Cardiovascular

Cardiac murmurs: bedside maneuvers and referral indications

Clinical Overview and When to Suspect Pathologic Murmurs

— Up to 70% of children have an innocent murmur at some point; <1% reflect structural disease

— In adults >65, prevalence of aortic sclerosis approaches 25%; true aortic stenosis (AS) ~2–4%

— Mitral regurgitation (MR) is the most common valvular lesion overall in adults

— Any diastolic or continuous murmur → always pathologic

— Systolic murmur with intensity ≥3/6, harsh quality, holosystolic timing, or radiation

— Murmur accompanied by symptoms: syncope, exertional dyspnea, chest pain, palpitations, edema

— Associated abnormal findings: thrill, abnormal S2, S3/S4, displaced PMI, abnormal pulses

— New murmur in a febrile patient (consider endocarditis) or post-MI patient (papillary muscle rupture, VSD)

— Rheumatic fever history, IV drug use, indwelling catheters, congenital heart disease, prior radiation, connective tissue disease (Marfan, Ehlers-Danlos), bicuspid aortic valve family history

Definition: A cardiac murmur is turbulent blood flow audible on auscultation; the family physician's task is distinguishing innocent/functional from pathologic murmurs and triaging accordingly.

Epidemiology in primary care:

When to suspect pathology in the ambulatory setting:

Risk factors prompting closer evaluation:

Step 3 management: In an asymptomatic adult with a soft (1–2/6) midsystolic murmur, normal S2, no radiation, and no other findings, no further workup is required. Document and reassess at routine visits. Order TTE only if any "red flag" feature is present.

Board pearl: The single most useful initial bedside question is "Is this murmur systolic or diastolic?" — all diastolic murmurs warrant echocardiography regardless of intensity. The second is "Are there symptoms?" — symptomatic murmurs always need imaging, even if soft.

Approach murmurs as a screening + triage problem: identify innocent murmurs to avoid overtesting; identify pathologic murmurs early enough to refer before irreversible ventricular remodeling.

Presentation Patterns and Key History

— Asymptomatic, soft (≤2/6), midsystolic, vibratory or musical, no radiation

— Louder supine, softer upright; varies with respiration and position

— Common contexts: pregnancy, anemia, fever, hyperthyroidism, athletes (high-output states)

— Aortic stenosis (SAD triad): Syncope (especially exertional), Angina, Dyspnea on exertion → median survival without intervention 5/3/2 years respectively

— Mitral stenosis: dyspnea, hemoptysis, atrial fibrillation, embolic stroke; often a woman in her 30s–50s with prior rheumatic disease or immigrant history

— Mitral regurgitation: fatigue, exertional dyspnea, palpitations; acute MR (papillary rupture, endocarditis) → flash pulmonary edema

— Aortic regurgitation: chronic AR often asymptomatic for years, then exertional dyspnea, orthopnea, "pounding heart"; acute AR (dissection, endocarditis) → cardiogenic shock

— HOCM: young athlete with exertional syncope, family history of sudden cardiac death

— MVP: atypical chest pain, palpitations, anxiety; thin young woman

— Rheumatic fever, strep throat with prolonged illness in childhood

— IV drug use, recent dental/GU/GI procedures, indwelling lines

— Connective tissue disease, chest radiation, prior cardiac surgery

— Functional status (NYHA class), exercise tolerance trend

Innocent (functional) murmur clues:

Symptom clusters that point to specific lesions:

Pediatric red flags: failure to thrive, cyanosis, recurrent respiratory infections, feeding difficulty, family history of congenital heart disease or sudden death <50

Pregnancy context: physiologic systolic ejection murmur in 90% of pregnancies due to ↑ plasma volume; diastolic murmurs are never physiologic and warrant echo

Targeted history checklist:

Key distinction: Exertional syncope = AS or HOCM until proven otherwise; vasovagal syncope occurs with prolonged standing, heat, or emotional triggers and lacks an exertional trigger.

Board pearl: A change in functional class (e.g., previously asymptomatic AS patient now dyspneic climbing one flight) is itself an indication for echo and surgical referral — symptoms drive timing of intervention.

Physical Exam Findings and Bedside Maneuvers

— Crescendo-decrescendo systolic: AS, HOCM, pulmonic stenosis, flow murmur

— Holosystolic (plateau): MR, TR, VSD

— Early diastolic decrescendo: AR, PR (Graham Steell)

— Mid-diastolic rumble with opening snap: MS

— Continuous "machinery": PDA, AV fistula

— Valsalva (strain phase) and standing: ↓ preload → louder HOCM and MVP; softer almost everything else

— Squatting / passive leg raise: ↑ preload and afterload → softer HOCM and MVP, louder AS, MR, AR

— Handgrip (sustained isometric): ↑ afterload → louder MR, AR, VSD; softer AS and HOCM

— Inspiration (Carvallo sign): ↑ right-sided return → louder right-sided murmurs (TR, PR, PS, TS)

— Expiration / left lateral decubitus: accentuates left-sided murmurs, especially MS rumble at apex

— Sitting forward with held expiration: accentuates AR decrescendo

— Amyl nitrite (rarely used now): ↓ afterload → louder AS/HOCM, softer MR/AR

— AS: pulsus parvus et tardus, soft/absent S2, S4

— AR: wide pulse pressure, water-hammer pulse (Corrigan), Quincke, Duroziez, de Musset, Hill sign

— MS: loud S1, opening snap (shorter S2–OS interval = more severe), malar flush

— MR: displaced PMI, S3, soft S1

— HOCM: bifid carotid pulse, S4, dynamic LVOT obstruction

Systematic auscultation: Use both diaphragm (high-frequency: AR, MR, AS) and bell (low-frequency: MS rumble, S3, S4) at all four areas — right 2nd ICS (aortic), left 2nd ICS (pulmonic), left lower sternal border (tricuspid), apex (mitral).

