CVS SIGNS1. Signs develop only when MR becomes moderate to severe. Inspection and palpation may detect a brisk apical implse and sstained le!t parasternal movement de to systolic e"pansion o! an enlarged #$. $n #V implse that is sstained% enlarged% and displaced downward and to the le!t sggests #V hypertrophy and dilation. $ di&se precordial li!t occrs with severe MR becase the #$ enlarges% casing anterior cardiac displacement% and plmonary hypertension cases right ventriclar hypertrophy. $ regrgitant mrmr 'or thrill( may also be palpable in severe cases.)n ascltation% the1st heart sond 'S 1 ( may be so!t 'or occasionally lod(. $ *rd heart sond 'S * ( at the ape" re+ects a dilated #V and important MR.,. $n S * that accompanies mitral regrgitation sggests a dilated le!t ventricle and progression to heart !ailre. Mitral Regrgitation Mrmr -ith *rd .eart Sond*. /he cardinal sign o! MR is a holosystolic 'pansystolic( mrmr% heard best at the ape" with the diaphragm o! the stethoscope when the patient is in the le!t lateral decbits position. In mild MR% the systolic mrmr may be abbreviated or occr late in systole. /he mrmr begins with S 1 in conditions casing lea+et incompetency throghot systole% bt it o!ten begins a!ter S 1 'eg% when chamber dilation dring systole distorts the valve apparats or when myocardial ischemia or 0brosis alters dynamics(. -hen the mrmr begins a!ter S 1% it always contines to the ,nd heart sond 'S ,(. /he mrmr radiates toward the le!t a"illa1 intensity may remain the same or vary. I! intensity varies% the mrmr tends to crescendo in volme p to S ,. MR mrmrs increase in intensity with handgrip or s2atting becase peripheral vasclar resistance to ventriclar e3ection increases% agmenting regrgitation into the#$1 mrmrs decrease in intensity with standing or the Valsalva manever. $ short rmbling mid4diastolic in+ow mrmr de to torrential mitral diastolic +ow may be heard !ollowing an S *.5.In patients with posterior lea+et prolapse% the mrmr may be coarse and radiate to the pper sternm% mimicking aortic stenosis.6. /his holosystolic mitral regrgitation mrmr maintains the same intensity throghot systole and e"tends !rom S 1 to S ,. 7. Mitral Regrgitation Mrmr may be con!sed with tricspid regrgitation% which can be distingished becase tricspid regrgitation mrmr is agmented dring inspiration.8. /he mrmr o! $S typically increases with manevers that increase #V volme and contractility 'eg% leg4raising% s2atting% Valsalva release% a!ter a ventriclar prematre beat( and decreases with manevers that decrease #V volme 'Valsalva manever( or increase a!terload 'isometric handgrip(. /hese dynamic manevers have the opposite e&ect on the mrmr o! hypertrophic cardiomyopathy% which can otherwise resemble that o! $S. /he mrmr o! mitral regrgitation de to prolapse o! the posterior lea+et may also mimic $S