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Extra Heart Sounds (Murmurs)

What is Extra heart sounds (murmurs)?

Extra heart sounds, commonly referred to as heart murmurs, are abnormal noises that can be heard during a cardiac auscultation (listening with a stethoscope). They are produced by turbulent blood flow within the heart chambers or great vessels. Murmurs are not a disease themselves; rather, they are a sign that something may be altering the normal flow of blood.

Most murmurs are innocent (also called functional or physiologic) and do not indicate heart damage. However, some murmurs are pathologic, meaning they are caused by structural heart disease or other serious conditions that may require further evaluation and treatment.

Common Causes

Below are the most frequently encountered conditions that generate extra heart sounds. Some are benign, while others demand medical attention.

• Innocent (physiologic) murmurs – common in children, pregnant women, and athletes; usually harmless.
• Congenital heart defects – such as ventricular septal defect (VSD), atrial septal defect (ASD), patent ductus arteriosus (PDA), or tetralogy of Fallot.
• Valve calcification or degeneration – especially aortic stenosis and mitral regurgitation in older adults.
• Rheumatic heart disease – damage to valves after untreated streptococcal throat infection.
• Infective endocarditis – infection of the heart valves producing regurgitant murmurs.
• Hypertrophic cardiomyopathy (HCM) – thickened heart muscle causing outflow obstruction.
• Heart failure with reduced ejection fraction – can lead to functional mitral regurgitation.
• Myocardial ischemia or infarction – acute changes may create new murmurs.
• Thyroid disorders – hyperthyroidism can increase cardiac output, creating flow‑murmurs.
• Anemia or high-output states – rapid blood flow through normal valves may be audible.

Associated Symptoms

While many murmurs are silent aside from the audible sound, pathologic murmurs often accompany other clinical findings.

• Shortness of breath, especially on exertion or when lying flat.
• Chest pain or pressure.
• Palpitations or irregular heartbeat.
• Fatigue or reduced exercise tolerance.
• Swelling of the ankles, feet, or abdomen (edema).
• Syncopal episodes (fainting) or near‑syncope.
• Blue‑tinged lips or fingertips (cyanosis) in severe congenital defects.
• Rapid weight gain due to fluid retention.

When to See a Doctor

Any newly‑detected heart murmur in an adult should prompt a medical evaluation, especially if it is accompanied by any of the following:

• Persistent shortness of breath or unexplained fatigue.
• Chest discomfort, especially with activity.
• Swelling of the legs, ankles, or abdomen.
• Fainting, dizziness, or light‑headedness.
• History of a recent infection (e.g., strep throat) that was untreated.
• Family history of congenital heart disease or early heart failure.
• Rapid heart rate (tachycardia) or irregular rhythm.

If you notice any of these signs, schedule an appointment with your primary‑care provider or a cardiologist promptly.

Diagnosis

Diagnosing the cause of a murmur involves a stepwise approach that combines clinical assessment with specific investigations.

Clinical Examination

• Auscultation – the physician listens for timing (systolic vs. diastolic), location, intensity (grade 1‑6), pitch, and radiation of the murmur.
• Physical exam – assessment for signs of heart failure, cyanosis, clubbing, or signs of systemic disease.
• History taking – onset, changes over time, associated symptoms, and family or maternal health history.

Imaging & Tests

• Echocardiography (transthoracic or transesophageal) – gold‑standard for visualizing valve structure, chamber size, and flow patterns. It can differentiate innocent from pathologic murmurs.
• Electrocardiogram (ECG) – detects arrhythmias, chamber enlargement, or prior infarction.
• Chest X‑ray – evaluates heart size and pulmonary vasculature.
• Cardiac MRI or CT – used for complex congenital lesions or detailed anatomy.
• Cardiac catheterization – measures pressures and visualizes coronary arteries when surgical planning is needed.
• Blood tests – CBC for anemia, thyroid panel, inflammatory markers (CRP, ESR) if endocarditis is suspected, and streptococcal antibody titers for rheumatic fever.

Treatment Options

Treatment is directed at the underlying cause; the murmur itself does not need “treatment” unless it signals a serious problem.

Innocent Murmurs

• Usually require no intervention; reassurance and routine follow‑up are sufficient.

Structural Valve Disease

• Medical management – diuretics, ACE inhibitors, beta‑blockers, or vasodilators to control heart failure symptoms.
• Antibiotic prophylaxis – for certain high‑risk valve conditions before dental procedures (per AHA guidelines).
• Surgical repair or replacement – indicated for severe stenosis/regurgitation, progressive symptoms, or left‑ventricular dysfunction.

Congenital Heart Defects

• Observation for small, hemodynamically insignificant lesions.
• Interventional catheter‑based closure (e.g., for ASD, PDA).
• Open‑heart surgery for complex defects.

Infective Endocarditis

• Intravenous antibiotics for 4–6 weeks (often in hospital).
• Surgical valve repair or replacement if there is valve destruction, heart failure, or persistent infection.

Hypertrophic Cardiomyopathy

• Beta‑blockers or calcium‑channel blockers to reduce outflow obstruction.
• Septal myectomy or alcohol septal ablation for severe cases.
• Implantable cardioverter‑defibrillator (ICD) in patients at high risk for sudden cardiac death.

High‑Output States (Anemia, Hyperthyroidism)

• Treat the underlying disorder – iron supplementation, thyroid‑blocking medication, or management of chronic lung disease.

Lifestyle & Home Measures

• Maintain a heart‑healthy diet low in saturated fat and sodium.
• Engage in regular, moderate‑intensity aerobic exercise (unless contraindicated).
• Avoid smoking and limit alcohol consumption.
• Monitor weight and blood pressure regularly.
• Adhere to prescribed medications and attend scheduled follow‑up appointments.

Prevention Tips

While you cannot prevent congenital heart defects, many pathologic murmurs are linked to modifiable risk factors.

• Treat streptococcal throat infections promptly – complete the full course of antibiotics to avoid rheumatic fever.
• Control blood pressure, cholesterol, and diabetes – reduces the risk of valve calcification and coronary disease.
• Practice good oral hygiene – decreases bacterial load that could seed the heart in high‑risk individuals.
• Stay up‑to‑date on vaccinations – influenza and pneumococcal vaccines help prevent infections that can exacerbate heart strain.
• Avoid illicit drug use, especially intravenous drugs, which increase the risk of infective endocarditis.
• Regular prenatal care – the physiological increase in cardiac output during pregnancy can unmask pre‑existing murmurs; early detection facilitates monitoring.
• Screening in families with known hereditary heart disease – echocardiograms can identify silent lesions before symptoms develop.

Emergency Warning Signs

If you experience any of the following, seek emergency medical care (call 911 or go to the nearest emergency department) immediately.

• Sudden, severe chest pain or pressure that does not improve with rest.
• Rapid, irregular heartbeat (palpitations) accompanied by dizziness or fainting.
• New onset of severe shortness of breath at rest.
• Swelling of the face, lips, or tongue with difficulty breathing (possible allergic reaction in patients with endocarditis).
• Sudden loss of consciousness or near‑syncope.
• High‑fever (>101°F / 38.3°C) with chills, night sweats, and a new or changing murmur – possible infective endocarditis.
• Signs of stroke – sudden weakness, slurred speech, or facial droop – which can occur with cardiac emboli.

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Sources: Mayo Clinic, Cleveland Clinic, American Heart Association, CDC, National Institutes of Health (NIH), and peer‑reviewed articles from Journal of the American College of Cardiology and Circulation.

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