Timing and shape:

Bedside maneuvers — the high-yield core:

Associated findings:

Board pearl: HOCM and MVP are the only two murmurs that get LOUDER with Valsalva and standing — this single fact resolves most exam vignettes.

Key distinction: Aortic sclerosis has normal S2 and normal carotid upstroke and is benign; aortic stenosis has soft/absent A2 and delayed carotid upstroke → echo indicated.

Diagnostic Workup — Initial Office Evaluation

— Diastolic murmur (any intensity)

— Continuous murmur

— Holosystolic murmur

— Late systolic murmur

— Systolic murmur grade ≥3/6

— Any systolic murmur with associated symptoms, abnormal ECG, abnormal CXR, or other exam abnormalities (thrill, abnormal S2, click)

— ECG: LVH (AS, AR, HOCM), LAE/RVH (MS), p-mitrale, conduction disease; pre-excitation if Ebstein

— CXR: cardiomegaly, chamber enlargement, pulmonary edema, valve calcification, dilated aorta (AR), "double density" of LAE in MS, Kerley B lines

— CBC: anemia as a high-output cause of flow murmur

— TSH: hyperthyroidism causing flow murmur or precipitating AF in MS

— BNP/NT-proBNP: trend marker in surveillance, particularly asymptomatic severe AS or AR considering intervention

— Routine TTE for a clearly innocent murmur in an asymptomatic child or adult

— Stress testing as a first study for an undefined murmur

— Cardiac MRI or CT as initial study (these are second-line)

Step 1: Decide if any imaging is needed at all. The 2020 ACC/AHA Valvular Heart Disease guidelines support TTE for any of the following:

Initial workup adjuncts (low cost, often first):

What NOT to order:

Step 3 management: A 55-year-old woman with a soft 2/6 midsystolic murmur, normal S2, normal ECG, no symptoms → reassure, no echo, recheck at next annual visit. A 55-year-old with the same murmur but a soft S2 and delayed carotid upstroke → order TTE this week.

CCS pearl: When ordering the TTE in CCS, also advance the clock to obtain the result and document a follow-up appointment to review it; do not leave the patient without scheduled disposition.

Board pearl: All diastolic murmurs and any murmur ≥3/6 deserve echocardiography, full stop — this is the single most testable triage rule.

Diagnostic Workup — Echocardiography and Advanced Imaging

— Quantifies valve area, mean gradient, regurgitant volume/fraction, LV size and EF, pulmonary pressures, chamber dimensions

— Severe AS: valve area <1.0 cm², mean gradient ≥40 mmHg, peak velocity ≥4 m/s

— Severe MR: regurgitant volume ≥60 mL, regurgitant fraction ≥50%, ERO ≥0.40 cm²

— Severe AR: vena contracta >0.6 cm, regurgitant fraction ≥50%

— Severe MS: valve area ≤1.5 cm² (very severe ≤1.0)

— Asymptomatic severe AS with equivocal symptoms → exercise stress to unmask symptoms or BP drop

— Low-flow, low-gradient AS → dobutamine stress echo to distinguish true severe AS from pseudosevere

— Asymptomatic severe MR with preserved EF → exercise echo for pulmonary pressure response

— Coronary angiography before valve surgery in men ≥40, postmenopausal women, or anyone with CAD risk factors/symptoms

— Direct hemodynamics when noninvasive data are discordant with clinical picture

Transthoracic echocardiogram (TTE): First-line confirmatory test.

Transesophageal echo (TEE): Use when TTE is technically limited, when endocarditis is suspected (sensitivity ~90% vs ~60% TTE), to evaluate prosthetic valves, or for periprocedural planning (TAVR, MitraClip, LAA closure).

Stress echocardiography:

Cardiac MRI: Quantifies regurgitation when TTE is discordant; characterizes HOCM (late gadolinium enhancement predicts SCD risk); evaluates aortic root in bicuspid valve or Marfan.

Cardiac CT: Aortic root and ascending aorta sizing, coronary anatomy before valve surgery in low-risk patients, TAVR planning.

Cardiac catheterization:

Key distinction: Aortic sclerosis (peak velocity <2.5 m/s, normal valve area, focal leaflet thickening) does NOT require serial echo. Mild AS (velocity 2.0–2.9 m/s) → echo every 3–5 years; moderate every 1–2 years; severe asymptomatic every 6–12 months.

Board pearl: In low-flow, low-gradient AS with reduced EF, never accept the resting numbers — order dobutamine stress echo to identify pseudosevere AS (gradient rises with flow but valve area opens) versus true severe AS (valve area stays fixed).

