Grading of murmur

The intensity of a systolic murmur is not always proportional to the hemodynamic disturbance. Yet murmurs are classified according to the loudness.
Freeman and Levine were the first to introduce a numerical scale for grading heart murmur intensity in 1933. This grading is still used but with some modifications.

Grade 1 - so faint that it can be heard only with special effort.
Grade 2 - faint but can be heard easily.
Grade 3 - moderately loud but no thrill.
Grade 4 - very loud and thrill may be there.
Grade 5 - extremely loud and can be heard if only the edge of stethoscope is in contact with skin.
Grade 6 - exceptionally loud and can be heard with stethoscope just removed from skin contact.

Keren, Tereschuk and Luan suggested that we can use heart sounds as an internal reference to differentiate between grades 1-3, the only limitation of the study being a small sample used. The grading is the same as above but. . .

Grade 1 - clearly softer than the heart sounds.
Grade 2 - approximately equal in intensity to the heart sounds.
Grade 3 - clearly louder than the heart sounds.

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