Maneuvers That Aid in Diagnosis of Murmurs

Amyl nitrite

Causes intense venodilation, which reduces venous return to the right heart

Augments murmurs of hypertrophic obstructive cardiomyopathy, aortic stenosis and mitral valve prolapse

Reduces murmur of mitral regurgitation.

Inspiration

Decreases intrathoracic pressure, which simultaneously increases venous flow into the right ventricle (RV) and decreases pulmonary venous flow into the left heart

Augments right heart sounds (eg, murmurs of tricuspid stenosis and regurgitation, those of pulmonic stenosis* [immediately] and regurgitation [usually])

Reduces left heart sounds

Isometric handgrip

Increases afterload and peripheral arterial resistance

Reduces murmurs of aortic stenosis, hypertrophic obstructive cardiomyopathy,mitral valve prolapse, or papillary muscle dysfunction

Augments murmurs of mitral regurgitation and aortic regurgitation and diastolic murmur of mitral stenosis

Release of Valsalva maneuver

Increases volume of RV and LV

Augments murmurs of aortic stenosis, aortic regurgitation (after 4 or 5 beats), and pulmonic regurgitation or pulmonic stenosis* (immediately)

Reduces murmur of tricuspid stenosis

Squatting

Simultaneously increases venous return to the right heart and increases afterload and peripheral resistance

Augments murmurs of aortic regurgitation, aortic stenosis, mitral regurgitation and diastolic murmur of mitral stenosis

Reduces murmur of hypertrophic obstructive cardiomyopathy and mitral valve prolapse

Valsalva maneuver

Increases intrathoracic pressure, which reduces size of left ventricle (LV); decreases venous return to the right heart and subsequently to the left heart

Augments murmur of hypertrophic obstructive cardiomyopathy and mitral valve prolapse

Reduces murmurs of aortic stenosis, mitral regurgitation, and tricuspid stenosis