Murmur grading in humans and animals: past and present.

Cardiac murmurs were first described approximately 200 years ago. Subsequently, various clinicians, starting with Samuel Levine, have proposed grading schemes, depicting intensity, or other murmur characteristics, in an attempt to differentiate pathological and physiological murmurs or different degrees of pathology. In the 1960s, these schemes were adapted by veterinary cardiologists and have been used over the last 50 years. However, the clinical utility of these schemes has only recently been examined in veterinary medicine (and never examined in humans), and these studies suggest that the current, commonly used murmur grading scheme is unnecessarily complex and contains redundant information. A simpler, more intuitive grading scheme might achieve the same desired outcome as the more complex scheme, potentially with less confusion. This review examines the history of murmur grading and proposes a reconsideration of the current grading scheme to improve clinical communication.

Austin Flint: on cardiac murmurs.

Austin Flint first ausculted the murmur associated with his name in 1859. Suspecting it to be of mitral origin, he identified it as occurring in aortic insufficiency three years later. Recent echocardiographic study has indicated that this murmur is produced by an aortic insufficiency jet colliding with the anterior mitral valve leaflet. Flint was among the first to recognize the importance of normal cardiac and respiratory sounds. He advocated routine auscultation on all patients, and had great influence in popularizing auscultation in American medicine.

The Graham Steell murmur: eponymous serendipity?

On 7 March 1888 Dr Graham Steell addressed the Manchester Medical Society in the premises of the Literary and Philosophical Society in George Street, Manchester. He chose as his subject 'The auscultatory signs of mitral obstruction and regurgitation', and later that year published two papers on the same theme in the Manchester Medical Chronicle. In one he wrote: 'I wish to plead for the admission among the recognised auscultatory signs of disease of a murmur due to pulmonary regurgitation, such regurgitation occurring independently of disease or deformity of the valves, and as the result of long-continued excess of blood pressure in the pulmonary artery'. His observations were later confirmed by pathological correlation, and more cases were reported, notably by Paul White. The early diastolic murmur of pulmonary incompetence caused by pulmonary hypertension is now associated eponymously with Dr Graham Steell. We review the life and work of this physician and conclude that the original source of the observation, subsequently validated by modern techniques, was probably George Balfour of Edinburgh, and that Graham Steell was fortunate to have this physical sign attributed to him.

Tricuspid stenosis. Atrial systolic murmur, tricuspid opening snap, and right atrial pressure pulse.

Observations on the atrial systolic murmur, the tricuspid opening snap, and the right atrial pressure pulse of tricuspid stenosis are presented, based on catheter manometer intracardiac sound and pressure recordings in five patients with hemodynamically significant tricuspid stenosis. The manometer-recorded right atrial pressure pulse of tricuspid stenosis differed from the normal, with (1) elevation of right atrial pressure, (2) different morphologic features (tall, spiky A wave complete before C; small V wave with an interruption, the tricuspid opening snap notch at termination of the gradual Y descent; a diastolic plateau, the relatively flat diastolic segment of the right atrial pressure pulse following the tricuspid opening snap notch prior to the next A wave), and (3) the relative lack of right atrial pressure and right atrial pressure pulse response with normal respiration. The atrial systolic murmur, recorded in the right ventricular inflow tract, was complete by S1; the crescendo-decrescendo atrial systolic murmur configuration paralleled the right ventricular-right atrial diastolic pressure gradient at the time of the atrial A wave. The right atrial contraction-relaxation process, as reflected by the right atrial A wave ascent and descent, was complete at the onset of ventricular systole with P-R intervals of 170 to 200 msec. Thus, the timing and configuration of the atrial systolic murmur reflected the timing and completion of the right atrial contraction-relaxation process prior to the onset of right ventricular systole and the configuration of the tricuspid diastolic pressure gradient. The tricuspid opening snap was recorded in the right ventricular inflow tract and occurred at the time of a notch at the termination of the Y descent of the right atrial pressure pulse V wave, while right atrial pressure exceeded right ventricular pressure. The sound-pressure events were consistent with angiographic and echocardiographic studies, which showed doming or ballooning of the mobile, fused, stenotic tricuspid valve into the right ventricle during the Y descent of the right atrial pressure pulse. The tricuspid opening snap occurred at the time of the termination of the diastolic movement of the fused tricuspid unit into the right ventricle. These observations are presented within the framework of previous studies in order to trace the development of medical ideas about the pathophysiologic basis for the sound and pressure events of tricuspid stenosis.