Abnormal heart sounds

Content Reviewers:
Rishi Desai, MD, MPH, Justin Ling, MD, MS

If you put a stethoscope over the chest, you'll usually hear something
that sounds like lub dub, lub dub, lub dub, which repeats over and over again, with
each cardiac cycle, or heartbeat.
Now, the question is, where does this sound come from? Normally, blood is
constantly moving through the four chambers of the heart- coming through the veins
into the right atrium, going to the right ventricle, then shooting off via the pulmonary
artery to the lungs and coming back from the pulmonary veins into the left atrium and
the left ventricle, to be pumped into the aorta. So, in every step, some valves have to
open and others have to close. Valves are just “communicating doors” that, when
open, allow blood to pass through, and when closed, hold blood within a chamber.
So, in total, our heart has four valves- two atrioventricular valves, which separate
the atria from the ventricles and are the tricuspid valve, on the right side, and
the mitral valve, on the left side, and two semilunar valves, which separate the
ventricles from the large arteries coming off of them and are the pulmonary valve, on
the right side, and the aortic valve, on the left side. And when these valves are
closing, just like a door slamming shut, they are going to make a sound that is
transmitted in the direction of the blood flow. The heart is positioned in such a way in
the chest cavity, so that the sound of the closing of each of these valves is projected
onto a small area of the anterior chest wall. So, let's start from the right side. If we
place our stethoscope between the second and third rib, known as the right second
intercostal space, just next to the upper border of the sternum, we’ll best hear the
closing of the aortic valve. Then, right over on the left side, in the left second
intercostal space, left upper sternal border, there is the pulmonary valve closing.
Making our way down, between the fourth and fifth rib, next to the left lower border of
the sternum, we’ll be closer to the tricuspid valve. Finally, let’s move a bit further to
the left and downwards, between the fifth and sixth rib, so in the left fifth intercostal
space, and in the midclavicular line. This means if we drew a line from the midpoint
of the left clavicle, or the collarbone, straight down in a longitudinal fashion, we’ll find
a point that would intersect with the fifth intercostal space. And that’s where the
closing of the mitral valve is best heard. Now in reality, a lot of these things are
happening at once, like a factory with lots of things happening in parallel. For
example, the right and left atria are both full of blood, and that blood moves through
them tricuspid and the mitral valve to get down into the ventricles. Initially, the blood
flows passively into the ventricles, but near the end when there’s just a bit left,
there’s an atrial contraction that gives the blood an extra hard push to help get it out.
This part of the heartbeat, when blood is filling the relaxed ventricles is
called diastole. Now once the ventricles have filled up, both of the atrioventricular
valves snap shut, creating a long, loud sound that sounds a bit like “lub”. That’s
the first heart sound, or S1. And because it’s basically the tricuspid and mitral
valve closing, it’s best heard in the tricuspid valve area, so in the left fourth
intercostal space, lower sternal border, as well as in the mitral valve area, so in the
left fifth intercostal space, in the mid- clavicular line. So, at this point, the ventricles
are full of a whole lot of blood and are ready to squeeze it out. And to do that,
the aortic valve, on the left side, and the pulmonic valve, on the right side, quietly
open up. Blood flows from the left ventricle into the aorta and from the right
ventricle into the pulmonary artery. This part of the heartbeat, when blood is
ventricles are contracted and pushing blood out is called systole. Eventually, the
ventricles finish squeezing, so these two valves close down, making a short,
sharp sound that sounds a bit like a “dub”. And this dub is called the second heart
sound, or S2. This is heard louder in the aortic valve area, so in the right second
intercostal space, right upper sternal border, and the pulmonary valve area, in the
left second intercostal space, left upper sternal border. During inspiration, though, if
you listen carefully with a stethoscope, this S2 sound actually splits into two
separate sounds. That’s because the diaphragm muscle lowers during inspiration,
