Cardiology Question 16 Instructor

How do you rate intensity of heart murmurs?

By tradition, murmurs are graded on a scale of 1 to 6 which was initially a research tool used for the study of systolic murmurs (Freeman & Levine, 1993) and is known as the Levine system.

Grade Intensity
Grade 1 Faint; heard only with special effort
Grade 2 Soft but readily detected
Grade 3 Prominent but not loud
Grade 4 Loud, accompanied by a thrill
Grade 5 Very loud
Grade 6 Loud enough to be heard with the stethoscope just removed from contact with the chest wall

Levine system was initially developed for classifying benign vs. pathological (grade 3 or more) murmurs. However, there are limitations in terms of reproducibility and inter-rater reliability. More recently, it has been shown using heart sounds as an internal reference improved the reproducibility (Keren et al.)

Grade Intensity
Grade 1 Clearly softer than the heart sounds
Grade 2 Approximately equal in intensity to the heart sounds
Grade 3 Clearly louder than the heart sounds, but no thrill
Grade 4 Associated with a thrill by palpation
Grade 5 Heard with one edge of the stethoscope lifted
Grade 6 Heard with both edges of the stethoscope lifted

Freeman AR, Levine SA: Clinical significance of systolic murmurs: Study of 1000 consecutive “noncardiac” cases. Ann Intern Med 6: 1371-1379. 1933.

Keren R, Tereschuk M, Luan X. Evaluation of a novel method for grading heart murmur intensity. Arch Pediatr Adolesc Med. 2005 Apr; 159(4):329-34.


Subscribe to Pearls

Uncle Sam wants you to subscribe to Medical Pearls

Subscribe today! It’s always free, and you can easily unsubscribe at any time. We will never share your email address. Subscribe to...

Multiple Pearls
Cardiology Pearls
Endocrinology Pearls
Hematology Pearls
Nephrology Pearls
Rheumatology Pearls
Transplant Pearls
General Internal Medicine Pearls
Instructor Pearls

Subscribe to receive your pearls today—it's free!