Materiały źródłowe

• #1 CV Physiology | Murmurs

  https://cvphysiology.com/heart-disease/murmurs

  Murmurs are abnormal heart sounds that are heard using a stethoscope. The sounds most commonly originate from the abnormal movement of blood across valves and between cardiac chambers. When this occurs, turbulence results, which produces vibrations in the chambers of the heart or outflow vessels (aorta or pulmonary artery) that are detected as audible, low-frequency sounds. […] To understand the pathophysiology of murmurs, it is first necessary to understand the physical factors governing the flow of blood (i.e., hemodynamics), the basic anatomy of the heart, and the sequence of events that occurs as the heart contracts and relaxes (i.e., cardiac cycle). […] Murmurs can also be separated into systolic and diastolic murmurs. The former occurs during ventricular contraction (systole) and the latter occurs during ventricular filling (diastole).

• #2 Heart murmur pathophysiology – wikidoc

  https://www.wikidoc.org/index.php/Heart_murmur_pathophysiology

  Turbulent flow is responsible for most murmurs. Turbulent flow occurs when the velocity of blood flow becomes critically high because of a high volume of flow, the flow goes through an irregular or narrow area, the flow empties into a dilated vessel or chamber, or if the flow goes backward through an incompetent valve, septal defect, or patent ductus arteriosus. Frequently, a combination of these factors is operative. The sounds most commonly originate from the abnormal movement of blood across valves and between cardiac chambers. When this occurs, turbulence results, which produces vibrations in the chambers of the heart or outflow vessels that are detected as Murmurs. […] Aortic stenosis is a progressive narrowing. When the aortic valve area decreased by at least half, there will be a change in the antegrade velocity at the level of the aortic valve and also at the subvalvular (below the aortic valve) or supravalvular (above the aortic valve) levels. this will lead to chronic pressure overload in the left ventricle.

• #3 Physiology, Cardiovascular Murmurs – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK525958/

  Murmurs of the cardiac system develop due to alterations in blood flow or mechanical operation. […] The development of murmurs is highly dependent on the etiology and is not always associated with a pathologic process. […] Murmurs develop from a multitude of mechanisms. […] Regardless of underlying etiology, all involve the creation of disturbed blood flow, which produces a murmur. […] Hypertrophic obstructive cardiomyopathy is an inherited myocardial disease in which the myocardium undergoes hypertrophic changes. […] These changes cause a systolic ejection murmur due to the mitral valve hitting the thickened septal wall during systole. […] The murmur is heard best between the apex and the left sternal border. […] It becomes louder with any maneuver that decreases preload or afterload, such as Valsalva or abrupt standing.

• #4 Heart Murmurs Topic Review | Learn the Heart

  https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/heart-murmurs

  Disease of the cardiac valves and other cardiac structures frequently results in abnormal, turbulent blood flow within the heart, causing murmurs. […] When normal laminar blood flow within the heart is disrupted, an audible sound is created by turbulent blood flow. […] There are four major causes of cardiac murmurs. […] Valvular stenosis: If blood is forced through a tight area, turbulent blood flow ensues, as is the case in valvular stenosis. […] Valvular insufficiency: Blood abnormally travels backward through an incompetent valve in valvular insufficiency, causing turbulence when it meets normal, forward blood flow. […] Congenital anomaly: If blood is forced through a congenital anomaly from one chamber to another, as in an atrial septal defect or ventricular septal defect, a murmur is produced — again due to turbulence.

• #5 Physiology, Cardiovascular Murmurs – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK525958/

  Murmurs of the cardiac system develop due to alterations in blood flow or mechanical operation. […] The development of murmurs is highly dependent on the etiology and is not always associated with a pathologic process; benign murmurs are common in children and during pregnancy. […] Murmurs develop from a multitude of mechanisms. Typical cases include low blood viscosity from anemia, septal defects, failure of the ductus arteriosus to close in newborns, excessive hydrostatic pressure on cardiac valves causing valve failure, hypertrophic obstructive cardiomyopathy, and valvular specific pathologies. Regardless of underlying etiology, all involve the creation of disturbed blood flow, which produces a murmur. […] Murmurs have been closely linked to a multitude of diseases throughout the centuries. There are several common murmurs and cardiac disease states from which each specific murmur develops.

