Heart marmar with mnemonic
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heart murmur mnemonic PASS RILE SPASM cardiology
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Here is a complete, high-yield guide to heart murmurs (marmur/marmar) with all key mnemonics:
Heart Murmurs (Marmar) - Complete Guide with Mnemonics
1. Auscultation Locations - "APE To Man"
| Letter | Area | Location |
|---|---|---|
| A | Aortic | Right 2nd ICS, sternal edge |
| P | Pulmonic | Left 2nd ICS, sternal edge |
| E | Erb's Point | Left 3rd ICS |
| T | Tricuspid | Left 4th-5th ICS, sternal border |
| M | Mitral (Apex) | Left 5th ICS, midclavicular line |
Think of the stethoscope path going top-right to bottom-left across the chest.
2. Systolic Murmurs - "MR PASS MVP"
| Letter | Meaning |
|---|---|
| M | Mitral |
| R | Regurgitation |
| P | Physiologic (flow murmur) |
| A | Aortic |
| S | Stenosis |
| S | Systolic |
| MVP | Mitral Valve Prolapse (bonus - also systolic!) |
All systolic murmurs occur between S1 and S2 (lub - murmur - dub)
Key Systolic Murmurs at a Glance
| Murmur | Timing | Character | Best Heard | Radiation |
|---|---|---|---|---|
| Aortic Stenosis (AS) | Mid-systolic | Crescendo-decrescendo, harsh | Right 2nd ICS | Carotids |
| Mitral Regurgitation (MR) | Holosystolic | Blowing, plateau | Apex | Left axilla |
| Tricuspid Regurgitation (TR) | Holosystolic | Blowing | Lower left sternal border | Louder with inspiration |
| Pulmonary Stenosis (PS) | Mid-systolic | Crescendo-decrescendo | Left 2nd ICS | - |
| VSD | Holosystolic | Harsh | Left sternal border | - |
| MVP | Late-systolic with click | "Honking" | Apex | - |
| HOCM | Mid-systolic | Decreases with squatting | Left sternal border | - |
Aortic Stenosis symptoms - "SAD"
- S - Syncope
- A - Angina
- D - Dyspnea (heart failure)
3. Diastolic Murmurs - "MS ARD"
| Letter | Meaning |
|---|---|
| M | Mitral |
| S | Stenosis |
| A | Aortic |
| R | Regurgitation |
| D | Diastolic |
All diastolic murmurs occur between S2 and the next S1 (lub - dub - murmur)
4 Types - "Aunt Polly Makes Tea"
| Letter | Murmur |
|---|---|
| A | Aortic regurgitation |
| P | Pulmonary regurgitation |
| M | Mitral valve rumble (stenosis) |
| T | Tricuspid valve rumble (stenosis) |
Key Diastolic Murmurs at a Glance
| Murmur | Timing | Character | Best Heard | Special Feature |
|---|---|---|---|---|
| Aortic Regurgitation (AR) | Early diastolic | High-pitched, blowing, decrescendo | Left sternal border | Leaning forward at end-expiration |
| Mitral Stenosis (MS) | Mid-late diastolic | Low-pitched rumble | Apex, with bell | Opening snap; presystolic accentuation |
| Pulmonary Regurgitation | Early diastolic | Blowing | Left 2nd ICS | Graham Steell murmur (with pulm. HTN) |
4. Continuous Murmur
- PDA (Patent Ductus Arteriosus) - "Machinery murmur" - crescendos to S2 then continues into diastole
- Mnemonic: "PDA = Persistent Dull Audience" - it never stops
Key distinction: A continuous murmur crosses S2; a to-and-fro murmur (e.g., AS + AR) has a gap at S2.
5. Effects of Bedside Maneuvers - "HISS STAND"
| Maneuver | Effect | Murmur affected |
|---|---|---|
| Valsalva / Standing | Decreases preload | Decreases most murmurs; increases HOCM & MVP |
| Squatting / Leg raise | Increases preload | Increases most murmurs; decreases HOCM & MVP |
| Inspiration | Increases right heart filling | Increases right-sided murmurs (TR, PS, TS) - Carvallo's sign |
| Hand grip | Increases afterload | Increases MR, AR, VSD; decreases AS, HOCM |
HOCM & MVP memory trick:
"HOCM and MVP are drama queens - they get louder when there's less blood (Valsalva/standing) and quieter when there's more (squatting)."
6. Murmur Grading - "1 to 6"
| Grade | Description |
|---|---|
| 1 | Barely audible, only in quiet room |
| 2 | Soft but easily heard |
| 3 | Moderately loud, no thrill |
| 4 | Loud + palpable thrill |
| 5 | Very loud, heard with stethoscope edge |
| 6 | Heard without stethoscope |
Mnemonic: "1-2 = soft, 3-4 = loud + thrill starts at 4, 5-6 = very loud" Murmurs grade 3+ are almost always pathological.
Visual Reference - Heart Murmur Timing Diagram
(From Harrison's Principles of Internal Medicine, 22E)
- A = Presystolic (MS/TS in sinus rhythm)
- B = Holosystolic (MR, TR, VSD)
- C = Aortic ejection murmur (AS) - ends before S2
- D = Pulmonary stenosis - spills through A2
- E = Early diastolic decrescendo (AR, PR)
- F = Long diastolic rumble of MS (with opening snap OS)
- G = Short mid-diastolic after S3
- H = Continuous murmur (PDA)
Quick Summary Cheat-Sheet
| Systolic (S1→S2) | Diastolic (S2→S1) | Continuous | |
|---|---|---|---|
| Mnemonic | MR PASS MVP | MS ARD | PDA machinery |
| Key examples | AS, MR, TR, PS, VSD, MVP | AR, MS | PDA |
| Increases with inspiration | TR, PS (right-sided) | TS | - |
| Increases with Valsalva | HOCM, MVP | - | - |
Sources: Harrison's Principles of Internal Medicine 22E (2025), p. 326-331; Latrina Walden Exam Solutions; Fitzgerald Health Education Associates
For an excellent audio walkthrough with actual murmur sounds, see this video:
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