Causes of Heart Murmur

List of causes of Heart Murmur

Following is a list of causes or underlying conditions (see also Misdiagnosis of underlying causes of Heart Murmur) that could possibly cause Heart Murmur includes:

• Normal development - some mild murmurs may be normal
• Arrhythmias
• Heart disorder
• Heart valve disease
• See underlying causes of Arrhythmias
• See also causes of symptom Heart Murmur

More causes: see full list of causes for Additional Heart Sounds

Causes of Heart Murmur (Diseases Database):

The follow list shows some of the possible medical causes of Heart Murmur that are listed by the Diseases Database:

• Sinus of Valsalva aneurysm

Source: Diseases Database

Causes of Heart Murmur: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about the causes of Heart Murmur.

Palpitations: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Premature atrial contractions
• Premature ventricular contractions
• Sinus tachycardia
  –Regular heart rhythm at 100–140 bpm
• Atrial fibrillation
  –Irregularly irregular heart rate
• Atrial flutter
  –Regular heart rhythm at about 150 bpm
• Drugs leading to tachyarrhythmias (e.g., aminophylline, amphetamines, alcohol, atropine, cocaine, coffee, epinephrine, ephedrine, MAO inhibitors, tea, thyroid extract, tobacco)
• Psychiatric disorders (anxiety, panic reactions)
• Anemia (with exertion)
• Heart failure (with exertion)
• Menopausal syndrome (with hot flashes)
• Paroxysmal atrial tachycardia
• Re-entry tachycardias, including Wolff-Parkinson-White syndrome
• Ventricular tachycardia
• Atrioventricular heart blocks
• Junctional tachycardia
• Mitral valve prolapse
• Myocardial ischemia
• Hyperthyroidism-associated arrhythmias
• Severe deconditioning (with exertion)
• Hypoglycemia
• Postural hypotension
• Atrial septal defect
• Adrenal tumor
• Pheochromocytoma

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Murmurs - Diastolic: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Aortic insufficiency
  –Decrescendo murmur heard best at the right second intercostal space
• Austin Flint murmur
  –Late diastolic rumble of severe aortic regurgitation
  –A result of aortic regurgitation so severe that it causes diastolic mitral regurgitation
• Mitral stenosis
  –Opening snap with mid-diastolic rumble, especially in the left lateral decubitus position
• Pulmonary insufficiency
  –Accentuated P2 and decrescendo murmur at the left second/third intercostal spaces
• Tricuspid stenosis
  –Mid-diastolic rumble at the left sternal border
  –Increases with inspiration
• Cervical venous hum (disappears upon pressure to the jugular vein)
• Hepatic venous hum (disappears with epigastric pressure)
• Mammary souffle (in pregnancy; disappears on compressing breast)
• PDA (continuous machinery sound)
• Coronary or pulmonary arteriovenous fistula
• Coarctation of the aorta
• ASD with left-to-right shunt
• Atrial myxoma (“tumor plop”)
• Pericardial knock (constrictive pericarditis)
• Bronchial collaterals (congenital heart disease)
• Anomalous pulmonary venous drainage with left-to-right shunt
• Pulmonary artery branch stenosis
• Carey-Coombs murmur (mid-diastolic murmur that occurs in acute rheumatic fever)

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Murmurs - Systolic: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Innocent systolic murmur
  –Heard at left sternal border
  –Increased when supine
  –May be caused by increased flow states (e.g., anemia, hypovolemia, fever)
• Still's murmur
• Mitral valve prolapse
  –Midsystolic click with late systolic murmur that shifts with maneuvers
• Aortic stenosis
  –Right side at second intercostal space
  –Radiates to carotid arteries
• Aortic sclerosis
  –Right side at second intercostal space
  –Midsystole
• Hyperthyroidism
• Cervical venous hum
  –Disappears with jugular vein pressure
• Hepatic venous hum
  –Disappears with epigastric pressure
• Mammary souffle
  –Occurs in pregnancy
  –Disappears upon compression of breast
• Bicuspid aortic valve
  –Right side at second intercostal space
  –Little radiation
  –Possible early diastolic aortic murmur
  –Opening sound of aortic valve heard in early systole (systolic ejection click)
• Mitral insufficiency
  –Holosystolic murmur heard best in the left lateral decubitus position
  –S₁ is usually diminished in intensity
• Tricuspid insufficiency
  –Holosystolic murmur at second/third intercostal spaces
• Endocarditis
  –Abrupt onset of new murmur
• Peripheral pulmonary artery stenosis
• Atrial or ventricular septal defect
• Ventricular septal defect
• Patent ductus arteriosus (continuous machinery sound, second left intercostal space)
• Coarctation of the aorta
• Left ventricular outflow tract obstruction
• Pulmonary artery stenosis
• Prosthetic valve noises
• Pericardial friction rubs
• Papillary muscle dysfunction
• Pulmonic outflow obstruction
• Coronary/pulmonary arteriovenous fistula

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Abdominal Bruit: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Abdominal aortic aneurysm
• Hepatocellular carcinoma (hepatoma)
• Cirrhosis
• Liver hemangioma
• Arteriovenous malformation
• Renal artery stenosis
• Celiac artery stenosis
• Superior mesenteric artery stenosis
• Tricuspid regurgitation
• Turbulence of the splenic artery
• Hepatic venous hum
  –High-pitched continuous murmur that decreases with forced held expiration
• Cruveilhier-Baumgarten murmur
  –High-pitched venous hum of portal hypertension that becomes louder with forced expiration
• Abdominal friction rub
  –Associated with hepatoma, cholangiocarcinoma, liver metastases, inflammatory processes
• Takayasu's arteritis

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Carotid Bruits: Differential Diagnosis
(In a Page: Signs and Symptoms)

