Cardiac Auscultation in the Older Adult

Mark E. Williams, MD


January 18, 2012

In This Article

Clinical Maneuvers That Affect Murmurs

Respiratory Effects

All right-sided murmurs increase with inspiration (Carvallo sign). Many left-sided murmurs decrease with inspiration, but they may be very difficult to hear. Therefore, respiratory variation can help differentiate corresponding right-sided from left-sided murmurs; for example, tricuspid regurgitation from mitral regurgitation.

Changes in Position

Standing decreases venous return and ventricular filling. As a result, standing decreases the intensity of all murmurs except IHSS and mitral valve prolapse.

Squatting increases peripheral resistance and increases ventricular filling. It brings out the murmurs of ventricular septal defect, aortic insufficiency, and mitral insufficiency.

Sitting up and leaning forward accentuates the second heart sound and increases the aortic insufficiency murmur. The left lateral decubitus position increases murmur of mitral stenosis. Some people feel that the exercise component of moving into the left lateral decubitus position accounts for the increase in the murmur.

Increasing Peripheral Resistance

Maneuvers to increase peripheral resistance are more helpful in ruling out rather than ruling in murmurs. Methods include squatting and bilateral isometric handgrip. For the latter method, have the patient squeeze (hard) a rolled-up blood pressure cuff or towel.

  • An increase in systolic murmur with an increase in peripheral resistance excludes aortic stenosis and IHSS.

  • A decrease in the systolic murmur excludes mitral regurgitation and ventricular septal defect.

  • A decrease in a diastolic murmur excludes aortic insufficiency and mitral stenosis.

Arterial Compression

Use a blood pressure cuff on each arm, inflate them above systolic pressure, and hold. This will increase left-sided regurgitant murmurs, such as aortic regurgitation (an excellent maneuver), mitral regurgitation, or ventricular septal defect.