Risk Stratification and Referral Logic

— Tier 1 — Reassure and observe: Innocent murmur, asymptomatic aortic sclerosis, trivial/mild regurgitation in asymptomatic patient

— Tier 2 — Order TTE, follow as outpatient, refer to cardiology if abnormal: Any systolic murmur ≥3/6, any new murmur, any murmur with mild symptoms or abnormal ECG

— Tier 3 — Urgent/emergent referral: Diastolic murmur, syncope with exertion, acute severe regurgitation (pulmonary edema with new murmur), suspected endocarditis, suspected aortic dissection

— A: at risk (bicuspid valve, rheumatic exposure)

— B: progressive (mild–moderate, asymptomatic)

— C: asymptomatic severe (C1 normal LV, C2 LV dysfunction)

— D: symptomatic severe → intervention indicated

— Any stage C or D lesion

— Severe asymptomatic lesion approaching intervention thresholds (e.g., AS with peak velocity ≥5 m/s, AR with LVEF <55% or LVESD >50 mm, MR with LVEF 30–60% or LVESD ≥40 mm)

— Bicuspid aortic valve with aortic root ≥4.0 cm (serial surveillance and surgical consideration at 5.0–5.5 cm)

— Pregnancy planning with known valvular disease

— Pre-noncardiac surgery clearance with severe or symptomatic valvular disease

Three-tier triage from primary care:

Stages of valvular heart disease (ACC/AHA, A→D):

Indications for cardiology referral:

Step 3 management: A 70-year-old man with newly diagnosed severe AS (valve area 0.8 cm²) and exertional dyspnea → refer to cardiology and cardiothoracic surgery for valve intervention (TAVR vs SAVR); do NOT start vasodilators, do NOT delay for "medical optimization."

Board pearl: Symptoms in severe AS, AR, or MR are a Class I indication for intervention regardless of LV function — symptoms are the trigger that flips the survival curve. Conversely, asymptomatic severe disease requires careful EF and chamber-size thresholds before intervention.

Pharmacotherapy in Valvular Heart Disease

— No medical therapy alters AS progression — statins do NOT slow calcific AS

— Treat coexisting HTN cautiously with ACEi/ARB (avoid hypotension)

— Avoid nitrates and high-dose vasodilators in severe AS — preload-dependent → syncope

— Treat coexisting CAD, AF, HF per standard guidelines

— Vasodilators (ACEi, ARB, dihydropyridine CCB, hydralazine) only if symptomatic and not surgical candidates, or if hypertensive

— Routine vasodilator therapy in asymptomatic AR with normal LV is not recommended

— Primary (degenerative) MR: no evidence vasodilators help asymptomatic patients; treat HTN normally

— Secondary (functional) MR: treat underlying HF aggressively with GDMT (ACEi/ARB/ARNI, beta-blocker, MRA, SGLT2i) and CRT if eligible — this may reduce MR

— Rate control for AF: beta-blocker or non-DHP CCB first-line

— Anticoagulation with warfarin (NOT DOACs) for AF with moderate–severe MS or mechanical valve

— Diuretics for pulmonary congestion

— First-line: non-vasodilating beta-blocker (metoprolol, atenolol); second-line verapamil or disopyramide

— Avoid: ACEi/ARB, dihydropyridine CCBs, nitrates, diuretics (all worsen outflow gradient)

— Mavacamten (cardiac myosin inhibitor) for obstructive HOCM with persistent symptoms

General principle: Medical therapy in valvular disease is adjunctive, not curative. The definitive treatment for severe symptomatic valvular disease is mechanical correction (surgery or transcatheter).

Aortic stenosis:

Aortic regurgitation:

Mitral regurgitation:

Mitral stenosis:

HOCM:

Endocarditis prophylaxis (2021 AHA): Only for prosthetic valves, prior IE, unrepaired cyanotic CHD, or valvulopathy after transplant — and only for dental procedures involving gingival manipulation, or infected skin/respiratory tract procedures. Amoxicillin 2 g PO 30–60 min before.

Board pearl: No medical therapy delays AS or alters primary MR progression — recognize this to avoid the distractor answer of "start statin" or "start ACEi" in a severe AS vignette.

Procedural and Surgical Management

— Symptomatic severe AS (stage D)

— Asymptomatic severe AS with LVEF <50% (stage C2)

— Severe AS undergoing other cardiac surgery

— Class IIa: very severe asymptomatic AS (V ≥5 m/s), abnormal exercise test, rapid progression, BNP >3× normal

— Age <65 or life expectancy >20 years → SAVR

— Age 65–80 → shared decision, either reasonable

— Age >80 or high surgical risk → TAVR

— Bicuspid valve, severe aortopathy, or need for concomitant CABG → SAVR favored

— Symptomatic severe AR

— Asymptomatic severe AR with LVEF ≤55%

— Severe AR undergoing other cardiac surgery

— Aortic root ≥5.5 cm (≥5.0 cm in bicuspid with risk features, ≥4.5 cm in Marfan)

— Primary severe MR: repair preferred over replacement; intervene when symptomatic OR asymptomatic with LVEF 30–60% or LVESD ≥40 mm, or new AF/PHTN

— Transcatheter edge-to-edge repair (TEER, MitraClip): primary MR with prohibitive surgical risk; secondary MR persistent despite GDMT with LVEF 20–50%

— Percutaneous mitral balloon valvuloplasty (PMBV): rheumatic MS with favorable valve morphology (Wilkins score ≤8), no LA thrombus, no moderate MR

— Valve replacement when valvuloplasty contraindicated

Aortic stenosis intervention thresholds (Class I):

TAVR vs SAVR (2020 ACC/AHA):

Aortic regurgitation surgery (Class I):

Mitral regurgitation:

Mitral stenosis:

HOCM: Septal reduction (surgical myectomy preferred, alcohol septal ablation if poor surgical candidate) for drug-refractory symptoms with LVOT gradient ≥50 mmHg

CCS pearl: Before any valve intervention, order coronary angiography in any patient with CAD risk factors or age threshold (men ≥40, postmenopausal women), and dental clearance to reduce postoperative endocarditis risk.

