Aortic Stenosis
Crescendo-decrescendo systolic ejection murmur at RUSB radiating to carotids; pulsus parvus et tardus; SAD triad (Syncope, Angina, Dyspnea).
Aortic Regurgitation
Early decrescendo diastolic murmur at LUSB; wide pulse pressure, water-hammer (Corrigan) pulse, and head bobbing (de Musset sign).
Mitral Stenosis
Opening snap followed by low-pitched mid-diastolic rumble at apex; secondary to Rheumatic Heart Disease; risk of AFib and pulmonary HTN.
Dynamic Maneuvers
Valsalva & standing DECREASE most murmurs, but INCREASE HCM and MVP (earlier click/longer murmur). Handgrip increases AR, MR, and VSD.
Systolic Murmurs: Aortic Stenosis vs. Mitral Regurgitation vs. MVP
| Valvular Disorder | Auscultation Timing & Location | Radiation & Quality | Hemodynamic Response to Maneuvers |
|---|---|---|---|
| Aortic Stenosis (AS) | Mid-systolic crescendo-decrescendo; Right 2nd intercostal space (RUSB) | Radiates to carotid arteries; harsh; soft S2 with paradoxical splitting | Increases with squatting/leg raise (increased preload); Decreases with Valsalva/standing |
| Mitral Regurgitation (MR) | Holosystolic blowing murmur; Left 5th intercostal space midclavicular (Apex) | Radiates to left axilla; prominent S3 if severe ventricular overload | Increases with handgrip (increased afterload); Decreases with amyl nitrite |
| Mitral Valve Prolapse (MVP) | Late systolic crescendo murmur preceded by a mid-systolic click at apex | Tensing of chordae tendineae; associated with Marfan and Ehlers-Danlos | Valsalva/standing: click moves earlier, murmur lengthens; Squatting: click moves later |
| Hypertrophic Cardiomyopathy (HCM) | Harsh crescendo-decrescendo systolic ejection murmur at LLSB | No carotid radiation; worsened by dynamic LV outflow tract obstruction | Increases with Valsalva and standing (decreased preload worsens obstruction!); Decreases with squatting |
Diastolic Murmurs: Aortic Regurgitation vs. Mitral Stenosis
| Valvular Disorder | Timing & Landmark | Associated Exam Signs & Etiology | Management Guidelines |
|---|---|---|---|
| Aortic Regurgitation (AR) | Early diastolic decrescendo high-pitched blowing; LUSB (valvular) or RUSB (aortic root disease) | Bounding 'water-hammer' carotid pulse, pistol-shot femoral sounds (Traube sign), capillary pulsations in nailbeds (Quincke sign) | Vasodilators (DHP CCBs, ACEi); surgical valve replacement when symptomatic or LVEF ≤ 50% |
| Mitral Stenosis (MS) | Mid-to-late diastolic low-pitched rumble preceded by an opening snap; localized to apex in left lateral decubitus | Shorter A2-to-opening snap interval indicates more severe stenosis; classic sequela of acute rheumatic fever (group A strep) | Balloon mitral valvuloplasty if pliable non-calcified valve; anticoagulation if atrial fibrillation develops |
OMM Board Correlate: Valvular Strain & Autonomics
- Cardiac Autonomics: Sympathetic preganglionics originate from T1–T5. Right deep cardiac plexus affects SA node (supraventricular arrhythmias); left deep cardiac plexus innervates AV node and posterior LV wall (ventricular arrhythmias).
- Chapman Reflex: Anterior Chapman point for myocardium is located in the 2nd intercostal space adjacent to the sternum. Posterior point lies between the spinous and transverse processes of T2 and T3.
- Thoracic Inlet Decompression: Decompressing the thoracic inlet (clavicle, 1st rib, T1) and performing gentle rib raising balances sympathetic tone, assists right lymphatic duct drainage, and relieves pulmonary venous congestion.
Board Traps & Common Distractors
- In severe aortic stenosis, NEVER administer nitrates or aggressive vasodilators; sudden reduction in preload can precipitate catastrophic cardiovascular collapse and fatal cardiac arrest.
- New-onset diastolic murmurs (AR or MS) are ALWAYS pathologic and warrant prompt transthoracic echocardiography.
- Any patient with a history of rheumatic fever who develops hemoptysis, hoarseness (Ortner syndrome from recurrent laryngeal nerve compression), or new irregular pulse has critical mitral stenosis until proven otherwise.