• #6 Systolic Murmurs – Heart Murmurs – Heart Auscultation – Signs and Symptoms – McMaster Textbook of Internal Medicine

  https://empendium.com/mcmtextbook/chapter/B31.I.1.107.2.1.

  In systole, ventricular pressures exceed aortic and pulmonary artery pressures as well as atrial pressures. Outflow murmurs occur due to blood flow through a stenotic semilunar valve (aortic or pulmonary) or obstructed ventricular outflow tract. Regurgitant murmurs occur due to retrograde blood flow through an incompetent atrioventricular valve (mitral or tricuspid). Physiologic or flow murmurs occur due to increased blood flow through an otherwise normal valve. Ventricular septal defects result in left-to-right shunting of blood through the defect as left ventricular pressures usually exceed those on the right. […] Midsystolic Murmurs […] Mechanism: Blood flowing through a narrowed valve or increased cardiac output in a person with a normal valve area; rarely due to inflow of blood into a dilated vessel. […] Pansystolic Murmurs […] Causes: Mitral or tricuspid regurgitation (backflow of blood from the ventricle into the atrium), ventricular septal defect (blood flow between the left and right ventricle).

• #7 Heart Murmurs

  https://www.utmb.edu/pedi_ed/CoreV2/Cardiology/cardiologyV2/cardiologyV24.html

  Continuous murmurs are heard during both systole and diastole. They occur when there is a constant shunt between a high and low pressure blood vessel. Examples: patent ductus arteriosus (PDA) and systemic arterio-venous fistulas. This may also occur in surgically placed shunts such as a BT shunt between the aorta and the pulmonary artery. […] Innocent murmurs are common in children and have the following characteristics: Grade III or less in intensity, an otherwise normal cardiac examination and normal heart sounds, no associated cardiac symptoms, change in intensity with body position (e.g. louder in supine position).

• #8 Heart Sounds and Murmurs – Cardiovascular Pathophysiology for Pre-Clinical Students

  https://pressbooks.lib.vt.edu/cardiovascularpathophysiology/chapter/chapter-5-heart-sounds-and-murmurs/

  Aortic stenosis produces a midsystolic murmur that has a crescendodecrescendo pattern (intensity builds up, then fades). This pattern relates to the level of turbulent flow through the narrowed valveslow at first as the resistance is overcome, then fading away as blood flow decreases. […] Mitral/tricuspid regurgitation produces a holosystolic murmur as the incompetent valve allows a constant turbulent (and reverse) flow from the ventricle back to the atria. […] Ventricular septal defect produces a holosystolic murmur when severe. Turbulent flow through the defect is constant as the left ventricular pressure is higher than right ventricular pressure throughout systolehence a continuous leftright shunt is established. […] Aortic regurgitation produces a blowing diastolic murmur that is usually decrescendo. This early diastolic murmur is short because rapidly rising ventricular pressure (due to atrial and aortic contributions) ends the reverse flow from the aorta. In cases when the aortic pressure is high, the regurgitation may be sustained and the murmur becomes pandiastolic. […] Mitral stenosis produces a diastolic murmur that starts late as the stenosed valve prevents atria-to-ventricular flow until high atrial pressures are established. The murmur may be preceded by a middiastolic click as the atrial pressure finally flings the valve open.

• #9 5.1: Heart sounds and murmurs – Medicine LibreTexts

  https://med.libretexts.org/Courses/Virginia_Tech_Carilion_School_of_Medicine/Cardiovascular_Pathophysiology_for_Pre-Clinical_Students_(Binks)/05%3A_Heart_Sounds_and_Murmurs/5.01%3A_Heart_sounds_and_murmurs

  A murmur is the sound of turbulence associated with abnormal blood flow through a valve or chamber. The turbulent flow produces low-frequency audible sounds that are distinct from heart sounds associated with valve closures. Murmurs can be divided into those caused by valvular defects and those caused by abnormal interchamber flow. Depending on the defect involved, the murmur may occur during diastole and systole, hence distinguishing whether a murmur is diastolic or systolic is a useful first diagnostic step. […] Aortic stenosis produces a midsystolic murmur that has a crescendodecrescendo pattern (intensity builds up, then fades). This pattern relates to the level of turbulent flow through the narrowed valveslow at first as the resistance is overcome, then fading away as blood flow decreases.

