Heart Sounds & Murmurs

2. 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
o

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

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

4. Listening Posts
5. Cardiac Cycle
6. Systolic vs. Diastolic systole S1 S2 diastole
7. Gallops systole S1 S2 S4 S3 diastole
8. 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
9. Abnormal S1
Loud First Heart Sound

Hyperdynamic (fever, exercise)

Mitral stenosis

short AV intervals like Wolff-Parkinson-White syndrome

Soft First Sound

o

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

10. 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
11. Abnormal S2
Loud Second Heart Sound (aortic)

Systemic hypertension

Dilated aortic root

Soft Second Heart Sound (aortic)

o

Calcified aortic stenosis

Loud Second Heart Sound (pulmonary)

o

Pulmonary hypertension

12. 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. .
13. S4 Heart Sound
Low frequency sound in late diastole

Le-lub-Dub cadence similar to "Tennessee" a-STIFFwall

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.

14. Gallop Sounds Split S1 Split S2 S3 S4 Summation Gallop Gallops & Other
Sounds Sound Answer Normal
15. 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

o

ventricular septal defect

atrial septal defect

mitral regurgitation

16. Murmur Assessment

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

17. Murmurs Made Easy systole S1 S2 diastole

18. Murmurs 1 2 3 systole diastole S1 S2
Systolic or Diastolic?

Blowing or Grating?

Open or Closed?

19. Murmurs 1 2 3
Systolic or Diastolic?

Blowing or Grating?

Open or Closed?

Systolic What is it? (Whats my Aortic Valve doing?) Grating Open AORTIC
STENOSIS
20. Murmurs 1 2 3
Systolic or Diastolic?

Blowing or Grating?

Open or Closed?

Systolic What is it? (Whats my Aortic Valve doing?) Blowing Closed MITRAL
INSUFFICIENCY
21. Murmurs 1 2 3
Systolic or Diastolic?

Blowing or Grating?

Open or Closed?

Diastolic What is it? (Whats my Aortic Valve doing?) Blowing Closed AORTIC
INSUFFICIENCY
22. Murmurs 1 2 3
Systolic or Diastolic?

Blowing or Grating?

Open or Closed?

Diastolic What is it? (Whats my Aortic Valve doing?) Grating Open MITRAL
STENOSIS
23. Systolic Murmurs
Valvular

Mitral regurgitation

Tricuspid regurgitation

Aortic stenosis

Pulmonic stenosis

Nonvalvular
o

PDA

VSD

24. 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)

o

resulting in a mid-systolic click

after the click, a brief crescendo-decrescendo murmur

usually best at the apex

25. Systolic Valvular Murmurs

Tricuspid regurgitation
o

high pitch pansystolic blowing quality

Best at tricuspid area (4 th ICS LSB)

little radiation

26. Systolic Valvular Murmurs

Aortic stenosis
o

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.

27. Systolic Valvular Murmurs

Pulmonic stenosis
o

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

28. 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

29. 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.

30. 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

31. Diastolic Murmurs

Valvular

Aortic regurgitation

Pulmonic regurgitation

mitral stenosis

tricuspid stenosis

Nonvalvular
o

PDA

32. Diastolic Valvular Murmurs

Mitral stenosis

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

best heard at the apex

Tricuspid stenosis
o

medium pitch quiet murmur, louder with inspiration. Rumble quality

best heard at 4 th ICS LSB

33. Diastolic Valvular Murmurs

Aortic regurgitation

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

quality

2 nd ICS RSB & 3 rd ICS LSB

Radiation to the neck

Pulmonic regurgitation
o

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
34. 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.

35. Intensity of Murmurs Murmur Grades Grade Volume Thrill 1/6 very 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 5/6 heard with the stethoscope partially off the
chest yes 6/6 heard with the stethoscope completely off the chest yes

 36. 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
o

Split S2 and flow murmurs

37. 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

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