• Internal carotid artery stenosis
• External carotid artery stenosis
• Normal (nonstenotic), yet tortuous, carotid arteries
• Heart murmur with radiation to the neck (e.g., aortic stenosis)
• Excessive compression of the stethoscope over the neck vessels, resulting in deformity of vessel wall and turbulence
• Hyperthyroidism
  –Results in hyperdynamic circulation, tachycardia, and hypertension
• Takayasu's arteritis
  –Decreased pulses and bruits may occur over the abdominal aorta, carotid arteries, brachial arteries, and subclavian arteries
• Fisher's contralateral systolic bruit
  –Heard over the carotid bifurcation, eyeball, and/or skull on the “normal side” due to increased flow, as the “silent” side is completely occluded

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Breath Sounds (Decreased): Differential Diagnosis
(In a Page: Signs and Symptoms)

Decreased airflow through respiratory tree

• Airway obstruction
  –Aspirated foreign body
  –Asthma
  –Bronchitis
  –Bronchiolitis
  –Croup
  –Epiglottitis
  –Neoplasm
  –Goiter
• Alveolar or interstitial processes
  –Pulmonary edema
  –Pneumonia
  –Pleurisy
  –Sarcoidosis
• Decreased lung expansion
  –Atelectasis
  –COPD or emphysema
  –Bronchiectasis
  –Kyphosis or scoliosis
  –Increased abdominal girth (e.g., ascites, obesity, pregnancy)
  –Pulmonary fibrosis
  –Diaphragmatic paralysis
  –Abdominal, chest wall, or pleuritic pain
  Obstructed transmission of sound
  • Obesity
  • Pleural effusion
  • Pneumothorax, hemothorax, or chylothorax
  • Pleural thickening
  • Large pulmonary embolus
  • Less common etiologies (“zebras”) include cystic fibrosis, alveolar hemorrhage, BOOP, now called COP, pneumonectomy (postsurgical), systemic lupus erythematosus, vocal cord paralysis, vocal cord dyskinesia, and psychogenic

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Abnormal Heart Sounds: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Abnormal S2 –Most important auscultatory finding; normally, S2 is single on inspiration and narrowly split on expiration, indicating normal pulmonary arterial pressures; difficult to learn, especially in babies with fast heart rates or a screaming child
  –Single and/or loud S2: Increased pulmonary artery pressure (large L to R shunt, pulmonary hypertension), also seen in patients with only single outlet from heart (i.e., pulmonary atresia)
  –Wide fixed-split S2: ASD, right bundle branch block, post-cardiac surgery

• Systolic murmur
  –Up to 50% of children at some point in life
  –Mid-systolic/ejection type: S1 and S2 separate from the murmur (lub-shhh-dub), due to flow across semilunar valve, harsh indicates semilunar valve stenosis, whereas low-pitched, vibratory, musical indicates innocent murmur
  –Holosystolic/regurgitant murmur: Begins with S1 (which is not clearly heard); always pathologic (mitral valve regurgitation, VSD, subaortic stenosis)

• Diastolic sounds
  –Always abnormal
  –Early and medium/high pitch murmur indicates semilunar valve insufficiency, low frequency rumbling indicates mitral/tricuspid stenosis
  –S3/S4/opening snap: Soft S3 can be normal in healthy children; any sound clearly heard is probably an abnormality of the mitral/tricuspid valve (opening snap) or ventricular filling (S3/S4)

• Continuous murmur
  –Murmur in systole that continues into diastole (may not fill entire diastole)
  –Venous hum: Low pitched, continuous murmur at both upper sternal borders; disappears when supine; innocent
  –Patent ductus arteriosus: Harsh, machinery-like murmur at left upper sternal border (LUSB)

• Systolic ejection click
  –High-pitched sound
  –Early: Bicuspid aortic valve, loudest at apex/LLSB, often confused with split S1
  –Mid/late: Mitral valve prolapse

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Tachycardia/Palpitations: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Sinus tachycardia
  –Most common cause of a fast heart rate
  –Normal response to stress (fever, pain, anxiety, dehydration, exercise, anemia, caffeine, tobacco, albuterol)
  –<180 beats/min and variable; ECG shows an upright P wave in lead I and AVF

• Supraventricular tachycardia (SVT)
  –Most common pathologic cause of tachycardia/palpitations in children
  –Narrow QRS complex (<0.08 seconds)
  –Almost all hemodynamically stable
  –Often paroxysmal
  –Usually AV re-entry or AV node re-entry; both have HR >180 and intermittent sudden onset and resolution

• AV re-entry
  –Involves an accessory electrical bypass tract connecting the atrium and ventricle (thereby “bypassing” the AV node)
  –Often associated with Wolff-Parkinson-White (WPW) syndrome (short PR interval, widened QRS interval, “delta” wave)
  –Most common in <10 years of age

• AV node re-entry
  –Involves re-entry within the AV node
  –Most common in >10 yrs of age

• Atrial fibrillation/flutter
  –Occurs almost exclusively in patients with underlying congenital heart disease
  –Macro (flutter) or micro (fibrillation) re-entry circuits within the atrium, usually around an old surgical scar
  –Common in patients status post-Fontan or Mustard-Senning procedures

• Ectopic/multifocal atrial tachycardia
  –Involves one or more automatic electrical foci in the atrium causing irregular tachycardia with a heart rate <180
  –The tachycardia has a slow onset and resolution

• Wide-complex tachycardia
  –Assume ventricular tachycardia until proven otherwise
  –SVT with bundle branch block (either permanent or rate-related)
  –Antidromic WPW: Re-entry loop in which the ventricle is depolarized via the bypass tract, creating a wide-complex tachycardia
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Bruits: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Abdominal aortic aneurysm. A pulsating periumbilical mass accompanied by a systolic bruit over the aorta characterizes abdominal aortic aneurysm. Associated signs and symptoms include a rigid, tender abdomen; mottled skin; diminished peripheral pulses; and claudication. Sharp, tearing pain in the abdomen, flank, or lower back signals imminent dissection.

