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Murmurs: Do you hear what I hear? When does it matter?. Nikhil K Chanani MD. Audience Poll. You are examining a 5 day old and find either: A) a 2/6 systolic murmur in an otherwise asymptomatic child B) a saturation of 89% in an otherwise asymptomatic child with no murmurs

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audience poll
Audience Poll
  • You are examining a 5 day old and find either:
    • A) a 2/6 systolic murmur in an otherwise asymptomatic child
    • B) a saturation of 89% in an otherwise asymptomatic child with no murmurs
    • C) poor pulses and mottled skin in a distressed infant with no murmurs
  • Which is least likely to have hemodynamically significant cardiac disease?
  • Up to 2/3 of children will have a murmur heard at some point in their childhood
  • Incidence of congenital heart disease is 8/1000
    • This means less than 2% of all murmurs are associated with congenital heart disease
  • As many as 80% of heart lesions are missed during initial neonatal exam*

* Emslie et al, Examination for cardiac malformations at six weeks of age. Arch. Dis. Child Fetal Neonatal ed. 1999; 80: F46.


A cardiac murmur is the sound of turbulent blood flow. A murmur does not necessarily indicate heart disease.

  • The clinician should emphasize this fact to the patient’s family.
  • A murmur is merely one part of a complete cardiovascular assessment.
    • History, vital signs, physical diagnosis, diagnostic testing
  • S1: closing of mitral & tricuspid valves
    • Normally single
    • heard best at apex or LLSB
    • Split S1 uncommon
      • Conduction delay: RBBB, LBBB
      • Valvular problem, ex: Ebstein’s
  • S2: closing of aortic & pulmonary valves
    • Physiologic splitting, varies with respiration
    • Heard best at LUSB
    • Physiologic demo
  • Abnormal S2
    • Widely split
    • Narrowly split
    • Single S2
    • Paradoxically split
    • Abnormal intensity
  • S3: rapid ventricular filling
    • Occurs soon after S2
    • Best heard at the apex or LLSB
    • May be normal in older children (not infants!)
    • Dilated ventricles
      • large shunts
      • dilated cardiomyopathy
      • myocarditis
  • S4: increased atrial pressure against stiff ventricle
    • Best heard at the apex
    • Never normal in children
    • Immediately prior to S1
    • Indicates poor ventricular compliance
      • HTN,
      • decreased ventricular


      • HCM
  • Clicks
    • Ejection click
      • Sounds like split S1, but heard at base
      • Dysplastic semilunar valve, dilated great artery
    • Midsystolic click
      • Heard at apex in MVP
  • Opening snap
    • Early diastolic, at

apex in mitral stenosis

  • Friction Rub
    • Pericarditis, effusion
physical exam murmurs
Physical exam - Murmurs

Sound created by turbulant

bloodflow through heart and

great vessels









  • Systolic Murmurs
    • Ejection
      • interval b/w S1 & murmur
      • crescendo-decrescendo
      • innocent or pathologic
    • Regurgitant/holosystolic
      • begins with S1
      • always pathologic
        • VSD, TR, MR
  • Diastolic Murmurs: between S2 & S1
    • Early: decrescendo
      • AI and PI
    • Mid/Late: low pitched, may start with S3
      • AV valve stenosis or increased flow
  • Continuous Murmurs: continue through S2
    • AP or AV connections: PDA, AVM, shunts
    • Combination systolic and diastolic
      • To-fro murmurs: AS and AI, PS and PI
    • Venous hum
grading murmurs
Grading Murmurs
  • Without thrill
    • Grade 1: very faint, barely audible
    • Grade 2: soft but easily heard
    • Grade 3: intermediate
grading murmurs cont
Grading Murmurs (cont.)
  • With thrill
    • Grade 4: loud, with a palpable vibration (thrill)
    • Grade 5: very loud, audible with edge of stethoscope on chest
    • Grade 6: very loud, audible with stethoscope just off chest
      • Diastolic murmurs are graded from 1-4
systolic murmurs
Systolic Murmurs
  • A systolic murmur generally represents
    • forward flow through the aortic or pulmonary valve
    • backward flow through the mitral or tricuspid valve
    • flow through the VSD
    • innocent (Still’s) murmur through the LV cavity
    • innocent flow murmurs through aortic and pulmonary valves with anemia, bradycardia, fever or hyperthyroidism
diastolic murmurs
Diastolic Murmurs
  • A diastolic murmur generally represents
    • forward flow through the mitral or tricuspid valve
    • backward flow through the aortic or pulmonary valve
    • innocent flow murmurs across mitral or tricuspid valve with anemia, bradycardia, fever, or hyperthyroidism
continuous murmurs
Continuous Murmurs
  • Venous hums
  • Patent ductus arteriosus
  • Collateral vessels
  • Coronary arterial fistulae or any arteriovenous fistula
  • Surgical systemic arterial to pulmonary arterial shunts
  • Aorticopulmonary windows
innocent murmurs
Innocent Murmurs

