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Physiologic and pharmacologic maneuvers in the differential diagnosis of heart murmurs and sounds

Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Section Editor
Catherine M Otto, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC


Cardiac auscultation is one of the most useful investigative tools to detect alterations in cardiovascular anatomy and physiology. Physiologic maneuvers during auscultation (dynamic auscultation) may sufficiently alter the systemic hemodynamics to change the character, behavior, and intensity of heart sounds and murmurs, thereby improving the diagnostic accuracy of the physical examination (figure 1).

The most common maneuvers used during auscultation will be reviewed here (table 1). Concerns about the use of these maneuvers are that they may be difficult to interpret and may not be reproducible, particularly when performed by nonexperts, and their diagnostic utility has rarely been validated.

In current clinical practice, echocardiography is the standard for establishing the cause of a murmur. As noted in major society guidelines, an echocardiogram is indicated for diagnosis and evaluation of patients with known or suspected valve disease [1,2]. Echocardiography is not needed in asymptomatic patients with a benign flow murmur but is appropriate in patients with cardiac symptoms and any cardiac murmur and 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.

A full discussion of cardiac auscultation is presented separately. (See "Auscultation of cardiac murmurs in adults" and "Auscultation of heart sounds".)


Venous return to the right ventricle increases during normal inspiration resulting in an increase in its volume. In contrast, inspiration causes a decrease in venous return to the left ventricle and a reduction in its volume. These changes in venous return can alter the intensity of murmurs and heart sounds, primarily those that originate from the right side of the heart. (See "Auscultation of cardiac murmurs in adults" and "Auscultation of heart sounds".)

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Literature review current through: Sep 2017. | This topic last updated: Aug 24, 2017.
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