❑ Abdominal aortic atherosclerosis. Loud systolic bruits in the epigastric and midabdominal areas are common. They may be accompanied by leg weakness, numbness, paresthesia, or paralysis; leg pain; or decreased or absent femoral, popliteal, or pedal pulses. Abdominal pain is rarely present.

❑ Anemia. Increased cardiac output causes increased blood flow. In patients with severe anemia, short systolic bruits may be heard over both carotid arteries and may be accompanied by headache, fatigue, dizziness, pallor, jaundice, palpitations, mild tachycardia, dyspnea, nausea, anorexia, and glossitis.

❑ Carotid artery stenosis. Systolic bruits can be heard over one or both carotid arteries. Other signs and symptoms may be absent. However, dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals a TIA and may herald a stroke.

❑ Carotid cavernous fistula. Continuous bruits heard over the eyeballs and temples are characteristic, as are vision disturbances and protruding, pulsating eyeballs.

❑ Peripheral arteriovenous fistula. A rough, continuous bruit with systolic accentuation may be heard over the fistula; a palpable thrill is also common.

❑ Peripheral vascular disease.Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower-extremity ulcers that heal with difficulty.

❑ Renal artery stenosis. Systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear.

❑ Subclavian steal syndrome. With subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of arterial lumen narrowing. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.

❑ Thyrotoxicosis. A systolic bruit is commonly heard over the thyroid gland. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.

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Murmurs: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Aortic insufficiency

Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S₂ may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Complications may not develop until the patient is between ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

Aortic stenosis

With aortic stenosis, the murmur is systolic, beginning after S₁ and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

If the patient has advanced disease, S₂ may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical, but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

Cardiomyopathy (hypertrophic)

Hypertrophic cardiomyopathy generates a harsh late systolic murmur, ending at S₂. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S₃or S₄. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

Mitral insufficiency

Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S₂ and commonly an S₄. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

Mitral prolapse

Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

Mitral stenosis

With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S₁ or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise helps make this murmur audible.

With severe stenosis, the murmur of mitral regurgitation may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

Myxomas

A left atrial myxoma (most common) usually produces a mid- diastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S₄, an early diastolic thudding sound (tumor plop), and a loud, widely split S₁.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border; arrhythmias; dyspnea; and syncope.

A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S₂ and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

Papillary muscle rupture

With papillary muscle rupture — a life-threatening complication of an acute MI — a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

Rheumatic fever with pericarditis

A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral regurgitation, a midsystolic murmur due to swelling of the mitral valve leaflet, and the diastolic murmur of aortic regurgitation. Other signs and symptoms include a fever, joint and sternal pain, edema, and tachypnea.

Tricuspid insufficiency

Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

Tricuspid stenosis

Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S₁ may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

Other causes

Treatments

Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

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Palpitations: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anxiety attack (acute)

Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, patients hyperventilate, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

Hypertension

With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with a headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and a decreased level of consciousness.

Hypocalcemia

Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Mitral prolapse

Mitral prolapse is a valvular disorder that may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, a migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillation.

Thyrotoxicosis

A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or a ventricular gallop.

Other causes

Drugs

Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics, such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; and minoxidil.

Herb Alert

Herbal remedies, such as ginseng, may cause adverse reactions, including palpitations and an irregular heartbeat.

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Bruits: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Abdominal aortic aneurysm

A pulsating periumbilical mass accompanied by a systolic bruit over the aorta characterizes an abdominal aortic aneurysm. Associated signs and symptoms include a rigid, tender abdomen; mottled skin; diminished peripheral pulses; and claudication. Sharp, tearing pain in the abdomen, flank, or lower back signals imminent dissection.

Abdominal aortic atherosclerosis

Loud systolic bruits in the epigastric and midabdominal areas are common in this disorder. They may be accompanied by leg pain, weakness, numbness, paresthesia, or paralysis or by decreased or absent femoral, popliteal, or pedal pulses. Abdominal pain is rare.

Anemia

Increased cardiac output in anemia causes increased blood flow. In patients with severe anemia, short systolic bruits may be heard over both carotid arteries and may be accompanied by headache, fatigue, dizziness, pallor, jaundice, palpitations, mild tachycardia, dyspnea, nausea, anorexia, and glossitis.

Carotid artery stenosis

Systolic bruits heard over one or both carotid arteries may be the only sign of this disorder. However, dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals TIA and may herald a stroke.

Carotid cavernous fistula

Continuous bruits heard over the eyeballs and temples are characteristic, as are vision disturbances and protruding, pulsating eyeballs.

Peripheral arteriovenous fistula

A rough, continuous bruit with systolic accentuation may be heard over the fistula; a palpable thrill is also common.

Peripheral vascular disease

Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower extremity ulcers that heal with difficulty.

Renal artery stenosis

Systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear.

Subclavian steal syndrome

In subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of narrowing of the arterial lumen. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.

Thyrotoxicosis

A systolic bruit is commonly heard over the thyroid gland. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.

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Murmurs: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Aortic insufficiency

Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S₂ may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur—a rumbling, mid-to-late diastolic murmur best heard at the apex—may also occur. Complications may not develop until ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

Aortic stenosis

With this valvular disorder, the murmur is systolic, beginning after S₁ and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

If the patient has advanced disease, S₂ may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

Cardiomyopathy (hypertrophic)

This disorder generates a harsh late systolic murmur, ending at S₂. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S₃or S₄. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

Mitral insufficiency

Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S₂ and commonly an S₄. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

Mitral prolapse

This disorder generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

Mitral stenosis

With this valvular disorder, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S₁ or an opening snap—a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

Myxomas

A left atrial myxoma (most common) usually produces a middiastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S₄, an early diastolic thudding sound (tumor plop), and a loud, widely split S₁.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border, arrhythmias, dyspnea, and syncope.

