Heart Sounds & Murmurs

The Stethoscope

• The Bell – used to hear low-pitched sounds– used for mid-diastolic murmur of mitral

stenosis or S3 in heart failure

• The Diaphragm– filters out low-pitched sounds– highlights high-pitched sounds– used for analyzing the second heart

sound, ejection and midsystolic clicks and for the soft but high-pitched early diastolic murmur of aortic regurgitation

Positioning

• Patients can be examined while lying supine, in the left lateral decubitus position, sitting, and leaning forward.

Listening Posts

Cardiac Cycle

Systolic vs. Diastolic

systole

S1 S2

diastole

Gallops

systole

S1 S2

S4 S3

diastole

S1 (lubb)• The 1st heart sound,

marks the beginning of systole (end of diastole).

• Related to the closure of the mitral and tricuspid valves.

• Loudest at the apex and lower left sternal border.

The first heart sound can usually be heard easily with both the bell and the diaphragm

Abnormal S1• Loud First Heart Sound

– Hyperdynamic (fever, exercise) – Mitral stenosis

– short AV intervals like Wolff-Parkinson-White syndrome

• Soft First Sound– Low cardiac output (rest, heart failure) – Tachycardia – Severe mitral reflux (caused by destruction of

valve) – long PR interval

• Variable Intensity of First Sound– Atrial fibrillation – Complete heart block

S2 (dub)• The 2nd heart sound,

marks the end of systole (beginning of diastole).

• Related to the closure of the aortic and pulmonic valves.

• Loudest at the base.

For the second heart sound the diaphragm is invaluable, with the stethoscope usually best placed at the base

Abnormal S2• Loud Second Heart Sound (aortic)

– Systemic hypertension

– Dilated aortic root

• Soft Second Heart Sound (aortic)

– Calcified aortic stenosis

• Loud Second Heart Sound (pulmonary)

– Pulmonary hypertension

S3 Heart Sound • Heard in early diastole

• Lub-dub-by cadence similar to "Kentucky“ SLOSH’-ing-in

• It can be thought of as a sound which is generated when the ventricle is forced to dilate beyond its normal range because the atrium has overloaded volume. As seen in congestive heart failure, which is the most common cause of a S3.

• May be normal physiological finding in patients less than age 30.

S3 is low frequency and thus best heard with the bell of the stethoscope at the apex while the patient is in the left lateral decubitus position. .

S4 Heart Sound• Low frequency sound in late diastole

• Le-lub-Dub cadence similar to "Tennessee" a-STIFF’-wall                 

• Caused by the atrial kick into a noncompliant ventricle

• Seen in patients with stiffened left ventricles, resulting from conditions such as hypertension, aortic stenosis, ischemic or hypertrophic cardiomyopathy, acute MI.

• In patient with mitral regurgitation, suggestive of acute onset of regurgitation due to the rupture of the chorda tendinae that anchor the Valvular leaflets.

It is heard best with the bell of the stethoscope at the apex.

Gallop Sounds

Gallops & Other Sounds

Sound Answer

Normal

Split S1

Split S2

S3

S4

Summation Gallop

MurmursBlood flow through a structure normally closed during systole (mitral or tricuspid valves). Regurgitation

Blood flow through a valve normally open in systole but abnormally narrowed (e.g. aortic or pulmonary). Stenosis

Increased blood flow through a normal valve High flow states like… pregnancy, fever, anemia, hypothyroidism

Due to structural cardiac abnormality and increased flow

ventricular septal defect atrial septal defect mitral regurgitation

Murmur Assessment

1. note where it is heard best and where it radiates to

2. try to discern if the murmur occurs in systole or diastole by timing it against S1 and S2

3. Note the sound of the murmur, is it blowing or grating?

4. Note the intensity of the murmur

Murmurs Made Easy

systole

S1 S2

diastole

systole

diastole

S1 S2

Murmurs 1 2 3

1. Systolic or Diastolic?

2. Blowing or Grating?

3. Open or Closed?

Murmurs 1 2 3

1. Systolic or Diastolic?

2. Blowing or Grating?

3. Open or Closed?

Systolic

What is it?(What’s my Aortic Valve doing?)

Grating

Ope

n

AORTIC STENOSIS

Murmurs 1 2 3

1. Systolic or Diastolic?

2. Blowing or Grating?

3. Open or Closed?

Systolic

What is it?(What’s my Aortic Valve doing?)

Blowin

gClosed

MITRAL INSUFFICIENCY

Murmurs 1 2 3

1. Systolic or Diastolic?

2. Blowing or Grating?

3. Open or Closed?

Diastolic

What is it?(What’s my Aortic Valve doing?)

