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Heart Sounds

Factors that decrease the intensity of the heart

sounds and murmurs:
1. mechanical ventilation
2. obstructive lung disease
3. obesity
4. pendulous breasts
5. pneumothorax
6. pericardial effusion
1. First Heart Sound (S1)
- mitral (M1) and tricuspid (T1) valve closure
- best heard: lower left sternal border
- splitting: complete RBBB
- intensity early rheumatic mitral stenosis,
hyperkinetic states, short P-R intervals
(<160 milliseconds)
- intensity late rheumatic mitral stenosis,
contractile dysfunction, -adrenergic
receptor blockers, long P-R intervals
(>200 milliseconds)
2. Second Heart Sound (S2)
- aortic (A2) and pulmonic (P2) valve closure
- A2 is normally louder than P2
- widening: complete RBBB
- splitting: A2-P2 interval during inspiration
and with expiration
- fixed splitting: ostium secundum ASD
- paradoxical splitting: complete left bundle
branch block, RV apical pacing, severe
aortic stenosis, HOCM, myocardial ischemia
- intensity of P2 relative to A2: pulmonary
artery hypertension
- best heard: 2nd left interspace
Systolic Sounds
1. Ejection sound
- high-pitched early systolic sound
- coincides in timing with the upstroke of
the carotid pulse
- associated with congenital bicuspid
aortic or pulmonic valve disease
- pulmonic valve disease: intensity with
inspiration (only right-sided cardiac
event to behave in this manner)
- best heard: lower left sternal border

Diastolic Sounds
1. Opening snap (OS)
- high-pitched early diastolic sound
- heard in mitral stenosis
- distance after S2
2. Pericardial knock (PK)
- high-pitched early diastolic sound
- abrupt cessation of ventricular
expansion after AV valve opening and to
the prominent y descent
- seen in the jugular venous waveform in
patients with constrictive pericarditis
3. Tumor plop
- low-pitched sound
- atrial myxoma (rare)
- arises from the diastolic prolapse of
tumor across the mitral valve
4. Third heart sound (S3)
- occurs during the rapid filling phase of
ventricular diastole
- may be normally present in children,
adolescents, young adults, pregnant
- indicates systolic heart failure in older
- left-sided S3:
- low-pitched
- best heard over the LV apex,
- left lateral decubitus position
- right-sided S3:
- usually heard at the lower left
sternal border or in the
subxiphoid position
- supine
- louder with inspiration
5. Fourth heart sound (S4)
- occurs during the atrial filling phase of
ventricular diastole
- thought to indicate presystolic
ventricular expansion
- common in patients with accentuated
atrial contribution to ventricular filling
(e.g., LV hypertrophy)

result from audible vibrations caused by

increased turbulence
defined by their timing within the cardiac



Very faint, heard only after listener has

tuned in; may not be
heard in all positions
Quiet, but heard immediately after placing
the stethoscope
on the chest
Moderately loud
Loud, with palpable thrill
Very loud, with thrill. May be heard when the
stethoscope is partly off the chest
Very loud, with thrill. May be heard with
stethoscope entirely
off the chest


1. Systolic Murmurs
a. Early
- high-frequency
- begins with S1 and ends before S2
- decrescendo in configuration
- causes: acute severe MR, acute TR
with normal pulmonary artery
pressures ( intensity with
inspiration, may be audible at the
lower left sternal border)
b. Midsystolic
- high frequency
- begin after S1 and end before S2
- d/t blood flow through the semilunar
- crescendo-decrescendo in
- causes: aortic stenosis, HOCM,
pulmonic stenosis, large ASD, leftto-right shunt
- isolated grade 1 or 2 midsystolic
murmur in the absence of
symptoms or other signs of heart
disease is a benign finding

c. Late
- starts after S1, if left sided, extends
up to S2
- usually in a crescendo manner
- usually indicates MVP
- similar murmur may be heard
transiently during an episode of
acute MI
d. Holosystolic or Pansystolic
- plateau in configuration,
- start at S1 and extends up to S2
- usually d/t regurgitation in cases
such as mitral regurgitation,
tricuspid regurgitation, or VSD
- MR: cardiac apex
- TR: lower left sternal border
- SD: mid-left sternal border, thrill is
palpable in most patients
2. Diastolic Murmurs
a. Early
- start at the same time as S2, end
before S1
- causes: aortic or pulmonary
regurgitation, left anterior
descending artery stenosis
b. Mid-diastolic
- start after S2 and end before S1
- due to turbulent flow across the
atrioventricular valves during the
rapid filling phase
- causes: mitral or tricuspid stenosis
c. Late diastolic or Presystolic
- start after S2 and extend up to S1
- crescendo configuration
- causes: mitral stenosis, tricuspid
stenosis, atrial myxoma, complete
heart block, acute rheumatic mitral
valvulitis (Carey Coombs murmur)
d. Austin Flint murmur
- low-pitched mid- to late apical
diastolic murmur
- sometimes associated with AR
- can be distinguished from mitral
stenosis on the basis of its
response to vasodilators and the
presence of associated findings

3. Continuous Murmurs
- implies a pressure gradient between two
chambers or vessels during both systole
and diastole
- begin in systole, peak near S2, and
continue into diastole
- causes PDA, ruptured sinus of Valsalva
aneurysm, and coronary, great vessel,
hemodialysis-related arteriovenous
a. Cervical venous hum
- blood flow causing vibration of
jugular veins
- benign phenomenon
- heard throughout the cardiac cycle
- placing a finger on the jugular vein
when listening to the heart will
abolish or change the noise
b. Mammary souffl
- high-pitched
- late pregnancy, postpartum
lactation, adolescence
- disappears at the end of lactation
- best heard directly over the breast
- pressure with a finger or
stethoscope in the area where the
souffle is best heard may make it