A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S₂ and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

Papillary muscle rupture

With this life-threatening complication of an acute MI, a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

Rheumatic fever with pericarditis

A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

Tricuspid insufficiency

This valvular abnormality is characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

Tricuspid stenosis

This valvular disorder produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S₁ may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

Other causes

Treatments

Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

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Palpitations: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anemia

Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

Anxiety attack (acute)

Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

Hypertension

With this disorder, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

Hypocalcemia

Typically, this disorder produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Hypoglycemia

When blood glucose levels drop significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

Mitral prolapse

This valvular disorder may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of this valvular disorder typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

Pheochromocytoma

This rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

Sick sinus syndrome

A patient with this disorder may experience palpitations, as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.

Thyrotoxicosis

A characteristic symptom of this disorder, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

Wolff-Parkinson-White syndrome

Seen in children and adolescents, this disorder results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.

Other causes

Drugs

Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; and minoxidil.

Exercise

Exercise can normally cause palpitations, as well as in patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly.

herb alert  Herbal remedies, such as ginseng and ephedra (ma huang), may cause adverse reactions, including palpitations and an irregular heartbeat. (Note: The FDA has banned the sale of dietary supplements containing ephedra because they pose an unreasonable risk of injury or illness).

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Diastolic Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Aortic regurgitation

❑ Pulmonic regurgitation

❑ Mitral stenosis

❑ Tricuspid stenosis

❑ Atrial septal defect

❑ Left anterior descending artery stenosis

❑ Atrial myxoma

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Continuous Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Aortic stenosis/aortic insufficiency

❑ Pericardial friction rub

❑ Pulmonary arteriovenous fistula

❑ Venous hum

❑ Mammary souffle

❑ Aortic coarctation

❑ Mediastinal air dissection

❑ Patent ductus arteriosis

❑ Ruptured sinus of Valsalva

❑ Coronary artery fistula

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Systolic Murmur: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Systolic ejection murmur

❑ Mitral regurgitation

❑ Mitral valve prolapse

❑ Aortic stenosis

❑ Aortic valve sclerosis

❑ Hypertrophic obstructive cardiomyopathy

❑ Atrial septal defect

❑ Pulmonic stenosis

❑ Tricuspid regurgitation

❑ Ventricular septal defect

❑ Aortic coarctation

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Carotid Bruit: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Carotid artery stenosis

❑ Carotid artery ruptured plaque

❑ Transmitted valvular murmur

❑ Carotid tortuosity

❑ Carotid compression

❑ Jugular venous hum

❑ Thyrotoxicosis

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Palpitations/Tachycardia: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Sinus tachycardia

❑ Paroxysmal supraventricular tachycardia

❑ Atrial fibrillation

❑ Atrial flutter

❑ AV nodal re-entrant tachycardia

❑ Ventricular premature beats

❑ Anxiety

❑ Drugs

❑ Anemia

❑ Multifocal atrial tachycardia

❑ Ventricular tachycardia

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Discrete Heart Sounds: Differential Overview
(Field Guide to Bedside Diagnosis)

Phenomena

❑ S₄ gallop

❑ Midsystolic click

❑ S₃ gallop

❑ Loud S₂

❑ Widely split S₁

❑ Widely split S₂

❑ Ejection click

❑ Variable S₁

❑ Paradoxical splitting of S₂

❑ Loud S₁

❑ Fixed splitting of S₂

❑ Opening snap

❑ Pericardial knock

❑ Tumor plop

❑ Sail sound

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Murmurs: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Aortic insufficiency

Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S₂ may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Complications may not develop until ages 40 to 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

Aortic stenosis

With aortic stenosis — avalvular disorder — the murmur is systolic, beginning after S₁ and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

If the patient has advanced disease, S₂ may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms usually don’t appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

Cardiomyopathy (hypertrophic)

Cardiomyopathy generates a harsh late systolic murmur, ending at S₂. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S₃or S₄. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

Mitral insufficiency

Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S₂ and commonly an S₄. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

Mitral prolapse

Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex and left sternal border. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

Mitral stenosis

With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S₁ or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

With severe stenosis, the murmur of mitral regurgitation may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

Myxomas

A left atrial myxoma (most common) usually produces a middiastolic murmur and a holosystolic murmur that’s loudest at the apex, with an S₄, an early diastolic thudding sound (tumor plop), and a loud, widely split S₁.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

A right atrial myxoma causes a late diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border, arrhythmias, dyspnea, and syncope.

A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S₂ and a tumor plop, best heard at the left sternal border. It’s accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

Papillary muscle rupture

Papillary muscle rupture is a life-threatening complication of an acute MI, in which a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

Rheumatic fever with pericarditis

A pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral regurgitation, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic regurgitation. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

Tricuspid insufficiency

Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign), decreases with exhalation and Valsalva’s maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy asymptomatic period, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

Tricuspid stenosis

Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S₁ may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

Other causes

Medical treatments

Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

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Palpitations: Medical causes
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Anemia

Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

Anxiety attack (acute)

Anxiety is the most common cause of palpitations. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate as well as decreased blood pressure, confusion, pallor, oliguria, and diaphoresis.

Hypertension

With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg.

Hypocalcemia

Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Hypoglycemia

When the blood glucose level drops significantly, the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions. These include blurred or double vision, muscle weakness, hemiplegia, and an altered LOC.

Mitral prolapse

A valvular disorder, mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of mitral stenosis — a valvular disorder — typically include sustained palpitations accompanied by exertional dyspnea, fatigue, paroxysmal nocturnal dyspnea, and atrial fibrillations. Auscultation also reveals a loud S₁ or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, peripheral edema, jugular vein distention, ascites, and hepatomegaly.