• #10 Heart murmur pathophysiology – wikidoc

  https://www.wikidoc.org/index.php/Heart_murmur_pathophysiology

  chronic pressure caused by aortic stenosis lead to a slow compensatory mechanisms, the most prominent one is ventricular hypertrophy that leads to diastolic dysfunction and systolic dysfunction. […] Aortic insufficiency develop when the pressure in the left ventricle falls below the pressure in the aorta, leading to volume overload of the left ventricle. […] In acute aortic insufficiency: Sudden decrease in stroke volume and increase in left ventricular end diastolic volume causing decrease cardiac output and reflex tachycardia, which eventually lead to profound hypotension and cardiogenic shock. […] In chronic aortic insufficiency: there is compensation for increased left ventricular end diastolic volume by progressive left ventricular dilatation and left ventricular hypertrophy, which maintains normal wall stress.

• #11 Physiology, Cardiovascular Murmurs – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK525958/

  Aortic stenosis is caused by narrowing the aortic valve and is the most common valvular pathology in the developed world. […] Aortic regurgitation, also known as aortic insufficiency, is a decrescendo blowing diastolic murmur heard best at the left lower sternal border, heard when blood flows retrograde into the left ventricle. […] This type of murmur is usually mid-systolic, caused by increased cardiac output. […] Pulmonary stenosis is a systolic murmur best heard at the upper left sternal border and commonly associated with tetralogy of Fallot, carcinoid syndrome, congenital rubella syndrome, and Noonan syndrome. […] Mitral regurgitation is a systolic murmur, best heard at the left 5th midclavicular line with possible radiation to the left axilla. […] Hypertrophic obstructive cardiomyopathy is an inherited myocardial disease in which the myocardium undergoes hypertrophic changes. These changes cause a systolic ejection murmur due to the mitral valve hitting the thickened septal wall during systole.

• #12 Heart murmur pathophysiology – wikidoc

  https://www.wikidoc.org/index.php/Heart_murmur_pathophysiology

  Mitral stenosis (MS) is most commonly secondary to acute rheumatic fever. Generally, the initial valvulitis is associated with valvular regurgitation then over the years, the commissures fuse and the valves thicken and calcify. […] When the cross sectional area goes below 2 cm2: there will be impediment to the flow of blood into the left ventricle, creating a pressure gradient that increased by increases in the heart rate or cardiac output. […] When the mitral valve area goes less than 1 cm2: the pressure gradient across the mitral valve will be 20 mm Hg and the left atrial pressure about 25 mm Hg. […] Acute Mitral Regurgitation Develop when there is sudden disruption of one or more of the components of the mitral valve, such as leaflet perforation, rupture of a chordae tendineae, or rupture of the papillary muscle.

• #13 Heart murmur pathophysiology – wikidoc

  https://www.wikidoc.org/index.php/Heart_murmur_pathophysiology

  In the acute setting, the total stroke volume is increased, but the forward cardiac output into the aorta is decreased because a proportion of the blood is going backward into the left atrium. […] Chronic decompensated mitral regurgitation: In this phase, the ventricular myocardium is no longer able to contract adequately to compensate for the volume overload of MR, and the stroke volume of the left ventricle begins to decrease.

• #14 Physiology, Cardiovascular Murmurs – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/books/NBK525958/

  This effect occurs because the lower ventricular blood volume from reduced preload or afterload allows for a closer approximation of the mitral valve to the hypertrophied septal wall, causing more turbulent blood flow. […] Chronic rheumatic heart disease is a sequela of untreated streptococcal pharyngitis and acute rheumatic fever. […] Autoimmune driven destruction occurs as a result of molecular mimicry between streptococcal M protein and the cardiac tissue.

• #15 Heart murmur – Wikipedia

  https://en.wikipedia.org/wiki/Heart_murmur

  Atrial septal defect will present with a systolic crescendo-decrescendo murmur. It is best heard at the left upper sternal border. This is the result of an increased volume going through the pulmonary valve. It has association with a fixed, split S2 and a right ventricular heave. […] Ventricular septal defect (VSD) will present as a holosystolic murmur. One can hear it at the left lower sternal border. It has association with a palpable thrill, and increases with isometric handgrip. A right to left shunt (Eisenmenger syndrome) may develop with uncorrected VSDs. This is due to worsening pulmonary hypertension. Pulmonary hypertension will increase the murmur intensity and may present with cyanosis.