Board pearl: In severe symptomatic AS, the timing of referral matters more than the choice of TAVR vs SAVR — once symptoms develop, survival drops sharply without intervention; do not delay for "trials of medical therapy."

Special Populations — Elderly, Renal, and Hepatic Considerations

— Calcific AS is the dominant valvular lesion >70; symptoms may be attributed to "deconditioning" or "aging" — actively probe exertional capacity

— TAVR has dramatically expanded options for octogenarians and surgical-risk patients; frailty assessment (gait speed, grip strength, Katz ADLs) informs decision

— Polypharmacy: avoid nitrates and aggressive antihypertensives in severe AS — orthostatic syncope risk

— Aortic sclerosis is common and benign but independently associated with cardiovascular events — pursue ASCVD risk factor optimization even when valve itself needs no intervention

— Accelerated valve calcification; AS progresses faster in CKD and dialysis patients

— Contrast considerations for TAVR planning CT — hydration, minimize contrast volume, hold metformin around procedure

— Anticoagulation choice in AF + MS: warfarin remains preferred; in non-MS valvular AF, DOACs are acceptable per CKD stage (apixaban tolerates lower GFR)

— Affects warfarin dosing (INR targeting trickier), avoid hepatotoxic agents

— Cirrhotic cardiomyopathy may coexist with valvular disease; high-output state from AV shunting can produce flow murmurs

— Start beta-blockers low and titrate in elderly (e.g., metoprolol succinate 12.5–25 mg)

— Diuretics in MS: aggressive diuresis can drop preload and cardiac output — go gently

— Digoxin: reduce dose in CKD; level 0.5–0.9 ng/mL in HF

Elderly patients:

Chronic kidney disease:

Hepatic impairment:

Dosing pearls:

Step 3 management: An 84-year-old frail woman with severe symptomatic AS, STS score 9% → refer for TAVR evaluation rather than SAVR; coordinate with geriatrics for frailty optimization and goals-of-care discussion before procedure.

Board pearl: Frailty, not chronologic age, drives valve intervention decisions. A vigorous 85-year-old is a better candidate than a frail 70-year-old; use objective tools (gait speed <0.5 m/s predicts poor outcomes).

Key distinction: Aortic sclerosis → optimize ASCVD risk; aortic stenosis → echo surveillance plus consider intervention when criteria met.

Special Populations — Pregnancy and Pediatrics

— 30–50% ↑ plasma volume, ↑ CO, ↓ SVR → physiologic systolic ejection murmur in 90%, mammary souffle, venous hum

— Diastolic or continuous murmurs are never physiologic — order echo

— Severe MS (worst tolerated — fixed obstruction + tachycardia + volume load) → preconception PMBV ideal

— Severe AS, especially symptomatic

— Mechanical valves (anticoagulation dilemmas)

— Marfan with aortic root >4.0 cm, severe pulmonary HTN, bicuspid valve with root >5.0 cm

— Beta-blockers: metoprolol or labetalol preferred; avoid atenolol (IUGR)

— Anticoagulation in mechanical valves: warfarin most effective for valve thrombosis prevention but teratogenic in 1st trimester (especially >5 mg/day); options include LMWH throughout, LMWH 1st trimester then warfarin, or warfarin throughout — shared decision

— Avoid: ACEi, ARB, ARNI, MRAs, statins, mavacamten

— Mode of delivery: vaginal preferred for most; cesarean for aortic dissection risk, severe symptomatic AS, or warfarin near term

— Still's murmur: musical/vibratory, LLSB, ages 3–8, decreases with standing

— Pulmonary flow murmur: soft systolic at LUSB, common in adolescents

— Venous hum: continuous, infraclavicular, abolished by lying supine, turning head, or compressing jugular

— Carotid bruit: systolic, supraclavicular, normal heart

Pregnancy physiology and murmurs:

High-risk valvular lesions in pregnancy (mWHO class III–IV):

Pregnancy management:

Pediatric murmurs — common innocent types:

Pediatric red flags: holosystolic murmur, diastolic murmur, fixed split S2 (ASD), ejection click, cyanosis, FTT, abnormal pulses (radial-femoral delay = coarctation), syndromic features (Turner, Williams, Marfan, Down)

Step 3 management: A pregnant woman at 28 weeks with new soft 2/6 systolic murmur at LUSB, normal S2, asymptomatic → reassure, no echo needed. Same patient with a diastolic murmur → order TTE.

Board pearl: Mitral stenosis is the valvular lesion most likely to decompensate during pregnancy — heart rate rise shortens diastolic filling. Pre-pregnancy valvuloplasty for moderate–severe rheumatic MS is the right answer.

