Semeiotics of the heart: knowing and recognising systolic and diastolic heart murmurs

Heart murmurs are typical noises caused by turbulent blood flow

Heart murmurs occur

  • When there are abrupt changes in the amplitude of the flow bed
  • When blood flows very fast
  • When the blood has a much lower viscosity than normal (anaemia)

Heart murmurs have

  • A point of origin
  • An irradiation
  • A time of onset and duration

Heart murmurs have a different degree intensity

grade 1 (the murmur is barely perceptible)

grade 2 (the murmur is weak)

grade 3 (the murmur is quite strong)

grade 4 (the murmur is strong)

grade 5 (the puff is very strong)

grade 6 (the breath is so strong that it can be heard without a phonendoscope).


Holosystolic (or pansystolic) heart murmurs

They begin with the 1st tone and end by merging with the 2nd tone.

They are produced when there is an abnormal communication in systole between two cavities with very different pressures (mitral insufficiency, tricuspid, interventricular communication).

Mesosystolic (ejection) heart murmurs

They begin after the first tone and end before the second tone.

They typically, but not exclusively, originate at the aortic and pulmonary semilunar valves.

They have an intensity that increases until mid-systole and then decreases.

Telesystolic heart murmurs

Later and usually shorter than mesosystolic.

Associated with dysfunction of the papillary muscles in ischaemic heart disease.


Protodiastolic cardiac murmurs

Begin almost immediately after the second tone.

Characteristic of aortic and pulmonary insufficiency, they have a high frequency (soft timbre) and are prolonged decreasing in intensity during diastole.

They may be proto- or protomeso- or holodiastolic.

Mesotelediastolic heart murmurs

They are due to absolute or relative stenosis across the mitral or tricuspid.

They are appreciated in a narrow area at the tip and tricuspid foci respectively.

The frequency is low (roll), often only crescendoing because they increase in intensity in telediastole due to atrial contraction (presystolic reinforcement).

Telediastolic or presystolic

These are rather weak murmurs which are heard when atrial contraction causes a higher pressure gradient between the atrium and ventricle.


Continuous or systo-diastolic murmurs

They occupy all or almost all of systole and continue for a longer or shorter time in diastole.

Typical is the persistent Botallo’s duct blow which connects the aorta with the pulmonary artery district.

Pericardial rubs

Prolonged, puff-like noises caused by rubbing between the parietal and visceral pericardial leaflets.

Usually associated with pericarditis with fibrin-rich effusion.

They may be systolic, protodiastolic or presystolic or combined, have variable localisation, high pitch and especially scratchy timbre.

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