Cardiac Cycle and Heart Sounds Part I

Mary Beth Fontana

Block Objectives
Diagram the cardiac cycle, relating electrical and mechanical events to chamber and great artery pressures and ventricular volume; identify systole and diastole Describe the mechanism of production of normal and abnormal heart sounds: relate them to the electrical and pressure events of the cardiac cycle

Objectives
Describe the use of the stethoscope
Auscultatory areas Use of bell and diaphagm Interpret the meaning of the auscultatory findings

Resources
Lilly 5th edition Chapter 2 pp. 28-36, Table 2.2 P. 42 Blaufuss.org. heart sound tutorial quiz There will be auscultation practice sessions in week 7 The Blaufuss Sound Builder program used in the practice sessions is available in the App store for a fee

Always Keep In Mind-- The history and physical examination of the cardiovascular system make the vast majority of the diagnoses!!!!!!!

Auscultation Requires.
A quiet environment A stethoscope with a bell for low pitched sounds and diaphragm for high pitched sounds, well fitting ear pieces and short tubing A thinking auscultator who knows where to place the stethoscope to hear specific sounds-based on anatomic relationships of the heart and great vessels to chest wall landmarks

Auscultatory Areas
Auscultatory Areas

Aortic

Pulmonic

Aortic 2nd ICS RSB Pulmonic 2nd ICS LSB Tricuspid LLSB Mitral Apex 5th ICS MCL

Tricuspid

Mitral

A Thinking Auscultor
Can describe the events in the cardiac cycle responsible for the production of the normal and abnormal heart sounds. can reproduce the diagram below relating electrical events, mechanical events and heart sounds. This cardiac cycle diagram will be the reference for the discussion of all of the heart sounds.

Cardiac Cycle

Chamber and Arterial Pressures

ECG Electrical activation causes chamber contraction which raises pressure. Chamber relaxation and emptying cause pressure to fall

Generation of Heart Sounds

The opening and closing of the heart valves are determined by pressure differences between the chambers and great vessels on either side of the valves Most of the heart sounds discussed in these 2 lectures are related to opening and closing of the cardiac valves The sounds occur when the valve leaflets, vessel or ventricular walls tense when they stop moving

Normal Heart Sounds

First Heart Sound (S1) occurs when the mitral and tricuspid valves close Second Heart Sound occurs when the aortic and pulmonic valves close Opening of normal cardiac valves is silent

Descriptors of Heart Sounds

Intensity or loudness Frequency (high pitched or low pitched) Splitting clinically important for the second heart sound

Intensity Depends Upon..

Mobility of the valve leaflets The distance the leaflets move The rate of pressure generation driving the leaflet movement Mass of the valve leaflets Source to stethoscope distance

Cardiac Cycle
LV 140/12 Ao 140/90 RV 30/8 PA 30/10 LA (12) RA (8) Chamber and Arterial Pressures

ECG Left heart pressures and velocities are higher than in the right heart, so the contributions to S1 and S2 are louder, higher in frequency

First Heart Sound S1

S1 LLSB and Apex with the diaphragm

Mitral valve closes Tricuspid valve closes Ventricular depolarization causes ventricular contraction. S1 occurs when ventricular pressure exceeds atrial pressure. Mitral closes before tricuspid

Increased First Heart Sound

Short PR interval High cardiac output or tachycardia Mobile valve leaflets with increased mass
Scarred stenotic mitral valve Redundant prolapsing mitral valve

Decreased First Heart Sound

Long PR interval Mitral regurgitation murmur obscures S1, lack of leaflet coaptation, slow closing velocity Decreased leaflet mobility from scarring, calcification atrioventricular valve stenosis Noncompliant LV high diastolic pressure precloses leaflets

Second Heart Sound S2

Aortic valve closes A2

S1 S2

Pulmonic valve closes P2

LV and RV pressures drop below aortic and PA pressures after ejection and relaxation. A2 is louder, best at 2RSB; normal P2 only heard at 2LSB

Increased A2, P2
Arterial hypertension Mobile leaflets with increased mass Increased pulmonary blood flow (P2)

Decreased A2,P2
Decrease mobility in severe valve stenosis Calcification of aortic valve may restrict mobility so severely that A2 is absent

Normal Splitting of S2
A2 and P2 normally superimposed in expiration Inspiration delays P2 due to..
Negative intrathoracic pressure increases right heart filling. The RV takes longer to eject the increased volume Negative intrathoracic pressure increases pulmonary capacitance, delaying the back flow to close the pulmonic valve

Abnormal Splitting of S2
Widened splitting electrical or mechanical delay of the RV delays P2. Split S2 in expiration widens with inspiration Fixed splitting atrial septal defect continuously increases right heart filling, delaying P2, unaffected by respiration Paradoxical splitting electrical or mechanical delay in LV delays A2 so it follows P2. P2 moves out to meet A2 with inspiration

Cardiac Cycle and Heart Sounds Part II

Mary Beth Fontana

Extra Systolic Heart Sounds

Ejection Clicks
Aortic valve opens

Audible opening of mobile congenitally stenotic aortic or pulmonic valves, also dilated aorta or PA

S1

EC

S2

Follows S1 by duration of isovolumic contraction

Pulmonic valve opens

High pitched, best at LSB

Nonejection Clicks

S1

SC

A2

Prolapsing mitral or tricuspid valve leaflets reach limit of motion and tense later in systole

Extra Diastolic Heart Sounds

Opening Snaps

S2 S1 OS

Audible opening of mobile stenotic mitral or tricuspid valves; high pitched at LLSB or apex

Mitral valve opens Tricuspid valve opens

Ventricular pressure drops below atrial pressure

Third Heart Sound S3

Early diastole after S2. Low pitched-with the bell, left lateral decubitus

S2 S1 S3

Dilated ventricle with poor function and/or increased early diastolic filling
LV early diastolic filling S3 RV early diastolic filling S3

Fourth Heart Sound S4

In late diastole before S1. Low pitched with the bell LLSB, apex

S4 S1

S2

Atrial contraction empties blood into a noncompliant ventricle

Atrial contraction S4

Summary of Heart Sounds

EC

P2 S3

S4

S1

SC

A2 OS