and that creates negative pressure in the chest to bring in air, and that negative
pressure also brings a bit more venous blood back to the right atrium and right
ventricle. It takes a little bit longer for the right ventricle to squeeze this extra blood in
the pulmonary artery and it takes a little bit longer for the pulmonary valve to close.
So during inspiration, the closing of the pulmonary valve is heard slightly later than
the aortic valve, and that’s called physiologic splitting of the S2. Now after both
the aortic and pulmonary valves have shut down, the atrioventricular valves open
again, letting the cycle start all over again.
Alright, now in addition to S1 and S2, there are two other "extra" sounds that are
sometimes heard in the cardiac cycle, called S3 and S4. S3 and S4 are heard in
different parts of diastole. In early diastole, right after S2, which signifies the closing
of the aortic and pulmonic valves, the atrioventricular valves are open and blood is
flowing into the ventricles. If there’s a lot of blood coming in, the ventricles fill up
quickly, and send fluid waves that bounce off of the walls of the ventricles which
makes them vibrate and create a third heart sound, or S3. S3 sounds kind of like
“lub-dub-ta”. In trained athletes and also in pregnancy this is totally normal and just
means that the ventricles are handling some extra blood volume. But an S3 can also
be a sign of volume overload, like in congestive heart failure, where there is too
much volume coming into that ventricle. Now, at the end of diastole, just before S1,
the atria are contracting to get that last bit of blood into the ventricles. If the ventricles
are too stiff, meaning that they can’t easily relax, the atria will have to contract extra
hard to push that blood in, creating the fourth heart sound, or S4. So, S4 sounds kind
of like "ta-lub-dub". In most cases, this stiffness is because the ventricular muscles
have hypertrophied, or increased in size, in order to pump against high blood
pressure in the aorta or pulmonary artery. In other words, S4 is usually a sign of
pressure overload, or severe hypertension.
Okay, now in addition to distinct heart sounds, there are also heart murmurs, which
result from turbulent, or rough blood flow through the heart. Some children, whose
hearts are perfectly healthy, sometimes have what are called “innocent” heart
murmurs which are just sounds that come from the fact that their heart walls are thin
and vibrate with rushing blood. These innocent heart murmurs typically disappear by
adulthood. In most cases, though, murmurs actually indicate a problem with
the heart valves themselves. Systolic murmurs are the ones that can be heard
between S1 and S2, kind of like “lub-whoosh-dub”. This is when the aortic and
pulmonary valves are normally open, and the mitral and tricuspid valves are closed.
A systolic murmur might come from an aortic or pulmonary valve might isn’t fully
open, called stenosis, which causes blood to flow through a more narrow opening
and that creates turbulence which produces a murmur. Sometimes, the valves are
really hard to open and the ventricles have to contract extra hard to open them up in
the first place, causing them to snap open, which sounds like a “click” which is called
an ejection click. Alternatively, the mitral or tricuspid valve might not be able to make
a perfect seal. This is known as regurgitation, and it allows blood to leak back from
the ventricles into the atria, which again creates a murmur. On the flip
side, diastolic murmurs are heard between S2 and S1 of the next cycle, kind of like
“lub-dub-whoosh”. This is when the aortic or pulmonary valves are normally closed,
and the mitral and tricuspid valves are open. So, there are 4 major ways
a diastolic murmur could be produced- that is from an aortic or pulmonary valves that
is regurgitant, meaning that they don’t completely shut, or a mitral or tricuspid
valves that’s stenotic, meaning that they don’t fully open.

SUMMARY

All right, as a quick recap, heart sounds are generated as blood flows through the
beating heart. There are two normal heart sounds- S1, caused by the atrioventricular
valves closing, at the beginning of systole, and S2, caused by the aortic and
pulmonary valves closing, at the beginning of diastole. Two extra heart sounds may
be present- S3, in cases of volume overload, and S4, in cases of pressure overload.
Also, systolic or diastolic heart murmurs may be heard, usually due to valvular
problems, like stenosis or regurgitation.