Levine and Harvey’s grading of cardiac murmurs

Murmurs are graded depending on their intensity from grade 1 to grade 6, grade 6 being the loudest. Though the presence of thrill is not part of the grading, in general, murmurs of grade 4 and above are associated with a thrill. Grade 1 murmur is very faint while grade 6 murmur can be heard with the stethoscope kept near the chest without actual contact. The grading is often called Levine’s grading though it was described by Harvey and Levine.

Heart failure in acute rheumatic fever

Heart failure in acute rheumatic fever is generally due to acute valvular regurgitations, mostly mitral regurgitation. Even though rheumatic fever causes pancarditis with involvement of pericardium, myocardium and endocardium, it is often the valvular involvement as part of the endocardial involvement which causes heart failure rather than myocardial failure. Hence heart failure without significant valvular involvement is unlikely to be due to acute rheumatic fever and is more likely to be due to some other form of myocarditis.

Aortic stenosis murmur and heart failure

When the stroke volume falls in heart failure, the intensity of aortic stenosis murmur falls and may even be inaudible. This is why critical aortic stenosis comes in the differential diagnosis of dilated cardiomyopathy. Even the Doppler gradient across the aortic valve may be low in such cases and may require inotropic stimulation to assess the true gradient and severity of aortic stenosis.