Murmurs Quiz

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Which heart murmur is classically associated with mitral valve regurgitation?

A Early diastolic decrescendo murmur best heard at the left sternal edge
B Continuous machinery-like murmur throughout the cardiac cycle
C Ejection systolic murmur radiating to the carotids
D Holosystolic murmur heard between the first and second heart sounds ✓
E Mid-diastolic murmur with an opening snap

The answer is D: Holosystolic murmur heard between the first and second heart sounds

Explanation

Why D is correct

See Mitral Valve Regurgitation. Option D is correct because in mitral regurgitation the mitral valve (the valve between the left atrium and the left ventricle) does not close tightly, so blood leaks back from the left ventricle into the left atrium throughout ventricular systole (the phase when the ventricle contracts). The leak starts as soon as the ventricle begins to contract, which is the moment of the first heart sound, and carries on until systole ends at the second heart sound. That is why the murmur is holosystolic (also called pansystolic), meaning it fills the whole of systole from the first to the second heart sound. It is blowing in quality, loudest at the apex (the lowest, outermost point of the heartbeat, in the fifth intercostal space) and typically spreads towards the left armpit. Over time the left atrium and left ventricle enlarge to cope with the extra volume, which can lead to atrial fibrillation and heart failure.

Mechanism: The mitral valve does not close tightly, so blood leaks from the left ventricle into the left atrium throughout systole.
Timing: Holosystolic (pansystolic), from the first to the second heart sound.
Site: Blowing, loudest at the apex and spreading towards the left armpit.

A useful habit is to pair each murmur with its timing: mitral regurgitation is the one that is loud throughout systole at the apex.

Why the other options are incorrect

A. Early diastolic decrescendo murmur best heard at the left sternal edge: An early diastolic decrescendo murmur at the left sternal edge is the sound of aortic regurgitation, not mitral regurgitation. The mitral leak happens in systole.
B. Continuous machinery-like murmur throughout the cardiac cycle: A continuous, machinery-like murmur through the whole cardiac cycle is typical of a patent ductus arteriosus, an open channel between the aorta and the pulmonary artery. It is not a valve murmur.
C. Ejection systolic murmur radiating to the carotids: An ejection systolic murmur radiating to the carotids is the sound of aortic stenosis. It is also in systole, but it is a diamond-shaped murmur at the base of the heart rather than a murmur lasting the whole of systole at the apex.
E. Mid-diastolic murmur with an opening snap: A mid-diastolic murmur with an opening snap is the sound of mitral stenosis, a narrowed mitral valve. In regurgitation the valve leaks rather than narrows, and the leak is in systole.

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More questions from this set. Start the quiz to answer them and see each explanation.

1
Which auscultatory finding is most characteristic of aortic valve regurgitation?
2
A cardiac murmur is heard during diastole at the apex of the heart and is associated with turbulent blood flow across a narrowed valve. Which underlying valve pathology best explains this finding?

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