Version June 2024
| Identification of flow murmur |
| A systolic ejection murmur (SEM) begins after S1, terminates before A2 and/or P2-A2, is clearly heard over the cardiac apex, and is usually crescendo-decrescendo configuration. |
| Useful maneuvers to differentiate from regurgitant murmur: |
| Hand grip usually decreases the intensity of the ejection murmur |
| Amyl nitrite usually increases the intensity of the ejection murmur |
| Types of flow murmurs without significant obstruction (all have normal carotid pulse) |
| Increased flow across the aortic valve |
| Aortic regurgitation: aortic diastolic murmur and other features of aortic regurgitation |
| Hypermetabolic state: hyperdynamic cardiac impulse |
| Aortic sclerosis |
| Elderly patients |
| Short and soft SEM |
| Normal S1 and S2 |
| Normal cardiac impulse |
| "Grunting" quality of the murmur may be present. |
| Uncomplicated bicuspid aortic valve |
| Short and soft SEM |
| Normal S1 and S2 |
| Aortic ejection sound in the absence of aortic aneurysm, hypertension |
| Short, early aortic diastolic murmur may be present. |
| Normal cardiac impulse |
| Atrial septal defect |
| Short and soft SEM |
| Wide and fixed splitting of S2 |
| Wide splitting of S1; tricuspid opening snap; mid-diastolic rumble over the lower left sternal border may be present. |
| Hyperdynamic left parasternal impulse |
| Suspected idiopathic dilatation of the pulmonary artery |
| Short and soft SEM |
| S1 normal; S2 may be widely split; normal inspiratory increase in A2-P2 interval |
| Pulmonary ejection sound |
| Short, early pulmonary diastolic murmur may be present. |
| Normal cardiac impulse |
| Innocent murmur |
| Short and soft SEM |
| Normal S1 and S2 |
| Normal cardiac impulse |
| No evidence for any hemodynamic abnormality |
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