Pheochromocytoma

Pheochromocytoma, a rare adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

Sick sinus syndrome

A patient with sick sinus syndrome may experience palpitations as well as bradycardia, tachycardia, chest pain, syncope, and heart failure.

Thyrotoxicosis

A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

Wolff-Parkinson-White (WPW) syndrome

Seen in children and adolescents, WPW syndrome results in recurrent palpitations and frequent episodes of paroxysmal tachycardia.

Other causes

Drugs

Cardiac glycosides and other drugs that precipitate cardiac arrhythmias or increase cardiac output can cause palpitations. Ganglionic blockers, beta-adrenergic blockers, calcium channel blockers, atropine, minoxidil, and sympathomimetics, such as cocaine, can also cause palpitations.

Exercise

Palpitations can occur normally with exercise. Patients with coronary heart disease, hypertension, mitral valve prolapse, and cardiomegaly may experience palpitations with exercise.

Herbal remedies

Ginseng and other herbal remedies may cause adverse reactions that include palpitations and an irregular heartbeat.

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Bruits: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Abdominal aortic aneurysm

A pulsating periumbilical mass accompanied by a systolic bruit over the aorta characterizes an abdominal aortic aneurysm. Associated signs and symptoms include a rigid, tender abdomen; mottled skin; diminished peripheral pulses; and claudication. Sharp, tearing pain in the abdomen, flank, or lower back signals imminent dissection.

Abdominal aortic atherosclerosis

Loud systolic bruits in the epigastric and midabdominal areas are common in abdominal aortic atherosclerosis. They may be accompanied by leg weakness, numbness, paresthesia, or paralysis; leg pain; or decreased or absent femoral, popliteal, or pedal pulses. Abdominal pain is rarely present.

Carotid artery stenosis

Systolic bruits can be heard over one or both carotid arteries in a patient with carotid artery stenosis. Other signs and symptoms may be absent. However, dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals TIA and may herald a stroke.

Peripheral arteriovenous fistula

With a peripheral arteriovenous fistula, a rough, continuous bruit with systolic accentuation may be heard over the fistula; a palpable thrill is also common. Other signs and symptoms depend on the location of the fistula. For example, there may be claudication or absent pulses distal to the fistula. Skin distal to the fistula may be cool.

Peripheral vascular disease

Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower extremity ulcers that heal with difficulty.

Renal artery stenosis

With renal artery stenosis, systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear.

Subclavian steal syndrome

With subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of narrowing of the arterial lumen. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.

Thyrotoxicosis

A systolic bruit heard over the thyroid gland commonly occurs with thyrotoxicosis. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.

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Murmurs: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Aortic insufficiency

Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that’s best heard when the patient sits and leans forward and at the end of a forced held expiration. S₂ may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that’s best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur — a rumbling, mid-to-late diastolic murmur best heard at the apex — may also occur. Findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

Aortic stenosis

With aortic stenosis, the murmur is systolic, beginning after S₁ and ending at or before aortic valve closure. It’s harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb’s point), and over the carotid arteries.

If the patient has advanced disease, S₂ may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical but is absent when the valve is severely calcified. Associated signs and symptoms may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

Cardiomyopathy (hypertrophic)

Hypertrophic cardiomyopathy generates a harsh late systolic murmur, ending at S₂. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S₃or S₄. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

Mitral insufficiency

Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S₂ and commonly an S₄. This murmur doesn’t get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that’s loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

Mitral prolapse

Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

Mitral stenosis

With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S₁ or an opening snap — a cardinal sign. It’s best heard at the apex with the patient in the left lateral position. Mild exercise will help make this murmur audible.

With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

Papillary muscle rupture

Papillary muscle rupture, a life-threatening complication of an acute MI, produces a loud holosystolic murmur that can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

Rheumatic fever with pericarditis

A pericardial friction rub along with murmurs and gallops is heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard in patients with rheumatic fever are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the leaflet of the mitral valve, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

Tricuspid insufficiency

Tricuspid insufficiency is a valvular abnormality that’s characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo’s sign) and decreases with exhalation and Valsalva’s maneuver. This murmur is best heard over the lower left sternal border and the xiphoid area. Following a lengthy period without symptoms, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

Tricuspid stenosis

Tricuspid stenosis is a valvular disorder that produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva’s maneuver. S₁ may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

Other causes

Treatments

Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

READ BOOK EXCERPT ONLINE »

Palpitations: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Anemia

Palpitations may occur with anemia, especially on exertion. Pallor, fatigue, and dyspnea are also common. Associated signs include a systolic ejection murmur, bounding pulse, tachycardia, crackles, an atrial gallop, and a systolic bruit over the carotid arteries.

Anxiety attack (acute)

Anxiety is the most common cause of palpitations in children and adults. With this disorder, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, the patient hyperventilates, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias

Paroxysmal or sustained palpitations may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; chest pain; syncope; oliguria; and diaphoresis.

Hypertension

With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness (LOC).

Hypocalcemia

Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek’s and Trousseau’s signs.

Hypoglycemia

Hypoglycemia occurs when blood glucose levels drop significantly and the sympathetic nervous system triggers adrenaline production. This may cause sustained palpitations, which may be accompanied by fatigue, irritability, hunger, cold sweats, tremors, tachycardia, anxiety, and headache. Eventually, the patient may develop central nervous system reactions, including blurred or double vision, muscle weakness, hemiplegia, and altered LOC.

Mitral prolapse

Mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis

Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap, and a rumbling diastolic murmur at the apex. Patients may also experience such related signs and symptoms as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillations.

