Identification of flow murmur |
A systolic ejection murmur (SEM) begins after S1, terminates before A2 and/or P2-A2, is clearly heard over the cardiac apex, and is usually crescendo-decrescendo configuration. |
Useful maneuvers to differentiate from regurgitant murmur: |
Hand grip usually decreases the intensity of the ejection murmur |
Amyl nitrite usually increases the intensity of the ejection murmur |
Types of flow murmurs without significant obstruction (all have normal carotid pulse) |
Increased flow across the aortic valve |
Aortic regurgitation: aortic diastolic murmur and other features of aortic regurgitation |
Hypermetabolic state: hyperdynamic cardiac impulse |
Aortic sclerosis |
Elderly patients |
Short and soft SEM |
Normal S1 and S2 |
Normal cardiac impulse |
"Grunting" quality of the murmur may be present. |
Uncomplicated bicuspid aortic valve |
Short and soft SEM |
Normal S1 and S2 |
Aortic ejection sound in the absence of aortic aneurysm, hypertension |
Short, early aortic diastolic murmur may be present. |
Normal cardiac impulse |
Atrial septal defect |
Short and soft SEM |
Wide and fixed splitting of S2 |
Wide splitting of S1; tricuspid opening snap; mid-diastolic rumble over the lower left sternal border may be present. |
Hyperdynamic left parasternal impulse |
Suspected idiopathic dilatation of the pulmonary artery |
Short and soft SEM |
S1 normal; S2 may be widely split; normal inspiratory increase in A2-P2 interval |
Pulmonary ejection sound |
Short, early pulmonary diastolic murmur may be present. |
Normal cardiac impulse |
Innocent murmur |
Short and soft SEM |
Normal S1 and S2 |
Normal cardiac impulse |
No evidence for any hemodynamic abnormality |