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Diastolic murmurs Sound: Place in cycle: Cause: Most common diagnoses: Aortic regurgitation murmur Usually a high-pitched, decrescendo and often faint puffing or blowing sound, with the cycle sound described as: LUB Pew Begins with A2, the aortic component of S2 Turbulence as blood flows through a constricted, dilated or defective aortic valve or aorta, with regurgitation into the left ventricle. Pulmonary regurgitation murmur Usually a high-pitched, decrescendo blowing sound similar to an aortic murmur that increases on inspiration. When not linked to pulmonary hypertension the pitch is lower and it may be crescendo-decrescendo. Usually early diastolic: begins with P2, the pulmonary component of S2 Turbulence as blood flows through a constricted, dilated or defective pulmonary valve or pulmonary trunk/artery Pulmonary valve regurgitation, often as a result of severe pulmonary hypertension Pulmonary valve endocarditis Congenital valve abnormalities Usually a low-pitched rumbling crescendo murmur Mid-diastole and/or late diastole (presystole) Turbulence due to defect or disease that obstructs or increases the flow of blood through the mitral valve 1. Obstructed flow – most commonly mitral stenosis – often with a loud S1 and an opening snap – but also left atrial myxoma, cor triatriatum and localised pericardial constriction. Mitral rumble When not linked to pulmonary hypertension it may occur mid-diastolic Aortic regurgitation Note: Easily mistaken for a systolic murmur if heart rate is rapid, which shortens diastole – palpate the carotid artery to confirm A2. May resemble pulmonary regurgitation murmur – bounding pulse and wide pulse pressure point to aortic regurgitation. 2. Increased flow – most commonly mitral regurgitation but also ventricular septal defect, patent ductus arteriousus, complete heart block Tricuspid rumble Usually a low-pitched rumbling murmur that gets louder on inspiration, often with a crescendo-decrescendo presystolic component and sometimes an opening snap Mid-diastole and/or late diastole (presystole) Turbulence due to defect or disease that obstructs or increases the flow of blood through the tricuspid valve 1. Obstructed flow – most commonly tricuspid stenosis but also right atrial myxoma, localised pericardial constriction 2. Increased flow – atrial septal defect, tricuspid regurgitation