• #16 Physiology, Cardiovascular Murmurs – StatPearls – NCBI Bookshelf

  https://www.ncbi.nlm.nih.gov/sites/books/NBK525958/

  Carcinoid syndrome causes thickening of the tricuspid and pulmonary valves, which leads to either stenosis or regurgitation murmurs from the valves. […] Chronic rheumatic heart disease is a sequela of untreated streptococcal pharyngitis and acute rheumatic fever. Autoimmune driven destruction occurs as a result of molecular mimicry between streptococcal M protein and the cardiac tissue.

• #17 Heart murmurs – Symptoms & causes – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/heart-murmurs/symptoms-causes/syc-20373171

  Heart murmurs are sounds such as whooshing or swishing made by rapid, choppy (turbulent) blood flow through the heart. […] A heart murmur is caused by rapid, choppy (turbulent) blood flow through the heart. A heart murmur may happen: […] In children, worrisome murmurs are usually due to a problem with the heart’s structure that’s present at birth (congenital heart defect). […] In adults, worrisome heart murmurs are usually due to heart valve problems that develop later in life (acquired heart valve disease). […] Calcium deposits can cause a heart valve such as the mitral valve or the aortic valve to become stiff and narrow (valve stenosis). […] A murmur may occur if the infection is untreated and affects the heart valves. […] When rheumatic fever affects the heart valves, it’s called rheumatic heart disease. A heart valve problem can cause a murmur.

• #18 Heart Auscultation (Heart Sounds and Murmurs) | Doctor

  https://patient.info/doctor/heart-auscultation

  Not all murmurs arise from heart valves. Some are flow murmurs where rapid flow during ejection causes turbulence, especially at the pulmonary or aortic outlet. This occurs in a hyperdynamic state as in anaemia, severe thyrotoxicosis or possibly with fever. It may also occur in pregnancy but it is essential to exclude cardiac disease. The flow murmur of atrial septal defect is described below. […] Atrial septal defect with a significant left to right shunt will produce a pulmonary flow murmur. The murmur does not originate from the atria and, unless there is a significant shunt, there may be no murmur. Ventricular septal defect produces a harsh systolic murmur, heard best along the left sternal edge. […] Infective endocarditis can be difficult to diagnose but carries a high mortality and a change in the murmur may be an important feature.

• #19 Heart Murmurs: Causes, Diagnosis, Treatment, Prevention

  https://www.webmd.com/heart-disease/heart-murmur-causes-treatments

  Mitral or aortic regurgitation. Blood flows the wrong way through your mitral or aortic valve and back into your heart. Your heart must work harder to force blood through the damaged valve. Over time, this can weaken or enlarge your heart and lead to heart failure. […] Other heart conditions that can cause a murmur include: […] Endocarditis. The bacteria or other germs that cause this infection attack and damage your heart valves. […] Calcium buildup. Calcium can deposit on a heart valve and make it stiff and narrow. The valve may not be able to close all the way, which allows blood to flow backward. […] Marfan syndrome. This inherited condition affects the connective tissue that holds your body together. Marfan syndrome can make your valves larger than normal. Blood flows backward through the faulty valves when your heart pumps. […] Rheumatic fever. This is a complication of untreated strep throat. Rheumatic fever is rare in the U.S., but it can damage the heart valves and cause a murmur.

• #20 Heart Murmurs

  https://www.utmb.edu/pedi_ed/CoreV2/Cardiology/cardiologyV2/cardiologyV24.html

  Murmurs are additional sounds generated by turbulent blood flow in the heart and blood vessels. Murmurs may be systolic, diastolic or continuous. […] Systolic ejection murmurs (SEM, crescendo-decrescendo) result from turbulent blood flow due to obstruction (actual or relative) across the semilunar valves, outflow tracts or arteries. The murmur is heard shortly after S1 (pulse). The intensity of the murmur increases as more blood flows across an obstruction and then decreases (crescendo-decrescendo or diamond shaped). Innocent murmurs are the most common cause of SEM. Other causes include stenotic lesions (aortic and pulmonary stenosis, coarctation of the aorta, tetralogy of Fallot) or relative pulmonary stenosis due to increased flow from an ASD. […] Holosystolic (regurgitant) murmurs start at the beginning of S1 (pulse) and continue to S2. Examples: ventricular septal defect (VSD), mitral and tricuspid valve regurgitation.

