Cardiac Auscultation in the Older Adult

Mark E. Williams, MD


January 18, 2012

In This Article

Specific Murmurs and Their Characteristics

Table 3 provides typical characteristics of common murmurs.

Tricuspid Stenosis

The tricuspid stenosis murmur is diastolic and a soft rumble, heard best at the left lower sternal border. It will increase in intensity with inspiration (Carvallo sign). Other clinical signs include giant "a" waves on the jugular venous pulse, loss of the "y" descent on jugular venous pulse, an increase in jugular venous pressure on inspiration (Kussmaul sign), and a jugular presystolic click. Otherwise, this clinically resembles mitral stenosis.

Tricuspid Insufficiency

Tricuspid insufficiency is a harsh, holosystolic murmur heard best at the left lower sternal border. This murmur can radiate to the axilla in severe pulmonary hypertension. Maneuvers that change the quality of the murmur include an increase in intensity with inspiration (Carvallo sign), an increase in intensity with increased venous return, and an increase in intensity with pushing on the liver (Vitmus sign).

Primary causes of tricuspid insufficiency include endocarditis or rheumatic disease. A secondary cause is right ventricular dilation. Other clinical signs of tricuspid insufficiency include prominent "v" waves in the jugular venous pulse, winking earlobes (Wood sign), a murmur over peripheral veins, and liver pulsations.

Pulmonic Stenosis

The pulmonic stenosis murmur is diamond-shaped systolic and is heard best at the left upper sternal border. Primary causes include congenital abnormality and rheumatic disease. Secondary causes are atrial septal defect and ventricular septal defect. Other clinical signs of pulmonic stenosis are a right ventricular heave and a widely split S2 with a soft P2. The murmur may radiate to the left carotid artery.

Pulmonic Insufficiency

Pulmonic insufficiency is an early diastolic decrescendo murmur heard best at the left upper sternal border.

Syphilis and subacute bacterial endocarditis (SBE) tend to spare the pulmonic valve. Endocarditis is a very rare cause, and rheumatic heart disease involving this valve is an even rarer cause of pulmonary insufficiency.

A secondary cause of pulmonic insufficiency is pulmonary hypertension (Graham Steell murmur). Other clinical signs include a palpable pulmonary artery and finding dullness to percussion to the left of the sternum.

Mitral Stenosis

The mitral stenosis murmur is a low-pitched diastolic rumble with presystolic accentuation. The loudness of the rumble may correlate with the degree of stenosis. Beware if the patient has aortic insufficiency, as this could be an Austin Flint murmur producing relative mitral stenosis. (A mitral stenosis murmur is heard best at the apex, with the patient in left lateral decubitus position.)

Causes of mitral stenosis include rheumatic fever, calcified mitral annulus, carcinoid syndrome, systemic lupus erythematosus, and rheumatoid arthritis. Other clinical signs of mitral stenosis include a loud S1, a loud P2, and an opening snap. The S2-OS interval may help in estimating severity (the shorter the interval, the greater the gradient across the valve). Patients with mitral stenosis may have flushed cheeks.

Mitral Insufficiency

Mitral insufficiency is a blowing, harsh, whooping, or honking holosystolic murmur heard best at the apex. Such murmurs usually radiate to the axilla. Primary causes include mitral valve prolapse, bacterial endocarditis, or rheumatic conditions. Secondary causes include cardiac enlargement, papillary muscle dysfunction, mitral annular calcification, or Gallavardin phenomenon in aortic stenosis (see below).Other clinical signs of mitral insufficiency include systolic clicks, which can be checked in patients with pectus excavatum or, in general, with the patient standing.

Aortic Stenosis

The aortic stenosis murmur is diamond-shaped and systolic and radiates along the aortic outflow tract. The peaking of the murmur moves toward S2 as the valve area narrows. Classically, the aortic stenosis murmur is heard best at the right upper sternal border (where it is harsh and noisy). It radiates to the right supraclavicular area. (Lack of radiation to this area should raise the question of another cause for the murmur.) The aortic stenosis murmur may become purer and musical as one listens toward the apex (Gallavardin phenomenon). It is important to appreciate this so you do not mistakenly diagnose a nonexistent mitral murmur. If the patient performs an isometric handgrip while you listen at the apex, you will hear the aortic stenosis murmur with Gallavardin phenomenon decrease in intensity. A coexistent mitral insufficiency murmur will increase in intensity with this maneuver.

