Heart murmurs are listened for at four primary spots on the chest, each corresponding to one of the heart’s four valves. A fifth point, located between two of these areas, is often included as well. Knowing these locations matters whether you’re a student learning auscultation, a nurse brushing up on technique, or simply curious about what your doctor is doing when they move the stethoscope around your chest.
The Four Standard Listening Points
Each valve in the heart produces sound that travels to a specific spot on the chest wall. These aren’t directly over the valves themselves. Instead, they’re where blood flow from each valve is best heard through the stethoscope. The four classic points, typically assessed in order from top to bottom, are:
- Aortic area: right side of the breastbone, in the space between the second and third ribs (second intercostal space). This is where sounds from the aortic valve are loudest.
- Pulmonic area: left side of the breastbone, also at the second intercostal space, mirroring the aortic point on the opposite side.
- Tricuspid area: lower left edge of the breastbone, at the fourth intercostal space (between the fourth and fifth ribs).
- Mitral area: the apex of the heart, located at the fifth intercostal space on the left side, roughly in line with the middle of the collarbone (the midclavicular line). This is the lowest and most lateral of the four points.
A helpful way to remember the order is the mnemonic “All Patients Take Medicine,” corresponding to Aortic, Pulmonic, Tricuspid, and Mitral from top to bottom.
Erb’s Point: The Fifth Listening Area
Between the pulmonic and tricuspid areas sits a fifth spot known as Erb’s point, located at the third intercostal space on the left sternal border. This is a particularly useful site for picking up murmurs related to aortic regurgitation and for hearing the second heart sound clearly. Many clinicians include it as a routine stop when moving the stethoscope down the chest.
Which Murmurs Are Heard Where
The location where a murmur sounds loudest is one of the first clues to which valve is involved. Aortic stenosis, for example, produces a murmur best heard at the aortic area in the upper right chest, and it often radiates up into the neck along the carotid arteries. Mitral regurgitation is typically loudest at the apex (the mitral area) and can radiate toward the left armpit.
Timing matters just as much as location. Murmurs that occur while the heart is contracting (systolic murmurs) point toward different problems than those heard while the heart is relaxing (diastolic murmurs). Aortic stenosis and mitral regurgitation are both systolic. Aortic regurgitation and mitral stenosis are diastolic. Identifying where the murmur is loudest and when it occurs in the heartbeat narrows the diagnosis considerably.
Bell vs. Diaphragm of the Stethoscope
Most stethoscopes have two sides: a flat diaphragm and a smaller, concave bell. They aren’t interchangeable. The diaphragm filters out low-pitched sounds and is better for high-frequency murmurs, such as the blowing murmur of aortic regurgitation. The bell, pressed lightly against the skin, picks up low-frequency sounds more effectively. It’s the preferred choice for hearing the low-pitched rumble of mitral stenosis.
If you press the bell firmly against the chest, it stretches the skin underneath and essentially turns it into a diaphragm, filtering out the low-pitched sounds you’re trying to hear. Light pressure is key when using the bell side.
Positioning That Makes Murmurs Louder
Certain body positions bring the heart closer to the chest wall or change blood flow patterns, making specific murmurs easier to detect.
For aortic regurgitation, the best approach is to have the patient sit upright on the exam table, lean forward, and hold their breath after a full exhale. This positions the aortic valve closer to the stethoscope and makes the diastolic murmur more audible. Listen at Erb’s point or the aortic area with the diaphragm during this maneuver.
For mitral stenosis, the left lateral decubitus position works best. The patient lies on their left side, which shifts the heart’s apex closer to the chest wall. The bell of the stethoscope is placed at the mitral area. This combination can reveal a faint rumbling murmur that would otherwise be missed with the patient sitting or lying flat on their back.
How Murmurs Are Graded
Once a murmur is detected, its intensity is rated on a six-point scale known as the Levine system:
- Grade 1: barely audible, even in a quiet room
- Grade 2: soft but detectable with a stethoscope placed normally on the chest
- Grade 3: easily heard, but without a vibration you can feel with your hand (no palpable thrill)
- Grade 4: loud, with a palpable thrill felt through the chest wall
- Grade 5: very loud, audible with the stethoscope barely touching the chest
- Grade 6: so loud the stethoscope doesn’t need to touch the chest at all
Murmurs of grade 3 or higher are more likely to reflect a significant structural problem with a valve. Grades 1 and 2 can still be clinically important, but many soft murmurs, especially in children and young adults, are innocent flow murmurs with no underlying disease.
How Reliable Is Auscultation Alone
Listening with a stethoscope is the first screening step, but it has real limitations. A systematic review published in BMJ Open found that the sensitivity of auscultation for detecting valve disease ranged from as low as 16% to as high as 91%, depending on the examiner and the specific condition. For aortic stenosis, sensitivity was relatively strong (72% to 97%), while mitral regurgitation was more variable (30% to 100%).
These wide ranges reflect differences in examiner skill, patient body type, and the severity of the valve problem. A thin patient with severe aortic stenosis is far easier to assess than an overweight patient with mild mitral regurgitation. When a murmur is detected or strongly suspected, an echocardiogram (ultrasound of the heart) is the standard next step to visualize the valve and measure how well it’s working. Auscultation is a powerful screening tool, but it works best as the beginning of the diagnostic process rather than the end of it.