Blowin

gClosed

AORTIC INSUFFICIENCY

Murmurs 1 2 3

1. Systolic or Diastolic?

2. Blowing or Grating?

3. Open or Closed?

Diastolic

What is it?(What’s my Aortic Valve doing?)

Grating

Ope

n

MITRAL STENOSIS

Systolic MurmursValvular

Mitral regurgitation

Tricuspid regurgitation

Aortic stenosis

Pulmonic stenosis

Nonvalvular

PDA

VSD

Systolic Valvular Murmurs

Mitral regurgitationhigh pitch pansystolic (holosystolic) murmur with blowing qualitybest heard at the apexradiation into the axilla. plateau shaped May follow MVP

Mitral valve prolapse (MVP) resulting in a mid-systolic clickafter the click, a brief crescendo-decrescendo murmur usually best at the apex

Systolic Valvular Murmurs

Tricuspid regurgitation

high pitch pansystolic blowing quality

Best at tricuspid area (4th ICS LSB)

little radiation

Systolic Valvular Murmurs

Aortic stenosis

medium to high pitch rough, harsh quality

heard best over the “aortic area” or right second intercostal space

radiation into the right neck. This radiation is such a sensitive finding that its absence should cause the physician to question the diagnosis of aortic stenosis.

Systolic Valvular Murmurs

Pulmonic stenosis

Medium to high pitch with a harsh, grinding quality

the second intercostal space along the left sternal border

radiating into the neck or the back

Patent ductus arteriosus

• PDA occurs in about 1 in 2,000 infants

• This murmur is best heard over the upper left sternal edge, associated with a thrill, and is characteristically continuous and machinery-like

Ventricular septal defect

• VSD is one of the most common congenital (present from birth) heart defects.

• It is usually best heard over the “tricuspid area”, or the lower left sternal border, with radiation to the right lower sternal border because this is the area which overlies the defect.

Atrial septal defect (ASD) is a congenital heart defect.

• ASD is present in 4 out of 100,000 people.

• Symptoms usually have manifested by age 30.

• This murmur is best heard over the “pulmonic area” of the chest, and may radiate into the back

Diastolic Murmurs

Valvular

Aortic regurgitation

Pulmonic regurgitation

mitral stenosis

tricuspid stenosis

Nonvalvular

PDA

Diastolic Valvular Murmurs

Mitral stenosis

low pitched, decrescendo pattern, quiet to loud with thrill, rough, rumble quality

best heard at the apex

Tricuspid stenosis

medium pitch quiet murmur, louder with inspiration. Rumble quality

best heard at 4th ICS LSB

Diastolic Valvular Murmurs

Aortic regurgitation

high pitch, faint to medium in intensity, decrescendo pattern, blowing quality

2nd ICS RSB & 3rd ICS LSB

Radiation to the neck

Pulmonic regurgitation

Medium pitch, faint intensity, and blowing quality

These can sound alike but only aortic regurgitation will be associated with a bounding arterial pulses…”water hammer pulse” brisk femoral pulsation

Pericardial Friction Rub

• Caused by the beating of the heart against an inflamed pericardium or lung pleura, which itself has a wide variety of etiologies.

• This sound is usually continuous, and heard diffusely over the chest.

• If the rub completely disappears when the patient holds his breath it is more likely due to pleural, not pericardial, origin.

Intensity of MurmursMurmur Grades

Grade Volume Thrill

1/6very faint, only heard with optimal conditions

no

2/6 loud enough to be obvious no

3/6 louder than grade 2 no

4/6 louder than grade 3 yes

5/6heard with the stethoscopepartially off the chest

yes

6/6heard with the stethoscopecompletely off the chest

yes

Significant or not?

• consider is the clinical scenario

• presence of symptoms such as effort syncope, chest pain, palpitations, shortness of breath, or paroxysmal nocturnal dyspnea

• some common variations of normal heart sounds without an underlying structural pathology

– Split S2 and flow murmurs

Sites for practicehttp://depts.washington.edu/physdx/heart/tech.html

http://www.med.ucla.edu/wilkes/Systolic.htm

http://www.medstudents.com.br/cardio/heartsounds/heartsou.htm

http://www.uni-duesseldorf.de/WWW/MedFak/Herz-Kreislauf-Physiologie/lehre/sounds/intro.html

Laptop has download as well. Cardiac Auscultation (heart sounds) from 3M Littmann Stethoscopes

Now you have a whole new meaning to the phrase “listen to your heart.”