Pheochromocytoma

This adrenal medulla tumor causes episodic hypermetabolism, commonly associated with paroxysmal palpitations. The cardinal sign of pheochromocytoma is dramatically elevated blood pressure, which may be sustained or paroxysmal. Associated signs and symptoms include tachycardia, headache, chest or abdominal pain, diaphoresis, warm and pale or flushed skin, paresthesia, tremors, insomnia, nausea and vomiting, and anxiety.

Thyrotoxicosis

A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or ventricular gallop.

Other causes

Drugs

Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics such as cocaine; ganglionic blockers; beta blockers; calcium channel blockers; atropine; and minoxidil.

Exercise

Exercise can normally cause palpitations. In patients with coronary heart disease, exercise can also cause hypertension, mitral valve prolapse, and cardiomegaly.

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Heart Murmurs (Asymptomatic): Principal Causes of Heart Murmurs (Asymptomatic)
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Normalmurmurs
   1. Systolicejection murmurs
      1. Vibratory systolic murmur
      2. Pulmonary systolic murmur (pulmonarytrunk)
      3. Physiologic peripheral pulmonary systolicmurmur (pulmonary branches)
      4. Supraclavicular or brachiocephalicmurmur
   2. Continuous murmurs
      1. Venoushum
2. Pathologic murmurs
   1. Systolicmurmurs
      1. Maximalintensity at the upper right sternal border
         1. Valvaraortic stenosis
      2. Maximal intensity at the upper leftsternal border
         1. Valvar pulmonic stenosis
         2. Atrial septal defects
         3. Mild-to-moderate coarctation of theaorta
         4. Small patent ductus arteriosus
      3. Maximal intensity at the lower leftsternal border
         1. Ventricular septal defect
         2. Tricuspid incompetence
      4. Maximal intensity at the apex
         1. Mitralincompetence
         2. Mitral valve prolapse
   2. Diastolic murmurs
      1. Maximalintensity at the upper right sternal border
         1. Aorticvalve incompetence
      2. Maximal intensity at the upper leftsternal border
         1. Pulmonic valve incompetence
      3. Maximal intensity at the lower leftsternal border
         1. Atrial septal defects
         2. Tricuspid stenosis
         3. Moderate-to-severe tricuspid incompetence
      4. Maximal intensity at the apex
         1. Mitralstenosis
         2. Moderate-to-severe mitral incompetence
         3. Moderate left-to-right shunt lesions
   3. Continuous murmurs
      1. Maximalintensity at the upper left sternal border
         1. Moderate patent ductus arteriosus
      2. Maximal intensity at the left mid sternalborder
         1. Aorticpulmonary window
      3. Maximal intensity with variable location
         1. Coronaryarteriovenous fistula
         2. Systemic arteriovenous fistula

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Bruits: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Abdominal aortic aneurysm.A pulsating periumbilical mass accompanied by a systolic bruit over the aorta characterizes abdominal aortic aneurysm. Associated signs and symptoms include a rigid, tender abdomen; mottled skin; diminished peripheral pulses; and claudication. Sharp, tearing pain in the abdomen, flank, or lower back signals imminent dissection.

Abdominal aortic atherosclerosis.Loud systolic bruits in the epigastric and midabdominal areas are common with abdominal aortic atherosclerosis. They may be accompanied by leg weakness, numbness, paresthesia, or paralysis; leg pain; or decreased or absent femoral, popliteal, or pedal pulses. Abdominal pain is rarely present.

Anemia.In patients with severe anemia, short systolic bruits may be heard over both carotid arteries and may be accompanied by headache, fatigue, dizziness, pallor, jaundice, palpitations, mild tachycardia, dyspnea, nausea, anorexia, and glossitis.

Carotid artery stenosis.Systolic bruits can be heard over one or both carotid arteries with carotid artery stenosis. Other signs and symptoms may be absent. Dizziness, vertigo, headache, syncope, aphasia, dysarthria, sudden vision loss, hemiparesis, or hemiparalysis signals a TIA and may herald a stroke.

Carotid cavernous fistula.A carotid cavernous fistula causes characteristic continuous bruits heard over the eyeballs and temples. Vision disturbances and protruding, pulsating eyeballs are also common.

Peripheral arteriovenous fistula.A rough, continuous bruit with systolic accentuation may be heard over the fistula in a peripheral arteriovenous fistula. A palpable thrill is also common.

Peripheral vascular disease.Peripheral vascular disease characteristically produces bruits over the femoral artery and other arteries in the legs. It can also cause diminished or absent femoral, popliteal, or pedal pulses; intermittent claudication; numbness, weakness, pain, and cramping in the legs, feet, and hips; and cool, shiny skin and hair loss on the affected extremity. It also predisposes the patient to lower-extremity ulcers that heal with difficulty.

Renal artery stenosis.With renal artery stenosis, systolic bruits are commonly heard over the abdominal midline and flank on the affected side. Hypertension commonly accompanies stenosis. Headache, palpitations, tachycardia, anxiety, dizziness, retinopathy, hematuria, and mental sluggishness may also appear.

Subclavian steal syndrome.With subclavian steal syndrome, systolic bruits may be heard over one or both subclavian arteries as a result of arterial lumen narrowing. They may be accompanied by decreased blood pressure and claudication in the affected arm, hemiparesis, vision disturbances, vertigo, and dysarthria.

Thyrotoxicosis.With thyrotoxicosis, a systolic bruit is commonly heard over the thyroid gland. Accompanying signs and symptoms appear in all body systems, but the most characteristic ones include thyroid enlargement, fatigue, nervousness, tachycardia, heat intolerance, sweating, tremor, diarrhea, and weight loss despite increased appetite. Exophthalmos may also be present.

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Murmurs: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Aortic insufficiency.Acute aortic insufficiency typically produces a soft, short diastolic murmur over the left sternal border that's best heard when the patient sits and leans forward and at the end of a forced held expiration. S₂ may be soft or absent. Sometimes, a soft, short midsystolic murmur may also be heard over the second right intercostal space. Associated findings include tachycardia, dyspnea, jugular vein distention, crackles, increased fatigue, and pale, cool extremities.

