Heart murmur

Auscultation sites of the heart sounds

As a heart murmur is called a mostly pathological, in or on the heart arising noise or longer than 0.1 seconds sustained sound phenomenon from the outside of the chest can be heard. A stethoscope ( auscultation ) or a microphone ( phonocardiography ) is used for this, and an ear placed on the chest is sufficient for loud noises. Heart murmurs are not to be confused with the "normal" heart sounds . Heart tones can be heard in any healthy person, but heart murmurs usually indicate a disease. A systolic heart murmur ( systolic ) occurs during the ejection phase ( systole ), whereas a diastolic heart murmur ( diastolic ) occurs during the filling phase ( diastole ) of the heart. Continuous (systolic-diastolic) sounds, which, however, do not originate in the heart itself, are less common.

Terminology - classification

In addition to the above-mentioned classification into systolic, diastolic and continuous, or the classification into "organic", "functional" and "accidental" heart sounds, heart sounds are often classified according to their volume , the location of the greatest volume or loudest perception ( punctum maximum , abbreviated pm or PM ), their noise pattern and their noise quality.

Volume of heart murmurs

The volume or intensity of a sound is classified into six degrees (or six sixths) according to Samuel A. Levine.

Grade 1 (1/6): Very quiet, only recognizable when you have “listened to” something (so-called “chief physician heart murmur” or “ cardiologist heart murmur”). Possibly. not audible in every posture.
Grade 2 (2/6): Quiet, but immediately audible noise when the stethoscope is put on, quieter than the breathing noise.
Grade 3 (3/6): Moderately loud, about the same level as the breathing noise.
Grade 4 (4/6): Very loud noise, with a palpable buzz, louder than the sound of breathing.
Grade 5 (5/6): Very loud, with a palpable buzz. Also audible when the stethoscope is only partially placed on the chest wall.
Grade 6 (6/6): Very loud, also audible when the stethoscope is slightly raised from the chest wall (distance noise).

The location of the greatest volume is described anatomically (example: "second intercostal space on the right", abbreviated "2. ICR right") or according to the heart valve that is probably causing the problem (example: "aortic area").

The noise pattern is described as rising ( crescendo ), falling ( decrescendo ), rising and falling again ("spindle-shaped") or band-shaped (constant) (cf. tone intensity ) and the sound quality is often described in terms such as rough, rubbing, breathing, pouring or musical occupied.

The duration (early, medium or late systolic or diastolic) and the radiation (into the carotid arteries or the armpit ) of a heart murmur can also be important.

Holosystolic is a sound that spreads over the entire systole. Mesosystolic is one in the middle.

meaning

Systolic heart murmur

A systolic heart murmur can be completely normal, especially in children, adolescents, pregnant women and when excited or after exertion. It is then also called an accidental heart murmur. Accidental heart murmurs occur frequently, especially in children, and are of no disease value.

In adults, systolic heart murmurs are mostly an expression of a pathological disturbance of the flow in the heart, for example

an obstruction to the opening of a pocket valve ( aortic valve stenosis , sclerosis or pulmonary valve stenosis ) or

an inability to close an atrioventricular valve ( mitral or tricuspid regurgitation ).

Less common causes of a systolic are hypertrophic cardiomyopathy , ventricular septal defect or coarctation of the aorta .

Diastolic heart murmur

A diastolic sound always indicates an abnormal ( pathological ) process in the heart. It refers to

an incapacitation of a pocket valve ( aortic or pulmonary insufficiency) or
a narrowing of an atrioventricular valve ( mitral stenosis or the very rare tricuspid stenosis)

Other heart murmur

Combined aortic valve defects (aortic stenosis and insufficiency) as well as many complex heart defects lead to systolic-diastolic noises. Such a noise is very typical for the open ductus arteriosus when it is loudest below the left collarbone (→ machine noise ). The so-called pericardial rubbing in the case of an inflammation of the pericardium ( pericarditis ) can typically be heard both in systole and in diastole.

Division into organic, functional and accidental sounds

Organic heart sounds are sounds caused by turbulence in constricted or functionally restricted heart valves, heart or vascular malformations.

Functional heart murmurs arise from an enlarged heartbeat volume with increased flow velocity through a relatively narrow opening.

Accidental heart murmurs have no pathognomic significance and are not characterized by a specific mechanism of origin or location.

For the patient

Since some heart murmurs are completely normal and others can occur even with slight pathological changes, the sound finding alone usually does not allow any statement about its meaning. Although doctors with cardiological experience can often make a very precise diagnosis with the findings of the physical examination including auscultation , the cause of a heart murmur can often only be reliably clarified with the help of echocardiography .

literature

Walter Siegenthaler (Ed.): Siegenthaler's differential diagnosis. 19th edition. Georg Thieme Verlag, Stuttgart / New York 2005, ISBN 3-13-344819-6 .
Douglas P. Zipes et al. (Ed.): Braunwald's Heart Disease: A Textbook of Cardiovascular Medicine. 7th edition. WB Saunders Company, Philadelphia 2004, ISBN 1-4160-0014-3 .
S2k guideline for the clarification of a heart murmur in children and adolescents of the German Society for Pediatric Cardiology (DGPK). In: AWMF online (as of 2013)
Klaus Holldack, Klaus Gahl: Auscultation and percussion. Inspection and palpation. Thieme, Stuttgart 1955; 10th, revised edition, ibid. 1986, ISBN 3-13-352410-0 , pp. 128-208.

Web links

Cardiac Examination / Heart Sounds ( Memento from March 5, 2015 in the Internet Archive ) Tutorial (English)
https://www.practicalclinicalskills.com/heart-sounds-murmurs Tutorial (English)

Individual evidence

^ AR Freeman, SA Levine: Clinical significance of systolic murmurs. Ann Intern Med 1933; 6, pp. 1371-1385. In the first publication, only grades 1, 2 and 6 were precisely defined. In 1959 Levine proposed the definition given here for grade 5, the distinction between grade 3 and 4 was left to the examiner. A tactile buzz was later introduced as a criterion for this.

[1] AR Freeman, SA Levine: Clinical significance of systolic murmurs. Ann Intern Med 1933; 6, pp. 1371-1385. In the first publication, only grades 1, 2 and 6 were precisely defined. In 1959 Levine proposed the definition given here for grade 5, the distinction between grade 3 and 4 was left to the examiner. A tactile buzz was later introduced as a criterion for this.