Complications and Adverse Outcomes

— Sudden cardiac death (1% per year in asymptomatic; rises sharply after symptom onset)

— Heart failure, AF, conduction disease (calcium extending to conduction system)

— Heyde syndrome: AS + acquired vWF deficiency + GI angiodysplasia bleeding

— Progressive LV dilation and dysfunction (often irreversible if intervention delayed past LVESD 50 mm or LVEF <55%)

— Acute AR (dissection, endocarditis) → cardiogenic shock, requires emergent surgery

— LA dilation → AF, thromboembolism

— Pulmonary hypertension, RV failure

— Acute MR (papillary muscle rupture post-MI, ruptured chordae, endocarditis) → flash pulmonary edema

— AF in 30–40% (LA enlargement); stroke risk markedly elevated → anticoagulation

— Pulmonary hypertension, RV failure, hemoptysis (ruptured bronchial veins), Ortner syndrome (hoarseness from recurrent laryngeal nerve compression by enlarged LA)

— Sudden cardiac death (SCD) — leading cause of death in young athletes; ICD for high-risk (prior arrest, sustained VT, family history of SCD, syncope, massive LVH >30 mm, LGE on MRI)

— AF (poorly tolerated due to loss of atrial kick), embolic stroke

— TAVR: paravalvular leak, stroke, complete heart block requiring pacemaker (~10–15%), vascular access complications

— SAVR: standard cardiac surgery risks; structural valve degeneration in bioprosthetic

— Mechanical valves: lifelong warfarin, thromboembolism, bleeding, hemolysis

Aortic stenosis:

Aortic regurgitation:

Mitral regurgitation:

Mitral stenosis:

HOCM:

Infective endocarditis: Any valvular lesion is a substrate; complications include valve destruction, abscess, embolic stroke, mycotic aneurysm, glomerulonephritis

Procedural complications:

CCS pearl: Post-TAVR patient with new bradycardia or syncope → order ECG and admit for telemetry / pacemaker eval — conduction disease can present days to weeks after procedure.

Board pearl: Heyde syndrome triad (severe AS + iron-deficiency anemia + GI bleed from angiodysplasia) often resolves after AVR — recognize on board vignettes featuring an elderly anemic patient with AS.

When to Escalate Care

— New murmur + acute pulmonary edema → suspect acute severe MR (papillary muscle rupture, chordal rupture, endocarditis) or acute severe AR (dissection, endocarditis) → IV diuretics, afterload reduction, urgent TTE/TEE, emergent cardiothoracic surgery consult

— New murmur + fever + risk factors (IVDU, indwelling line, prosthetic valve) → admit for blood cultures × 3, empiric antibiotics, TTE then TEE — IE workup

— New diastolic murmur + chest/back pain + BP differential → suspect aortic dissection with AR → CT angiography, urgent cardiothoracic surgery

— Exertional syncope in patient with known or suspected severe AS or HOCM → admit for telemetry, echo, expedited intervention

— Post-MI new harsh murmur (3–7 days out): VSD (holosystolic LLSB) vs papillary muscle rupture (apical MR with shock) → emergent echo, IABP/Impella, cardiothoracic surgery

— Newly diagnosed severe valvular disease, even if asymptomatic

— Symptomatic moderate disease with progression

— Pregnancy in patient with significant valvular disease

— Asymptomatic moderate disease for surveillance plan

— Bicuspid aortic valve, even with normal function (root surveillance)

— Mechanical valve patients for anticoagulation co-management

— Stable, asymptomatic, no red flags → outpatient TTE + clinic follow-up

— Symptoms, hemodynamic instability, suspected IE/dissection → inpatient

Emergent (ED / direct admit):

Urgent (cardiology referral within days):

Routine (cardiology referral within weeks):

Inpatient vs outpatient workup:

Step 3 management: A 65-year-old presents with one episode of exertional syncope and a harsh crescendo-decrescendo murmur radiating to carotids → admit, telemetry, urgent TTE, NPO after midnight, cardiology and CT surgery consults — do not discharge for outpatient workup.

CCS pearl: In CCS cases, write "counsel patient: avoid heavy exertion until cardiology evaluation" for any patient with newly identified severe AS or HOCM awaiting outpatient workup — exertional restriction is a documentable safety intervention.

Key Differentials — Other Valvular and Structural Causes

— Aortic stenosis: crescendo-decrescendo at RUSB, radiates to carotids, soft S2, delayed carotid upstroke

— Aortic sclerosis: similar location, normal S2, normal carotid upstroke, peak velocity <2.5 m/s

— HOCM: crescendo-decrescendo at LLSB, louder with Valsalva/standing, bifid carotid pulse, no radiation to neck

— Mitral regurgitation: holosystolic at apex, radiates to axilla, louder with handgrip

— Mitral valve prolapse: midsystolic click + late systolic murmur, click moves earlier with Valsalva/standing

— Tricuspid regurgitation: holosystolic LLSB, louder with inspiration (Carvallo), JVD with prominent V wave, pulsatile liver

— Pulmonic stenosis: crescendo-decrescendo LUSB, radiates to left shoulder, ejection click

— VSD: harsh holosystolic LLSB with thrill; small VSD louder than large

— ASD: soft systolic ejection murmur at LUSB with fixed split S2 (key clue — ASD itself doesn't produce a loud murmur; the flow across the pulmonic valve does)

— Aortic regurgitation: early decrescendo, LSB, leaning forward, wide pulse pressure

— Pulmonic regurgitation: similar but at LUSB, louder with inspiration (Graham Steell when due to pulmonary HTN)

— Mitral stenosis: opening snap + mid-diastolic rumble at apex, left lateral decubitus, loud S1

— Tricuspid stenosis: rare, rumble at LLSB, louder with inspiration

— Austin Flint murmur: mid-diastolic apical rumble in severe AR — regurgitant jet hits anterior mitral leaflet; no opening snap, no loud S1

— PDA (machinery murmur, LUSB), AV fistula, ruptured sinus of Valsalva, coronary AV fistula, venous hum (benign)

Systolic murmurs — work through the differential:

Diastolic murmurs:

Continuous murmurs:

Key distinction: MVP click moves with maneuvers: ↓ preload (Valsalva, standing) → click earlier and longer murmur; ↑ preload (squat) → click later and shorter murmur. This is the classic exam item.

