ACC/AHA guideline summary: Interventions used to alter the intensity of cardiac murmurs

Respiration
Right-sided murmurs typically increase with inspiration, while left-sided murmurs generally are louder
during expiration.
Valsalva maneuver
Most murmurs decrease in length and intensity during the Valsalva maneuver. Two exceptions are the
systolic murmur of hypertrophic cardiomyopathy (HCM), which usually becomes much louder, and the
systolic murmur of mitral valve prolapse (MVP), which becomes longer and often louder. Following
release of the Valsalva, right-sided murmurs tend to return to baseline intensity earlier than left-sided
murmurs.
Positional changes
Most murmurs diminish with standing due to reduced preload. However, the murmur of HCM becomes
louder, and the murmur of MVP lengthens and often is intensified.
Similarly, most murmurs become louder with prompt squatting (or usually passive leg raising), while the
murmurs of HCM and MVP typically soften and may disappear.
Exercise
Murmurs caused by blood flow across normal or obstructed valves (eg, mitral or pulmonic stenosis)
become louder with both isotonic and submaximal isometric (handgrip) exercise. Murmurs of mitral
(MR) and aortic regurgitation (AR) and ventricular septal defect (VSD) also increase with handgrip
exercise.

BASIC MANEUVERS
These include effect of inspiration and expiration
1) INSPIRATION : Inspiration increase right-sided heart sounds n murmurs
2) EXPIRATION : Expiration inc. left-sided heart sounds n murmurs
Mechanism : During inspiration, there is more negative pressure in the thoracic cavity which pull the blood
into right side of heart More blood in right side of heart lead to increased intensity of murmurs n heart sounds
of right side similarly during expiration, left side of heart is filled with blood more so left-sided heart sounds
and murmurs get aggravated
How to remember : RILE Right sided Inspiration Left sided Expiration


ADVANCED MANEUVERS
There r three more important maneuvers three groups actually
1) Maneuvers increasing preload (by inc venous return) e.g. rapid squatting, passive leg raising or reclining
position.
2) Maneuvers decreasing preload (by dec. venous return) e.g. second phase of valsalva, amyl nitrite inhalation
or standing.
3) Maneuvers increasing afterload (by inc TPR) e.g. hand grip
RAPID SQUATTING : Increase intensity of most murmurs incl AS, Decrease intensity of HOCM and
MVP murmurs
Mechanism : Maneuvers which inc preload makes most of the murmurs louder as there is more blood in heart
to pump thru those valves this incl. AS
Inc. preload causes LV filling and stretching of LV walls which inc distance between mitral valve leaflet and
interventricular septum this dec. LV outflow obstruction and dec. intensity of HOCM
for MVP.. its because inc. LV wall stretch lead to stretching to chordae tendinae holding the mitral valve
leaflets and so it dec. the prolapse and lead to dec. intensity and delayed click in MVP
VALSALVA : Decrease intensity of most murmurs incl AS, Increase intensity of HOCM and MVP
murmurs
Mechanism : vice versa of the mechanism discussed in rapid squatting

HAND GRIP : Increase intensity of MVP murmur while decrease intensity of HOCM murmur
Mechanism : Handgrip inc. TPR and thus inc. afterload This inc. afterload lead to decreased gradient
between LV pressure and aortic pressure.. which dec. LV outflow obstruction this dec. the intensity in
HOCM while inc. afterload cause more LV pressure needed to push against the inc. aortic pressure which
lead to inc. prolapse and thus inc. intensity and early click in MVP this can b remembered as HOCM can b
squashed by hand grip
How to remember : HOCM murmur can be squashed with hands
Summary :


First Aid 2014: