Cardiac Auscultation :

Normal Heart Sounds

Sisca Natalia Siagian

Division of Pediatric Cardiology & CHD

Department of Cardiology & Vascular Medicine, Faculty of Medicine Universitas Indonesia
National Cardiovascular Center Harapan Kita, Jakarta
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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Audibility of Heart Sounds
The Stethoscopes
The Membrane
• Purpose of the membrane: damp
out low frequencies and unmask
high frequencies
• Ideal for high pitched sound and
murmurs The Bell
• Murmurs: the soft aortic and • Ideal for low pitched sound and
pulmonary diastolic murmur and murmurs
the soft mitral regurgitation
murmur • Murmurs: diastolic murmurs
through atrioventricular valves
• Sounds: splitting of first or second (mitral and tricuspid)
heart sounds and nonejection
clicks • Sounds: the diastolic sounds
known as the S3 and S4
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HEART SOUNDS

 Heart sounds are made by the closure of

the heart valves and the acceleration and
deceleration or vibration of valves due to
blood flow in the cardiac chambers

 First and second heart sounds are normally

heard during each cardiac cycle

One may hear a 3rd or 4th heart sound

Heart Sounds

• S1 – onset of the ventricular contraction

• S2 – closure of the semilunar valves
• S3 – ventricular gallop
• S4 – atrial gallop
• Other – opening snap, ejection sound
• Murmurs

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WHERE WE CAN HEAR THE HEART SOUNDS

Guyton and Hall

The Origin of Heart Sounds

• Valvular theory
• Vibrations of the heart valves
during their closure

• Cardiohemic theory
• Vibrations of the entire
cardiohemic system: heart
cavities, valves, blood

Rushmer, R.F., Cardiovascular

Dynamics, 4yh ed. W.B. Saunders,
Philadelphia, 1976
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Heart Sounds
• Low frequency
• S1 has components in 10-140Hz bands
• S2 has components in 10-400Hz bands
• Low intensity
• Transient
• 50-100 ms
• Non-stationary
• Overlapping components
• Sensitive to the transducer’s properties and location
FIRST HEART SOUND (S1)

 First heart sound is produced due to the closure of Atrio-ventricular valves (Tricuspid
and Mitral)
• It occurs at the beginning of the systole
• Sounds like LUB
• Frequency: 25-45 CPS (cycles per second) or Hz
• Soft when the heart rate is slow because ventricles are well filled with blood and the leaflets of
the A-V valves float together before systole begins

• Time: 0.14 sec [Guyton]; 0.15 Sec [Ganongs]

Guyton and Hall Ganongs

FIRST HEART SOUND
(S1)
• Turbulent rushing of blood towards A-V valves
• The closure of the A-V valves
• Semi-lunar valves open
• Turbulent blood flow into large arteries

• The mitral component heard at the apex beat area

[left 5th intercostal space at midclavicular line]

• The tricuspid component is best heard in the 4th

intercostal space at the left sternal border
Sub-Components of S1

Rushmer, R.F., Cardiovascular Dynamics Obaidat M.S., J. Med. Eng. Tech., 1993 13
First Heart Sound (S1)
Intensity of S1 determined by:
• the distance separating the leaflets
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)
• This sound is produced by the vibration associated with the closure of the semilunar
valves (aortic and pulmonary) at the end of ventricular systole
• Duration: 0. 11 sec [Guyton]; 0.12 [Ganong]
• Frequency: 50 Hz or CPS
• This sound is sharp and loud and described as “DUB”

• Two sub components

• Pulmonary component heard at the level of 2nd left intercostal space
• Aortic component is heard at the level of the 2nd right interscostal space near the right border of
the sternum

Guyton and Hall; Ganong

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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Sub-Components of S2

Obaidat M.S., J. Med. Eng. Tech., 1993 17

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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Second heart sound has physiological inspiratory splitting
 • Occurs at the beginning of middle third of
Diastole
• Cause of third heart sound
THIRD HEART • Rush of blood from Atria to Ventricle during rapid
filling phase of Cardiac Cycle
SOUND (S3) • It causes vibration in the blood
• Frequency:20-30 Htz
• Time: 0.1 sec
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 filling 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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 • Occurs at the last one third of Diastole [Just
FOURTH before S1]
• Produced due to Atrial contraction which causes
HEART SOUND rapid flow of blood from Atria to Ventricle and
(S4) vibration in the blood
• Frequency: 20 cycles / sec or less [Htz]
OR ATRIAL • Third and Fourth heart sound are low pitched
SOUND sounds therefore not easily audible normally
with stethoscope
 Heart
Occurs during: Associated with:
Sound
Isovolumetric Closure of mitral and tricuspid
S1
contraction valves
Isovolumetric Closure of aortic and pulmonic
SUMMARY OF S2
relaxation valves
HEART
SOUND Early ventricular
Normal in children; in adults,
S3 associated with ventricular dilation
filling
(e.g. ventricular systolic failure)

Associated with stiff, low compliant

S4 Atrial contraction ventricle (e.g., ventricular
hypertrophy
HEART SOUNDS: ASSOCIATION WITH CARDIAC CYCLE

VS VD

0.3Sec. 0.5 sec.

1 st Heart Sound 2 nd Heart Sound 3 rd Heart Sound 4 th Heart Sound

AS – Atrial Systole; AD – Atrial Diastole ; VS – Ventricular systole; VD – Ventricular diastole

CARDIAC CYCLE:
ASSOCIATION
WITH
HEART SOUNDS

Guyton and Hall

CARDIAC CYCLE:
ASSOCIATION
WITH
HEART SOUNDS

Ganongs
 Hearing abnormal heart sounds is difficult
It requires:
Practice and experience
Knowledge of cardiac physiology
A good ear

Knowing the normal heart sound is a big first step to be knowing the abnormal ones