Heart Murmurs

1. Overview

A heart murmur is an extra sound caused by turbulent blood flow through the heart or great vessels. Murmurs may be systolic, diastolic or continuous. In OSCEs, the aim is to describe the murmur accurately, identify the likely valve lesion, assess severity, look for complications and decide whether the patient needs echocardiography or urgent cardiology review.

Important causes include aortic stenosis, mitral regurgitation, mitral stenosis, aortic regurgitation, tricuspid regurgitation, pulmonary stenosis, ventricular septal defect and innocent flow murmurs. Diastolic murmurs are usually pathological and should be investigated.

Key OSCE priorities

• Clarify symptoms: chest pain, dyspnoea, syncope, palpitations and reduced exercise tolerance.
• Assess for heart failure symptoms.
• Ask about infective endocarditis risk factors and symptoms.
• Ask about rheumatic fever history.
• Perform a structured cardiovascular examination.
• Describe murmur timing, location, radiation, pitch, character and dynamic changes.
• Look for peripheral signs of specific valve lesions.
• State that echocardiography is the key investigation.

Common valve lesions

• Aortic stenosis: ejection systolic murmur, usually loudest at the right upper sternal edge and may radiate to the carotids.
• Mitral regurgitation: pansystolic murmur, usually loudest at the apex and may radiate to the axilla.
• Tricuspid regurgitation: pansystolic murmur, usually loudest at the lower left sternal edge and may increase with inspiration.
• Mitral stenosis: low-pitched mid-diastolic rumbling murmur, usually loudest at the apex with the bell.
• Aortic regurgitation: early diastolic decrescendo murmur, usually best heard at the left sternal edge with the patient leaning forward.
• Ventricular septal defect: harsh pansystolic murmur, usually loudest at the lower left sternal edge.

Symptoms suggesting significant disease

• Exertional chest pain.
• Exertional syncope.
• Progressive breathlessness.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Palpitations.
• Reduced exercise tolerance.
• Peripheral oedema.
• Fever or night sweats suggesting infective endocarditis.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about their heart murmur and general health.
• Gain consent.
• Check whether the patient currently has chest pain, severe breathlessness, syncope or fever.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Presenting complaint

• Ask how the murmur was discovered.
• Ask whether it was found during routine examination, pre-operative assessment, pregnancy review or after symptoms.
• Ask whether the patient has been told they had a murmur before.
• Ask whether they know the cause of the murmur.
• Ask whether they have had previous echocardiography.
• Ask whether they are under cardiology follow-up.

Cardiac symptoms

• Chest pain or pressure.
• Shortness of breath.
• Exertional dyspnoea.
• Syncope or presyncope.
• Palpitations.
• Reduced exercise tolerance.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Peripheral oedema.
• Fatigue.

Aortic stenosis symptoms

• Exertional chest pain.
• Exertional syncope.
• Exertional breathlessness.
• Reduced exercise tolerance.
• Heart failure symptoms.
• Ask specifically about symptoms during exercise because severe aortic stenosis may become dangerous when symptomatic.

Mitral valve disease symptoms

• Breathlessness.
• Orthopnoea.
• Paroxysmal nocturnal dyspnoea.
• Palpitations suggesting atrial fibrillation.
• Haemoptysis in severe mitral stenosis.
• Fatigue.
• Stroke or TIA symptoms if atrial fibrillation or embolic risk is present.

Infective endocarditis screen

• Fever.
• Night sweats.
• Weight loss.
• Malaise.
• New or changing murmur.
• Recent dental procedures.
• Poor dental hygiene.
• Intravenous drug use.
• Prosthetic heart valve.
• Previous infective endocarditis.
• Indwelling lines or recent invasive procedures.
• Immunosuppression.

Congenital and childhood history

• Known congenital heart disease.
• Previous cardiac surgery.
• Cyanosis in childhood.
• Poor exercise tolerance since childhood.
• Recurrent chest infections.
• Growth problems in childhood.
• Family history of congenital heart disease.

Rheumatic fever history

• History of rheumatic fever.
• Recurrent sore throats in childhood.
• Migratory joint pains.
• Previous diagnosis of rheumatic heart disease.
• Previous long-term antibiotic prophylaxis.
• Country or region where rheumatic disease is more common.

