart sounds. For instance, the high-pitched murmur of mitral regurgita-
tion might be described as “lubHoooooooodub,” with “lub” indicating mitral valve
closure, “Hoooooooo” indicating the regurgitant flow across the mitral valve, and
“dub” indicating aortic valve closure. The murmur of aortic stenosis is often described
as “harsh,” owing to the combination of both high-pitched and low-pitched sounds.
The clinician may hear a guttural “lub gRRRrrr dub” murmur with aortic stenosis. An
aortic murmur that has a “blowing” nature is less likely to be severe aortic stenosis
(LR 0.1).5
Mitral valve prolapse is a common pathology accompanied by a “midsystolic click”
that sounds similar to a “k” sound. Regurgitant flow across the mitral valve may
develop over time. The combined sound of mitral valve prolapse and mitral regurgita-
tion may be described as “lub...kHoooooooodub.”

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 Approach to the Patient with a Murmur 549

Sound intensity may also be indicated with onomatopoeia. For example, the early
diastolic high frequency blowing decrescendo murmur of aortic regurgitation may
obscure S2 and be indicated as “Lub. PEWWww....”. If this murmur is grade 3 inten-
sity or louder, the patient likely has moderate to severe aortic regurgitation (1LR 8.2).
The absence of the characteristic diastolic murmur is strong evidence against the ex-
istence of moderate to severe aortic regurgitation (LR 0.1).
The low-pitched murmur of mitral stenosis begins in mid-diastole, occasionally after
a snap (the sound of the stenotic leaflets opening). It may sound like “up bu duprrrrRR-
Rup,” with “up” being S1 (which may be louder than normal), “bu” being S2, and “dup”
being the opening snap. The rumble may eclipse the beginning of S1.

Location on Chest Wall (Broad or Small Apical-base, Broad Apical, LLSB, Apical
Only, Base Only)
The distribution of sound on the chest wall is helpful in differentiating systolic murmurs.
The third left parasternal space overlies both the aortic and mitral valves and is thus
used as a landmark to help classify systolic murmurs into 1 of 6 possible patterns
(Fig. 2). The primary determinant of a murmur’s radiation is not necessarily the direc-
tion of blood flow, but rather how the abnormal blood flow generates vibrations in the
ventricles and/or great arteries, which are also transmitted because of adjacent bony
vibration. Vibrations of the ventricles and lower ribs will generate sound below the third
left parasternal space, and vibrations of the great arteries, sternum, and clavicles will
generate sound above the third left parasternal space.
The location on the chest wall helps to identify whether murmurs are characteristic
for certain valvular pathologies. Increased aortic valve velocity (suggestive of aortic
stenosis) results in a broad apical-base pattern (1LR 9.7) on the chest wall. A broad
apical pattern increases the probability of mitral regurgitation (1LR 6.8), whereas
the left lower sternal pattern increases the probability of tricuspid regurgitation (1LR
8.4).6
The diastolic murmur of aortic regurgitation is often heard most prominently at the
left sternal border (and occasionally at the right sternal border). The diastolic murmur
of pulmonic regurgitation is typically loudest at the left sternal border at the second
intercostal space.
All 4 components of auscultation—timing, intensity, onomatopoeia, and location—
should be interpreted in relation to one another with their associated likelihood ratios
(Table 1).

Visualization and Palpation in Valvular Heart Disease

Direct observation of the patient’s undraped chest and neck may help determine the
etiology of a murmur. Visualization and/or palpation of the cardiac apex may also be
helpful; normally there is a single apical impulse per cardiac cycle. A double apical im-
pulse may suggest left ventricular (LV) hypertrophy (1LR 5.6). A hyperkinetic apical im-
pulse may be seen in mitral regurgitation (1LR 11.2). On the other hand, the absence
of an enlarged apical impulse decreases the probability of moderate to severe aortic
regurgitation (LR 0.1).
With severe tricuspid regurgitation, the right ventricle becomes dilated and oc-
cupies the cardiac apex. In systole, the apex may be seen to move inward, and a
simultaneous outward motion may be seen at the left or right lower sternal border
signifying the increased flow into the dilated right atrium. This visual finding is known
as the right ventricular rock (1LR 31.4). A pulsatile liver may also be palpated with se-
vere tricuspid regurgitation (1LR 6.5).7

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550 Landefeld et al

Fig. 2. Location on the chest wall of 6 systolic murmur patterns. (Reproduced with permis-
sion from Evidence-Based Physical Diagnosis, 4th Ed., Steven McGee, Fig 43.1 Six systolic
murmur patterns. Copyright Elsevier 20.)