The aortic stenosis murmur increases after a premature ventricular contraction due to the increased gradient across the valve produced by the enhanced diastolic filling with the compensatory pause.

The causes of aortic stenosis include calcific degeneration or a bicuspid valve. Other clinical signs of aortic stenosis are paradoxical split of S2 and pulsus parvus et tardus. You can estimate the degree of stenosis by feeling the delay between the PMI and the carotid pulse (the greater the delay, the greater the stenosis). Some clinicians are remarkably adept and consistent at estimating the valve area using combinations of these techniques.

Idiopathic Hypertrophic Subaortic Stenosis

Subaortic stenosis is a harsh, diamond-shaped, mid-systolic murmur heard best at the left sternal border. Maneuvers that change the murmur include the fact that it becomes louder during a PVC, softer on the beat following PVC, softer with squatting, and louder with standing. Idiopathic hypertrophic subaortic stenosis (IHSS) is caused by a subvalvular muscular ring or obstructive cardiomyopathy. Other clinical signs include a diminished pulse after a PVC or a bisferiens pulse.

Aortic Insufficiency

Aortic insufficiency is an early diastolic decrescendo murmur heard best at the right upper sternal border. It is useful to have the patient sitting upright, leaning forward, and exhaling. While in expiration, the patient should hold the breath, because the quality and acoustic frequency of the murmur are similar to the breath sounds and can be completely obscured by them. Sometimes there is a late diastolic rumble (Austin Flint murmur). Maneuvers to increase intensity of the aortic insufficiency murmur include arterial occlusion, squatting, or sitting up.

If the murmur radiates to the left lower sternal border, consider rheumatic valve disease or syphilitic aortitis. Radiation to the right lower sternal border suggests aortic dissection, bacterial endocarditis, or aneurysm of the sinus of Valsalva. When present, radiation to the left axilla (Cole-Cecil murmur) is a useful way to differentiate aortic from pulmonic insufficiency.

Other clinical signs of aortic insufficiency include the Duroziez sign, Hill sign, or Corrigan pulse.

Duroziez sign. To check the Duroziez sign, gently place the diaphragm of the stethoscope over the femoral artery, and, with the stethoscope end facing the head, push down (also gently) to produce a bruit (a universal finding with enough compression). The stethoscope should be tilted about 30 degrees with the caudle end above the skin. Hearing 2 systolic sounds suggests a high output condition, such as hyperthyroidism, anemia, blood loss, or arteriovenous fistula in the leg, in which case consider previous cardiac catheterization.

Continue to push, and an early diastolic sound will be heard in aortic insufficiency, which creates a to-and-fro swishing sound. Tilt the stethoscope so that the caudle portion is compressing the artery and the other end is up at a 30-degree angle in the other direction. An increase in the diastolic sound with this maneuver is the Duroziez sign. Hearing the Duroziez sign but not finding the Hill sign (below) suggests atherosclerotic disease in the leg or a low output cardiac state. The time for surgical repair may have passed.

Hill sign. The Hill sign is helpful in determining the severity of the aortic incompetence and the amount of increased stroke volume. With the patient supine, measure the brachial and dorsalis pedis blood pressures. Normally, the blood pressure in the legs will be up to 20 mm Hg higher than in the arms as an artifact. An apparent increase in leg blood pressure of more than 20 mm Hg correlates with the degree of aortic insufficiency or the increase in stroke volume. Takayasu disease can give a false positive result by reducing the upper extremity blood pressure. Note that the Hill sign cannot be obtained in atrial fibrillation because the systolic blood pressure varies so much with the variable R-R interval.

Corrigan's pulse. Corrigan's pulse is a bounding pulse with wide pulse pressure and quick relaxation. It resembles an old water hammer and signifies aortic insufficiency.