associated murmurs in MS
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Now I have comprehensive information. Let me compile the full answer on murmurs associated with mitral stenosis.
Murmurs in Mitral Stenosis (MS)
1. The Classic MS Murmur (Primary Murmur)
| Feature | Detail |
|---|---|
| Type | Low-pitched, rumbling, mid-diastolic murmur |
| Location | Apex (mitral area) |
| Position | Best heard in left lateral decubitus position |
| Instrument | Bell of stethoscope, applied lightly |
| Duration | Proportional to severity - increases in length as stenosis worsens |
| Character | Diastolic with presystolic accentuation (in sinus rhythm) |
Presystolic accentuation occurs because atrial contraction against a stenotic valve at end-diastole increases turbulent blood flow, augmenting murmur intensity. This is absent in atrial fibrillation (no coordinated atrial contraction). - Frameworks for Internal Medicine
Tip for detection: Heart rate-increasing maneuvers (sit-ups, phantom bicycling) increase the transmitral diastolic gradient and help reveal a faint murmur.
2. Complete Auscultatory Findings in MS (4 Key Features)
- Loud/pronounced S1 - the high transmitral gradient holds the mitral valve wide open throughout diastole; ventricular systole then snaps it shut with force, producing a loud S1. (In advanced calcified MS, S1 becomes soft.)
- Opening snap (OS) after S2 - early diastolic, high-pitched sound from sudden tensing of abnormal leaflets during opening. The shorter the S2-OS interval, the higher the LA pressure and greater severity.
- Rumbling mid-diastolic murmur at the apex (as above).
- Presystolic accentuation (in sinus rhythm only).
- Frameworks for Internal Medicine; Goldman-Cecil Medicine; Fuster and Hurst's The Heart, 15th Ed.
3. Associated / Eponymous Murmurs
Graham Steell Murmur
- What: High-pitched, early diastolic, decrescendo murmur of pulmonary regurgitation secondary to pulmonary hypertension complicating MS.
- Location: Left sternal border, 2nd left intercostal space.
- Mechanism: Longstanding elevated pulmonary artery pressures from MS dilate the pulmonary valve annulus, causing functional PR.
- Key point: Must be distinguished from aortic regurgitation murmur (aortic valvulography has historically been used for this).
- Frameworks for Internal Medicine; Harrison's Principles of Internal Medicine 22E; Fuster and Hurst's The Heart, 15th Ed.
Carey-Coombs Murmur
- What: Transient mid-diastolic apical murmur occurring in acute rheumatic fever (the very condition that leads to MS).
- Mechanism: Active mitral valvulitis with leaflet edema creates relative obstruction to mitral inflow; the inflamed mitral valve leaflets also vibrate during diastole. It disappears as the acute inflammation resolves.
- Significance: Marker of active carditis in rheumatic fever; not permanent MS.
- Harrison's Principles of Internal Medicine 22E; Braunwald's Heart Disease
Austin-Flint Murmur
- What: Mid-to-late diastolic, low-pitched apical rumble mimicking MS.
- Mechanism: Occurs in severe aortic regurgitation - the AR jet hits the anterior leaflet of the mitral valve, causing it to reverberate and creating functional mitral obstruction. This is not true MS but simulates it closely.
- Distinction from MS: No opening snap, soft S1 (instead of loud S1), signs of AR (wide pulse pressure, diastolic decrescendo murmur at left sternal border).
- Practical note: Handgrip (increases afterload) accentuates the true MS murmur; amyl nitrite (decreases afterload/preload) decreases the Austin-Flint murmur.
- Fuster and Hurst's The Heart, 15th Ed.; Symptom to Diagnosis, 4th Ed.
4. Other Coexisting Murmurs Due to Associated Valve Disease
| Murmur | Cause | Notes |
|---|---|---|
| Tricuspid regurgitation (TR) | Pulmonary HTN from MS causes RV dilation and tricuspid annular dilation | Holosystolic murmur at left sternal border, increases with inspiration (Carvallo's sign) |
| Tricuspid stenosis (TS) | Rheumatic involvement of tricuspid valve (occurs alongside MS in rheumatic disease) | Low-pitched diastolic rumble at left sternal border; giant A wave in JVP |
| Mitral regurgitation (MR) | Same rheumatic process that causes MS can render the valve both stenotic and regurgitant | Holosystolic murmur at apex; "mixed mitral disease" |
| Aortic regurgitation (AR) | Rheumatic disease - next most common combination with MS in rheumatic heart disease | Diastolic decrescendo murmur at left sternal border |
- Creasy & Resnik's Maternal-Fetal Medicine; Fuster and Hurst's The Heart, 15th Ed.; Textbook of Clinical Echocardiography
Quick Summary Table
| Murmur | Type | Location | Associated With |
|---|---|---|---|
| MS rumble | Mid-diastolic, low-pitched | Apex | MS itself (primary) |
| Presystolic accentuation | End-diastolic crescendo | Apex | Sinus rhythm in MS |
| Graham Steell | Early diastolic decrescendo | Left sternal border | Pulmonary HTN from MS |
| Carey-Coombs | Mid-diastolic | Apex | Acute rheumatic fever/carditis |
| Austin-Flint | Mid-to-late diastolic | Apex | Severe AR (mimics MS) |
| TR murmur | Holosystolic | Left sternal border | Pulmonary HTN, RV dilation |
| TS murmur | Diastolic rumble | Left sternal border | Rheumatic tricuspid valve |
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