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Heart murmurs

It’s important to consider three characteristics in relation to a murmur:

– Chronological location: systole or diastole

– Highest intensity spot

– Pitch

We determine the underlying pathology through these characteristics.

Mitral stenosis

Representación de estenosis mitral

Mild mitral stenosis:


Mid- and telediastolic murmur of highest intensity at the apex of the heart. The patient must be auscultated in dorsal decubitus and in left lateral decubitus.
The auscultatory complex is as follows: accentuated first heart sound and opening snap.

Moderate to severe mitral stenosis:


In case of progression, the auscultatory complex would be: accentuated first heart sound, opening snap and rumbling mid-diastolic murmur. This murmur can be better heard with the patient in the left lateral decubitus position, placing the bell of the stethoscope very gently.

Mitral stenosis with sinus


The total primary auscultatory complex of mitral stenosis in patients with sinus rhythm is as follows: accentuated first heart sound, opening snap, mid-diastolic murmur and presystolic murmur.

Mitral stenosis with atrial fibrillation:


The total primary auscultatory complex of mitral stenosis in patients with atrial fibrillation is as follows: accentuated first heart sound, opening snap and mid-diastolic murmur.

Mitral regurgitation

Representación de una insuficiencia mitral

High-pitched systolic murmur loudestat the apex.

Grade 2 out of 6:


Grade 3 out of 6:


Grade 3 out of 6 with third heart sound:


Double mitral valve disease

Representación de una valvupatia mitral doble

It is a mitral stenosis combined with mitral regurgitation:


Tricuspid regurgitation

Representación de una insuficiencia tricúspeda
High-pitched systolic murmur loudest at the tricuspid point (xiphoid process).

It can vary during respiration, being louder during inspiration:


Aortic stenosis

Representación de una estenosis aórtica

It is a harsh murmur that reaches its highest intensity at 2RICS and ends before the second heart sound.


Aortic regurgitation

Representación de una insuficiencia aórtica
It is a high-pitched, aspiration murmur that reaches its highest intensity at 3LICS ⎯Erb’s point:


In case of severe aortic regurgitation, a mid-diastolic murmur can be heard at the apex. This murmur is known as Austin-Flint:


Double aortic valve disease

Representación de la valvupatia aortica doble
It is an aortic stenosis combined with aortic regurgitation:


Patent ductus arteriosus

Representación de la persistencia del ductus arterial
Continuous murmur heard at 2LICS.

It is also called machinery murmur because of its quality.


Ventricular septal defect

It is a holosystolic murmur, which can be better heard at the third or fourth left intercostal spaces.


It is sometimes common to hear a third sound at the apex due to the blood hyperflow passing through the mitral valve:


Atrial septal defect

It consists of a systolic murmur loudest at 2LICS and a fixed split second sound:


Pulmonary stenosis

It is a harsh systolic murmur loudest at 2RICS:


Pericardial friction rub

It is the friction between visceral and parietal pericardial layers. It can be heard more commonly between the apex and the sternum.
Its highest intensity is during inspiration:


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Doctor Alberto
Domínguez Rodríguez

Doctor Alberto Domínguez Rodríguez, clinical cardiologist in the cardiology department of the University Hospital of the Canary Islands (UHCI). I have designed a website to make the study of the heart sounds easier, besides helping professionals and students through aural examples that can only be heard through earphones, in order to offer them a better learning experience.

Fotografía del doctor Alberto Dominguez Rodriguez

Doctor Alberto Domínguez Rodríguez’s Resumé

  • Graduate in Medicine from the University of La Laguna, Spain.
  • Doctor in Medicine.
  • Cardiology Expert from the University Hospital of the Canary Islands, Tenerife, Spain.
  • Cardiology Attending Physician ⎯Clinical Cardiologist⎯ at the UHCI, Tenerife, Spain.
  • Supervisor of Doctoral Theses.
  • Corresponding Member at the Royal Academy of Medicine of Santa Cruz de Tenerife (2018).
  • Postgraduate Professor at the European University of the Canary Islands (2012−present).
  • Research on melatonin and its role on cardiovascular physiopathology.
  • Circadian rhythm in relation to cardiovascular physiopathology.
  • Biomarkers in ischemic heart disease.
  • Environmental pollution and cardiovascular risk.
  • Pathological approaches in cardiovascular pathology.
  • Cardiopulmonary exercise test in cardiovascular physiopathology.
  • Author of 280 articles indexed on PubMed.
    H-index = 38.
  • First author in 85% of the scientific articles included among Q1-Q3, according to the JCR.
  • Author of 184 presentations in local and international conferences.
  • Member of the Editorial Board of several cardiovascular biomedical magazines.
  • Partner Researcher at the Spanish Network Research Center in Cardiovascular Diseases, known as CIBERCV (2017−present).
  • Twelve years of research recognized by Spain’s National Agency for Quality Assessment and Accreditation (ANECA).
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