Chronic aortic insufficiency causes a high-pitched, blowing, decrescendo diastolic murmur that's best heard over the second or third right intercostal space or the left sternal border with the patient sitting, leaning forward, and holding his breath after deep expiration. An Austin Flint murmur—a rumbling, mid-to-late diastolic murmur best heard at the apex—may also occur. Complications may not develop until the patient is between ages 40 and 50; then, typical findings include palpitations, tachycardia, angina, increased fatigue, dyspnea, orthopnea, and crackles.

Aortic stenosis.With aortic stenosis, the murmur is systolic, beginning after S₁ and ending at or before aortic valve closure. It's harsh and grating, medium-pitched, and crescendo-decrescendo. Loudest over the second right intercostal space when the patient is sitting and leaning forward, this murmur may also be heard at the apex, at the suprasternal notch (Erb's point), and over the carotid arteries.

If the patient has advanced disease, S₂ may be heard as a single sound, with inaudible aortic closure. An early systolic ejection click at the apex is typical, but is absent when the valve is severely calcified. Associated signs and symptoms usually don't appear until age 30 in congenital aortic stenosis, ages 30 to 65 in stenosis due to rheumatic disease, and after age 65 in calcific aortic stenosis. They may include dizziness, syncope, dyspnea on exertion, paroxysmal nocturnal dyspnea, fatigue, and angina.

Cardiomyopathy (hypertrophic).Hypertrophic cardiomyopathygenerates a harsh late-systolic murmur, ending at S₂. Best heard over the left sternal border and at the apex, the murmur is commonly accompanied by an audible S₃ or S₄. The murmur decreases with squatting and increases with sitting down. Major associated symptoms are dyspnea and chest pain; palpitations, dizziness, and syncope may also occur.

Mitral insufficiency.Acute mitral insufficiency is characterized by a medium-pitched blowing, early systolic or holosystolic decrescendo murmur at the apex, along with a widely split S₂ and commonly an S₄. This murmur doesn't get louder on inspiration as with tricuspid insufficiency. Associated findings typically include tachycardia and signs of acute pulmonary edema.

Chronic mitral insufficiency produces a high-pitched, blowing, holosystolic plateau murmur that's loudest at the apex and usually radiates to the axilla or back. Fatigue, dyspnea, and palpitations may also occur.

Mitral prolapse.Mitral prolapse generates a midsystolic to late-systolic click with a high-pitched late-systolic crescendo murmur, best heard at the apex. Occasionally, multiple clicks may be heard, with or without a systolic murmur. Associated findings include cardiac awareness, migraine headaches, dizziness, weakness, syncope, palpitations, chest pain, dyspnea, severe episodic fatigue, mood swings, and anxiety.

Mitral stenosis.With mitral stenosis, the murmur is soft, low-pitched, rumbling, crescendo-decrescendo, and diastolic, accompanied by a loud S₁ or an opening snap—a cardinal sign. It's best heard at the apex with the patient in the left lateral position. Mild exercise helps make this murmur audible.

With severe stenosis, the murmur of mitral insufficiency may also be heard. Other findings include hemoptysis, exertional dyspnea and fatigue, and signs of acute pulmonary edema.

Myxomas.A left atrial myxoma (most common) usually produces a mid-diastolic murmur and a holosystolic murmur that's loudest at the apex, with an S₄, an early diastolic thudding sound (tumor plop), and a loud, widely split S₁.Related features include dyspnea, orthopnea, chest pain, fatigue, weight loss, and syncope.

A right atrial myxoma causes a late-diastolic rumbling murmur, a holosystolic crescendo murmur, and tumor plop, best heard at the lower left sternal border. Other findings include fatigue, peripheral edema, ascites, and hepatomegaly.

A left ventricular myxoma (rare) produces a systolic murmur, best heard at the lower left sternal border; arrhythmias; dyspnea; and syncope.

A right ventricular myxoma commonly generates a systolic ejection murmur with delayed S₂ and a tumor plop, best heard at the left sternal border. It's accompanied by peripheral edema, hepatomegaly, ascites, dyspnea, and syncope.

Papillary muscle rupture.With papillary muscle rupture—a life-threatening complication of an acute MI—a loud holosystolic murmur can be auscultated at the apex. Related findings include severe dyspnea, chest pain, syncope, hemoptysis, tachycardia, and hypotension.

Rheumatic fever with pericarditis.With rheumatic fever, a pericardial friction rub along with murmurs and gallops are heard best with the patient leaning forward on his hands and knees during forced expiration. The most common murmurs heard are the systolic murmur of mitral insufficiency, a midsystolic murmur due to swelling of the mitral valve leaflet, and the diastolic murmur of aortic insufficiency. Other signs and symptoms include fever, joint and sternal pain, edema, and tachypnea.

Tricuspid insufficiency.Tricuspid insufficiency is characterized by a soft, high-pitched, holosystolic blowing murmur that increases with inspiration (Carvallo's sign), decreases with exhalation and Valsalva's maneuver, and is best heard over the lower left sternal border and the xiphoid area. Following a lengthy period without symptoms, exertional dyspnea and orthopnea may develop, along with jugular vein distention, ascites, peripheral cyanosis and edema, muscle wasting, fatigue, weakness, and syncope.

Tricuspid stenosis.Tricuspid stenosis produces a diastolic murmur similar to that of mitral stenosis, but louder with inspiration and decreased with exhalation and Valsalva's maneuver. S₁ may also be louder. Associated signs and symptoms include fatigue, syncope, peripheral edema, jugular vein distention, ascites, hepatomegaly, and dyspnea.

Other causes

Treatments.Prosthetic valve replacement may cause variable murmurs, depending on the location, valve composition, and method of operation.

