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Auscultation of cardiac murmurs in adults

Author
Theo E Meyer, MD, PhD
Section Editor
William A Zoghbi, MD, FASE, FAHA, MACC
Deputy Editor
Susan B Yeon, MD, JD, FACC

INTRODUCTION

Cardiac auscultation is one of the most useful diagnostic tools that a clinician can use at the bedside to detect alterations in cardiovascular anatomy and physiology. Significant valvular heart disease is often first diagnosed based upon the finding of a murmur. Auscultation has a reported sensitivity of 70 percent and a specificity of 98 percent for detection of valvular heart disease [1]. However, the sensitivity and specificity vary substantially with the expertise of the examiner. The expertise and proficiency in auscultation has been waning in the modern era, which has led to a greater dependence on more expensive imaging techniques [2-5].

In clinical practice, echocardiography is the standard for establishing the cause of a murmur. As noted in major society guidelines, an echocardiogram is indicated for the diagnosis and evaluation of patients with known or suspected valve disease [2,3]. Echocardiography is not needed in asymptomatic patients with a benign flow murmur but is appropriate in patients with cardiac symptoms and any cardiac murmur. It is also indicated in asymptomatic patients with a diastolic murmur, a grade 3 or greater systolic murmur, or a systolic murmur in association with other abnormal exam findings, such as a systolic click or reduced carotid upstroke. The optimal management of valvular heart disease is based upon early diagnosis, before the patient has become symptomatic.

This topic will review the auscultation of cardiac murmurs in adults, including the maneuvers (eg, respiration, Valsalva maneuver) that can be used to differentiate one murmur from another. These maneuvers, as well as auscultation of other heart sounds, are discussed in detail separately. (See "Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds" and "Auscultation of heart sounds".)

Cardiac murmurs in infants and children are discussed separately. (See "Approach to the infant or child with a cardiac murmur" and "Overview of common causes of cardiac murmurs in infants and children".)

ORIGIN OF MURMURS

Cardiac murmurs are the direct result of blood flow turbulence. The amount of turbulence and consequently the intensity of a cardiac murmur depend on the size of the orifice or vessel through which the blood flows; the pressure difference or gradient across the narrowing; and the blood flow or volume across the site [6,7]. Murmurs are generally the loudest near the point of origin since sound radiates away from its source, and the intensity diminishes with the square of the distance. Other factors influence this relationship including the transmission characteristics of the tissues (eg, fat and air), the distance from the location of auscultation to the origin of the murmur (eg, truncal obesity, emphysema), and the course of flow.

                                                              

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Literature review current through: Jul 2017. | This topic last updated: Dec 22, 2016.
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