Abnormal heart sounds and murmurs

Murmurs and abnormal heart sounds may be detected on physical examination. Although systolic murmurs are often “innocent” or physiologic, diastolic murmurs are virtually always pathologic. A thorough history and physical examination almost always identify which patient cases require further investigation and management.

• Abnormal heart sounds

  • S 1 (e.g., mitral stenosis, atrial fibrillation)

  • S 2 (e.g., hypertension, aortic stenosis)

  • S 3 (e.g., heart failure)

  • S 4 (e.g., hypertension)

  • Abnormal splitting (e.g., atrial septal defect)

• Systolic murmurs

  • Ejection murmurs (e.g., physiologic, aortic stenosis)

  • Pansystolic murmurs (e.g., mitral regurgitation)

• Diastolic murmurs

  • Early (e.g., aortic regurgitation)

  • Mid-diastolic (e.g., mitral stenosis)

• Pericardial friction rubs

Given a patient with a murmur or abnormal heart sounds, the candidate will differentiate innocent from pathologic conditions; diagnose the cause, severity, and complications; and initiate an appropriate management plan.

• list and interpret critical clinical findings, including

  • the origin of the abnormal sound and/or murmur; and

  • results of an appropriate history and physical examination aimed at determining the underlying pathological condition, including severity and complications (e.g., heart failure, endocarditis);

• list and interpret critical investigations, including

  • diagnostic screening for cardiac arrhythmia by means of clinical findings and electrocardiogram; and

  • appropriate diagnostic imaging, including echocardiography, for further investigation of the murmur or abnormal heart sounds; and

• construct an effective initial management plan, including

  • initiating management for the underlying condition and its complications (e.g., heart failure, atrial fibrillation, endocarditis);

  • recommending endocarditis prophylaxis if indicated; and

  • determining whether the patient requires specialized care.