Diastolic Murmur

Diastolic Murmur: Excerpt from Field Guide to Bedside Diagnosis

Differential Overview

❑ Aortic regurgitation

❑ Pulmonic regurgitation

❑ Mitral stenosis

❑ Tricuspid stenosis

❑ Atrial septal defect

❑ Left anterior descending artery stenosis

❑ Atrial myxoma

Diagnostic Approach

A diastolic murmur is always abnormal. An early diastolic murmur, caused by aortic or pulmonic regurgitation, is high-pitched and decrescendo. The duration of the murmur is an index of severity. A mid-diastolic murmur suggests mitral or tricuspid stenosis.

The murmur of mitral stenosis decreases or does not change with inspiration whereas the murmur of tricuspid stenosis increases.

Clinical Findings

Aortic regurgitation  There is an early diastolic murmur beginning with A₂, which is a high-frequency (heard with the diaphragm), decrescendo blowing sound. Heard best at Erb’s point (the 3rd left ICS) or the 2nd right ICS, it may be accentuated with the patient sitting upright and leaning forward with the breath held in full expiration. The murmur may vary from a short, faint wisp to a loud musical pandiastolic murmur audible in the elbow and the top of the head. The Austin Flint murmur is a low-pitched rough and rumbling late-diastolic apical murmur, often with pre-systolic accentuation. It is heard best with the bell with the patient in the left lateral decubitus position. Its presence indicates hemodynamically significant aortic regurgitation. Quincke pulse is alternating flushing and blanching of nail beds, seen in moderate to severe aortic regurgitation. The Corrigan pulse rapidly rises and falls, and is accentuated by elevating the wrist. The Duroziez sign is a to-and-fro femoral artery murmur produced by applying finger pressure proximally and distally to the stethoscope. De Musset sign is the head bobbing with each heartbeat. The brachial-popliteal pressure differential correlates with increasing degrees of severity of aortic regurgitation. Below 20 mm Hg–hemodynamically insignificant AR; 20 to 24 – mild to moderate AR; 40 to 60 – moderate to severe AR; .60 – severe AR.

Pulmonic regurgitation  Regurgitation begins with pulmonic closure, but because closure is delayed beyond A₂ due to a prolonged right ventricular ejection time, the murmur appears to start in midsystole. The second heart sound will be single, and P₂ accentuated. Pulmonic regurgitation associated with pulmonary hypertension produces a Graham Steel murmur at the left sternal border. High-pitched and blowing, it is difficult to distinguish from aortic regurgitation.

Mitral stenosis  A diastolic rumble is loud early in diastole, softens in
middiastole, and is accentuated in late diastole. This latter phase, resulting from flow produced by atrial contraction, is lost in atrial fibrillation. The murmur is best heard at the apex, with the bell, in the left lateral decubitus position. It begins with an opening snap. The duration of the murmur is correlated with the diastolic pressure gradient across the valve, so is a guide to severity. Concurrent findings include dyspnea, hemoptysis, and a malar flush.

Tricuspid stenosis  It has the same characteristics as mitral stenosis but is of lower frequency due to lower flow, a mid-diastolic rumble at the left sternal border. The sound should become louder with inspiration (Carvallo sign) and increased stroke volume. A prominent jugular a wave associated with edema, ascites, and hepatomegaly are useful clues to severe stenosis.

Atrial septal defect  A low-pitched rumbling is found at the mid-left sternal border. There is a prominent right ventricular impulse with a palpable pulmonary artery pulsation. When pulmonary vascular resistance rises, the left-to-right shunt decreases, and a single S₂ with a murmur of pulmonic insufficiency develops. Cyanosis and clubbing are usually present at this point.

Left anterior descending artery stenosis  A localized diastolic murmur is heard over the 2nd or 3rd interspace at the left sternal border.

Atrial myxoma  Myxoma mimics mitral stenosis, but is accompanied by systemic emboli. A “tumor plop,” changing intensity and character of the
murmur, and sinus rhythm all favor atrial myxoma.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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