Location of Heart Murmurs

Senile Aortic Stenosis (AS)

• Begins at 70 years old, more prominent at 80 years old and above
• Causes calcification of the aortic valve, leading to stenosis
• Atherosclerotic aorta

Accentuated P2

• Caused by increased pressure against the closed pulmonic valve
• Seen in pulmonary hypertension, ASD, and truncus arteriosus

Diminished P2

• Caused by diminished pulmonary artery pressure, resulting in reduced tension on the pulmonary valve
• Seen in pulmonic stenosis (PS)

Widened Inspiratory Splitting of S2

• Caused by delayed tensing of the pulmonic valve or early tensing of the aortic valve
• Seen in Right Bundle Branch Block, Atrial Septal Defect, and Pulmonary Stenosis

Reverse or Paradoxical Splitting of S2

• Caused by delay of LV ejection, causing A2 to coincide with or occur after P2
• Seen in hypertrophic cardiomyopathy, aortic stenosis, and left bundle branch block

S3 (Ventricular or Protodiastolic Gallop)

• Occurs during the transition from rapid filling to slow filling phase
• Best heard at the apex when the patient is lying on their left side and in expiration
• Accentuated by exercise, abdominal pressure, and flexing the knees on the abdomen
• Normal in children and young adults, abnormally seen in systolic dysfunction, fever, anemia, and hyperthyroidism

Location of Heart Murmurs

• Aortic valve: auscultated at the right 2nd ICS, radiates to the neck
• Pulmonic valve: auscultated at the left 2nd ICS
• Tricuspid valve: auscultated at the parasternal border
• Mitral valve: auscultated further away (apex), radiates to the anterior axillary or at the back
• Systolic: TR and MR vs Diastolic: AR and PR

Aortic Stenosis

• Diminished S1: when AV valves are closely approximated at the onset of systole
• Varied Intensity of S1: due to asynchronous AV contraction and variable diastolic filling
• Wide Splitting of S1: seen in RBBB due to delay in ventricular contraction

S2

• Accentuated Aortic compartment of S2: caused by increased pressure against the closed AV valve
• Diminished A2: seen when the valve is rigid and immobile

Intensity of Murmurs

• Grade 1: very soft, heard only with great effort
• Grade 2: easily heard, but not particularly loud
• Grade 3: loud, but not accompanied by a palpable thrill
• Grade 4: very loud, accompanied by a thrill
• Grade 5: loud enough to be heard only with the edge of the stethoscope touching the chest
• Grade 6: loud enough to be heard with the stethoscope slightly off the chest