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The Diastolic Murmurs

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The Diastolic Murmurs Published online: 2019-12-30 THIEME 228 TheClinical Diastolic Rounds Murmurs Patnaik The Diastolic Murmurs Amar Narayan Patnaik1 1Department of Cardiology, Star Hospitals, Hyderabad, Telangana, Address for correspondence Amar Narayan Patnaik, MD, DM, India FSCAI, FACC, Department of Cardiology, Star Hospitals, 8-2-594/B, Rd Number 10, Banjara Hills, Hyderabad, Telangana 500034, India (e-mail: [email protected]). Ind J Car Dis Wom 2019;4:228–232 By definition, a murmur that starts with or after the second murmurs occupying more than 50% of diastole are regarded heart sound (S2) but ends at or before the first heart sound as long murmurs. Gradation of intensity: It can be graded into (S1) is called a diastolic murmur. Unlike the systolic murmurs 6 as it is done conventionally for the systolic murmur, but which are quite prevalent even in those without a significant some believe that using only 4 grades (grade I–barely audible, cardiac defect, the diastolic murmur almost all times sug- grade II–audible but soft, grade III–easily audible, and grade gests a significant cardiac abnormality. IV–loud and clear) is more appropriate. Frequency/ pitch/ configuration: The frequency (low, medium, and high), low (25–150 Hz) or high pitch and the configurations like cre- Scheme of Evaluation of a Murmur scendo or decrescendo are assessed. Low-pitched murmurs Any cardiac murmur including the diastolic murmurs are best heard with bell of the stethoscope which is applied should be assessed for the timing, intensity (grade), pitch very light. High-pitched murmurs are best heard with the (frequency), configuration, quality, location, and radiation. diaphragm of the stethoscope. These high-frequency mur- Sometimes maneuvers like inspiration/expiration, change of murs can be missed in presence of noise in the doctor’s clinic posture, leg rising, hand-grip, Valsalva/Muller, or use of amyl or the wards. With aging, the physicians may develop hearing nitrate may have to be used to understand the true nature of difficulties with the high-pitched murmurs. Site of maximum a murmur.1 intensity and transmission: This will give valuable informa- Timing: Diastolic murmur is more precisely timed as early tion about the origin of a murmur. (starts with A2 or P2 and ends at a variable distance in dias- Maneuvers and dynamic auscultation (►Table 1): An alter- tole but does not reach S1), mid (starts after A2 or P2 with ation in any of the features of a murmur due to change in a gap between the A2 or P2 and murmur, and end before posture, respiration, leg-raising, isometric hand grip, Val- S1), or late (starts well after the middle of the diastole but salva/Muller’s maneuvers, or by use of drugs like amyl nitrate extends up to M1 or T1) (►Fig. 1). Duration: In general, the may give a clue about the murmurs. Inspiration increases the murmur of mild to moderate pulmonic stenosis (PS), pul- monary regurgitation (PR), tricuspid regurgitation (TR), and tricuspid stenosis (TS). Expiration also augments mitral ste- nosis (MS) murmur. Valsalva—during strain phase, there is reduced venous return, decreased right and left ventricular volumes, and decreased systemic pressure leading to dimin- ished intensity of flow murmurs as well as the murmurs of aortic regurgitation (AR), PR, and MS. Amyl nitrate inhalation causes potent systemic vasodilatation resulting in decreasing the intensity of AR murmur. It is followed by reflex tachycar- dia which increases the right-sided murmurs.1 The diastolic murmurs are classified as early, mid, or Fig. 1 The auscultogram pictures in various diastolic murmurs. late diastolic murmurs based on the timing and they can be (a) Early diastolic decrescendo murmur occupying less than 50% caused by a variety of clinical entities as outlined in ►Table 2. of diastole (mild chronic AR or PR). (b) Mid-diastolic murmur with presystolic murmur, that started with on opening snap—typical of a significant mitral stenosis. (c) Late diastolic murmur crescendo type. Early Diastolic Murmurs (d) Short mid-diastolic murmur after an S3 (generally a flow mur- mur). Abbreviations: S1, first heart sound; S2, second heart sound; Semilunar valve damage leads high velocity regurgi- S3, third heart sound; OS, opening snap. tant flow in early diastole from the great artery into the published online DOI https://doi.org/ ©2019 Women in Cardiology and December 30, 2019 10.1055/s-0039-3402692 Related Sciences The Diastolic Murmurs Patnaik 229 Table 1 Dynamic auscultation to define the diastolic murmurs Change in posture Inspiration/expiration Leg rising Hand-grip Valsalva-strain Amy lnitrate MS Left lateral Expiration augments MS Murmur Diminished Murmur increases murmur increases intensity TS Leg raising Inspiration increases the Increased Murmur increases murmur of TS murmur AR Sitting, leaning forward Held expiration Murmur Increased Diminished intensity increases intensity PR Inspiration increases the Increased Murmur increases murmur of PR murmur Table 2 Conditions producing diastolic