• #21 Heart Murmurs Topic Review | Learn the Heart

  https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/heart-murmurs

  A ventricular septal defect produces yet another holosystolic murmur. […] Diastolic murmurs include aortic and pulmonic regurgitation (early diastolic) and mitral or tricuspid stenosis (mid- to late-diastolic). […] The murmur of aortic regurgitation is a soft, high-pitched, early diastolic, decrescendo murmur usually heard best at the third intercostal space on the left. […] Mitral stenosis results in a uniquely-shaped, low-pitched, diastolic murmur best heard at the cardiac apex. […] Dynamic auscultation refers to using maneuvers to alter hemodynamic parameters during cardiac auscultation in order to diagnose the etiology of a heart sound or murmur.

• #22 Heart Murmurs Topic Review | Learn the Heart

  https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/heart-murmurs

  Increased blood flow: Yet another cause of cardiac murmurs is increased flow of blood through a normal valve. […] The intensity of a murmur is primarily determined by the volume/velocity of blood flowing through a defect and the distance between the stethoscope and the lesion. […] The shape of a murmur describes the change of intensity throughout the cardiac cycle. […] A murmur will be high pitched if there is a large pressure gradient across the pathologic lesion and low pitched if the pressure gradient is low. […] The anatomic location where the murmur is best heard is an important factor in determining the etiology of the lesion. […] While murmurs are usually most intense at one specific listening post, they often radiate to other listening posts or areas of the body. […] The murmur of aortic stenosis is a high-pitched, crescendo-decrescendo (diamond shaped), midsystolic murmur located at the aortic listening post and radiating toward the neck.

• #23 Auscultation of cardiac murmurs in adults – UpToDate

  https://www.uptodate.com/contents/auscultation-of-cardiac-murmurs-in-adults

  Cardiac murmurs are the direct result of blood flow turbulence. The amount of turbulence and consequently the intensity of a cardiac murmur depend on the size of the orifice or vessel through which the blood flows; the pressure difference or gradient across the narrowing; and the blood flow or volume across the site. […] Murmurs are generally the loudest near the point of origin since sound radiates away from its source, and the intensity diminishes according to the inverse square law (inversely proportional to the square of the distance from the source). Other factors influence this relationship including the transmission characteristics of the tissues (eg, fat and air), the distance from the location of auscultation to the origin of the murmur (eg, truncal obesity, emphysema), and the course of flow.

• #24 Heart Murmurs | American Heart Association

  https://www.heart.org/en/health-topics/heart-murmurs

  Innocent heart murmurs are sounds made by blood circulating through the heart’s chambers and valves, or through blood vessels near the heart. […] Non-innocent (or abnormal) heart murmurs are often caused by defective heart valves. For example, a stenotic heart valve has a smaller-than-normal opening and can’t open completely. Or a valve may also be unable to close completely. This leads to regurgitation, which is blood leaking backward through the valve when it should be closed. […] Certain congenital defects and other conditions such as pregnancy, fever, anemia or thyrotoxicosis (a condition caused by an overactive thyroid gland) can also cause murmurs. […] A murmur that occurs when the heart muscle relaxes between beats is called a diastolic murmur. A systolic murmur occurs when the heart muscle contracts. […] Systolic murmurs are graded by intensity (loudness) from 1 to 6. A grade 1 is faint, heard only with a special effort. It’s softer than the normal heart sounds. A grade 6 is extremely loud, and can be heard with no contact between stethoscope and the chest.

