Heart Murmur in Adults: When Do You Need an Echocardiogram?

A physician hears a murmur during your annual physical. They may say it's probably nothing, or ask you to follow up with a cardiologist. Either way, you leave with a finding and no image. A murmur is a sound — detectable by stethoscope, but impossible to characterize by sound alone. The question of whether it matters clinically has only one answer: an echocardiogram. Here is what a murmur actually means, and when you need one.

What Is a Heart Murmur?

A heart murmur is the sound produced by turbulent blood flow through or around a cardiac valve. When blood moves smoothly and in an orderly laminar pattern, it is silent. When flow becomes turbulent — whether from a narrowed valve opening, a leaking valve, or simply an increased volume of blood moving through a normal valve — it creates an audible sound that a physician can detect with a stethoscope.

Murmurs fall into two broad categories. Innocent (functional) murmurs arise from normal blood flow in the absence of any structural valve disease. They are common in young adults, pregnant women, and anyone with high-output states such as anemia, fever, or hyperthyroidism. Once the underlying condition resolves, the murmur often disappears. These carry no cardiac risk and require no treatment.

Pathological murmurs are different. They arise from structural abnormalities — a valve that has calcified and can no longer open fully (stenosis), or a valve that fails to close completely and allows blood to leak backward (regurgitation). These are not incidental sounds. They reflect valve disease that may progress, cause chamber remodeling, and eventually require intervention.

A stethoscope cannot distinguish between the two with certainty, and it cannot quantify severity at all. Only imaging can do that.

When a Heart Murmur Requires an Echocardiogram

A heart murmur requires an echocardiogram when it's newly detected in an adult over 40, comes with symptoms like shortness of breath or chest discomfort, is graded 3/6 or higher, occurs during diastole, was never previously imaged, or runs in families with valve disease. Here's the full list of triggers we look for:

• Any new murmur is detected in an adult over 40
• The murmur is accompanied by symptoms — shortness of breath, chest discomfort, syncope, unexplained fatigue, or reduced exercise tolerance
• The murmur is graded 3/6 or higher on auscultation
• The murmur occurs during diastole (diastolic murmurs are always pathological and are never innocent)
• A murmur was noted previously on a physical exam but was never evaluated with imaging
• There is a known family history of valve disease, bicuspid aortic valve, or connective tissue disorder

What the Echocardiogram Will Show

An echocardiogram evaluating a murmur shows five things: valve anatomy, regurgitation severity, stenosis severity, chamber size and thickness, and ejection fraction. Together these measurements determine whether your murmur is innocent or reflects valve disease that needs monitoring or treatment. No other non-invasive test provides this complete a picture.

Valve anatomy. The sonographer visualizes each valve leaflet directly — whether the aortic valve is bicuspid or tricuspid, whether there is calcification on the leaflets, whether the mitral valve leaflets are prolapsing, whether the chordae tendineae are intact. This structural picture cannot be inferred from sound.

Regurgitation severity. Color Doppler maps the direction and volume of blood flow across each valve. Regurgitation is graded from trace to mild, moderate, or severe based on the size and characteristics of the regurgitant jet, the proximal flow convergence zone, and quantitative parameters including regurgitant volume and effective regurgitant orifice area.

Stenosis severity. Continuous-wave Doppler measures the peak and mean pressure gradients across the valve, and the valve area is calculated. These numbers determine whether stenosis is mild, moderate, or severe — and they directly inform the timing of intervention.

Chamber response. A diseased valve imposes a pressure or volume burden on the cardiac chambers upstream and downstream. The echo measures chamber dimensions and wall thickness to determine whether the heart is already remodeling in response. Concentric hypertrophy, eccentric dilation, and left atrial enlargement are all measurable findings that guide management.

Ejection fraction. The left ventricular ejection fraction reflects the heart's pumping capacity. A preserved ejection fraction in the setting of severe valve disease means the heart is still compensating; a reduced ejection fraction means it is not. This distinction is critical in deciding when surgical or transcatheter intervention is required.

Common Valve Conditions Found by Echo

The four valve conditions most often found on echocardiogram after a murmur are mitral regurgitation, aortic stenosis, tricuspid regurgitation, and mitral stenosis. Each has a distinct cause, typical patient profile, and severity grading system that the echocardiogram measures directly. Which one you have determines your monitoring and treatment plan.

Mitral regurgitation is the most common valve disorder in the United States. The mitral valve fails to close completely during systole, allowing blood to leak back into the left atrium. The most frequent causes in adults are mitral valve prolapse — where one or both leaflets bulge back into the atrium — annular dilation from cardiomyopathy or atrial fibrillation, and chordal rupture. The echocardiogram grades severity and monitors ventricular response over time.

Aortic stenosis is the most common valve condition requiring intervention in elderly patients. Calcific degeneration of the aortic valve leaflets progressively obstructs outflow from the left ventricle. In younger patients, a congenitally bicuspid aortic valve undergoes accelerated calcification and presents with significant stenosis two to three decades earlier than the trileaflet form. The echocardiogram measures gradients and valve area to stage severity and track progression.

Tricuspid regurgitation is frequently a secondary finding rather than a primary valve abnormality. It commonly develops in the setting of pulmonary hypertension or right heart dilation, where the tricuspid annulus stretches and the leaflets can no longer coapt. Because the tricuspid valve sits on the right side of the heart, tricuspid regurgitation also provides an accurate non-invasive estimate of pulmonary artery systolic pressure — a key clinical parameter.

Mitral stenosis is now uncommon in the United States, but it persists in patients with a history of rheumatic fever. Rheumatic disease causes scarring and fusion of the mitral valve leaflets, restricting the valve opening and obstructing flow from the left atrium into the left ventricle. When encountered, the echocardiogram measures mitral valve area and mean pressure gradient to assess severity.

Next Steps After Your Echo Results

Your echocardiogram results fall into three outcomes: a normal study needing no follow-up, mild valve disease requiring periodic monitoring every one to five years, or moderate to severe disease requiring cardiology referral. Which category you fall into determines your next steps and how often you'll need repeat imaging.

Normal echo with innocent murmur. Valve anatomy is normal, no regurgitation or stenosis of hemodynamic significance, chambers are normal in size and function. This is reassuring — no follow-up imaging is required unless symptoms develop.

Mild valve disease. Structural abnormality is present but not yet causing significant hemodynamic burden. The standard approach is serial monitoring with echocardiograms at intervals determined by which valve is affected and the rate of progression — typically every one to five years for mild disease. Establishing a baseline now is the most important thing you can do.

Moderate to severe valve disease. This requires cardiology referral. The cardiologist will determine the appropriate management — whether medical management, closer surveillance, or intervention — based on the echocardiographic findings, the patient's symptoms, and current guideline thresholds for repair or replacement.

BlackPoint Diagnostics provides a complete echocardiogram report reviewed by a board-certified cardiologist, delivered to you and your physician within 24 to 48 hours. You walk away with numbers, images, and a formal interpretation — not just a reassurance that a stethoscope thought things sounded acceptable.

Getting an Echocardiogram in Maine

BlackPoint Diagnostics offers mobile echocardiograms throughout Southern Maine. We perform the study at your home, workplace, or a partner location — no hospital visit, no waiting room. The price is $397 and no physician referral is required.

If you have been told you have a murmur and have never had it imaged, or if your last echocardiogram was more than three to five years ago, this is the right time to establish or update your baseline. Learn more about our echocardiogram service, or book your appointment directly.

Frequently Asked Questions