Page 108 - Clinical Pearls in Cardiology

96 Clinical Pearls in Cardiology

• Chronic mitral regurgitation—is usually high pitched
and radiates to the axilla
• Chronic tricuspid regurgitation—is softer than that
of chronic mitral regurgitation. It is loudest at the left
lower sternal border and it increases in intensity with
inspiration
• Ventricular septal defect—is loudest at the mid to
lower left sternal border, where it is usually
associated with a thrill and it radiates widely. There
is no change in intensity of the murmur with
respiration, but the intensity varies as a function of
the anatomic size of the defect (small defects
produce a loud murmur, whereas very large defects
produce a soft murmur).
19. How will you distinguish between the various short
systolic murmurs at the apical area?
The important short systolic murmurs heard at the
apical area are the murmurs of hypertrophic obstructive
cardiomyopathy (HOCM), mitral valve prolapse (MVP)
and papillary muscle dysfunction. Sometimes, the
murmur of valvular aortic stenosis is also best heard at
the apical area (especially in the elderly).
Dynamic auscultation is very helpful in differentiating
these short systolic murmurs at the cardiac apex. In
general, maneuvers which lead to a reduction in the size
of left ventricular chamber results in an increase in the
intensity of the murmurs of HOCM and MVP. But the
same maneuvers result in a decrease in the intensity
of the murmurs of papillary muscle dysfunction and
valvular aortic stenosis (Table 4).