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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
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.
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 |

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