• #25 Heart Murmurs: Types of Murmurs, Causes and Outlook | Nationwide Children’s Hospital

  https://www.nationwidechildrens.org/conditions/heart-murmurs

  Murmurs are extra or unusual sounds made by blood circulating through the heart’s chambers or valves, or through blood vessels near the heart. […] Systolic murmurs are divided into ejection murmurs (often due to blood flow through a narrowed vessel or irregular valve) and regurgitant murmurs (typically due to mitral or tricuspid regurgitation where the blood leaks back into the atria from the ventricles). […] Diastolic murmurs are due to a narrowing (stenosis) of the mitral or tricuspid valves, or regurgitation of the aortic or pulmonary valves. […] Murmurs related to a congenital (present at birth) heart defect or other problem involving the heart structures will be heard the loudest in the area of the chest where the problem occurs. […] Heart murmurs may be caused by a number of factors or diseases, including the following: Defective heart valves, Holes in the interior heart walls (atrial septal defect or ventricular septal defect), Congenital (present at birth) heart defects, Fever, Anemia (a decrease in the red blood cells). […] Not all heart murmurs are symptoms of heart disease.

• #26 Heart Murmurs Topic Review | Learn the Heart

  https://www.healio.com/cardiology/learn-the-heart/cardiology-review/topic-reviews/heart-murmurs

  The intensity of the murmur of AS is not a good indicator as to the severity of disease. […] The murmur of pulmonic stenosis is very similar to that of aortic stenosis. […] The murmur produced by an atrial septal defect is due to increased flow through the pulmonic valve, making it remarkably similar to that of PS. […] The murmur of hypertrophic obstructive cardiomyopathy is important to detect due to its clinical implications. […] Holotsystolic murmurs — also known as pansystolic — include the murmurs of mitral regurgitation, tricuspid regurgitation and ventricular septal defects. […] The murmur of mitral regurgitation is described as a high-pitched, “blowing” holosystolic murmur best heard at the apex. […] The murmur of tricuspid regurgitation is similar to that of MR in that it is high pitched and holosystolic.

• #27 Heart murmur – Wikipedia

  https://en.wikipedia.org/wiki/Heart_murmur

  Murmurs have seven main characteristics. These include timing, shape, location, radiation, intensity, pitch and quality. […] Aortic valve stenosis is a crescendo/decrescendo systolic murmur. It is best heard at the right upper sternal border (aortic area). It sometimes radiates to the carotid arteries. In mild aortic stenosis, the crescendo-decrescendo is early peaking. Whereas in severe aortic stenosis, the crescendo is late-peaking. In severe cases, obliteration of the S2 heart sound may occur. […] Mitral regurgitation is a holosystolic murmur. One can best hear it at the apex location and it may radiate to the axilla or precordium. When associated with mitral valve prolapse, one may hear a systolic click. In this scenario, valsalva maneuver will decrease left ventricular preload. This will move the murmur onset closer to S1. Isometric handgrip will increase left ventricular afterload. This will increase murmur intensity. In acute severe mitral regurgitation, one may not hear a holosystolic murmur.

• #28 Evaluation and Management of Heart Murmurs in Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/1001/p793.html

  Structural heart disease is more likely when the murmur is holosystolic, diastolic, grade 3 or higher, or associated with a systolic click; when it increases in intensity with standing; or when it has a harsh quality. […] Certain characteristics of the murmur may be considered red flags, prompting stronger consideration for structural heart disease. […] These include a holosystolic murmur (odds ratio [OR] of pathologic murmur = 54), grade 3 or higher (OR = 4.8), harsh quality (OR = 2.4), an abnormal S2 (OR = 4.1), maximal intensity at the upper left sternal border (OR = 4.2), a systolic click (OR = 8.3), diastolic murmur, or increased murmur intensity with standing. […] A decrease or lack of change in the murmur intensity with passive leg elevation (likelihood ratio [LR] = 8.0) or when the child moves from standing to squatting (LR = 4.5) increases the likelihood of hypertrophic cardiomyopathy.

• #29 Heart Sounds: Overview, First Heart Sound, Second Heart Sound

  https://emedicine.medscape.com/article/1894036-overview

  The AR murmur is a soft high-pitched sound, is decrescendo in configuration, and is most audible at the left sternal border or the right second ICS just to the right of sternum, with the patient leaning forward at end expiration. […] The murmur of pulmonary regurgitation is best audible at the pulmonary area. […] Mid- to late diastolic murmurs are produced by the blood flow across stenotic AV valves. […] The murmur of MS is increased in intensity with expiration and maneuvers that increase cardiac output, such as exercise. […] The presence of S3 with valvular MR indicates a more severe and hemodynamically significant lesion.

