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Opening snap in which OS is the mitral opening snap, and DM is the diastolic murmur. The ''aaaalve'' is the presystolic accentuation heard when a patient with mitral stenosis is in normal sinus rhythm. Figure 14-38 illustrates a diastolic atrioventricular murmur.

Diastolic semilunar murmurs begin immediately after S2, as heard in aortic or pulmonic regurgitation. In contrast to the diastolic atrioventricular murmurs, there is no delay after S2 to the beginning of the murmur. The high-pitched murmur is decrescendo in shape and is best heard with the diaphragm of the stethoscope while the patient is sitting up and leaning forward. A diastolic semilunar murmur is a sign of low sensitivity but high specificity. Figure 14-39 illustrates the pressure curves responsible for the generation of a diastolic semilunar murmur.

Table 14-8 lists important cardiac sounds according to the cardiac cycle. Figure 14-40 lists important characteristics of the systolic murmurs of aortic stenosis and mitral regurgitation. Table 14-9 summarizes the differentiation of some additional systolic murmurs. Figure 14-41 lists important characteristics of the diastolic murmurs of mitral stenosis and aortic regurgitation.

Figure 14-39 A diastolic semilunar murmur such as that occurring in aortic regurgitation. Note the systolic ejection murmur, which is related to the increased volume and flow.

Aorta

Left atrium

Left ventricle

Aorta

Left atrium

Left ventricle

(A2) S2

Table 14-8 Cardiac Sounds Cardiac Cycle

Early systolic Ejection click

Aortic prosthetic valve opening sound*

Midsystolic to late systolic Midsystolic click

Early diastolic Opening snap

Mitral prosthetic valve opening sound{ Tumor plop{

Mid-diastolic S3

Summation gallop§

Late diastolic (sometimes S4

called presystolic) Pacemaker sound

•Opening and closure of the prosthetic aortic valve are heard with many prosthetic valves. The opening is comparable to an ejection click; the closing is a "prosthetic" S2. ^Opening and closure of the prosthetic mitral valve are heard with many prosthetic valves. The opening is comparable to an opening snap; the closing is a "prosthetic" S^ {A left atrial myxoma that is pedunculated may "plop" in and out of the mitral annulus, simulating the auscultatory signs of mitral stenosis.

§At fast heart rates, the diastolic period shortens. If an S3 and S4 are present, the sounds may be summated into a single sound called a summation gallop.

Systolic Murmurs Differentiating AS from MR

Feature Aortic Stenosis Mitral Regurgitation

Location Aortic area Apex

Radiation Neck Axilla

Shape	Diamond	Holosystolic
Pitch	Medium	High
Quality	Harsh	Blowing
Associated signs	Decreased A2 Ejection click S4 Narrow pulse pressure Slow rising and delayed pulse	Decreased S-| S3 Laterally displaced diffuse PMI

PMI, point of maximum impulse.

PMI, point of maximum impulse.

S1 S2 S3

Figure 14-40 Systolic murmurs. A, Pathophysiology of aortic stenosis. Note the paradoxical splitting of the second heart sound (S2), the S4, and the ejection click. B, Mitral regurgitation. Note that the murmur ends after S2, and note the presence of the S3.

S1 S2 S3

Figure 14-40 Systolic murmurs. A, Pathophysiology of aortic stenosis. Note the paradoxical splitting of the second heart sound (S2), the S4, and the ejection click. B, Mitral regurgitation. Note that the murmur ends after S2, and note the presence of the S3.

Table 14-9 Differentiation of Other Systolic Murmurs

	Pulmonic	Tricuspid	Ventricular		Innocent
Feature	Stenosis	Regurgitation	Septal Defect	Venous Hum	Murmur
Location	Pulmonic area	Tricuspid area	Tricuspid area	Above clavicle	Widespread
Radiation	Neck	Right of sternum	Right of sternum	Right neck	Minimal
Shape	Diamond	Holosystolic	Holosystolic	Continuous	Diamond
Pitch	Medium	High	High	High	Medium
Quality	Harsh	Blowing	Harsh	Roaring; humming	Twanging; vibratory

•Usually between the apex and the left lower sternal border.

•Usually between the apex and the left lower sternal border.

Diastolic Murmurs Differentiating MS from AR Feature Mitral Stenosis

Location Apex

Radiation No

Shape

Pitch

Quality

Associated signs

Decrescendo Low

Rumbling

Increased St Opening snap RV rock*

Presystolic accentuation

Aortic Regurgitation

Aortic area No

Decrescendo High Blowing S3

Laterally displaced PMI Wide pulse pressure{ Bounding pulses Austin Flint murmur{ Systolic ejection murmur§

PMI, point of maximum impulse; RV, right ventricular. •Right ventricular impulse at lower left sternal border.

{The wide pulse pressure is the cause of the many physical signs of aortic regurgitation: Quincke's pulse, De Musset's sign, Duroziez's sign, Corrigan's pulse, and so forth.

{An apical diastolic murmur heard in association with aortic regurgitation, mimicking that of mitral stenosis. §A flow murmur across a valve that is relatively narrow for the increased blood volume as a result of aortic regurgitation. It is relatively stenotic and need not be anatomically stenotic, as in true aortic stenosis.

S1 S2 Opening snap

Figure 14-41 Diastolic murmurs. A, Pathophysiology of mitral stenosis. Note the intensity of St and the accentuation of the diastolic murmur in late diastole. B, Aortic regurgitation. Note the systolic flow murmur.

S1 S2 Opening snap

Figure 14-41 Diastolic murmurs. A, Pathophysiology of mitral stenosis. Note the intensity of St and the accentuation of the diastolic murmur in late diastole. B, Aortic regurgitation. Note the systolic flow murmur.

Useful Vocabulary
Listed here are the specific roots that are important for understanding the terminology related to cardiac disease.
Root	Pertaining to	Example	Definition
brady-	slow	bradycardia	Slow heart rate
-cardio-	heart	cardiomegaly	Enlargement of the heart
sphygmo-	pulse	sphygmomanometer	Instrument for measuring blood pressure
supra-	above	supraventricular	Above the level of the ventricles
tachy-	fast	tachycardia	Rapid heart rate