New murmur
Innocent flow murmur or structural disease — echo answers definitively.
Echo approach, step by step
Echo is recommended for patients with a murmur that suggests structural heart disease: diastolic, continuous, holosystolic, late systolic, or loud (grade ≥3) systolic murmurs, and any murmur with symptoms [7].
- LocaliseColour sweep of all four valves and both septa.
- AorticAS (Vmax, MG, AVA) or sclerosis; AR [4,5].
- LVOTHCM with obstruction [13].
- MitralMR mechanism and severity; MS; MVP [4,6].
- Septa and great vesselsVSD (high-velocity left-to-right jet), ASD (flow murmur across the pulmonary valve), PDA (continuous flow into the PA) [25,175].
- Right-sidedPulmonary stenosis, TR [194].
- High-outputNormal valves with high flow → anaemia, fever, pregnancy, thyrotoxicosis [201].
- All valves: stenosis / regurgitation
- LVOT gradient
- Septal defects
- PDA / coarctation
- High-output state
Causes & echo clues
| Murmur | Common causes | Echo confirms |
|---|---|---|
| Ejection systolic, base | AS, HCM, PS, flow murmur, ASD | Gradient and its level [5,13] |
| Holosystolic, apex | MR | Mechanism and grade [4] |
| Holosystolic, left sternal edge | VSD, TR | Jet location [25] |
| Late systolic, apex | MVP | Prolapse, late-systolic MR [4] |
| Early diastolic | AR, PR | Grade, root [4] |
| Mid-diastolic, apex | MS; flow (severe MR, VSD); Austin Flint | MVA [6] |
| Continuous | PDA, coronary fistula, ruptured sinus of Valsalva | Colour and CW [25] |
Clinical pathway to the diagnosis
- CharacteriseTiming, site, radiation and response to manoeuvres: Valsalva or standing increases HCM and MVP murmurs; handgrip increases MR, AR and VSD murmurs.
- Symptoms and contextFever, embolism, heart failure, pregnancy, recent MI.
- ECG and chest X-rayLVH, atrial enlargement, calcification.
- EchoFor murmurs that suggest structural disease [7].
- Treat per diagnosisValve disease pathways [6,7].
Clinical pearls & pitfalls
Practical tipA soft murmur can mean severe disease. In low-flow AS, acute severe MR (rapid pressure equalisation) and large VSDs with PH, the murmur may be soft or short [4,5].
- An innocent flow murmur is short, early systolic, soft (grade ≤2) and without other findings. Echo is not needed in asymptomatic young adults with such a murmur [7].
- Pregnancy produces flow murmurs. A diastolic murmur in pregnancy is abnormal; think of MS [6].
Red flags
- Any diastolic or continuous murmur is pathological [7]
- Murmur with fever → endocarditis [136]
- Murmur with chest pain, syncope or heart failure [7]
- New murmur after MI → VSD or papillary muscle rupture [138]