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 Approach to the Patient with a Murmur 551

Table 1
Clinically useful examination findings, as determined by likelihood ratios (DLR > 5, LLR < 0.2)

Likelihood Ratio if
Sensitivity Specificity Finding is
Finding (%) (%) Present Absent
Characteristic Systolic Murmur
Mild tricuspid regurgitation or worse 23 98 14.6 0.8
(LubSHSHSHSHdub in a left-lower
sternal pattern)
Mild or worse aortic stenosis (Lub 90 85 5.9 0.1
GRRRR dub in a broad apical-base
pattern or small apical-base pattern)
Mild or worse mitral regurgitation 56–75 89–93 5.4 0.4
(LubSHSHSHSHdub in a broad apical
pattern)
Mitral valve prolapse 55 96 12.1 0.5
(Lub.kSHSHSHdub with midsystolic
click in broad apical pattern)
“Blowing” sound throughout aortic 4 67 0.1 1.4
flow murmur for significant aortic
stenosis
Characteristic Diastolic Murmur
Mild or worse aortic regurgitation 54–87 75–98 9.9 0.3
(early diastolic high-frequency
decrescendo murmur along lower
sternal border)
Detecting pulmonary regurgitation 15 99 17.4 NS
(diastolic decrescendo murmur in
2nd intercostal space at left upper
sternal border)
Intensity of S1 and S2
S2 inaudible for increased aortic valve 12.7
peak velocity in aortic stenosis
Maneuvers
Louder during inspiration (for TR) 78–95 87–97 7.8 0.2
Louder with Valsalva strain for HCM 70 95 14 0.3
Louder with squat-to-stand (for HCM) 95 84 6 0.1
Softer with stand-to-squat (for HCM) 88–95 84–97 7.6 0.1
Softer with passive leg elevation (for 90 90 9 0.1
HCM)
Visualization and Palpation
Hyperkinetic apical movement (for 74 93 11.2 0.3
detecting MR)
Double apical movement (for LVH) 57 90 5.6 0.5
Right ventricular rock (for TR) 5 100 31.4 NS
Pulsatile liver (for TR) 12–30 92–99 6.5 NS
C-V wave (for TR) 37 97 10.9 0.7

Abbreviation: HCM, hypertrophic cardiomyopathy; LVH, left ventricular hypertrophy; MR, mitral
regurgitation; TR, tricuspid regurgitation.

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552 Landefeld et al

The jugular veins may demonstrate prominent outward pulsations or giant (fused)
“c-v” waves in severe tricuspid regurgitation. The x-descent is obliterated and the
“v” wave, representing right atrial filling, increases when the regurgitant jet crosses
the tricuspid valve from the right ventricle. This finding, also known by the eponym
Lancisi sign, can be seen in Video 1 in the online version of this text. It is important
to differentiate the jugular venous pulsation from the carotid pulse; bounding carotid
arteries may be seen in severe aortic regurgitation.
Patients with aortic regurgitation generate a large stroke volume followed by rapid
diastolic emptying of aortic blood into the left ventricle, causing the arterial pulse
wave to both rise and collapse abruptly. This is known as water-hammer pulses or
Corrigan pulse. The same physiology produces fascinating pulsations throughout
the body and has generated many eponyms such as Quincke pulse (capillary pulsa-
tions in the nail bed), de Musset sign (bobbing of the head), Müller sign (pulsation of
the uvula), and Landolfi sign (pulsatile constriction of the iris, seen in Video 2 in the on-
line version of this text). Although interesting, such findings do not offer particular diag-
nostic value in terms of likelihood ratios. However, widened pulse pressure (>80 mm
Hg) or low diastolic pressure (<50 mm Hg) strongly suggest underlying aortic regurgi-
tation (1LR 10.9 and 1LR 19.3, respectively).8
By applying these findings on visualization and observation to the findings heard on
auscultation, the clinician can further hone the differential diagnosis for a given
murmur.

