Massive hypertrophy of ventricular muscle is associated with unusually rapid ejection of blood from the left ventricle during systole. Obstruction to flow may coexist. Accompanying distortion of the mitral valve may cause mitral regurgitation.
Location. Right 2nd interspace
Radiation. Often to the neck and down the left sternal border, even to the apex
Intensity. Sometimes soft but often loud, with a thrill
Pitch. Medium; at the apex, it may be higher
Quality. Often harsh; at the apex it may be more musical
Aids. Heard best with the patient sitting and leaning forward
A2 decreases as the stenosis worsens. A2 may be delayed, merging with P2 to form a single expiratory sound or causing paradoxical splitting. An S4, reflecting the decreased compliance of the hypertrophied left ventricle, may be present at the apex. An aortic ejection sound, if present, suggests a congenital cause. A sustained apical impulse often reveals left ventricular hypertrophy. The carotid artery impulse may rise slowly and feel small in amplitude.
Location. 3rd and 4th left interspaces
Radiation. Down the left sternal border to the apex, possibly to the base, but not to the neck
Aids. Decreases with squatting, increases with straining down
An S3 may be present.
An S4 is often present at the apex (unlike mitral regurgitation).
The apical impulse may be sustained and have two palpable components.
The carotid pulse rises quickly (unlike the pulse in aortic stenosis).
TABLE 7-7 ■ Pansystolic (Holosystolic) Murmurs
Pansystolic (holosystolic) murmurs are pathologic. They are heard when blood flows from a chamber of high pressure to one of lower pressure through a valve or
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