MR. PASS MVP
Systolic Murmurs
What you hear between S1 and S2 — the pressure-gradient murmurs.
The board-friendly take on murmur identification is that timing tells you most of what you need. MR PASS MVP groups the systolic murmurs — heard between S1 and S2 — into mitral regurgitation, physiologic flow murmurs, aortic stenosis, and mitral valve prolapse, the four you will see most often in primary care. Pair it with MS ARD for the diastolic side. AANP exam questions stack timing, location, radiation, and a dynamic maneuver (handgrip, Valsalva, squat) onto a vignette and ask the diagnosis. Get systolic versus diastolic right and you have already eliminated half the answer choices.
- MRMitral RegurgitationBlowing holosystolic at apex, radiates to axilla. Think post-MI papillary muscle dysfunction or MVP progression.
- PPhysiologic / Pulmonic stenosisInnocent flow murmurs in kids/athletes. PS = systolic ejection at LUSB.
- AAortic StenosisHarsh crescendo-decrescendo at RUSB, radiates to carotids. Triad: Syncope, Angina, Dyspnea (SAD).
- SSubaortic stenosis (HOCM)LOUDER with Valsalva or standing — the key distinguishing feature vs AS.
- SSeptal defect (VSD)Harsh holosystolic at LLSB. Paradoxically, smaller VSDs are louder.
- MVPMitral Valve ProlapseMid-systolic click + late systolic murmur at apex. Often asymptomatic.
Clinical Context
Systolic murmurs occur between S1 (mitral/tricuspid closure) and S2 (aortic/pulmonic closure) — during ventricular ejection. The three most tested in NP practice: Aortic Stenosis (SAD triad), Mitral Regurgitation (HF symptoms, post-MI), and MVP (click + late murmur).
Dynamic maneuvers differentiate: AS gets softer with standing/Valsalva (less preload lowers the gradient); HOCM gets LOUDER (less preload means more outflow obstruction). AANP loves the "which murmur gets louder with Valsalva" question — HOCM is the answer.
Related Mnemonics
- 5 T's — Cyanotic Congenital Heart Defects
- 6 P's — Acute Limb Ischemia
- CHA₂DS₂-VASc — Stroke Risk in Non-Valvular Atrial Fibrillation
- HAS-BLED — Bleeding Risk on Anticoagulation
- MS ARD — Diastolic Murmurs
Sources
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