Board pearl: Fixed split S2 = ASD until proven otherwise; the murmur is from increased pulmonic flow, not from the defect itself.

Key Differentials — Non-Valvular and Mimics

— Anemia: Hgb <8 commonly produces a soft systolic flow murmur; resolves with correction

— Hyperthyroidism: flow murmur, possible Means-Lerman scratch (systolic scratchy sound at LUSB)

— Pregnancy: physiologic systolic murmur in 90%; mammary souffle, venous hum

— Fever, sepsis: transient flow murmur in high-output state

— Athletic conditioning: physiologic LVH and increased stroke volume → soft flow murmur

— Pericardial friction rub: three components (atrial systole, ventricular systole, early diastole); scratchy, varies with position, not a murmur per se

— Pleural rub: disappears with breath-holding (key differentiator from pericardial rub)

— Mediastinal crunch (Hamman sign): crackling sound with heartbeat in pneumomediastinum

— Mechanical valves produce loud metallic clicks; muffled mechanical click or new murmur = valve thrombosis or pannus → emergency

— Bioprosthetic valves may develop new regurgitation as they degenerate (10–15 years)

— Hyperdynamic precordium without true murmur in young thin patients

— Cervical bruit from carotid disease vs radiated AS murmur — palpate carotid upstroke (delayed in AS, normal in isolated carotid disease)

— Carcinoid syndrome: right-sided lesions (TR, PS) from serotonin

— Rheumatic heart disease: MS > MR > AR > AS

— Connective tissue disease: Marfan (MVP, AR), Ehlers-Danlos, ankylosing spondylitis (AR)

— Radiation: mixed valvular disease 10–20 years post-mediastinal radiation

— Drug-induced valvulopathy: historical fenfluramine-phentermine, ergotamines, methysergide, pergolide

Functional / high-output flow murmurs (not structural):

Pericardial and extracardiac sounds:

Prosthetic valve sounds:

Conditions mimicking murmurs:

Systemic disease producing valvular pathology:

Key distinction: A carotid bruit with normal carotid upstroke is likely carotid disease; a "carotid bruit" with delayed upstroke is radiated AS — image the heart, not just the neck.

Board pearl: Means-Lerman scratch in hyperthyroidism is a board-favorite extracardiac mimic — TSH should be checked when a flow murmur appears in a tachycardic, restless patient.

Secondary Prevention and Long-Term Plan

— Prosthetic cardiac valve or prosthetic material used in repair

— Prior infective endocarditis

— Unrepaired cyanotic congenital heart disease, or repaired CHD with residual defects adjacent to prosthetic material (first 6 months after repair)

— Cardiac transplant recipients with valvulopathy

— Procedures covered: dental work involving gingival/periapical manipulation; invasive respiratory tract procedures with incision; procedures on infected skin/MSK tissue

— Not covered: GI/GU procedures routinely, MVP, isolated AS, bicuspid valve without prosthesis

— Regimen: amoxicillin 2 g PO 30–60 min pre-procedure (clindamycin no longer recommended; alternatives are azithromycin, doxycycline, or cephalexin)

— Penicillin G benzathine 1.2 million units IM every 4 weeks

— Duration: 5 years or until age 21 (no carditis), 10 years or age 21 (carditis without residual disease), 10 years or age 40 (carditis with residual valvular disease — often lifelong)

— Mechanical aortic valve: warfarin INR 2.5 (range 2.0–3.0); add aspirin 75–100 mg

— Mechanical mitral valve: warfarin INR 3.0 (range 2.5–3.5)

— Bioprosthetic valve + sinus rhythm: aspirin alone after 3–6 months; warfarin x 3 months optional

— AF + moderate–severe MS or mechanical valve: warfarin only (no DOACs)

— AF + non-MS valvular disease (including bioprosthetic): DOACs acceptable

— BP control (avoid hypotension in severe AS; target <130/80 in AR/MR)

— Lipid management per ASCVD risk (statins do not slow AS but reduce coronary events)

— Smoking cessation, weight management, moderate aerobic exercise as tolerated

— Dental hygiene — twice-yearly cleanings critical for IE prevention

Endocarditis prophylaxis — who actually qualifies (2021 AHA):

Rheumatic fever secondary prevention:

Anticoagulation in valve disease:

Lifestyle and risk factor optimization:

Step 3 management: Post-AVR with mechanical valve patient → warfarin INR 2.5 + aspirin 81 mg, lifelong, no DOACs, ensure dental clearance and 6-month dental follow-up, vaccinations (influenza annually, pneumococcal series).

Board pearl: DOACs are contraindicated in mechanical valves and in moderate–severe rheumatic MS — RE-ALIGN trial showed dabigatran worsened outcomes vs warfarin.

