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 diastole S2

Gallops
systole
S1
S4

S2
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-ParkinsonWhite 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" aSTIFF-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

Murmurs
Blood 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. 2. note where it is heard best and where it radiates to try to discern if the murmur occurs in systole or diastole by timing it against S1 and S2 Note the sound of the murmur, is it blowing or grating? Note the intensity of the murmur

3. 4.

Murmurs Made Easy

systole
S1 diastole S2

Murmurs 1 2 3
systole

S1
diastole

S2

1. Systolic or Diastolic?
2. Blowing or Grating?

3. Open or Closed?

Murmurs 1 2 3
AORTIC STENOSIS

1. Systolic or Diastolic?
2. Blowing or Grating?

Systolic
Grating

3. Open or Closed?

Open

(Whats my Aortic Valve doing?)

What is it?

Murmurs 1 2 3
MITRAL INSUFFICIENCY

1. Systolic or Diastolic?
2. Blowing or Grating?

Systolic
Blowing

3. Open or Closed?

Closed

(Whats my Aortic Valve doing?)

What is it?

Murmurs 1 2 3
AORTIC INSUFFICIENCY

1. Systolic or Diastolic?
2. Blowing or Grating?

Diastolic
Blowing

3. Open or Closed?

Closed

(Whats my Aortic Valve doing?)

What is it?

Murmurs 1 2 3
MITRAL STENOSIS

1. Systolic or Diastolic?
2. Blowing or Grating?

Diastolic
Grating

3. Open or Closed?

Open

(Whats my Aortic Valve doing?)

What is it?

Systolic Murmurs
Valvular
Mitral regurgitation Tricuspid regurgitation Aortic stenosis

Pulmonic stenosis

Nonvalvular
PDA
VSD

Systolic Valvular Murmurs

Mitral regurgitation
high pitch pansystolic (holosystolic) murmur with blowing quality best heard at the apex radiation into the axilla. plateau shaped May follow MVP

Mitral valve prolapse (MVP)

resulting in a mid-systolic click after 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 pulseswater 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 Murmurs
Murmur Grades
Grade 1/6 2/6 3/6 4/6 5/6 6/6 Volume very faint, only heard with optimal conditions loud enough to be obvious louder than grade 2 louder than grade 3 Thrill no no no yes yes yes

heard with the stethoscope partially off the chest

heard with the stethoscope completely off the chest

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 practice

http://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-KreislaufPhysiologie/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.