Table 8: Auscultation – murmurs

Physical Finding Associated cardiac condition(s)
Early systolic Ventricular septal defect, acute mitral regurgitation, acute tricuspid regurgitation
Holosystolic (pansystolic) Mitral regurgitation, tricuspid regurgitation, ventricular septal defect
Midsystolic (ejection systolic) Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy, atrial septal defect, aortic coarctation, pregnancy, mammary soufflé, innocent murmur
Late systolic Myocardial infarction, ischemia, diffuse myocardial disease, mitral regurgitation from mitral valve prolapse
Early diastolic Aortic regurgitation, pulmonary regurgitation (± Graham Steell murmur)
Middiastolic Mitral stenosis, tricuspid stenosis, atrial myxoma (right or left), acute severe aortic regurgitation (Austin-Flint murmur), acute rheumatic fever (Carey Coombs murmur)
Presystolic (Late diastolic) Tricuspid stenosis, mitral stenosis, atrial myxoma (right or left), acute severe aortic regurgitation (Austin-Flint murmur)
Continuous Patent ductusarteriosus, cervical venous hum, mammary soufflé, congenital or acquired arteriovenous shunt (e.g. coronary arteriovenous fistula, ruptured aneurysm of aortic sinus of valsalva into a right heart chamber, anomalous left coronary artery, intercostal arteriovenous fistula), small atrial septal defect with a high left atrial pressure, proximal coronary artery stenosis, pulmonary artery branch stenosis, bronchial collateral circulation, aortic coarctation
Modulation (shape)
Diamond (crescendo-decrescendo) Aortic stenosis, pulmonary stenosis, hypertrophic obstructive cardiomyopathy
Decrescendo Aortic regurgitation, pulmonary regurgitation
Plateau Mitral regurgitation, tricuspid regurgitation
5th intercostal space mid-clavicular line / apical Mitral stenosis/regurgitation, hypertrophic obstructive cardiomyopathy
Right 5th interspace Tricuspid stenosis/regurgitation
Right 2nd interspace / base Aortic stenosis/regurgitation
Right 1st interspace or higher Supravalvular aortic stenosis
Right supraclavicular fossa Cervical venous hum
Left 2nd interspace / upper sternal border Pulmonic stenosis/regurgitation, patent ductusarteriosus
Left 3rd-4th interspace Tricuspid regurgitation, hypertrophic obstructive cardiomyopathy
Left & Right of sternum, 4th-6th interspace Ventricular septal defect
Back/ interscapular Patent ductusarteriosus, aortic coarctation
1 Faint, must tune in
2 Easily heard
3 Moderately loud
4 Palpable thrill and loud
5 Very loud
6 Heard with stethoscope off chest
Frequency (pitch)
High Mitral regurgitation, acquired pulmonary regurgitation, aortic regurgitation
Low Mitral stenosis (rumble), tricuspid stenosis, congenital pulmonary regurgitation, acute severe aortic regurgitation
Axillary Mitral regurgitation (anterior or laterally directed jet)
Back / Subscapular Mitral regurgitation (posteriorly directed jet), patent ductusarteriosus, aortic coarctation
Neck (Carotids) Aortic stenosis, hypertrophic obstructive cardiomyopathy, supravalvular aortic stenosis (louder in right neck)
Blowing Mitral regurgitation
Varying throughout cycle Pericarditis (Pericardial friction rub)
Maneuver Murmur that becomes louder
Squatting, raising legs i.e. increase venous return (left ventricular volume) Aortic stenosis, aortic regurgitation, mitral stenosis, mitral regurgitation, ventricular septal defect, patent ductusarteriosus
Valsalva, inhalation of amyl nitrate, sitting up, standing i.e. decrease left ventricular volume Mitral valve prolapse (& lengthens murmur), hypertrophic obstructive cardiomyopathy
Handgrip, phenylephrine, or transient arterial occlusion by inflation of bilateral arm cuffs to 20mmHg above systolic blood pressure for 5 seconds (increases systemic arterial resistance) Mitral regurgitation, aortic regurgitation, ventricular septal defect
Holosystolic louder in inspiration Tricuspid regurgitation (Carvallo's sign), Pulmonary stenosis, pulmonary regurgitation
Following a premature beat or a long RR interval Aortic stenosis, pulmonary stenosis
Extra signs
Other physical findings to support your diagnosis Blood pressure, jugular venous pulse, thrill, apex beat, peripheral pulse characteristics, changes in first or second heart sound, presence of third or fourth heart sound
Pleural effusion Left heart failure
Inspiratory rales Left heart failure
Pulsatile mass below umbilicus Abdominal aortic aneurysm
Abdominal bruit (lateral) Renovascular hypertension