Past medical history

• Known valvular heart disease.
• Previous echocardiogram result.
• Previous myocardial infarction.
• Ischaemic heart disease.
• Heart failure.
• Atrial fibrillation.
• Hypertension.
• Stroke or TIA.
• Chronic kidney disease.
• Connective tissue disease such as Marfan syndrome.
• Previous chest radiotherapy.
• Previous cardiac surgery or valve replacement.

Drug history and allergies

• Current regular medications.
• Diuretics.
• Beta-blockers.
• ACE inhibitors, ARBs or ARNIs.
• Anticoagulants such as warfarin, apixaban or rivaroxaban.
• Antiplatelet therapy.
• Antibiotics if infective endocarditis is suspected.
• Medication adherence.
• Drug allergies and reaction.

Family history

• Family history of valve disease.
• Congenital heart disease.
• Sudden cardiac death.
• Cardiomyopathy.
• Marfan syndrome or aortic disease.
• Premature ischaemic heart disease.

Social history

• Smoking history.
• Alcohol intake.
• Recreational drug use, especially intravenous drug use.
• Occupation.
• Exercise tolerance and baseline activity.
• Impact on daily activities.
• Living situation and support.
• Dental hygiene and dental review.
• Pregnancy plans if relevant.

Functional assessment

• Ask how far the patient can walk on flat ground.
• Ask how many flights of stairs they can climb.
• Ask whether symptoms limit work, exercise or daily activities.
• Ask whether symptoms have progressed.
• Ask whether they avoid exertion because of symptoms.

Ideas, concerns and expectations

• Ask what the patient understands about the murmur.
• Ask what they think is causing it.
• Ask what they are most worried about.
• Ask whether they are concerned about surgery, heart failure or sudden death.
• Ask what they were hoping would happen today.

Red flags

• Exertional syncope.
• Exertional chest pain.
• Severe or progressive breathlessness.
• New heart failure symptoms.
• Fever with murmur suggesting infective endocarditis.
• New neurological deficit suggesting embolic event.
• New murmur after myocardial infarction.
• Known severe valve disease with worsening symptoms.
• Hypotension, shock or pulmonary oedema.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would perform a cardiovascular examination, check observations, arrange ECG and echocardiography, and escalate urgently if red flags are present.

3. Physical Examination

The cardiovascular examination should identify the murmur, describe it accurately, assess severity and look for peripheral signs, complications and underlying causes.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask if the patient has chest pain, breathlessness or dizziness.
• Position the patient at 45 degrees.
• Ensure adequate exposure of chest, arms and lower legs while maintaining dignity.
• Ask for a chaperone if appropriate.

General inspection

• Look from the end of the bed.
• Assess whether the patient is comfortable, breathless, cyanosed, pale or cachectic.
• Look for oxygen therapy, cardiac monitor, IV lines or GTN spray.
• Look for sternotomy scar, pacemaker or valve surgery scars.
• Look for features of heart failure such as breathlessness and peripheral oedema.
• Look for features of infective endocarditis such as fever or unwell appearance.

Vital signs

• Heart rate.
• Pulse rhythm.
• Blood pressure.
• Respiratory rate.
• Oxygen saturation.
• Temperature if infective endocarditis is suspected.

Hands

• Inspect for peripheral cyanosis.
• Check capillary refill time.
• Look for clubbing, which may occur in infective endocarditis or cyanotic congenital heart disease.
• Look for splinter haemorrhages suggesting infective endocarditis.
• Look for Janeway lesions.
• Look for Osler nodes.
• Look for nicotine staining.
• Look for palmar pallor suggesting anaemia.
• Look for arachnodactyly or hypermobility suggesting Marfan syndrome.

Pulse

• Assess radial pulse rate.
• Assess rhythm.
• An irregularly irregular pulse suggests atrial fibrillation.
• Assess pulse volume.
• Slow-rising pulse suggests aortic stenosis.
• Collapsing pulse suggests aortic regurgitation.
• Check radio-radial delay if vascular disease is suspected.
• Check radio-femoral delay if coarctation is suspected.

