Question:
A systolic murmur that becomes more prominent on standing is a feature of
A systolic murmur that becomes more prominent on standing is a feature of
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Ask whether the obstruction in each condition is a fixed narrow valve or something that changes shape with the size of the ventricle.
Updated On: Jul 16, 2026
- Valvular aortic stenosis
- Rheumatic mitral regurgitation
- Idiopathic hypertrophic subaortic stenosis (HOCM)
- Pulmonary stenosis
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The Correct Option is C
Solution and Explanation
Step 1: Understanding the Question:
The question asks which condition's systolic murmur gets louder when the patient stands up, a bedside manoeuvre that changes cardiac preload.
Step 2: Key Concept or Approach:
Standing suddenly reduces venous return to the heart, lowering preload. In idiopathic hypertrophic subaortic stenosis (HOCM), the left ventricular outflow tract obstruction is dynamic, not fixed: it is caused by the hypertrophied septum coming close to the anterior mitral leaflet during systole. When preload falls, the left ventricular cavity becomes smaller, the septum and mitral leaflet move closer together, and the outflow obstruction - and therefore the murmur - worsens. This is the opposite of what happens with a fixed valvular obstruction, where reduced flow across a rigid, narrowed valve actually softens the murmur.
Step 3: Working Through the Options:
Valvular aortic stenosis is a fixed anatomical obstruction; standing reduces flow across the stenotic valve, so the murmur becomes softer, not louder. Rheumatic mitral regurgitation is a fairly preload-independent murmur and does not characteristically intensify with standing. Idiopathic hypertrophic subaortic stenosis has a dynamic obstruction that worsens as the left ventricular cavity shrinks with reduced preload, so standing (and Valsalva) make the murmur louder - matching the question exactly. Pulmonary stenosis is also a fixed valvular obstruction whose murmur does not characteristically increase with reduced preload in this way.
Step 4: Conclusion:
A systolic murmur that becomes louder on standing is a feature of idiopathic hypertrophic subaortic stenosis.
The question asks which condition's systolic murmur gets louder when the patient stands up, a bedside manoeuvre that changes cardiac preload.
Step 2: Key Concept or Approach:
Standing suddenly reduces venous return to the heart, lowering preload. In idiopathic hypertrophic subaortic stenosis (HOCM), the left ventricular outflow tract obstruction is dynamic, not fixed: it is caused by the hypertrophied septum coming close to the anterior mitral leaflet during systole. When preload falls, the left ventricular cavity becomes smaller, the septum and mitral leaflet move closer together, and the outflow obstruction - and therefore the murmur - worsens. This is the opposite of what happens with a fixed valvular obstruction, where reduced flow across a rigid, narrowed valve actually softens the murmur.
Step 3: Working Through the Options:
Valvular aortic stenosis is a fixed anatomical obstruction; standing reduces flow across the stenotic valve, so the murmur becomes softer, not louder. Rheumatic mitral regurgitation is a fairly preload-independent murmur and does not characteristically intensify with standing. Idiopathic hypertrophic subaortic stenosis has a dynamic obstruction that worsens as the left ventricular cavity shrinks with reduced preload, so standing (and Valsalva) make the murmur louder - matching the question exactly. Pulmonary stenosis is also a fixed valvular obstruction whose murmur does not characteristically increase with reduced preload in this way.
Step 4: Conclusion:
A systolic murmur that becomes louder on standing is a feature of idiopathic hypertrophic subaortic stenosis.
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