What is the differential diagnosis of continuous thoracic murmurs and their origin?
In the order of descending frequency…
| Diagnosis | Key findings |
| Cervical venous hum | Maximal in R supraclavicular fossa & can radiate to contralateral area or below clavicle. Disappears on compression of jugular vein. |
| Hepatic venous hum | Often disappears with epigastric pressure |
| Mammary souffle | Disappears upon pressing hard with stethoscope, or patient moving into upright position |
| Patent ductus arteriosus (Gibson’s murmur) | Loudest at the 2nd left ICS. Machinery murmur. |
| Coronary arteriovenous fistula | Loudest at the lower sternal border. |
| Ruptured aneurysm of sinus of Valsalva | Loudest at the upper right sternal border, sudden onset |
| Bronchial collaterals | Associated signs of congenital heart disease |
| High grade coarctation | Brachial/pedal arterial pressure gradient |
| Anomalous left coronary artery arising from pulmonary artery | |
| Anomalous pulmonary artery arising from aorta | |
| Pulmonary artery branch stenosis | Heard outside the area of cardiac dullness |
| Pulmonary AV fistulas | Heard outside the area of cardiac dullness |
| ASD with mitral stenosis or atresia | Altered by Valsalva manoeuvre |
| Aortic-arterial fistulas | |
| Superior caval syndrome due to syphilitic aneurysmal dilatation of aortic root and mediastinitis | Systolic accentuation; 2nd and 3rd right ICS |
Sapira led. p.304