murmurs Common Uncommon EDM 1. Chronic aortic regurgitation (congenital valve deformity, rheumatic, endocarditis, Key Hodgkin’s murmur prolapse, postsurgical or balloon Valvotomy, trauma, dilated aortic root/annulus, aortic Cole Cecil murmur Dock’s murmur dissection). Cabot Locke murmur 2. Pulmonary regurgitation (secondary to PHTN, congenital defect, postvalvuloplasty, Carcinoid disease post-ICR for TOF, endocarditis, annular dilation due to Marfan/other collagen disorders Rheumatic PR or idiopathic dilatation of PA) Catheter-induced trauma to PV MDM 1. Mitral/tricuspid stenosis Prosthetic valve 2. Carey Coombs murmur 3. LA/RA myxoma 4. Carcinoid 5. Flow murmurs in ASD, PDA, VSD, or severe MR/ TR 6. Austin Flint murmur LDM Presystolic murmurs (MS/TS) Rytand’s murmur: In CHB Abbreviations: CHB, complete hear block; PA, pulmonary artery; PHTN, pulmonary hypertension. respective ventricle. This creates a high-pitched murmur systolic murmur due to the large stroke volume and Aus- starting with the semilunar valve closure. Decrescendo tin Flint murmur may be heard. configuration of the murmur is typical representing the 2. Acute AR: The murmur is softer and shorter because the pressure change. Generally large regurgitant volume LV diastolic pressure rises rapidly diminishing the aor- makes the murmur longer, but the correlation is well- tic-LV pressure gradient. Additionally, tachycardia, soft S1, matched. Inspiration increases the pulmonary regurgitant and absence of signs of aortic runoff are the clue to diag- murmur and at held expiration the AR murmur is best nose acute/subacute AR. The EDM is softer and shorter in heard. Chronic aortic regurgitation and pulmonary regur- acute AR. It can have a medium frequency. gitation are the most common causes of an end diastolic EDM due to pulmonary regurgitation can occur due to a murmur (EDM). variety of conditions like pulmonary hypertension (Graham 1. Chronic aortic regurgitation. High-pitched blowing de- Steell murmur), congenital defect, postvalvuloplasty, post- crescendo murmur is typical character of severe chronic ICR for TOF, endocarditis, carcinoid disease, annular dilation AR. The common entities that cause aortic regurgitation due to Marfan/other collagen disorders, or idiopathic dil- include congenital valve deformity, rheumatic, endocardi- atation of PA. Other rare causes of low-pressure PR include tis, prolapse, postsurgical or balloon valvotomy, trauma, carcinoid syndrome, rheumatic valve disease, and catheter dilated aortic root/annulus, aortic dissection, and so forth. induced trauma. Isometric handgrip increases systematic vascular resis- 3. PR associated secondary to PAH: It produces a variable du- tance (SVR) and AR murmur increases. The murmur may ration of localized (best heard in left second and third in- have a musical quality (diastolic whoop), when it occurs tercostal spaces) high-pitched blowing early decrescendo due to everted aortic cusp. The murmurs due to primary diastolic murmur like AR murmur which increases with aortic valve disease are best heard at left parasternal areas, inspiration. It is the most common example of PR and is whereas those due to dilated aortic root are often well popularly known as Graham Steell murmur.2 heard at the right sternal border. Sitting/leaning forward 4. PR that occurs following repair of tetralogy of fallot (TOF) posture will make the AR murmur more audible. Held ex- is typically low-pitched and soft due to normal PA pres- piration is the best time to hear the AR murmur clearly. It sures. There may be a to-and-fro murmur or no murmur can be augmented by maneuvers that increase afterload at all. ►Table 3 highlights important differences between like squatting and on isometric handgrip. Additionally, a AR and PR murmur. Indian Journal of Cardiovascular Disease in Women WINCARS Vol. 4 No. 4/2019 230 The Diastolic Murmurs Patnaik Table 3 Differentiating AR murmur from PR murmur murmur. A tumor-plop, a low-pitched murmur may be heard in a few cases especially in some postures. Feature AR murmur PR murmur 4. Tricuspid stenosis: Rheumatic tricuspid valve involve- Best site Aortic area Pulmonary area ment almost always occurs along with mitral valve Posture Sitting, leaning forward Supine lesions. The TS murmur is scratchy and becomes longer Signs of run off present Absent and louder by any maneuver that increases the venous Apex LV type (hyperdynamic RV type return like inspiration, leg rising, exercise, or Muller’s and unsustained) maneuver. The two murmurs can be distinguished sep- Associated – Loud P2, RV lift, MS arately based on the character and location (►Table 4). signs The murmur resembles mitral stenotic murmur but in- creases in intensity on inspiration (Carvallo’s sign) and Mid-Diastolic Murmurs may be confined to late diastole. There may be an open- Mitral stenosis produces the prototype mid-diastolic mur- ing snap and an occasional split first heart sound. The mur (MDM). A narrowed mitral valve produces a pressure a-wave in jugular venous pressure (JVP) may be prom- gradient between the left atrium and the left ventricle.
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