Blood pressure

• Measure blood pressure.
• Narrow pulse pressure may occur in severe aortic stenosis.
• Wide pulse pressure may occur in aortic regurgitation.
• Check both arms if aortic disease is suspected.
• Assess for postural symptoms if syncope or dizziness is present.

Face and eyes

• Look for conjunctival pallor.
• Look for central cyanosis.
• Look for xanthelasma and corneal arcus.
• Look for malar flush, which may be associated with mitral stenosis.
• Look for high-arched palate or lens features if Marfan syndrome is suspected.
• Inspect the mouth for dental hygiene if infective endocarditis risk is relevant.

Neck

• Assess jugular venous pressure at 45 degrees.
• Raised JVP suggests right heart failure, tricuspid disease or fluid overload.
• Look for prominent V waves in tricuspid regurgitation.
• Assess carotid pulse character.
• Auscultate the carotids if aortic stenosis radiation or carotid bruit is suspected.
• Do not press both carotids at the same time.

Precordial inspection

• Inspect the chest for scars.
• Look for sternotomy scar suggesting previous valve surgery or CABG.
• Look for thoracotomy scar.
• Look for pacemaker or ICD.
• Look for chest wall deformity.
• Look for visible pulsations.

Palpation of the chest

• Palpate the apex beat.
• Describe location and character of the apex beat.
• A displaced apex beat may suggest cardiomegaly.
• A tapping apex may suggest mitral stenosis.
• A hyperdynamic apex may occur in volume overload such as mitral or aortic regurgitation.
• Palpate for parasternal heave suggesting right ventricular hypertrophy.
• Palpate for thrills over valve areas.

Auscultation: standard valve areas

• Aortic area: right second intercostal space.
• Pulmonary area: left second intercostal space.
• Tricuspid area: lower left sternal edge.
• Mitral area: apex.
• Listen first with the diaphragm.
• Then use the bell for low-pitched murmurs, especially mitral stenosis.
• Identify first and second heart sounds.
• Identify whether the murmur is systolic, diastolic or continuous.

Describe the murmur

• Timing: systolic, diastolic or continuous.
• Shape: ejection, pansystolic, early diastolic, mid-diastolic or late systolic.
• Location: where it is loudest.
• Radiation: carotids, axilla, back or left sternal edge.
• Intensity: grade 1 to 6 for systolic murmurs.
• Pitch: high-pitched or low-pitched.
• Character: harsh, blowing, rumbling or musical.
• Effect of respiration and position.
• Associated sounds: clicks, opening snap, S3 or S4.

Radiation and manoeuvres

• Auscultate the carotids for radiation of aortic stenosis.
• Auscultate the axilla for radiation of mitral regurgitation.
• Ask the patient to roll onto the left side and listen with the bell at the apex for mitral stenosis.
• Ask the patient to sit forward, breathe out and hold expiration while listening along the left sternal edge for aortic regurgitation.
• Listen during inspiration for right-sided murmurs such as tricuspid regurgitation.
• Dynamic manoeuvres may be used if trained and clinically appropriate.

Classic murmur descriptions

• Aortic stenosis: harsh ejection systolic murmur at the right upper sternal edge, radiating to the carotids, with slow-rising pulse.
• Mitral regurgitation: blowing pansystolic murmur at the apex, radiating to the axilla.
• Tricuspid regurgitation: pansystolic murmur at the lower left sternal edge, louder on inspiration.
• Aortic regurgitation: early diastolic decrescendo murmur at the left sternal edge, best heard leaning forward in expiration.
• Mitral stenosis: low-pitched mid-diastolic rumble at the apex, best heard with the bell in the left lateral position.
• Ventricular septal defect: harsh pansystolic murmur at the lower left sternal edge.

Signs of heart failure

• Raised JVP.
• Displaced apex beat.
• Third heart sound.
• Bibasal crackles.
• Peripheral pitting oedema.
• Hepatomegaly.
• Ascites.

Respiratory examination

• Assess respiratory rate and work of breathing.
• Auscultate lung bases for crackles suggesting pulmonary oedema.
• Assess for pleural effusions if breathlessness or heart failure is suspected.

