The mammary souffle is another example of a continuous murmur. It occurs in ten to fifteen percent of pregnant women during the second and third trimesters and in the early post partum period. It is particularly prominent in lactating women and may be heard on either side between the second and sixth anterior intercostal spaces. This murmur may be obliterated by firm pressure on the stethoscope or by digital pressure applied just lateral to the side of auscultation. This murmur disappears after termination of lactation.
Supraclavicular systolic bruit
Another innocent murmur heard in children and young adults is the supraclavicular systolic bruit. It is best heard with the patient sitting. The murmur is maximal in the right or left supraclavicular fossa. The supraclavicular bruit is caused by turbulence in the major brachiocephalic arteries as these vessels exit the thoracic inlet. The murmur can be eliminated or greatly reduced by hyperextending the shoulders. This maneuver distinguishes it from either aortic valve or supravalvular stenosis. [Sounds]
Supraclavicular bruit - maneuver
Observe the effect of hyperextending the shoulders with the patient sitting up. [Sounds]
Older age patient - URSE
The older age individual commonly manifests a systolic murmur loudest at the upper right sternal edge that is transmitted to the apex. Now let us listen to this older age patient's murmur at the upper right sternal edge.
Aortic sclerosis
The murmur of aortic sclerosis is commonly heard in the older patient whose aortic valve is thickened and fibrotic. Although previously considered a variety of innocent murmur, it is not an innocent murmur. Thus, the terms innocent murmur of the elderly or innocent murmur of the older age are incorrect. This murmur reflects an anatomic abnormality and is an harbinger of or actually reflects some degree of aortic valve stenosis. Clinically, the absence of significant aortic stenosis is more likely when the patient demonstrates a negative history and otherwise normal cardiac physical findings. An echocardiogram with Doppler ultimately may be necessary to define whether or not an aortic valve gradient is present.
Systolic murmur pathologic if:
Distinguishing whether a systolic murmur is pathologic or innocent represents the most important component of murmur assessment. The following criteria provide a foundation for making this determination. Consider a systolic murmur pathologic if it begins simultaneously with the first heart sound, crescendos to end with or after the second heart sound, is holosystolic, causes a thrill, increases in intensity either with standing or during the strain phase of the Valsalva maneuver or is associated with either an ejection sound, a mid systolic click, fixed splitting of the second heart sound or a diastolic murmur.