Late Systolic Murmur in Coronary Artery Disease

¹ Associate Professor of Medicine, The George Washington University School of Medicine, and Chief of Cardiology, District of Columbia General Hospital

Late systolic murmur with or without a mid-late systolic click has not been reported in patients with coronary artery disease. Eighteen patients are reported with both late systolic murmur and significant coronary artery disease. The latter manifested as either angina pectoris or myocardial infarction. Radiographic confirmation including selective coronary arteriography of obstructive coronary artery disease was obtained in all patients. Left ventriculography revealed systolic prolapse of the posterior and sometimes the anterior mitral leaflets with varying degrees of mitral regurgitation. Differentiation between the late systolic murmur associated with coronary artery disease and the noncoronary "auscultatory-electrocardiographic" syndrome is important, though sometimes difficult. The common denominator in both is an abnormal mitral valve apparatus. Late systolic murmur in coronary artery disease represents a mild form of papillary muscle dysfunction. The discovery of a late systolic murmur in association with chest pain and abnormal electrocardiogram in a middle-aged or older man should not be passed off lightly as "benign". On the contrary, if it is associated with an accentuated first sound, presystolic and diastolic gallops, becomes softer after an extrasystole, and increases in intensity following inspiration, amyl nitrite inhalation or squatting, it should strongly suggest coronary artery disease and further diagnostic studies, including coronary arteriography, are indicated.

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