Reference — Cardiac
Heart Murmurs Reference
Two questions sort almost any murmur on the exam: when is it (systolic or diastolic) and where is it loudest? Match those to the valve and you have the lesion.
Educational use only. Murmur findings are interpreted alongside the full assessment and echocardiography. This reference is an educational aid, not a diagnostic tool. This material supports nursing education and exam review. It is not medical advice and is not a substitute for clinical judgment, institutional policy, or medical direction. Always follow facility protocols and current provider orders.
Which Valve, Which Murmur
| Lesion | Timing | Quality | Best heard |
|---|---|---|---|
| Aortic stenosis (AS) | Systolic | Harsh crescendo-decrescendo, radiates to carotids | Right 2nd intercostal space (aortic area) |
| Mitral regurgitation (MR) | Systolic | Holosystolic (blowing), radiates to axilla | Apex / 5th ICS midclavicular (mitral area) |
| Aortic regurgitation (AR) | Diastolic | Blowing, decrescendo; wide pulse pressure | Left sternal border (Erb's point) |
| Mitral stenosis (MS) | Diastolic | Low-pitched rumble with opening snap | Apex (left lateral position, bell) |
Memory aid: the two systolic lesions are Aortic Stenosis and Mitral Regurgitation (“ASMR” = systolic); the two diastolic lesions are aortic regurgitation and mitral stenosis.
Auscultation Sites — “APE To Man”
| Area | Location | |
|---|---|---|
| A | Aortic | Right 2nd ICS, sternal border |
| P | Pulmonic | Left 2nd ICS, sternal border |
| E | Erb's point | Left 3rd ICS, sternal border |
| T (To) | Tricuspid | Left 4th–5th ICS, sternal border |
| M (Man) | Mitral (apex) | Left 5th ICS, midclavicular line |
Grading & Tips
Murmurs are graded I–VI: grade I is barely audible; grade IV+ has a palpable thrill; grade VI is audible with the stethoscope off the chest.
Use the diaphragm for high-pitched sounds (AS, MR, AR) and the bell for low-pitched ones (MS rumble). Listen with the patient leaning forward (aortic regurgitation, pericardial rub) and in the left lateral decubitus position (mitral stenosis).
NCLEX Pearls
- ✦Systolic murmurs = aortic stenosis + mitral regurgitation; diastolic = aortic regurgitation + mitral stenosis.
- ✦Aortic stenosis radiates to the carotids; mitral regurgitation radiates to the axilla.
- ✦Auscultate in order: Aortic, Pulmonic, Erb's, Tricuspid, Mitral — 'APE To Man.'
- ✦A palpable thrill = grade IV or higher.
- ✦Use the bell (lightly) for low-pitched MS; diaphragm for high-pitched AS/MR/AR.
Related Resources
Standards & sources
Fact-checked Jun 20, 2026This page is written to align with American Heart Association (AHA) · American College of Cardiology (ACC) · AHA ACLS Guidelines. It is an educational summary, not a citation of any single document — always verify specific doses, values, and protocols against current guidelines and your facility policy. How we source content →