Clinical exam · Cardiovascular system
Dynamic auscultation: Valsalva, squatting, standing and handgrip !
- Maneuver
Changing the patient's posture or effort while listening alters murmurs and helps tell which one it is.
Updated 2026-11-01
See it in 3D: Left ventricle · Interventricular septum · Mitral posterior leaflet · Chordae tendineae · Inferior vena cava
What it is
Maneuvers change preload (blood returning to the heart) or afterload (resistance to outflow). Each murmur responds in a typical way. Their main use is to separate hypertrophic obstructive cardiomyopathy from aortic stenosis and to recognize mitral valve prolapse.
The anatomy it tests
- Valsalva (strain phase) and standing reduce preload: the left ventricle gets smaller. Most murmurs soften; outflow obstruction in hypertrophic cardiomyopathy worsens and mitral prolapse happens earlier.
- Squatting and leg raise increase preload (squatting also raises afterload): most murmurs get louder; hypertrophic cardiomyopathy softens.
- Handgrip raises afterload: regurgitant murmurs get louder (mitral regurgitation, aortic regurgitation, ventricular septal defect); aortic stenosis and hypertrophic cardiomyopathy soften.
- Inspiration: more return to the right heart, so tricuspid and pulmonic murmurs get louder.
How to do it
- Breathing: listen at the lower sternal border during quiet inspiration and expiration; inspiration makes right-sided murmurs louder.
- Valsalva: ask the patient to bear down against a closed glottis, as if straining at stool, for a few seconds while listening; then note the release.
- Squat to stand: the patient squats (listen), then stands quickly (listen again in the first beats).
- Handgrip: the patient squeezes both hands (or a ball) hard and steadily while you listen.
- Passive leg raise: with the patient supine, lift the legs; venous return rises.
- For each maneuver compare murmur intensity and length, and click timing, with baseline.
What a positive result means
- Systolic murmur louder with Valsalva and standing and softer with squatting: hypertrophic obstructive cardiomyopathy.
- Systolic murmur softer with Valsalva and handgrip: aortic stenosis.
- Click moving earlier and murmur lengthening with Valsalva or standing: mitral valve prolapse.
- Lower sternal border murmur that grows on inspiration: tricuspid regurgitation (Carvallo sign).
- An atypical response does not exclude the lesion: echocardiography decides.
Usefulness and limits
- Most useful to separate hypertrophic cardiomyopathy from aortic stenosis; responses are less clear with soft murmurs.
- Valsalva and squatting are not done in unstable patients, with active chest pain, or when the patient cannot cooperate; guard against falls on standing.
Test yourself
Think of the answer, then tap the question to see it.
Which maneuver best separates hypertrophic obstructive cardiomyopathy from aortic stenosis?
Valsalva or squat-to-stand: the hypertrophic cardiomyopathy murmur gets louder and the aortic stenosis murmur softer.
What does sustained handgrip do to mitral regurgitation?
It makes it louder, because raised afterload pushes more blood back into the left atrium.
Why does the mitral prolapse click move earlier on standing?
Venous return falls, the left ventricle gets smaller and the redundant leaflet prolapses earlier in systole.
Which murmurs get louder on inspiration?
Right-sided ones, such as tricuspid regurgitation, because inspiration increases venous return to that side.
See it in 3D
The structures of Durgical's 3D anatomy where it is found.
Related
- Valve murmurs: the table to know
- Murmurs: timing, grade, location and radiation
- Cardiac auscultation: the areas and the order
- Heart sounds: S1, S2 and its splitting, S3 and S4
Related conditions
- Mitral valve prolapse
- Hypertrophic cardiomyopathy
- Aortic Valve Stenosis
- Mitral regurgitation
- Aortic regurgitation
- Ventricular septal defect
Educational content on the clinical exam; it is learned and practised under supervision. It does not replace assessment by a health professional and is not for self-diagnosis.
Sources: 19.3 Cardiac Cycle - Anatomy and Physiology 2e | OpenStax (OpenStax (Rice University), 2022); Mitral valve prolapse: MedlinePlus Medical Encyclopedia (MedlinePlus, U.S. National Library of Medicine, 2026); 24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax (OpenStax (Rice University), 2024).
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Representative model, for educational purposes only.