Maneuvers in Valvular Heart Disease

Special maneuvers that change venous return and afterload, can aid the clinician in
differentiating the cause of a systolic murmur.
With inspiration, intrathoracic pressure decreases, increasing the volume of blood
entering the right-sided chambers from the vena cava, while decreasing return to
the left side of the heart. This elevated right-sided volume causes increased flow
across the tricuspid and pulmonic valves. A murmur that increases or varies in inten-
sity with inspiration suggests a murmur across the tricuspid or pulmonic valve.
Maneuvers that affect venous return are useful in evaluating suspected hypertrophic
cardiomyopathy (HCM), in which the characteristic harsh midsystolic murmur is influ-
enced by the degree of LV outflow tract obstruction by the anterior mitral valve leaflet
and the hypertrophic interventricular septum. With the Valsalva maneuver or changing
from squatting-to-standing, venous return to the right side of the heart decreases and
the LV cavity size diminishes, which aggravates the degree of outflow tract obstruction
and thus increases the intensity of the murmur (1LR 14 for Valsalva). On the other
hand, standing-to-squatting or passive leg elevation both increase venous return,
which enlarges the LV cavity size and causes the murmur intensity to decrease
(1LR 9 for passive leg elevation). The absence of this characteristic response de-
creases the probability of HCM (LR 0.1). Although the greatest risk of sudden death
from HCM occurs in patients younger than 30 years, the average age at diagnosis of
the condition is increasing (currently at over 50 years).9 This increasing age likely re-
flects increased provider awareness and greater use of sensitive imaging modalities.
Some of the maneuvers described earlier may be more challenging to conduct in
physically limited or frail patients, but the Valsalva maneuver can usually be performed
regardless of the patient’s functional status.
Proper technique in performing maneuvers such as the Valsalva maneuver is key to
eliciting the findings for which you can apply likelihood ratios to aid clinical decisions.
The Valsalva maneuver involves expiration against a closed airway for at least 20 sec-
onds. As described by Valsalva, this was accomplished by breathing against a

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 Approach to the Patient with a Murmur 553

pinched nose and closed mouth. However, this approach can increase pressure in the
Eustachian tubes, causing discomfort. Alternatively, breathing out against a closed
glottis is a modified technique that may be more tolerable to patients. Patients should
be instructed to strain their abdominal muscles as if to rapidly breath out, but to close
their mouth and their airway in the back of their throat. To assess whether Valsalva is
being performed correctly, the clinician should observe for distended neck veins or
facial flushing, and palpate the patient’s contracted abdominal muscles. The examiner
should listen for a change in the murmur after a 20-second Valsalva strain.

Functional or Innocent Murmurs

Systolic murmurs may be present but without associated valvular pathology by echo-
cardiography. Such murmurs, termed “functional” or “innocent” murmurs based on
lack of structural heart disease, are quite common, although their prevalence varies
with age. In young adults, the vast majority of systolic murmurs are functional.
Although the peak incidence of functional murmurs is around age 3 to 4 years, studies
suggest that 86% to 100% of younger adults with a systolic murmur will have a normal
echocardiogram. Echocardiograms of elderly patients with systolic murmurs are often
normal, although the percentage ranges widely (from 44% to 100%, depending on the
study).
Functional murmurs tend to be of lower intensity (usually 2/6 or lower on the Levine
grading scale), in early systole or midsystole, and are frequently loudest near the left

Auscultation

1. Tim ing in cardiac cycle

Systolic Diastolic
• Early systolic (distinct S2) • Early diastolic (may obscure S2)
• Mid-systolic (distinct S1 and S2) • Mid-diastolic (often after opening snap)
• Late systolic (distinct S1) • Late diastolic (pre-systole)
• Holosystolic (indistinct S1 and S2)

2. M urm ur Intensity
U sing 6 levels of Levine grading

3. Nature of sounds, e.g. onom atopoeia

• High pitched: SH H H H or PH EW EW EW
• Low pitched rumbling: RRRR
• Mid-systolic click: k
• Opening snap: rup

4. Location on chest wall

Relative to third left parasternal space and
apical/base patterns

Do these collectively reveal a

“Characteristic M urm ur?”

