Cardiac Auscultation in the Older Adult

Mark E. Williams, MD

Disclosures

January 18, 2012

In This Article

Special Circumstances

Differentiating Various Murmurs: General Points

Changes in a murmur with respiration (inhalation) can help distinguish a right-sided murmur from its corresponding left-sided murmur. All right-sided murmurs increase with inspiration (Carvallo sign). Increased volume either increases the gradient across a stenotic valve or the amount of regurgitation in a regurgitant murmur. Left-sided murmurs do not increase with inspiration.

Increasing the afterload by isometric handgrip can differentiate systolic murmurs at the apex from murmurs at the base. With handgrip, an increase in a systolic murmur excludes an aortic or pulmonic murmur. A decrease in a systolic murmur excludes mitral or tricuspid murmur.

Differentiating Systolic Murmurs at the Base

To differentiate aortic stenosis from pulmonic stenosis, do the following:

First, note the carotid upstroke compared with the PMI. A delayed carotid upstroke suggests aortic stenosis. Listen carefully to S2. A diminished S2 or a paradoxically split S2 suggests aortic stenosis.

Listen in the second intercostal space on each side of the sternum. A murmur heard best in the left space suggests pulmonic stenosis. An increase in the murmur with inspiration suggests pulmonic stenosis A murmur heard best in the right space suggests aortic stenosis, as does radiation of the murmur to under the right clavicle.

Differentiating aortic stenosis from aortic sclerosis. First, note the blood pressure. Aortic stenosis may reduce the pulse pressure to less than 40 mm Hg, while aortic sclerosis does not affect the pulse pressure. Next, check the carotid upstroke compared with the PMI. A delayed upstroke suggests aortic stenosis (pulsus parvus et tardus). Listen carefully to S2. A diminished S2 suggests aortic stenosis, as does a paradoxically split S2. Check to see if the murmur radiates to the right clavicle. Aortic stenosis radiates to the right clavicle and aortic sclerosis does not. Also check for radiation to the right carotid artery. Aortic stenosis radiates to the right carotid artery and aortic sclerosis does not.

Differentiating Aortic Stenosis From IHSS

First, check the carotid upstroke compared with the PMI. A delayed upstroke suggests aortic stenosis (pulsus parvus et tardus), 2 short pulses (pulsus bisferiens) suggests IHSS. You can confirm by listening over brachial artery and gently pushing down on the proximal portion with your stethoscope until you hear a soft compression bruit. In bisferiens pulse you will hear 2 soft bruits for each cardiac cycle.

Listen carefully to S2. A diminished S2 suggests aortic stenosis. A louder, clearer S2 suggests IHSS. Listen during an extrasystole. IHSS gets louder during an extrasystole. Aortic stenosis gets softer during the extrasystole, but the following beat has a louder aortic stenosis murmur due to the increased gradient caused by the increased filling.

Listen while the patient is standing; an IHSS murmur increases, while the aortic stenosis decreases. Listen as the patient squats; IHSS murmurs decrease, while aortic stenosis murmurs do not.

Identifying Aortic Insufficiency

Aortic insufficiency is an early decrescendo murmur that is loudest at base or left lower sternal border. Pulses may be bounding (Corrigan water hammer pulse), and the pulse pressure will be over 40 mm Hg. Pedal pulses are often surprisingly easy to palpate. Head bobbing may be present coincident with each heartbeat (de Musset sign). Pupillary contractions coincident with the pulse suggest aortic insufficiency (Landolfi sign). Retinal arteries may pulsate (Becker sign). The uvula may pulsate (Mueller sign). The fingertips may flush with transillumination coincident with the pulse. Downward pulling of the trachea coincident with the pulse, the tracheal tug, is Cardarelli sign. The murmur increases in intensity with patient exhaling and leaning forward. Severe regurgitation will increase in intensity when the blood pressure cuff on the arm is inflated to over systolic pressure.

An additional late diastolic murmur loudest at the apex (Austin Flint murmur) suggests aortic regurgitation. A swishing sound can be heard over the femoral artery in aortic insufficiency (Duroziez sign). A faint double sound over the femoral arteries suggests aortic insufficiency (Traube sign).

The Hill sign can determine the severity of the regurgitant volume sign, provided the patient has a regular cardiac rhythm (see above).

Differentiating tricuspid from mitral regurgitation. To differentiate tricuspid from mitral regurgitation, one must differentiate systolic murmurs at the apex or left sternal border.

Tricuspid regurgitation will increase with inspiration (Carvallo sign). It may increase with liver compression (Vitums sign) and may cause the right earlobe to pulse. Tricuspid regurgitation will produce a large "v" wave in the jugular veins. Mitral regurgitation will not increase with inspiration and will radiate to the left axilla. Hearing a click suggests mitral regurgitation.

Differentiating Mitral Stenosis From Tricuspid Stenosis

To differentiate mitral stenosis from tricuspid stenosis, one must differentiate diastolic murmurs heard best at the apex or left lower sternal border.

A soft malar flush suggests tight mitral stenosis (mitral facies). An early diastolic opening snap suggests mitral stenosis. An increase in the murmur in left lateral decubitus position suggests mitral stenosis. An increase in the murmur with inspiration suggests tricuspid stenosis.

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