• #30 Evaluation and Management of Heart Murmurs in Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/1001/p793.html

  Heart murmurs are common in healthy infants, children, and adolescents. […] Although most are not pathologic, a murmur may be the sole manifestation of serious heart disease. […] Historical elements that suggest pathology include family history of sudden cardiac death or congenital heart disease, in utero exposure to certain medications or alcohol, maternal diabetes mellitus, history of rheumatic fever or Kawasaki disease, and certain genetic disorders. […] Red flags that increase the likelihood of a pathologic murmur include a holosystolic or diastolic murmur, grade 3 or higher murmur, harsh quality, an abnormal S2, maximal murmur intensity at the upper left sternal border, a systolic click, or increased intensity when the patient stands. […] Echocardiography provides a definitive diagnosis and is recommended for evaluation of any potentially pathologic murmur, and for evaluation of neonatal heart murmurs because these are more likely to be manifestations of structural heart disease.

• #31 Heart Murmurs in Children: Evaluation and Management | AAFP

  https://www.aafp.org/pubs/afp/issues/2022/0300/p250.html

  Up to 8.6% of infants and 80% of children have a heart murmur during their early years of life. The presence of a murmur can indicate conditions ranging from no discernable pathology to acquired or congenital heart disease. […] In contrast, pathologic murmurs are associated with congenital or acquired structural heart disease and often require medical or procedural interventions. […] Murmurs result from perturbations in blood flow from pressure gradients or velocity changes that cause turbulent blood flow and vibration. […] Innocent murmurs are commonly referred to as flow murmurs, physiologic murmurs, or functional murmurs. […] Although most murmurs in older children are innocent murmurs, certain findings suggest the possibility of a pathologic murmur.

• #32 Evaluation and Management of Heart Murmurs in Children | AAFP

  https://www.aafp.org/pubs/afp/issues/2011/1001/p793.html

  Newborns are at higher risk of having serious structural heart disease that presents as an asymptomatic murmur. […] Approximately 1 percent of newborns have a heart murmur, and 31 to 86 percent of these infants have structural heart disease, including asymptomatic newborns. […] Because of the higher likelihood of structural heart disease in asymptomatic newborns and young infants with heart murmurs, referral to a pediatric cardiologist and/or for echocardiography is recommended.

• #33 Understanding Heart Murmurs: When Should You Worry? | Orlando | UCF Health

  https://ucfhealth.com/our-services/cardiology/when-to-worry-about-a-heart-murmur/

  Heart murmurs, abnormal sounds that become apparent during the heartbeat cycle, can leave many individuals concerned and uncertain about their implications. Addressing heart murmurs is crucial, as they can serve as potential indicators of underlying heart conditions. However, not all heart murmurs are cause for alarm. […] Heart murmurs are classified into two primary types: innocent (or benign) murmurs and pathological (abnormal or concerning) murmurs. […] In contrast, pathological murmurs resonate loudly persisting throughout the cardiac cycle. These murmurs, akin to thunderstorms in the hearts rhythm, often indicate significant heart problems. Conditions such as valve disorders (like stenosis or regurgitation), congenital heart defects (such as atrial or ventricular septal defects), infections like endocarditis or other heart conditions like cardiomyopathy can lead to these abnormal heart murmurs.

• #34 Understanding Heart Murmurs: When Should You Worry? | Orlando | UCF Health

  https://ucfhealth.com/our-services/cardiology/when-to-worry-about-a-heart-murmur/

  Problems with heart valves, such as stenosis (narrowing) or regurgitation (leakage), are significant culprits behind heart murmurs. […] Heart murmurs can also be a consequence of congenital heart defects, inherent abnormalities present at birth. […] Infections, such as endocarditis, an inflammation of the hearts inner lining, can wreak havoc on heart valves. […] Beyond valve disorders and congenital defects, various heart conditions can trigger murmurs. Cardiomyopathy, a disease affecting the heart muscle and hypertrophic obstructive cardiomyopathy, a condition characterized by the thickening of the heart muscle, are notable examples. […] If you experience persistent symptoms such as chest pain, shortness of breath, unexplained fatigue, dizziness or swelling, especially in adulthood, these should raise red flags. Additionally, any new onset of symptoms or the detection of a heart murmur as an adult should prompt immediate attention.

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