Mechanism of Heart Sound and

Heart Murmur
Presentation Outline
• Importance of understanding
mechanism of heart sound and heart
murmur
• The Stethoscope
• Heart sound
• Heart murmur
• Other cardiac auscultatory findings
• Closing remark

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The Importance of understanding mechanism of
heart sound and heart murmur

• Help better understanding of

physiology
• Easier to remember and recall the
cardiac auscultatory findings in
various conditions
• Better diagnosis  better treatment
• Cost-efficient

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The Phonocardiograph

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The Stethoscopes
The Membrane
• Purpose of the membrane: damp
out low frequencies and unmask
high frequencies
• Ideal for high pitched sound and
murmurs
• Murmurs: the soft aortic and
pulmonary diastolic murmur and
the soft mitral regurgitation
murmur.
• Sounds: splitting of first or
second heart sounds and
nonejection clicks.
The Bell
• Ideal for low pitched sound and
murmurs
• Murmurs: diastolic murmurs
through atrioventricular valves
(mitral and tricuspid).
• Sounds: the diastolic sounds
known as the S3 and S4
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First Heart Sound (S1)
• S1 is produced by the
closure of the mitral and
tricuspid valves in early
systole and is loudest
near the apex of the heart
• Mitral closure usually
precedes tricuspid
closure by only about
0.01 sec  human ear
appreciates only single
sound

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First Heart Sound (S1)
Intensity of S1 determined by:
• the distance separating the leafl
ets of the open valves at the onset
of ventricular contraction
• the mobility of the leaflets
(normal, or rigid because of
stenosis)
• the rate of rise of ventricular
pressure

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Second Heart Sound (S2)
• The second heart sound results
from the closure of the aortic
and pulmonic valves  A2 and
P2 components
• vary with the respiratory cycle:
fused as one sound during
expiration but become audibly
separated during inspiration 
physiologic splitting

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Other explanation of S2
• Valve “closure” itself probably produces no noise.
Echocardiography shows that the sounds occur slightly after the
coaptation of the leaflets. Shortly after apposition the sealed cusps
are made tense and then vibrate (stretch and recoil) due to the
rapid force of aortic or pulmonary artery recoil

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Splitting pattern
of Second Heart
Sound (S2)

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Fixed Split in ASD

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Extra Systolic Heart Sounds
Early systolic heart sound: ejection clicks Mid or late systolic heart sounds:
• occur shortly after S1 • usually the result of systolic
• sharp, high-pitched quality, heard best prolapse of the mitral or
with the diaphragm of the stethoscope tricuspid valves
placed over the aortic and pulmonic areas
• indicate the presence of aortic or
pulmonic valve stenosis
• Generated by rapidly ascending valve
reaches its elastic limit and decelerates
abruptly

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Extra Diastolic Heart Sounds:
Opening Snap, S3 and S4
Opening Snap
• Opening of mitral or tricuspid
valvular stenosis produces a sound
 snap
• High-pitched sound
• The severity of stenosis can be
approximated by the time interval
between A2 and the OS: the more
advanced the stenosis, the shorter
the interval
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Third Heart Sound (S3)
• occurs in early diastole, following the
opening of the AV valves
• dull, low-pitched sound best heard with
the bell of the stethoscope
• S3 result from tensing of the chordae
tendineae during rapid fi lling and
expansion of the ventricle
• a normal finding in children and young
adults
• in middle-aged or older adults, an S3 is
often a sign of disease

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 Fourth Heart Sound (S4)
• occurs in late diastole and
coincides with contraction of the
atria
• S4 is a dull, low-pitched sound
• generated by the left (or right)
atrium vigorously contracting
against a stiffened ventricle  a
decrease in ventricular compliance
• Left-sided S4 is loudest at the apex
with left lateral decubitus position

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 Murmurs:
sound generated by turbulent blood flow
• Flow across a partial Murmur description:
obstruction
• timing
• Increased flow through
normal structures • intensity
• Ejection into a dilated chamber • pitch
• Regurgitant flow across an • shape
incompetent valve • location
• Abnormal shunting of blood
from one vascular chamber to • radiation
a lower-pressure chamber • response to maneuvers
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Cause of
Turbulence

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Systolic Murmurs
Systolic ejection murmur
• typical of aortic or pulmonic
valve stenosis
• begins after S1 and terminates
before or during S2
• shape of the murmur is of the
crescendo-decrescendo
Pansystolic murmur
• caused by regurgitation of
blood across an incompetent
mitral or tricuspid valve or
through a VSD
• uniform intensity throughout
systole
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 Systolic Murmurs
Late systolic murmurs
• begin in mid-to-late systole
and continue to the end of
systole
• Eq: mitral regurgitation caused
by mitral valve prolapse
• usually preceded by a
midsystolic click

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 Diastolic Murmurs
early decrescendo murmurs Mid-to-late diastolic murmurs
• Result from regurgitant flow • result from turbulent fl ow across
through either the aortic or a stenotic mitral or tricuspid valve
pulmonic valve • MS murmur is low pitched, is
• Displays maximum intensity at heard best with the bell at left
its onset lateral decubitus position
• AR murmurs best heard using
the diaphragm with the patient
sitting, leaning forward, and
exhaling
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Continuous Murmurs
• heard throughout the cardiac cycle
• result from conditions in which there
is a persistent pressure gradient
between two structures during both
systole and diastole
• Eq: PDA
• The “to-and-fro” combined murmur
is different with Continuous Murmurs

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Continuous vs To-and-fro murmur

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Other Murmurs

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Austin Flint Murmur
• An apical diastolic rumble
imitating the murmur of
organic MS but is due to an
aortic regurgitation (AR)
stream that prevents the mitral
valve from opening fully

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Graham Steell Murmur Carey Coombs Murmur
• Murmurs with High Pressure • It is the diastolic inflow
in the Pulmonary Artery murmur usually ushered in by
• A Graham Steell murmur is a an S3 , heard in subjects with
PR murmur that is secondary cardiomegaly and MR due to
to pulmonary hypertension acute rheumatic fever

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Dynamic Auscultation
• Auscultate with altered hemodynamics
• Listening to the change in character, behavior and
intensity of the heart sound and murmurs to
physiological and pharmacological maneuvers..
• Standing-squatting
• Handgrip
• Valsalva maneuver
• Amyl Nitrit administration etc..

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CyberMD 30
References

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TERIMA KASIH