Salvatore Mangione, MD

1. What are the auscultatory areas of murmurs?

    Auscultation typically starts in the aortic area, continuing in clockwise fashion: first over the pulmonic, then the mitral (or apical), and finally the tricuspid areas (Fig. 2-1). Because murmurs may radiate widely, they often become audible in areas outside those historically assigned to them. Hence, “inching” the stethoscope (i.e., slowly dragging it from site to site) can be the best way to avoid missing important findings.

2. What is the Levine system for grading the intensity of murmurs?

    The intensity or loudness of a murmur is traditionally graded by the Levine system (no relation to this book’s editor) from 1/6 to 6/6. Everything else being equal, increased intensity usually reflects increased flow turbulence. Thus, a louder murmur is more likely to be pathologic and severe.

3. What are the causes of a systolic murmur?

4. What are functional murmurs?

    They are benign findings caused by turbulent ejection into the great vessels. Functional murmurs have no clinical relevance, other than getting into the differential diagnosis of a systolic murmur.

5. What is the most common systolic ejection murmur of the elderly?

    The murmur of aortic sclerosis is common in the elderly. This early peaking systolic murmur is extremely age related, affecting 21% to 26% of persons older than 65, and 55% to 75% of octogenarians. (Conversely, the prevalence of aortic stenosis [AS] in these age groups is 2% and 2.6%, respectively.) The murmur of aortic sclerosis may be due to either a degenerative change of the aortic valve or abnormalities of the aortic root. Senile degeneration of the aortic valve includes thickening, fibrosis, and occasionally calcification. This can stiffen the valve and yet not cause a transvalvular pressure gradient. In fact, commissural fusion is typically absent in aortic sclerosis. Abnormalities of the aortic root may be diffuse (such as a tortuous and dilated aorta) or localized (like a calcific spur or an atherosclerotic plaque that protrudes into the lumen, creating a turbulent bloodstream).

6. How can physical examination help differentiate functional from pathologic murmurs?

    There are two golden and three silver rules:

 The first golden rule is to always judge (systolic) murmurs like people: by the company they keep. Hence, murmurs that keep bad company (like symptoms; extra sounds; thrill; and abnormal arterial or venous pulse, electrocardiogram, or chest radiograph) should be considered pathologic until proven otherwise. These murmurs should receive extensive evaluation, including technology-based assessment.

 The second golden rule is that a diminished or absent S₂

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