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 S2

diastole
 Gallops

systole

S1 S2
S4 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-Parkinson-
White 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" a-
STIFF’-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. note where it is heard best and
where it radiates to

2. try to discern if the murmur occurs

in systole or diastole by timing it
against S1 and S2

3. Note the sound of the murmur, is

it blowing or grating?

4. Note the intensity of the murmur

Murmurs Made Easy

systole

S1 S2

diastole
Murmurs 1 2 3
systole

S1 S2

diastole

1. Systolic or Diastolic?
2. Blowing or Grating?
3. Open or Closed?
 Murmurs 1 2 3
AORTIC STENOSIS

1. Systolic or Diastolic? Systolic

2. Blowing or Grating? Grating

3. Open or Closed? Open

What is it?
(What’s my Aortic Valve doing?)
 Murmurs 1 2 3
MITRAL INSUFFICIENCY

1. Systolic or Diastolic? Systolic

2. Blowing or Grating? Blowing

3. Open or Closed? Closed

What is it?
(What’s my Aortic Valve doing?)
 Murmurs 1 2 3
AORTIC INSUFFICIENCY

1. Systolic or Diastolic? Diastolic

2. Blowing or Grating? Blowing

3. Open or Closed? Closed

What is it?
(What’s my Aortic Valve doing?)
 Murmurs 1 2 3
MITRAL STENOSIS

1. Systolic or Diastolic? Diastolic

2. Blowing or Grating? Grating

3. Open or Closed? Open

What is it?
(What’s my Aortic Valve doing?)
 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 pulses…”water 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 Volume Thrill
very faint, only heard with
1/6 no
optimal conditions
2/6 loud enough to be obvious no

3/6 louder than grade 2 no

4/6 louder than grade 3 yes

heard with the stethoscope
5/6 yes
partially off the chest
heard with the stethoscope
6/6 yes
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-Kreislauf-
Physiologie/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.”