Peripheral and abdominal examination

• Check for peripheral oedema.
• Assess peripheral pulses.
• Check for hepatomegaly if right heart failure is suspected.
• Assess for ascites if advanced right-sided failure is suspected.
• Look for signs of embolic phenomena if infective endocarditis is suspected.

To complete the examination

To complete my examination, I would review observations, perform an ECG, arrange transthoracic echocardiography to define the valve lesion and severity, request relevant blood tests, and consider blood cultures if infective endocarditis is suspected. I would escalate urgently if the patient has syncope, chest pain, pulmonary oedema, fever with a new murmur, shock or suspected acute severe valve disease.

4. Differential Diagnosis

Systolic murmurs

• Aortic stenosis.
• Mitral regurgitation.
• Tricuspid regurgitation.
• Pulmonary stenosis.
• Ventricular septal defect.
• Hypertrophic obstructive cardiomyopathy.
• Innocent or flow murmur.

Diastolic murmurs

• Aortic regurgitation.
• Mitral stenosis.
• Pulmonary regurgitation.
• Tricuspid stenosis.

Continuous murmurs

• Patent ductus arteriosus.
• Arteriovenous fistula.
• Venous hum.
• Mammary souffle in pregnancy.

Flow murmurs

• Anaemia.
• Pregnancy.
• Fever.
• Thyrotoxicosis.
• High-output states.
• Athletic circulation.

Important causes not to miss

• Severe aortic stenosis.
• Acute mitral regurgitation after myocardial infarction.
• Infective endocarditis.
• Severe aortic regurgitation.
• Hypertrophic obstructive cardiomyopathy.
• Congenital heart disease.

5. Investigations

Bedside tests

• Full observations.
• 12-lead ECG.
• Oxygen saturation.
• Temperature if infection or endocarditis is suspected.
• Urine dip if systemic illness or renal involvement is suspected.

Blood tests

• Full blood count for anaemia, infection or inflammation.
• Urea and electrolytes.
• Creatinine and estimated GFR.
• Liver function tests if right heart failure or congestion is suspected.
• CRP and ESR if infective endocarditis or inflammatory disease is suspected.
• Blood cultures before antibiotics if infective endocarditis is suspected.
• Troponin if acute coronary syndrome is suspected.
• BNP or NT-proBNP if heart failure is suspected.

Cardiac investigations

• Transthoracic echocardiography is the key investigation.
• Echocardiography assesses valve anatomy, valve severity, ventricular function, chamber size and pulmonary pressures.
• Transoesophageal echocardiography may be needed if prosthetic valve disease, infective endocarditis or poor transthoracic views are present.
• ECG can show atrial fibrillation, left ventricular hypertrophy, ischaemia or conduction disease.
• Chest X-ray can show cardiomegaly, pulmonary oedema or valve calcification.
• Cardiac MRI or CT may be used in selected structural or aortic disease cases.
• Coronary angiography may be required before valve surgery or if ischaemic disease is suspected.

Specific investigation points

• Do not rely on auscultation alone to determine severity.
• Echocardiography is needed for diagnosis and grading.
• Blood cultures are essential before antibiotics if infective endocarditis is suspected and the patient is stable enough to wait.
• An ECG may be normal even with significant valve disease.
• Chest X-ray may support heart failure but does not replace echocardiography.

6. Management

Management depends on the valve lesion, severity, symptoms, ventricular function, complications and surgical risk. In OSCEs, separate immediate management of an unstable patient from long-term valve disease management.

Immediate approach if acutely unwell

1. Assess ABCDE.
2. Call senior help if chest pain, syncope, pulmonary oedema, shock or fever with a new murmur is present.
3. Check observations and attach cardiac monitoring if unstable.
4. Perform urgent ECG.
5. Obtain IV access and send blood tests.
6. Treat pulmonary oedema, arrhythmia, sepsis or ACS according to local protocol.
7. Arrange urgent echocardiography if acute severe valve disease is suspected.

General management principles

• Confirm the diagnosis and severity with echocardiography.
• Assess symptoms and functional status.
• Assess left ventricular function.
• Treat complications such as heart failure, atrial fibrillation and pulmonary hypertension.
• Refer to cardiology for moderate or severe valve disease.
• Consider valve intervention if severe symptomatic disease or guideline criteria are met.
• Arrange surveillance echocardiography for stable valve disease according to severity and local protocol.