Follow-Up, Monitoring, and Counseling

— Mild AS: every 3–5 years; moderate AS: every 1–2 years; severe asymptomatic AS: every 6–12 months

— Mild AR/MR: every 3–5 years; moderate: every 1–2 years; severe asymptomatic with normal LV: every 6–12 months

— MS: mild every 3–5 years; moderate every 1–2 years; severe yearly

— Bicuspid aortic valve: baseline TTE; root surveillance every 1–2 years depending on size; cardiac MRI/CT if root not well visualized

— Post-bioprosthetic AVR/MVR: baseline at 1 month; annual after year 5; sooner if symptoms

— Functional class (NYHA), symptom diary

— BP, HR, rhythm (consider ambulatory monitor if palpitations)

— Weight (volume status), edema, JVD

— Trended labs: CBC (hemolysis in mechanical valves → ↑LDH, ↓haptoglobin, schistocytes), INR (warfarin), BNP trend

— Symptoms to report immediately: new dyspnea, exertional syncope, chest pain, palpitations, fever, weight gain >2–3 lb in 2 days, neurologic symptoms

— Dental hygiene — book cleanings, inform dentist of valve status, premedicate if criteria met

— Activity: moderate aerobic activity encouraged in mild–moderate disease; competitive athletic restriction in severe AS, HOCM, severe MR with PHTN, Marfan with root dilation — refer to Bethesda/AHA athlete guidelines

— Pregnancy counseling: preconception evaluation for any moderate–severe valve disease

— Travel: mechanical valve patients — bridging plans, INR access, carry medication list

Surveillance echo intervals (asymptomatic):

Clinic monitoring parameters:

Counseling points:

Cardiac rehab: indicated post-valve surgery and post-TAVR; improves functional capacity and quality of life

CCS pearl: After valve surgery, the standard post-op cadence is 2 weeks (wound check), 4–6 weeks (TTE baseline), 3 months, 6 months, then annually — write the follow-up appointments explicitly in CCS.

Board pearl: Symptom development between scheduled visits is itself an indication for echo — the surveillance interval is for the asymptomatic patient; never wait if symptoms appear.

Ethical, Legal, and Patient Safety Considerations

— Must include alternatives (medical management, SAVR, TAVR, watchful waiting), procedural risks (stroke ~2–4% TAVR, pacemaker ~10–15%, mortality), and the natural history of untreated severe AS (median survival 1–5 years post-symptom onset)

— In elderly or frail patients, integrate goals of care: a frail patient may prefer comfort-focused approach; document shared decision

— Capacity assessment for cognitively impaired patients — engage surrogate per state hierarchy

— Post-discharge after valve surgery: medication reconciliation is the highest-yield safety task — warfarin dose, target INR, aspirin status, beta-blocker, diuretic adjustment

— Ensure first INR check within 3–5 days of discharge and outpatient anticoagulation clinic enrollment

— Schedule cardiology follow-up before discharge; provide written symptom action plan

— Reconcile previously held meds (e.g., ACEi may now be appropriate after AS relieved)

— Newly diagnosed HOCM in a competitive athlete: discuss restriction from high-intensity competitive sport per current AHA/ACC guidelines (recent shared-decision model permits some return after evaluation, but disclose risk of SCD)

— Family screening for HOCM: first-degree relatives should receive ECG + TTE; genetic testing if pathogenic variant identified

— Patient with exertional syncope from severe AS: advise driving restriction until intervention completed and symptoms resolved; document counseling

— Some states require physician reporting of recurrent syncope — know your state law

— Avoid stigma; offer medication for opioid use disorder (buprenorphine, methadone) and harm reduction

— Recurrent endocarditis in active IVDU: ethical questions around repeat valve surgery — engage palliative care and addiction medicine, not unilateral refusal

— Counsel pre-procedure about ~10–15% risk of permanent pacemaker; document

— Discharge with clear instructions to seek care for syncope or new dizziness even weeks later

Informed consent for valve intervention:

Transition-of-care risks (Step 3 favorite):

Athlete clearance and disclosure:

Driving and syncope:

Endocarditis and IV drug use:

Patient safety pearl — pacemaker risk post-TAVR:

Step 3 management: A frail 88-year-old with severe symptomatic AS and dementia: convene family meeting, assess surrogate, discuss TAVR vs palliative approach including palliative balloon valvuloplasty as a bridge or comfort measure — document shared decision.

High-Yield Associations and Rapid-Fire Clinical Facts

— Valsalva/standing → louder: HOCM, MVP. Softer: everything else.

— Squat/leg raise → louder: AS, MR, AR. Softer: HOCM, MVP.

— Handgrip → louder: MR, AR, VSD. Softer: AS, HOCM.

— Inspiration (Carvallo) → louder: all right-sided murmurs (TR, TS, PS, PR).

— Sit forward, end-expiration → louder: AR.

— Left lateral decubitus → louder: MS rumble, S3, S4.