The following is a list of innocent murmurs and their characteristics in children and adolescents:

innocent murmurs cont
Innocent Murmurs (cont.)
  • Still’s murmur
    • Most common, vibratory, musical in nature; LLSB-apex; louder supine; murmur decreases with Valsalva strain; R/O VSD, MR, sub-AS
innocent murmurs cont1
Innocent Murmurs (cont.)
  • Supraclavicular arterial bruit
    • Above clavicles; murmur is low intensity and in early systole; possible associated thrill; R/O AS, PS, VSD, coarctation
innocent murmurs cont2
Innocent Murmurs (cont.)
  • Venous hum
    • Continuous; gravity-dependent; due to turbulent subclavian, innominate vein and SVC flow; murmur disappears when patient supine; R/O anemia, hyperthyroidism, cerebral AVM
innocent murmurs cont3
Innocent Murmurs (cont.)
  • Peripheral pulmonary stenosis (newborn)
    • Base, axillae, back bilaterally; relative PA hypoplasia and bracing; murmur persists until three to six months; R/O ASD, PDA, TOF
innocent murmurs cont4
Innocent Murmurs (cont.)
  • Physiologic pulmonary ejection murmur
    • Slightly harsh; second-third LICS; louder supine; no click; R/O ASD, valvular PS
pathologic murmurs
Pathologic Murmurs

For any of the following pathologic murmurs, referral to a pediatric cardiologist is indicated:

pathologic murmurs cont
Pathologic Murmurs (cont.)
  • Loud systolic murmur (> grade 4) outflow tract obstruction; AV valve insufficiency; VSD
pathologic murmurs cont1
Pathologic Murmurs (cont.)
  • Mid to late systolic murmur: MVP or TVP with insufficiency
pathologic murmurs cont2
Pathologic Murmurs (cont.)
  • Pansystolic murmur: VSD, MR, TR
pathologic murmurs cont3
Pathologic Murmurs (cont.)
  • Continuous murmur other than venous hum: blowing, crescendo-decrescendo (PDA, collateral, shunt)
pathologic murmurs cont4
Pathologic Murmurs (cont.)
  • Diastolic murmur: semilunar valve insufficiency; AV valve stenosis

(fixed vs. relative)

pathologic murmurs cont5
Pathologic Murmurs (cont.)
  • Associated CV abnormalities; pulses, perfusion; precordial impulse; heart sounds (S1-S4); clicks, blood pressure; symptoms; lab studies
pathologic murmurs cont6
Pathologic Murmurs (cont.)
  • Loud murmur in delivery room/nursery: outflow tract stenosis; AV valve insufficiency
  • Every baby has a large PDA after delivery. This should not, however, cause an audible murmur.

“Listen in all areas for heart murmurs.

First in systole and then in diastole. Concentrate on dissection.

After much practice, this should become automatic.”

From “Listening to Heart Murmurs in Infants and Children”

by Jerome Liebman, MD