SYSTOLIC MURMURS are com- monly encountered in family prac- tice. Sometimes their differential diag- nosis is difficult. How do you deter- mine if a murmur is significant? There are simple methods which can be carried out in a few minutes by any physician using only his hands, a , and a sphygmomano- meter plus an electrocardiogram. |- Ejection versus Regurgitant Or 'Just a Murmur'? Is the murmur caused by ejection, i.e. forward flow through the aortic or DONALD R. FULLER, MD pulmonary valves? Or is it regurgitant, i.e. due to flow from an area of high SUMMARY pressure through an abnormal opening Systolic murmurs are commonly encountered in family practice, to an area of lower pressure, as in often necessitating distinction between ejection and regurgitant mitral and tricuspid insufficiency, murmurs. This distinction can be made by the family physician ventricular septal defect and patent providing he is familiar with the characteristics of both, which are ductus arteriosus? A comparison of described in this article. Practice on normal hearts will help to characteristics for these two types is distinguish the abnormal. shown in Table 1. Dr. Fuller, a certificant of the College, practices in Tavistock, Characteristics of Ontario. Address for reprints: Tavistock Family Health Centre, Ejection Murmurs 80 Maria St., Tavistock, Ontario NOB 2R0. Ejection murmurs end before the second heart sound of their side. They preceded by an S4 (atrial sound or systolic impulse, a definite movement, tend to be crescendo-decrescendo; presystolic left ventricular distention is sustained in aortic stenosis. If there hence the murmur gives a 'rhythmic sound) whereas a flow murmur, an is also ventricular dilatation, the apex effect' when heard with the SI and S2. aortic valve sclerosis murmur or a will be displaced. Further, there may The first heart sound, then the peak of murmur of stenosis with no hemody- be a palpable S4 or late diastolic filling the murmur, then the S2 or second namic significance are not usually pre- impuse in significant aortic stenosis. heart sound give a rhythm of 'lub huh ceded by an S4. However, all these will This occurs just before the first heart dup'. The 'huh' represents the peak of also be propagated to the carotids. sound and may be palpable as an the murmur. This rhythmic effect is in 'extra' movement just before the contrast with the non-rhythmic regur- Peripheral systolic impulse or ''. There gitant or pansystolic murmurs. On physical examination the differ- is usually a thrill at the base in Ejec tion murmurs are usually entiation of significant aortic stenosis significant aortic stenosis which is best louder after a long diastole, i.e. after a from flow or functional murmurs or brought out on full expiration with premature ventricular contraction or non-significant stenotic murmurs - i.e. the patient leaning forward. These in atrial fibrillation, when there is a those without hemodynamic signific- latter findings are all absent in the longer diastole preceding the beat. ance - is aided by palpating the patient with a functional type of This is caused by more ventricular peripheral pulses. N.B. In the peri- ejection murmur. Thus the apex beat filling with longer diastole and all the pheral pulses, especially the carotid, is normal rather than sustained, there blood has to go through one narrowed the functional murmur is associated is no palpable S4 and rarely if ever a opening. Also, the peripheral pressure with a normal peripheral pres- thrill. drops further because of the longer sure with normal rate of rise, and is diastole allowing a greater gradient not sustained or plateau in character. Blood Pressure across the valve. However, the pulse of significant In significant aoftic stenosis there is aortic stenosis shows a decreased pulse rarely much elevation of the systolic Murmur and pressure with a slow rate of rise and a blood pressure and the pulse pressure The aortic stenosis murmur may be sustained or plateau effect. With a is decreased, so that the blood pressure heard loudest anywhere in a straight little practice on normal (fast rising) may be something in the range of line from the second right interspace carotid pulses in patients without valve 110/85 as compared to a normal pa- to the apex. This is not just in the disease, one can appreciate the con- tient who may have a blood pressure classic aortic area, which is the second trast in the carotid pulse of a patient of 130/80. right interspace, but anywhere in this with an obstructed valve. It has a slow 'sash or shoulder harness area'. As with rate of rise and produces a caressing Electrocardiogram any other flow murmur through the sensation instead of the normal brisk The electrocardiogram in significant aortic valve, the aortic stenosis mur- 'tap'. aortic stenosis shows the finding of mur tends to be propagated to the left ventricular hypertrophy with carotid and this helps differentiate it Palpation of Apex, strain pattern, i.e. there is ST sloping from a regurgitant mitral murmur. An S4 and Thrill and T inversion in Lead 1 and in the aortic stenosis murmur tends to be The apex beat or left ventricular left precordial leads. These electro-

