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.

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