Differential diagnosis of the diseases with which is normal in VSD but it is widely split in

systolic murmurs pulmonary stenosis.

 However, VSD is almost always pansystolic where
In answering this question, we have to first get to know the murmur of pulmonary stenosis is diamond-
the types of systolic murmurs and associated diseases. shaped and ends clearly before S2.
Many innocent murmurs also arise from this location
Systolic murmurs start at or after S1 and end before or but S1 and S2 must split normally.
at S2.
There are a few types of systolic murmurs

1.Midsystolic ejection murmurs Dilation of aortic root or pulmonary artery

– Mid-systolic murmurs begin after S1, have a Produces an ejection sound, with a short ejection
crescendo-decrescendo shape, and end before S2. systolic murmur and a relatively wide split S2. There is
Brief gaps are audible between the murmurs and no hemodynamic abnormality. This is similar to
the normal heart tones. The gap before S2 is often pulmonary hypertension except the latter has
easier to discern and usually confirms the murmurs hemodynamic instabilities.
as midsystolic. Midsystolic murmurs are often
related to the blood flow across the semilunar Increased semilunar blood flow
valves. This can occur in situations such as anemia,
pregnancy, or thyrotoxicosis.
– Midsystolic ejection murmurs are due to blood flow
through the semilunar valves. They occur at the
Aortic valve sclerosis
start of blood ejection, which start after S1, and
This is due to degenerative thickening of the roots of
end with the cessation of the blood flow, which is
the aortic cusps but produces no obstruction and no
before S2. Therefore, the onset of a midsystolic
hemodynamic instability and thus should be
ejection murmur is separated from S1 by the
differentiated from aortic stenosis. It is heard over right
isovolumic contraction phase; the cessation of the
second intercostals space with a normal carotid pulse
murmur and the S2 interval is the aortic or
and normal S2.
pulmonary hangout time. The resultant
configuration of this murmur is a crescendo-
Innocent midsystolic murmurs
decrescendo murmur.
These murmurs are not accompanied by other
– Causes of midsystolic ejection murmurs include abnormal findings. One example is Still's murmur in
outflow obstruction, increased flow through normal children.
semilunar valves, dilation of aortic root or
pulmonary trunk, or structural changes in the
1.Holosystolic (pansystolic) murmurs
semilunar valves without obstruction.
Usually due to regurgitation in cases such as mitral
regurgitation, tricuspid regurgitation, or ventricular
Aortic outflow obstruction
septal defect (VSD)
Murmurs can be due to aortic valve stenosis or
These murmurs start at S1 and extend up to S2
hypertrophic cardiomyopathy (HCM), with a harsh and
rough quality
Mitral regurgitation
 Valvular aortic stenosis can produce a harsh or even  In the presence of incompetent mitral valve, the
pressure in the L ventricle becomes greater than that
a musical murmur over the right second intercostals
in the L atrium at the onset of isovolumic contraction,
space which radiates into the neck over the two
which corresponds to the closing of the mitral valve
carotid arteries. The most common cause of AS
(S1). This explains why the murmur in MR starts at
(Aortic Stenosis) is calcified valves due to aging
the same time as S1. This difference in pressure
followed by congenital bicuspid aortic valves (normal
extends throughout systole and can even continue
valve is tricuspid). The distinguishing feature
after aortic valve has closed, explaining how it can
between these two causes is that bicuspid AS has
sometimes drown the sound of S2.
little or no radiation. It can be confirmed if it also has
an aortic ejection sound, a short early diastolic
 The murmur in MR is high pitched and best heard at
the apex with diaphragm of the stethoscope with
murmur, and normal carotid pulse. The murmur in
patient in the lateral decubitus position.
valvular AS decreases with standing and straining
with Valsalva maneuver.  Left ventricular function can be assessed by
determining the apical impulse. A normal or
hyperdynamic apical impulse suggests good ejection
 Supravalvular aortic stenosis is loudest at a point
fraction and primary MR. A displaced and sustained
slightly higher than in that of valvular AS and may
apical impulse suggests decreased ejection fraction
radiate more to the right carotid artery.
and chronic and severe MR.
 Subvalvular aortic stenosis is usually due to Tricuspid insufficiency
hypertrophic cardiomyopathy (HCM), with murmur
loudest over the left sternal border or the apex. The
 Can be best heard over the fourth left sternal border.
murmur in HCM increases in intensity with a standing  The intensity can be accentuated following
position as well as straining with Valsalva maneuver. inspiration (Carvallo's sign) due to increased
regurgitant flow in right ventricular volume.
Pulmonic outflow obstruction  Tricuspid regurgitation is most often secondary to
 A harsh murmur usually on left second intercostals pulmonary hypertension.
space radiating to left neck and accompanied by  Primary tricuspid regurgitation is less common and
palpable thrill. It can be distinguished from a VSD can be due to bacterial endocarditis following IV drug
(Ventricular Septal Defect) by listening to the S2,
 use, Ebstein's anomaly, carcinoid disease, or prior (Main answer for this question is DDx for diseases
right ventricular infarction. causing aortic stenosis, so can refer to question no. 29)

Ventricular septal defect

 VSD is a defect in the ventricular wall, producing a
shunt between the left and right ventricles.
 Since the L ventricle has a higher pressure than the
R ventricle, flow during systole occurs from the L to R
ventricle, producing the holosystolic murmur. It can
be best heard over the left third and fourth
intercostals spaces and along the sternal border.
 It is associated with normal pulmonary artery
pressure and thus S2 is normal. This fact can be used
to distinguish from pulmonary stenosis, which has a
wide splitting S2.
 If the shunt becomes reversed in the Eisenmenger
complex because the L ventricle becomes too "tired",
the murmur may be absent and S2 can become
markedly accentuated and single.

1.Early systolic murmur

– Early systolic murmurs begin with S1, decrescendo,
and end well before S2
– These murmurs are almost identical to holosystolic
murmurs, which start at S1 but ends before S2. It is
also associated with MR, TR, or VSD. The reason an
early systolic murmur is heard rather than a
holosystolic murmur is because the condition is
more acute and more severe.

1. Late systolic murmurs

– Late systolic murmurs begin in mid to late systole,
crescendo, and end at S2. An example of a late
systolic murmur would be the murmur of a
prolapsed mitral valve.
– Late systolic murmurs start after S1 and, if left
sided, extend up to S2, usually in a crescendo
manner.
– Causes include mitral valve prolapse, tricuspid
valve prolapse, and papillary muscle dysfunction.

Mitral valve prolapse

 This is the most common cause of late systolic
murmurs.
 It can be heard best over the apex of the heart,
usually preceded by clicks.
 The most common cause of mitral valve prolapse is
"floppy" valve (Barlow's) syndrome.
 If the prolapse becomes severe enough, mitral
regurgitation may occur.
 Any maneuver that decreases left ventricular
volume, such as standing, sitting, Valsalva
maneuver, and amyl nitrate inhalation, can produce
earlier onset of clicks, longer murmur duration, and
decreased murmur intensity.
 Any maneuver that increases left ventricular volume,
such as squatting, elevation of legs, hand grip, and
phenylephrine, can delay the onset of clicks, shorten
murmur duration, and increase murmur intensity.

Tricuspid valve prolapse

 Uncommon without concomitant mitral valve
prolapse.
 Best heard over left lower sternal border.
Papillary muscle dysfunction
 Usually due to acute myocardial infarction or
ischemia which causes mild mitral regurgitation.