90 CAN. FAM. PHYSICIAN 23:322 MARCH 1977 cardiographic findings are not present decreased in volume with a slow rate Conclusion in the patient with insignificant ste- of rise and a sustained plateau, suggest- You can recognize the decreased nosis, valvular sclerosis or functional ing significant aortic stenosis. He had a carotid rate of rise and dynamic apical murmurs, unless they have other palpable S4 or late ventricular filling thrust of aortic obstruction. Some cardiac disease. phenomenon. Cardiac catheterization practice on normals will make the was performed a few months later. At abnormal apparent. You can appreci- Course this time he was taking digitalis but ate the rhythmic nature of the ejection The typical course of aortic stenosis still experiencing moderate shortness murmur as compared to the usually is asymptomatic until the patient of breath on exertion and a much non-rhythmic regurgitant murmur. reaches his forties or fifties. However, decreased exercise tolerance. Over the Knowing that a symptomatic aortic when he begins to develop symptoms four months following his first cardiac stenosis patient is in danger will help the course is short. Thus a patient may catheterization he deteriorated rapidly you to push him to get full assessment. reach age 48 without significant to the point where he had anasarca This is different from patients with symptoms from his increasing obstruc- and marked even other chronic valve problems who tion and myocardial overload and then at rest on full digitalization with maxi- are usually symptomatic for years and suddenly develop congestive heart fail- mal doses of diuretics. At the time of deteriorate slowly. ure, syncope on exertion, or . surgery, eight months after the onset The average survival following the of congestive , he was onset of these symptoms is two years severely disabled even at rest with References or less for the patient with failure, 1. CONSTANT, J.: Bedside Cardiology 2nd shortness of breath and marked Ed. Boston, Little, Brown and Company, approximately three years for the pa- edema. Because of his marked signs 1976. tient with syncope, and on the average and symptoms of failure, his operative 2. MORROW, A. G. (Moderator): N.I.H. up to five years for the patient with risk was very poor. However, he sur- clinical staff conference on obstruction to angina. N.B. Therefore, a patient who vived his valve replacement with a left ventricular outflow. Ann Intern Med 69:1255-1286, 1968. begins to develop symptoms of aortic Starr-Edwards prosthesis, and gradu- 3. WOOD, P.: Diseases of the Heart and stenosis should be followed closely ally improved over the next weeks. He Circulation 2nd Ed. London, Eyre and and should be given the opportunity was able to return to increasing farm Spottiswoode, 1962. for valvular replacement early in his duties within a few months following 4. KEITH, J. D., ROWE, R. D., VLAD, P.: Heart Disease in Infancy and Childhood, 2nd symptomatic course. surgery and returned to doing his own Ed. New York, MacMillan, 1967. milking for the next eight years, when 5. PERLOFF, J. K.: Clinical recognition of Valve Replacement he sold his dairy herd but took up aortic stenosis. Prog Cardiovasc Dis What is the advantage of valvular more actively his 'part time' pursuit of 10:323-352, 1968. replacement? Many patients who have shoe repairing. He is now doing well 6. BRA WLEY, R. K. et al: Current status of BEALL, BJORK-SHILEY, BRA UNWOLD- been operated on in the past for aortic over ten years later. He takes digitalis CUTTER, LILLEHEI-CASTER, SMELOFF- stenosis have been severely limited and dicoumarol, does not require CUTTER Cardiac valve prosthesis. Am J prior to operation. Following opera- diuretics, and carries on an active life. Card 3S:855-865, 1975. tion the majority of those who have survived (there is an immediate opera- tive mortality of about eight to 15 percent) have improved substantially TABLE 1 in functional ability. Many, if not all, A Comparison of Characteristics of Ejection and Regurgitant Murmurs are able to return to their previous occupation. There is a dramatic de- Ejection Regurgitant crease in workload for the left Duration 1. if early components, they ventricle, usually with a significant start with first heart decrease in heart size. sound of their side Case History end before the second 2. if late component, they Mr. D.R. presents a typical history heart sound of their side go to or past the second of a patient with aortic stenosis. He heart sound of their side was a vigorous farmer carrying on Shape & crescendo-decrescendo or any shape usually no mixed farming until approximately the 'rhythm' diamond shape, producing rhythmic effect age of 55 when his first symptom was a rhythmic effect* that of syncope on hurrying. Approx- imately eight months later he began to Change with get louder no change - two openings develop some and shortness of long diastole i.e. semilunar or normal breath on exertion, together with valve plus abnormal opening other signs of congestive heart failure. Examination revealed a grade IV out Pitch or any, but usually mixed any, but often high fre- of VI systolic ejection murmur, max- 'frequency' frequencies i.e. high, quencies especially when imum over the upper sternum and medium and low, but soft (i.e. blowing like a propagated well into the carotids. when soft, retain low drawn out whispered 'huh') (Since it was a grade IV murmur this and medium frequencies automatically indicates that a thrill was present). The carotid pulse was *See paragraph on characteristics of ejection murmurs

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