1. DIASTOLIC MURMURSDIASTOLIC MURMURS
EARLY -DIASTOLIC
Aortic regurgitation
The murmur is low intensity, high-pitched, best heard over the left sternal border or over the right second
intercostal space, especially if the patient leans forward and holds breath in full expiration. The radiation is typically
toward the apex. The configuration is usually decrescendo and has a blowing character.
ETIOLOGY: Valvular, Dilation of valve ring, Widening of commissures in syphilis (Key-Hodgkin’s
murmur)
Pulmonic regurgitation
Pulmonary regurgitation is a high-pitched and blowing murmur with a decrescendo configuration. It may increase
in intensity during inspiration and best heard over left second and third inter-costal spaces. The murmur usually does not
extend to S1.
ETIOLOGY: Valvular, Dilation of valve ring as in pulmonary hypertension (Graham Steell murmur),
Congenital
Left anterior descending artery stenosis Dock's murmur, is similar to that of aortic regurgitation and is
heard at the left second or third intercostal space
MID -DIASTOLIC
Mitral stenosis
This murmur has a rumbling character and is best heard with the bell of the stethoscope in the left ventricular
impulse area with the patient in the lateral decubitus position. It usually starts with an opening snap.
Carey-Coombs murmur (mid-diastolic apical murmur in acute rheumatic fever)
Increased flow across nonstenotic mitral valve (e.g., MR, VSD, PDA, high-output states, and complete heart block)
Tricuspid stenosis
Best heard over the left sternal border with rumbling character and tricuspid opening snap with wide splitting S1.
Increased flow across nonstenotic tricuspid valve (e.g., TR, ASD, and anomalous pulmonary venous return)
Left and right atrial tumors (myxoma), mid-diastolic murmur similar to that of mitral stenosis
Severe or eccentric AR (Austin Flint Murmur)
LATE-DIASTOLIC
Pre-systolic accentuation of mitral stenosis murmur
Austin Flint murmur of severe or eccentric AR
Complete heart block: A short late diastolic murmur can occasionally be heard (Rytand's murmur).
Early diastolic murmurs start at the same
time as S2 with the close of the semi lunar
valves and typically ends before S1
Mid-diastolic murmurs start after S2 and
end before S1. They are due to turbulent
flow across the atrioventricular valves
during the rapid filling phase from mitral
or tricuspid stenosis
Late diastolic (presystolic) murmurs start
after S2 and extend up to S1 and have a
crescendo configuration

2. Ref: BRAUNWALD 8TH
edi, NEJM Dec 2010; Name That Murmur — Eponyms for the Astute Auscultation
Dr YELDHO EASON
VARGHESE