Characteristic Systolic M urmurs Characteristic Diastolic Murmurs

Tricuspid Regurgitation Pulmonic Regurgitation

Aortic Stenosis LubSHSHSH SHSDub in Diastolic decrescendo murmur
Lub GRRRRR Dub in left lower sternal pattern in 2nd intercostal space at left
broad apical-base or + LR 14.6 upper sternal border
+ LR 17.4
small apical base pattern
+ LR 5.9
- LR 0.1 + +
Mitral Regurgitation
LubSH SHSH SHDub in broad
Aortic Regurgitation
apical pattern
Early Diastolic high-frequency
+ LR 5.4
decrescendo murmur along
left sternal border
Mitral Valve Prolapse Lub… PEW W w w
Lub….kSHSH SHDub with + LR 9.9
mid systolic click + LR 8.2 if Grade 3 or louder
+ LR 12.1 for moderate to severe AR
- LR 0.1 if absent for
moderate to severe AR

Fig. 3. Cardiac examination of the patient with a murmur.

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554 Landefeld et al

upper sternal border. Functional murmurs are particularly common in children, and pe-
diatricians have described the “7 S’s” as key findings suggestive of a functional
murmur: sensitive (the murmur changes in intensity with bodily position or respiration),
short duration (not holosystolic), single (no clicks or gallops), small (the location is
limited or nonradiating), soft (low volume), sweet (not harsh or coarse), and systolic.10
However, because other pathologic murmurs can also have these characteristics,
functional murmurs are defined by the absence of other abnormal findings. This in-
cludes normal jugular veins, normal apical impulse, normal pulses, no cardiopulmo-
nary symptoms attributable to a pathologic murmur, and a decrease in intensity of
the murmur with standing or the Valsalva maneuver.
When a patient has an examination consistent with a functional murmur, the likeli-
hood ratio of the patient having a normal echocardiogram is 4.7. Although not partic-
ularly compelling compared with other likelihood ratios discussed in this article,
depending on the pretest probability for valvular disease, a clinician could reasonably
defer echocardiography in such a patient in accordance with principles of high-value
care. It is important to note, however, that functional murmurs may be associated with
other high cardiac output disease states (anemia, thyrotoxicosis) that may not present
with echocardiographic abnormalities, but may still merit evaluation and treatment.
Putting It Together
After a comprehensive cardiac examination, the clinician can integrate findings to
arrive at a differential diagnosis for the murmur in question. This may include the
particular valve involved, the direction of flow, and the severity of disease. The flow
chart in Fig. 3 demonstrates one such approach to arriving at likelihood ratios based
on these clinical examination results.

CLINICS CARE POINTS

A systematic approach to the cardiac examination can help determine the cause of a murmur.

Auscultation forms the crux of the physical examination for patients with murmurs;
visualization, palpation, and special maneuvers are useful adjuncts.

The physical examination is most useful for systolic murmurs, although certain findings
strongly suggest aortic regurgitation as the cause of a diastolic murmur.

Findings with strong likelihood ratios (1LR > 5 or LR < 0.2) should be applied to the pretest
probability to ascertain a post-test probability to inform further evaluation.

SUMMARY

In this article, we presented an exam-based approach to narrowing the differential di-

agnoses for systolic and diastolic murmurs. The systematic examination of the patient,
considering timing, intensity, onomatopoeia, and location of the murmur, as well as
visualization, palpation, and special maneuvers, can meaningfully impact the clini-
cian’s interpretation of a murmur. Applying likelihood ratios for these findings to the
pretest or prior probability of disease allows a prudent, timely, and thoughtful addi-
tional diagnostic workup and, in some instances, therapeutic intervention.

DISCLOSURE

The authors have nothing to disclose.

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 Approach to the Patient with a Murmur 555

SUPPLEMENTARY DATA

Supplementary data related to this article can be found online at https://doi.org/10.

1016/j.mcna.2021.12.011.

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