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Murmur evaluation

Maneuvers that affect murmurs

Inspiration

• Quiet inspiration (and firm abdominal pressure) primarily increase venous return.
• Right sided murmurs increase

Valsalva maneuver

• Decreases venous return and increases peripheral arterial resistance.
• Most murmurs decrease in intensity.
• Murmur of hypertrophic obstructive cardiomyopathy usually gets louder.
• Mid to late systolic murmur of mitral valve prolapse usually moves earlier into systole.

Standing & squatting

• Squatting and passive leg elevation increases both venous return and peripheral arterial resistance.
• Standing diminishes most murmurs
• Squatting or leg elevation increase most murmurs.
• Standing intensifies the murmur of HOMC and prolongs mitral prolapse murmur earlier into systole. Squatting and leg elevation have opposite effects.

Post-PVC potentiation

• Semilunar stenosis murmurs increase during the beat following a post extrasystolic pause, or during beat following long RR interval in atrial fibrillation.
• Mitral regurgitant murmurs tend to remain unchanged, or even diminish.

Handgrip

• Most murmurs increase with exercise.
• Murmurs of aortic stenosis or obstructive cardiomyopathy tend to decrease with peak handgrip.

Arterial-occlusion

• Blood pressure cuff inflation to both arms increases peripheral vascular resistance.
• Augments the murmurs of ventricular septal defects and of mitral and aortic regurgitation.

Disclaimer: Material is for discussion & review and is not advice or endorsement. Comments to Donald Vine MD.