HEART SOUNDS:
cardiac apex is close to the anterior chest wall
1 SOUND (systolic):
- Valve component: Vibrations of the cups of the
atrioventricular valves (mitral and tricuspid
valve) when valves are closed.
- Muscular: myocardial isometric contraction
- Vascular component: vibrations of the nearest
portions of the aorta and the pulmonary trunk.
Its longer and louder than the 2 sound.
2 SOUND (diastolic):
- Vibrations of the semilunar cusp of the aortic
and pulmonary valve closure.
- Vascular component: vibration at the
origination of these vessels.
is best heard at the heart base because. s. As distinct
from the first sound, the second sound is shorter and
higher.
PATHOLOGIC HEARD SOUNDS:
- The third sound is caused by vibrations during
passive filling of the ventricles with the blood
from the atria during diastole of the heart; it
arises in 0.15-1.12 s from the beginning of the
second sound.
- The fourth sound is heard at the end of
ventricular diastole and is produced by atrial
contractions during quick filling of the
ventricles with blood.
AUSCULTATORY AREAS:
1. area of the apex beat - for the mitral valves
because the vibrations are well transmitted by
the firm muscle of the left ventricle and the
during systole
2. lower part of the sternum xiphoid process (the
right-ventricular area) - for the tricuspid valves
3. Valves of the pulmonary trunk are best heard
at its anatomical projection onto the chest, i.e.
in the second intercostal space, to the left of
the sternum.
4. aortic valves are best heard in the second
intercostal space, to the right of the sternum
where the aorta is the nearest to the anterior
chest wall
5. heart sounds which are associated with the
contractions of aortic and mitral valves or
which develop during its affections can be
heard to the left of the sternum at the 3-rd and
4-th costosternal joints (the so-called fifth
listening post at the Botkin-Erb point).
ORDER OF AUSCULTATION:
The valve sounds should be heard in decreasing order of
their affection frequency. The mitral valve should be
heard first (at the heart apex); next follows the aortic
valve (in the second intercostal space to the right of the
sternum), the pulmonary valve (in the second
intercostal space, to the left of the sternum), tricuspid
valve (at the base of the xiphoid process), and finally
the aortic and mitral valve again at the Botkin-Erb point.
Intensity of the first heart sound diminishes in the
mitral and aortic valve insufficiency. The cusps of the
affected mitral valve fail to close completely the left
atrioventricular orifice during systole. Part of the blood
is thus regurgitated to the left atrium.
The first sound increases at the heart apex if the left
ventricle is not adequately filled with blood during
diastole. The first sound often becomes louder in
stenosis of the left atrioventricular orifice, when less
than normal amount of blood is discharged from atrium
to the ventricle during diastole. The muscle of the left
ventricle is therefore less distended by the blood by the
start of systole; it is more relaxed and contracts more
rapidly and energetically to intensify the first sound.
The second sound over the aorta is diminished in aortic
valve affections, the cusps of the valve are destroyed or
their vibrating power decreases due to developing
cicatrices. The second sound diminishes over the aorta
in cases of marked hypotension; the second sound
diminishes over the pulmonary trunk in cases of aortic
valve incompetence (in very rare cases).
The second sound may increase (accent) The aortic
second sound is accentuated when the blood pressure in
aorta increases (in essential hypertension, during heavy
exercise, in psychic excitation), because during early
diastole, the aortic valve cusps are closed with a greater
force due to increased blood pressure in the aorta.
The high second sound in pulmonary artery occurs when
pressure in the lesser circulation is elevated or when the
vessels of the lesser circulation are overfilled with blood
(e.g. in mitral heart diseases), disturbance circulation in
the lungs and stenosed pulmonary artery (in lung
emphysema or pneumosclerosis).
CARDIAC MURUMUS: Can be endo and exocardiac.
- Endocardiac murmurs can be: These may occur
in anatomical changes of the structure of the
heart (organic murmurs) or in dysfunction of
the intact valves (functional murmurs).
Decreased blood viscosity (e.g. in anemia)
increases the flow rate of blood and can also be
the cause of murmurs.
Systolic murmur: during systole, blood moves from one
chamber of the heart to another or from the heart to
the main vessels and meets an obstacle. Systolic
murmur is heard in the stenotic orifice of the aorta or
the pulmonary trunk because blood ejected from the
ventricles meets a narrowed vessel (ejection murmur).
Or in cases of mitral and tricuspid incompetence
(regurgitation murmur). Generation of systolic murmur
is explained by regurgitation of blood which is not
completely expelled into the aorta and pulmonary trunk
during the ventricular systole, but is partly returned to
the atrium through an incompletely closed mitral or
tricuspid orifice. Since this partly closed orifice is
actually a narrow slit, murmur is generated as blood
passes through it.
Diastolic murmur occurs if blood meets a narrowed
passage during diastole (ejection murmur). This
murmur is heard in a stenosed left or right
atrioventricular orifice, since blood meets a narrow
passage in its flow from the atria into the ventricles.
Diastolic murmur also occurs in aortic or pulmonary
valve incompetence. Murmur is generated when blood
flows back from the vessels into the ventricles through a
slit formed by incomplete closure of the cusps of the
affected valve (regurgitation murmur).
Systolic murmur due to mitral valve incompetence is
best heard at the heart apex. It can be transmitted by
the firm muscle of the left ventricle to the axillary area
or by the course of the backward blood flow from the
left ventricle to the left atrium, i.e. into the second and
third interspace, to the left of the sternum.
Diastolic murmur generated in a narrowed left
atrioventricular orifice (stenosis) is usually heard over a
limited area at the heart apex.
Systolic murmur due to stenosed aortic orifice is heard
in the second interspace, to the right of the sternum. As
a rule, it is well transmitted by the course of the blood
flow onto the carotid arteries. Since this heart defect is
characterized by a rough and loud sound, it can be
determined in auscultation over the entire heart region
and be transmitted to the interscapular space.
Diastolic murmur due to aortic valve incompetence is
better heard not over the aortic valve but rather at the
Botkin-Erb point, where it is transmitted by the back
flow of blood from the aorta to the left ventricle.
Properties of functional murmurs help differentiate
them from organic murmurs:
(1) in most cases of functional murmurs are
systolic;
(2) functional murmurs are not permanent and
may arise and disappear when the person
changes his posture, after exercise and during
various respiratory phases;
(3) they are mostly heard over the pulmonary trunk
and less frequently over the heart apex;
(4) functional murmurs are transient and are rarely
heard during the entire systole; these are soft
and blowing sounds;
(5) the murmurs are normally heard over a limited
area and are not transmitted to long distances
from their source;
(6) functional murmurs are not accompanied by
other signs of valve affections (e.g. enlargement
of the heart chambers or changes in the heart
sounds).