Diastolic Murmurs - Auscultation Course

This course presents diastolic murmurs which includes aortic and mitrol regurgitation, mitral stenosis and tricuspid stenosis. Before you take this course you should have finished the Normal, First and Second Heart sound, Extra Heart Sound and importantly systolic murmur courses. You should feel comfortable with the material presented.

Using this course

Each lesson in this course includes text describing the heart or lung abnormality and a simulated torso indicating the stethoscope chestpiece location. An audio recording of the sound is provided. Phonocardiograms or waveforms are included with each lesson. These waveforms can be a highly useful aid in learning to recognize heart murmurs. In addition, short videos clips illustrate the heart's motion for each abnormality. These animations indicate the origin of each murmur. Blood flow is also animated. For lung sounds, the source (location) of the sound can be revealed.

After completing a lesson, use the lesson table of contents to navigate to another lesson.

When all lessons have been completed, we recommend using the auscultation practice exercises or quiz. In order to gain a certificate of achievement, please complete the course lessons and practice drill during one session. Most users complete the course's lessons and quiz in 30-45 minutes.

Click To Begin Training Module

Lessons

Lesson #1: Aortic Regurgitation - Mild

This is an example of mild aortic regurgitation which can be caused by a bicuspid (thickened) aortic valve. The first heart sound is diminished due to premature closure of the mitral valve leaflets. An aortic ejection click follows the first heart sound by 75 milliseconds. S2 is normal. Systole is silent. A high-pitched decrescendo murmur occupying the first half of diastole can be heard starting immediately after the second heart sound. The murmur is best heard at Erb's Point and can be accentuated by having the patient sitting up and leaning forward holding his breath after expiration. In the animation you can see the turbulent blood flow from the aorta into the left ventricle during early diastole. You can see the minimally thickened aortic valve leaflets.

Lesson #2: Pulmonic Regurgitation - Mild

This is an example of mild pulmonic regurgitation which can be caused by an infection of the pulmonic valve leaflets. The first and second heart sounds are normal (S2 is split). Systole is silent. A high-pitched decrescendo murmur occupying the first half of diastole can be heard starting immediately after the second heart sound. The murmur is best heard at the pulmonic area and can be accentuated by having the patient sitting up and leaning forward. The intensity of the murmur increases with inspiration, indicating the right-sided origin of the murmur. In the animation you can see the turbulent blood flow from the pulmonary artery into the right ventricle during early diastole. You can see the minimally thickened pulmonic valve leaflets.

Lesson #3: Mitral Stenosis - Mild

This is an example of mild mitral stenosis which is most commonly due to rheumatic heart disease. The first heart sound is increased in intensity due to mild thickening of the mitral valve leaflets. The second heart sound is normal and unsplit Systole is silent. There is an opening snap 100 milliseconds into diastole. As mitral stenosis becomes more severe, the opening snap will occur earlier in diastole. The opening snap is followed by a diamond shaped low-frequency murmur. Use the bell of the stethoscope to hear this murmur. In the animation you can see the turbulent blood flow from the left atrium into the left ventricle. You can see the minimally thickened mitral valve leaflets and the minimally enlarged left atrium. The excursion of the mitral valve leaflets is minimally decreased.

Lesson #4: Mitral Stenosis - Moderate

This is an example of moderate mitral stenosis which is most commonly due to rheumatic heart disease. The first heart sound is increased in intensity due to moderate thickening of the mitral valve leaflets. The second heart sound is normal and unsplit Systole is silent. There is an opening snap 75 milliseconds into diastole. As mitral stenosis becomes more severe, the opening snap will occur earlier in diastole. The opening snap is followed by a diamond shaped low frequency murmur. Use the bell of the stethoscope to hear this murmur. There is a second murmur in late diastole due to contraction of the left atrium. In the animation you can see the turbulent blood flow from the left atrium into the left ventricle. You can see the moderately thickened mitral valve leaflets and the moderately enlarged left atrium. The excursion of the mitral valve leaflets is moderately decreased.

Lesson #5: Mitral Stenosis - Severe

This is an example of severe mitral stenosis which is most commonly due to rheumatic heart disease. The first heart sound is decreased in intensity due to severe thickening of the mitral valve leaflets. The second heart sound is normal and unsplit Systole is silent. There is an opening snap 50 milliseconds into diastole. As mitral stenosis becomes more severe, the opening snap will occur earlier in diastole. The opening snap is followed by a low frequency murmur which occupies the remainder of diastole. The first two thirds of the murmur is diamond shaped and the remainder is a crescendo. Use the bell of the stethoscope to hear this murmur. In the animation you can see the turbulent blood flow from the left atrium into the left ventricle. You can see the severely thickened mitral valve leaflets and the markedly enlarged left atrium. The excursion of the mitral valve leaflets is severely reduced.

Lesson #6: Tricuspid Stenosis - Moderate

This is an example of moderate tricuspid stenosis which is most commonly due to rheumatic heart disease. The first heart sound is increased in intensity due to moderate thickening of the tricuspid valve leaflets. The second heart sound is normal and unsplit. Systole is silent. There is a tricuspid opening snap followed by a diamond shaped low frequency murmur. Use the bell of the stethoscope to hear this murmur. There is a second murmur in late diastole due to contraction of the right atrium. In the animation you can see the turbulent blood flow from the right atrium into the right ventricle. You can see the moderately thickened tricuspid valve leaflets and the moderately enlarged right atrium. The excursion of the tricuspid valve leaflets is moderately decreased. For this condition the murmur intensity and tricuspid opening snap increase with inspiration.

Authors and Reviewers

Heart sounds by Dr. Jonathan Keroes, MD and David Lieberman, Developer, Virtual Cardiac Patient.
Lung sounds provided by Diane Wrigley, PA
Heart sounds mentorship by W. Proctor Harvey, MD>
Reviewed by Dr. Barbara Erickson, PhD, RN, CCRN.
Last Update: 12/14/2022

Sources

Heart Sounds and Murmurs Across the Lifespan (with CD) by Dr Barbara Ann Erickson
Publisher: Mosby
ISBN-10: 0323020453; ISBN-13: 978-0323020459
Heart Sounds and Murmurs: A Practical Guide with Audio CD-ROM 3rd Edition
Elsevier-Health Sciences Division
Barbara A. Erickson, PhD, RN, CCRN
Heart Sounds Made Easy with CD-ROM: (with CD-ROM) 2nd Edition
Anthony P. Salmon
ISBN-13: 978-0443069079
NCBI Review of Heart Sounds and Murmurs: A Practical Guide
The Virtual Cardiac Patient: A Multimedia Guide to Heart Sounds And Murmurs Jonathan Keroes, David Lieberman
Publisher: Lippincott Williams & Wilkin)
ISBN-10: 0781784425; ISBN-13: 978-0781784429
Ventricular Function Curves in the Exercising Dog
JONATHAN KEROES , ROGER R. ECKER , and ELLIOT RAPAPORT
Circulation Research, Vol. 25, No. 5
Electrocardiographic changes associated with ritodrine-induced maternal tachycardia and hypokalemia American Journal of Obstetrics Gynecology, VOLUME 154, ISSUE 4, P921-923, APRIL 01, 1986
Susan K Hendricks, MD, Jonathan Keroes, MD, Michael Katz, MD
A Multimedia Guide to Heart Sounds and Murmurs
January 2007 JAMA The Journal of the American Medical Association 297(2):217-218
DOI:10.1001/jama.297.2.217. M. Saleem Seyal, MD, Reviewer
Clinical Heart Disease W Proctor Harvey, MD