Continuous Murmur

Differential Overview

❑ 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

Diagnostic Approach

Continuous murmurs begin in systole and extend into diastole without interruption. The murmur results from blood flow from a higher pressure chamber or vessel to a lower pressure system, with the gradient maintained during both systole and diastole, for example with aortopulmonary and arteriovenous connections.

Clinical Findings

Aortic stenosis/aortic insufficiency  A to-and-fro murmur that radiates into the carotids.

Pericardial friction rub  Discrete harsh/scratching sounds are heard, synchronized with the heartbeat, composed of one, two, or three components.

Pulmonary arteriovenous fistula  The murmur is localized over one area of the chest, usually the left lower lobe or the right middle lobe. The murmur is louder during systole. Telangiectasias can usually be found cutaneously in patients with cirrhosis and on the lips and tongue in those with hereditary hemorrhagic telangiectasia.

Venous hum  The murmur is usually best heard over the supraclavicular fossa, increases with sitting, and disappears with compression of the jugular vein.

Mammary souffle  A shuffling sound is produced by increased blood flow with engorged breasts late in pregnancy or with breast-feeding.

Aortic coarctation  The murmur can be heard in the interscapular region, caused by enhanced flow within enlarged intercostal arteries. The blood pressure in the legs will be low compared with the arms.

Mediastinal air dissection  Usually a complication of mechanical ventilation, air dissection produces a continuous crunching sound and is associated with subcutaneous emphysema.

Patent ductus arteriosis  A “machinery” murmur with late systolic accentuation is best heard in the pulmonic area and is loudest at S₂. A thrill is present. If right-to-left shunting has developed, cyanosis will be observed, and the systolic component of the murmur may be absent.

Ruptured sinus of Valsalva  Marked by sudden development of a continuous murmur with a thrill over the base of the heart, it is caused by a ruptured aneurysm, usually as a complication of endocarditis.

Coronary artery fistula  A right coronary artery to right atrial fistula produces a parasternal continuous murmur. A circumflex to coronary sinus fistula produces a left axillary murmur.

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 Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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• Back to symptom: Slow heartbeat: Introduction (review 48 causes)
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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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