[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) › Murmurs: timing, grade, location and radiation [Clinical exam](https://durgical.com/en/clinical-exam/) · [Cardiovascular system](https://durgical.com/en/clinical-exam/#a-cardiovascular) # Murmurs: timing, grade, location and radiation - Sign A murmur is the sound of turbulent blood flow; describing it well almost always tells which valve is failing. Updated 2026-11-01 **See it in 3D:** [Mitral anterior leaflet](https://durgical.com/en/anatomy/anterior-leaflet-of-left-atrioventricular-valve/) · [Mitral posterior leaflet](https://durgical.com/en/anatomy/posterior-leaflet-of-left-atrioventricular-valve/) · [Aortic right coronary cusp](https://durgical.com/en/anatomy/right-coronary-leaflet/) · [Chordae tendineae](https://durgical.com/en/anatomy/chordae-tendineae-of-right-atrioventricular-valve/) · [Left ventricle papillary muscles](https://durgical.com/en/anatomy/superior-papillary-muscle-of-left-ventricle/) · [Interventricular septum](https://durgical.com/en/anatomy/interventricular-septum/) ## Key points - Attributes: timing, shape, location, radiation, grade (1–6), pitch and maneuvers. - Grade 4 or more = palpable thrill. - Every diastolic murmur is pathologic. - New murmur with fever: think infective endocarditis. ## What it is Murmurs come from turbulent flow through a narrow or leaking valve, a septal defect or high flow. They are always described with the same attributes: timing in the cycle, shape, location, radiation, intensity, pitch and change with maneuvers. Every diastolic murmur is pathologic. ## The anatomy it tests - Stenosis: the valve does not open fully and blood speeds up through it (aortic and pulmonic in systole; mitral and tricuspid in diastole). - Regurgitation: the valve does not close and blood flows back (mitral and tricuspid in systole; aortic and pulmonic in diastole). - Septal defects: flow passes from the high-pressure to the low-pressure chamber (ventricular septal defect is holosystolic). - Murmurs radiate in the direction of the jet: aortic stenosis to the carotids, mitral regurgitation to the axilla. ## How to elicit it - Identify S1 and S2 by feeling the carotid pulse and decide whether the murmur is systolic (between S1 and S2), diastolic (between S2 and S1) or continuous. - Specify timing: early, mid, late or holosystolic (from S1 to S2 without a gap). - Describe the shape: diamond (crescendo-decrescendo), plateau or decrescendo. - Find the area where it is loudest and inch the stethoscope toward the neck, axilla or back to trace radiation. - Grade intensity from 1 to 6 (Levine scale) and feel for a thrill. - Describe pitch (high, low) and quality (harsh, blowing, rumbling) and test the effect of breathing and maneuvers. ## What a positive result means - Grade 1: barely audible with effort; 2: soft but clear; 3: loud, no thrill; 4: with a thrill; 5: heard with the stethoscope edge; 6: heard with the stethoscope off the chest. - Innocent murmur: midsystolic, soft (grade 1–2), no thrill, normal S2, no symptoms; common in children, pregnancy, fever and anemia. - Point to a pathologic murmur: any diastolic or holosystolic murmur, grade 3 or more, a thrill, abnormal sounds, symptoms, or louder on standing. - Fever plus a new murmur suggests infective endocarditis; in Colombia and the region rheumatic heart disease is still a common cause of mitral murmurs. ## Usefulness and limits - Loudness does not measure severity: an aortic stenosis murmur can soften as the heart fails. - Echocardiography confirms the lesion and its severity; auscultation decides who needs it. ## Memory aid 'Four and you feel it': from grade 4/6 the murmur vibrates under the palm. ## Test yourself Think of the answer, then tap the question to see it. ## What separates a grade 4/6 murmur from a grade 3/6 one? Grade 4 comes with a palpable thrill; grade 3 is loud but has no thrill. ## Which valves produce systolic murmurs when they leak? The atrioventricular valves, mitral and tricuspid, because they should be closed during systole. ## Which features suggest a murmur is innocent? Midsystolic, soft (grade 1–2), no thrill, normal S2, an asymptomatic patient, and softer on standing. [Add to my cards (3)](https://durgical.app/estudiar/?add=/en/clinical-exam/murmurs-timing-grade-location-and-radiation/) ## See it in 3D The structures of Durgical's 3D anatomy where it is found. - [Mitral anterior leaflet](https://durgical.com/en/anatomy/anterior-leaflet-of-left-atrioventricular-valve/) - [Mitral posterior leaflet](https://durgical.com/en/anatomy/posterior-leaflet-of-left-atrioventricular-valve/) - [Aortic right coronary cusp](https://durgical.com/en/anatomy/right-coronary-leaflet/) - [Chordae tendineae](https://durgical.com/en/anatomy/chordae-tendineae-of-right-atrioventricular-valve/) - [Left ventricle papillary muscles](https://durgical.com/en/anatomy/superior-papillary-muscle-of-left-ventricle/) - [Interventricular septum](https://durgical.com/en/anatomy/interventricular-septum/) ## Related - [Valve murmurs: the table to know](https://durgical.com/en/clinical-exam/valve-murmurs-the-table-to-know/) - [Cardiac auscultation: the areas and the order](https://durgical.com/en/clinical-exam/cardiac-auscultation-the-areas-and-the-order/) - [Dynamic auscultation: Valsalva, squatting, standing and handgrip](https://durgical.com/en/clinical-exam/dynamic-auscultation-valsalva-squatting-standing-and-handgrip/) - [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/) - [Precordial inspection and palpation: apex beat, heaves and thrills](https://durgical.com/en/clinical-exam/precordial-inspection-and-palpation-apex-beat-heaves-and-thrills/) ## Related conditions - [Infective endocarditis](https://durgical.com/en/conditions/infective-endocarditis/) - [Rheumatic heart disease](https://durgical.com/en/conditions/rheumatic-heart-disease/) - [Aortic Valve Stenosis](https://durgical.com/en/conditions/aortic-valve-stenosis/) - [Mitral regurgitation](https://durgical.com/en/conditions/mitral-regurgitation/) - [Ventricular septal defect](https://durgical.com/en/conditions/ventricular-septal-defect/) - [Hypertrophic cardiomyopathy](https://durgical.com/en/conditions/hypertrophic-cardiomyopathy/) [← 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: [Heart murmurs: MedlinePlus Medical Encyclopedia](https://medlineplus.gov/ency/article/003266.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); [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). ## **Spotted a mistake?** We are always improving for the community. Tell us what is wrong and our team will review it. Report a mistake Representative model, for educational purposes only. --- Source: https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/ License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/clinical-exam/murmurs-timing-grade-location-and-radiation/