Heart murmurs and their physiologic responses to stress

Heart murmurs vary in quality and duration with specific physiological influences.Knowing these changes can help us differentiate between specific murmurs.



Right sided heart murmurs become loud with inspiration

  • Systolic sounds – TR/PS
  • Diastolic sounds – TS/PR
  • Right sided s3 and s4 also become louder


  • Left sided heart murmurs become loud with expiration.
  • Pulmonic ejection sound also becomes louder.

Valsalva manuever

  • Most murmurs decrease in length and intensity with valsalva.
  • Two exceptions are HCM and MVP.


Postional changes


  • Most murmurs decrease in intensity
  • Exceptions are HCM and MVP


  • Most murmurs become more intense with squatting
  • Exceptions are HCM and MVP which become softer.

Passive legraising

  • All murmurs except HCM and MVP increase in intensity


  • Murmurs due to blood flow across normal or stenotic valves(PS and MS) become louder with isotonic and Isometric (handgrip)exercise.
  • MR,VSD and AR also increase with handgrip.
  • Leftsided S3 and S4 gets accentuated
  • HCM decrease with near maximum handgrip.


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