— Fixed split S2 → ASD

— Paradoxical split S2 → LBBB, severe AS

— Loud S1 → MS, hyperdynamic states

— Soft/absent A2 → severe AS

— Opening snap close to S2 → severe MS

— S3 → volume overload / heart failure; physiologic in young

— S4 → stiff ventricle (HTN, AS, HOCM, ischemia)

— Pulsus parvus et tardus → AS

— Water-hammer (Corrigan) → AR

— Bifid carotid → HOCM (spike-and-dome) or severe AR

— Pulsus alternans → severe LV dysfunction

— Pulsus paradoxus → tamponade, severe asthma

— Turner: bicuspid valve, coarctation

— Marfan: AR, MVP, aortic root dilation

— Williams: supravalvular AS

— Down: AV canal defects, VSD

— Noonan: pulmonic stenosis

— Ehlers-Danlos: MVP, AR

— Ankylosing spondylitis, syphilis: AR

— Anorexigens (fen-phen), pergolide, methysergide → valvulopathy

— Mediastinal radiation → mixed valvular disease 10–20 years out

Maneuver cheat sheet (memorize cold):

Classic associations:

Pulse findings:

Syndromic murmurs:

Iatrogenic and drug-associated:

Board pearl: Memorize this single line — "HOCM and MVP go opposite to everything else with preload maneuvers" — and you will get the majority of exam vignettes on murmur identification correct.

Key distinction: Fixed splitting is ASD; wide and inspiratory splitting with delayed P2 is RBBB or pulmonic stenosis.

Board Question Stem Patterns

— If apical MR murmur with pulmonary edema → papillary muscle rupture (usually inferior MI, posteromedial pap muscle).

Stem 1 — The classic elderly AS: "72-year-old with two episodes of syncope while shoveling snow, harsh systolic murmur radiating to carotids, soft S2, delayed carotid upstroke." → Severe symptomatic AS; next step: TTE, then refer for AVR (TAVR vs SAVR).

Stem 2 — The young athlete who collapses: "17-year-old collapses during basketball, family history of unexplained death age 35, harsh systolic murmur at LLSB, louder with Valsalva." → HOCM; next step: ECG, TTE, restriction from competitive sport, family screening.

Stem 3 — Post-MI new murmur: "67-year-old, day 5 post-anterior STEMI, new harsh holosystolic murmur at LLSB with thrill, hypotension." → Ventricular septal rupture; next step: emergent echo, IABP, cardiothoracic surgery.

Stem 4 — Pregnant patient with murmur: "28-year-old at 24 weeks, diastolic rumble at apex with opening snap, immigrated from rural area, history of rheumatic fever." → Mitral stenosis; manage with beta-blocker, diuretic; PMBV if decompensates; anticoagulate if AF.

Stem 5 — IV drug user with fever: "34-year-old IVDU, fever, new holosystolic murmur at LLSB louder with inspiration, splinter hemorrhages." → Tricuspid valve endocarditis; blood cultures × 3, TTE then TEE, empiric vancomycin.

Stem 6 — Innocent murmur: "5-year-old with soft 2/6 musical systolic murmur at LLSB, decreases with standing, normal exam otherwise." → Still's murmur — reassure, no echo.

Stem 7 — MVP maneuvers: "Young woman with midsystolic click; click moves earlier with standing." → MVP; reassure if asymptomatic.

Stem 8 — Wide pulse pressure: "Pulse pressure 80, head bobbing, water-hammer pulse, diastolic murmur at LSB." → Aortic regurgitation; consider Marfan, syphilis, bicuspid valve.

Stem 9 — Carcinoid: "Flushing, diarrhea, TR murmur." → carcinoid heart disease.

Stem 10 — Elderly with GI bleed and AS: "Iron-deficiency anemia + colonic angiodysplasia + severe AS." → Heyde syndrome.

CCS pearl: When the vignette says "exertional syncope" alongside any systolic murmur, immediately think AS or HOCM — admit, do not discharge for outpatient workup.

Board pearl: When choices include "start ACEi" or "start statin" for severe AS — wrong; the answer is refer for valve intervention or TTE if not yet imaged.

One-Line Recap

The clinical mastery of cardiac murmurs in primary care reduces to three questions: (1) Is it systolic or diastolic? — all diastolic murmurs and any murmur ≥3/6 get echocardiography; (2) Are there symptoms? — symptoms in severe valvular disease trigger intervention regardless of LV numbers; (3) How does it move with maneuvers? — HOCM and MVP get louder with Valsalva/standing while everything else gets softer.

Triage rule: Innocent murmurs are soft, midsystolic, asymptomatic, with normal S2 and no radiation → reassure. Anything else → TTE.

Maneuver mantra: Valsalva/standing decreases preload → HOCM and MVP get louder; AS, MR, AR get softer. Right-sided murmurs amplify with inspiration (Carvallo); AR is best heard leaning forward in expiration; MS rumble in left lateral decubitus with the bell.

Intervention triggers: Symptomatic severe AS, AR, MR, or MS → refer for surgery/TAVR/PMBV. Asymptomatic severe disease intervenes when LV dilates (LVESD thresholds), EF declines, AF develops, or pulmonary hypertension emerges.

Step 3 management essentials: Endocarditis prophylaxis only for prosthetic valves, prior IE, or specific CHD before dental procedures with gingival manipulation. Mechanical valves and rheumatic MS require warfarin only — no DOACs. Pregnancy with severe MS is the riskiest combination; pre-conception PMBV is the optimal strategy. Post-valve surgery cadence: 2 weeks → 4–6 weeks (TTE) → 3 months → annually, with cardiac rehab and dental hygiene reinforcement.

Board pearl: The two facts that resolve more murmur vignettes than any others — diastolic murmurs always pathologic, and HOCM/MVP go opposite to all other murmurs with preload maneuvers.