Aortic stenosis management

• Assess for chest pain, syncope and breathlessness.
• Symptomatic severe aortic stenosis requires urgent cardiology review.
• Avoid excessive vasodilation or dehydration in severe disease unless supervised.
• Definitive treatment may involve surgical aortic valve replacement or transcatheter aortic valve implantation in selected patients.
• Monitor asymptomatic disease with cardiology follow-up and echocardiography.

Mitral regurgitation management

• Assess severity, cause and left ventricular function.
• Treat heart failure symptoms with appropriate medical therapy.
• Manage atrial fibrillation and anticoagulation if indicated.
• Cardiology review is needed for significant or symptomatic mitral regurgitation.
• Valve repair is preferred in suitable degenerative mitral regurgitation when intervention is indicated.

Mitral stenosis management

• Assess symptoms, valve area, pulmonary pressures and rhythm.
• Manage atrial fibrillation and anticoagulation where indicated.
• Diuretics may help congestion.
• Percutaneous balloon mitral valvotomy or surgery may be considered in suitable severe symptomatic disease.
• Consider rheumatic heart disease history and specialist follow-up.

Aortic regurgitation management

• Assess severity, symptoms and left ventricular size and function.
• Control blood pressure if hypertensive.
• Urgent review is needed for acute severe aortic regurgitation.
• Valve surgery may be required for severe symptomatic disease or ventricular dysfunction.
• Assess the aortic root if aortic disease is suspected.

Infective endocarditis management

• Suspect infective endocarditis in fever with a new murmur or risk factors.
• Take blood cultures before antibiotics if clinically safe.
• Start antibiotics according to local microbiology guidance.
• Arrange echocardiography.
• Involve cardiology, microbiology and infectious diseases teams.
• Look for complications such as emboli, heart failure and abscess.

Patient counselling points

• Explain that a murmur is a sound produced by turbulent blood flow.
• Explain that echocardiography is used to identify the cause and severity.
• Advise urgent medical review for chest pain, fainting, severe breathlessness, fever or new neurological symptoms.
• Encourage good dental hygiene.
• Discuss exercise advice depending on lesion severity and cardiology advice.
• Discuss pregnancy planning if relevant.
• Explain the need for follow-up if valve disease is confirmed.

7. Examiner Questions

1. How do you describe a heart murmur?
2. What are the causes of systolic murmurs?
3. What are the causes of diastolic murmurs?
4. What murmur suggests aortic stenosis?
5. What murmur suggests mitral regurgitation?
6. What murmur suggests mitral stenosis?
7. What murmur suggests aortic regurgitation?
8. What symptoms suggest severe aortic stenosis?
9. What features suggest infective endocarditis?
10. What is the most important investigation for a murmur?
11. What are the peripheral signs of aortic regurgitation?
12. When would you refer urgently to cardiology?
13. Why are diastolic murmurs important?
14. What is the significance of a new murmur after myocardial infarction?

Suggested short answers

8. OSCE Pearls

• Always identify whether the murmur is systolic or diastolic.
• Diastolic murmurs are usually pathological.
• Aortic stenosis radiates to the carotids.
• Mitral regurgitation radiates to the axilla.
• Right-sided murmurs usually increase with inspiration.
• Mitral stenosis is best heard with the bell at the apex in the left lateral position.
• Aortic regurgitation is best heard with the patient leaning forward in expiration.
• Ask about chest pain, syncope and breathlessness in suspected aortic stenosis.
• Ask about fever and dental procedures for infective endocarditis.
• Ask about rheumatic fever history.
• A normal ECG does not exclude valve disease.
• Echocardiography is the key investigation.
• Do not claim a murmur is innocent unless appropriate assessment has excluded pathology.
• New murmur with fever or after myocardial infarction is concerning.

9. Example Presentation to Examiner

10. References

• NICE Clinical Knowledge Summary: Heart valve disease.
• ESC/EACTS Guidelines for the management of valvular heart disease.
• AHA/ACC Guideline for the management of patients with valvular heart disease.
• NICE guidance on suspected infective endocarditis and local antimicrobial protocols.
• Standard undergraduate cardiovascular examination and OSCE teaching resources.