A. Diagnostic Clues
Usually the diagnosis is obvious from the patient’s effort tolerance and the finding of a murmur with the stetho¬scope as well as other symptoms. A cardiologist makes the diagnosis in the office with 95% confidence in more than 90% of cases.
1. Diagnostic Points
• The timing of the murmur relative to the first heart sound, S1, and to the second heart sound, S2: This provides the most meaningful piece of information that fixes the timing of the murmur as systolic or diastolic. If the murmur is difficult to time, the examiner should identify S2 of the base of the heart and move the

B. Classification
Murmurs are classified as follows:
• Systolic: beginning after S1 and ending at all or before the aortic or pulmonary sound, S2 (see Fig. 2)
• Diastolic: beginning with S2 and ending just before S1.
• Continuous: beginning in systole and continuing through S2 into part or all of diastole; continuous murmurs are rare
1. Systolic Murmurs
Nonsignificant systolic murmurs can be heard in more than 60% of children. The systolic murmur of aortic valve sclerosis without stenosis is heard in more than 50% of individuals older than 50 years. Systolic murmurs can be classified as early systolic, midsystolic, late systolic, or holosystolic (occurring all through the systolic time interval; Fig. 2).

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