[Durgical](https://durgical.com/en/) › [DurgiPedia](https://durgical.com/en/durgipedia/) › [Clinical exam](https://durgical.com/en/clinical-exam/) › [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) › Dynamic auscultation: Valsalva, squatting, standing and handgrip

[Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular)

# 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](https://durgical.com/en/anatomy/left-ventricle/) · [Interventricular septum](https://durgical.com/en/anatomy/interventricular-septum/) · [Mitral posterior leaflet](https://durgical.com/en/anatomy/posterior-leaflet-of-left-atrioventricular-valve/) · [Chordae tendineae](https://durgical.com/en/anatomy/chordae-tendineae-of-right-atrioventricular-valve/) · [Inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/)

## Key points

- Valsalva and standing: ↑ hypertrophic cardiomyopathy, earlier prolapse click; ↓ almost all others.
- Squatting and leg raise: ↓ hypertrophic cardiomyopathy; ↑ almost all others.
- Handgrip: ↑ mitral regurgitation, aortic regurgitation and VSD; ↓ aortic stenosis and hypertrophic cardiomyopathy.
- Inspiration: ↑ right-sided murmurs.

## 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.

## Memory aid

'Less blood, more block': anything that empties the ventricle (Valsalva, standing) worsens hypertrophic cardiomyopathy and brings the prolapse forward.

## 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.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/clinical-exam/dynamic-auscultation-valsalva-squatting-standing-and-handgrip/)

## See it in 3D

The structures of Durgical's 3D anatomy where it is found.

- [Left ventricle](https://durgical.com/en/anatomy/left-ventricle/)
- [Interventricular septum](https://durgical.com/en/anatomy/interventricular-septum/)
- [Mitral posterior leaflet](https://durgical.com/en/anatomy/posterior-leaflet-of-left-atrioventricular-valve/)
- [Chordae tendineae](https://durgical.com/en/anatomy/chordae-tendineae-of-right-atrioventricular-valve/)
- [Inferior vena cava](https://durgical.com/en/anatomy/inferior-vena-cava/)

## Related

- [Valve murmurs: the table to know](https://durgical.com/en/clinical-exam/valve-murmurs-the-table-to-know/)
- [Murmurs: timing, grade, location and radiation](https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/)
- [Cardiac auscultation: the areas and the order](https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/)
- [Heart sounds: S1, S2 and its splitting, S3 and S4](https://durgical.com/en/clinical-exam/heart-sounds-s1-s2-and-its-splitting-s3-and-s4/)

## Related conditions

- [Mitral valve prolapse](https://durgical.com/en/conditions/mitral-valve-prolapse/)
- [Hypertrophic cardiomyopathy](https://durgical.com/en/conditions/hypertrophic-cardiomyopathy/)
- [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/)
- [Mitral regurgitation](https://durgical.com/en/conditions/mitral-regurgitation/)
- [Aortic regurgitation](https://durgical.com/en/conditions/aortic-regurgitation/)
- [Ventricular septal defect](https://durgical.com/en/conditions/ventricular-septal-defect/)

[← All of the clinical exam](https://durgical.com/en/clinical-exam/)

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](https://openstax.org/books/anatomy-and-physiology-2e/pages/19-3-cardiac-cycle) (OpenStax (Rice University), 2022); [Mitral valve prolapse: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/000180.htm) (MedlinePlus, U.S. National Library of Medicine, 2026); [24.3 Nursing Assessment - Clinical Nursing Skills | OpenStax](https://openstax.org/books/clinical-nursing-skills/pages/24-3-nursing-assessment) (OpenStax (Rice University), 2024).

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Representative model, for educational purposes only.

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License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/dynamic-auscultation-valsalva-squatting-standing-and-handgrip/