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Palpitations: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anxiety attack (acute).With anxiety, palpitations may be accompanied by diaphoresis, facial flushing, trembling, and an impending sense of doom. Almost invariably, patients hyperventilate, which may lead to dizziness, weakness, and syncope. Other typical findings include tachycardia, precordial pain, shortness of breath, restlessness, and insomnia.

Cardiac arrhythmias.Paroxysmal or sustained palpitations of a cardiac arrhythmias may be accompanied by dizziness, weakness, and fatigue. The patient may also experience an irregular, rapid, or slow pulse rate; decreased blood pressure; confusion; pallor; oliguria; and diaphoresis.

Hypertension.With hypertension, the patient may be asymptomatic or may complain of sustained palpitations alone or with headache, dizziness, tinnitus, “blackouts,” and fatigue. His blood pressure typically exceeds 140/90 mm Hg. He may also experience nausea and vomiting, seizures, and decreased level of consciousness.

Hypocalcemia.Typically, hypocalcemia produces palpitations, weakness, and fatigue. It progresses from paresthesia to muscle tension and carpopedal spasms. The patient may also exhibit muscle twitching, hyperactive deep tendon reflexes, chorea, and positive Chvostek's and Trousseau's signs.

Mitral prolapse.Mitral prolapse may cause paroxysmal palpitations accompanied by sharp, stabbing, or aching precordial pain. The hallmark of this disorder, however, is a midsystolic click followed by an apical systolic murmur. Associated signs and symptoms may include dyspnea, dizziness, severe fatigue, a migraine headache, anxiety, paroxysmal tachycardia, crackles, and peripheral edema.

Mitral stenosis.Early features of mitral stenosis typically include sustained palpitations accompanied by exertional dyspnea and fatigue. Auscultation also reveals a loud S₁ or opening snap and a rumbling diastolic murmur at the apex. Patients may also experience related signs and symptoms, such as an atrial gallop and, with advanced mitral stenosis, orthopnea, dyspnea at rest, paroxysmal nocturnal dyspnea, peripheral edema, jugular vein distention, ascites, hepatomegaly, and atrial fibrillation.

Thyrotoxicosis.A characteristic symptom of thyrotoxicosis, sustained palpitations may be accompanied by tachycardia, dyspnea, weight loss despite increased appetite, diarrhea, tremors, nervousness, diaphoresis, heat intolerance and, possibly, exophthalmos and an enlarged thyroid. The patient may also experience an atrial or a ventricular gallop.

Other causes

Drugs.Palpitations may result from drugs that precipitate cardiac arrhythmias or increase cardiac output, such as cardiac glycosides; sympathomimetics, such as cocaine; ganglionic blockers; beta-adrenergic blockers; calcium channel blockers; atropine; thyroid supplements; and minoxidil.

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Heart Murmur as a complication of other conditions:

Other conditions that might have Heart Murmur as a complication may, potentially, be an underlying cause of Heart Murmur. Our database lists the following as having Heart Murmur as a complication of that condition:

• Bicuspid aortic valve

Heart Murmur as a symptom:

Conditions listing Heart Murmur as a symptom may also be potential underlying causes of Heart Murmur. Our database lists the following as having Heart Murmur as a symptom of that condition:

• Acute rheumatic fever
• Amyloidosis
• Aorta conditions
• Aortic coarctation
• Aortic valve disease
• Aortic Valve Insufficiency
• Aortic valves stenosis of the child
• Aorto-ventricular tunnel
• Atrial Septal Defect
• Axenfeld-Rieger anomaly with cardiac defects and sensorineural hearing loss
• Bacterial endocarditis
• Cardiac malformation
• Cardioauditory syndrome of Sanchez- Cascos
• Chromosome 12q duplication syndrome
• Chromosome 17p, partial deletion
• Chromosome 17q, partial duplication
• Chromosome 3, monosomy 3p
• Chromosome 4q duplication syndrome
• Chromosome 7p deletion syndrome
• Chromosome 8p inverted duplication syndrome
• Chromosome 9, monosomy 9p
• Congenital cardiovascular malformations
• Congenital heart defects
• Congenital mitral malformation
• Conotruncal heart malformations
• Cor biloculare
• Cor Triatriatum
• Coronaro-cardiac fistula
• DiGeorge's syndrome
• Eisenmenger Syndrome
• Endocarditis
• Heart cancer
• Heart Murmur
• Hypertrophic cardiomyopathy
• Kozlowski-Celermajer syndrome
• Loeffler's endocarditis
• Marfan syndrome
• Midline field defects
• Mitral valve prolapse syndrome
• Mitral-valve prolapse
• Mucopolysaccharidoses
• Mucopolysaccharidosis type I Hurler syndrome
• Mucopolysaccharidosis VI
• Mungan syndrome
• Pulmonary atresia - intact ventricular septum
• Pulmonary branches stenosis
• Pulmonary incompetence
• Pulmonary supravalvular stenosis
• Pulmonary valve disease
• Pulmonary venous return anomaly
• Rheumatic fever
• Seronegative spondyloarthropathy
• Tricuspid valve diseases
• Trisomy 5 mosaicism
• Valvular dysplasia of the child
• Velocardiofacial syndrome
• Ventricular septal defect
• Ventriculo-arterial discordance, isolated
• WAGR Syndrome
• Wilms tumor and radial bilateral aplasia
• Wilms tumour and pseudohermaphroditism
• Wilms' tumor
• Wolcott-Rallison syndrome
• Yorifuji Okuno syndrome
• Zunich neuroectodermal syndrome

Related information on causes of Heart Murmur:

As with all medical conditions, there may be many causal factors. Further relevant information on causes of Heart Murmur may be found in:

• Risk factors for Heart Murmur
• Hidden causes of Heart Murmur