Heart sounds and

arteriovenous pulses
Dr Chandana Hewage

30 7 2017
 Objectives
1. What are mechanical events in the heart?
2. What is cardiac cycle?
3. What are the sequence of events during the
cardiac cycle ?
– What are the pressure changes in a single cardiac
cycle ?
– How arterial & jugular venous pulses produce ?
– How heart sounds are produced ?
– What are murmurs, genesis and their timing in the
cardiac cycle?
• Heart sounds

Aortic Pulmonary

Tricuspid Mitral
 Heart sounds
1st  lub sound

Cause :
due to vibrations set up by sudden closure of M
V &TV
Site : apex of heart
Character : low pitched and prolonged (compared
to 2nd)
Timing : beginning of ventricular systole
good clinical indicator of systole
2nd  dup sound

Cause :
due to vibrations set up by sudden closure of AV
& PV
(physiological splitting during inspiration)

Site : in 2nd inter costal space

Character : high pitched & short duration

Timing : end of ventricular systole

3rd 

Cause :
due to vibrations set up by inrush of blood
during rapid ventricular filling

Site : tricuspid area

Character : soft & low pitched

Timing : diastole
• 4th heart sound
• Usually pathological
• Cause – due to ventricular filling when atri
al pressure is high or the ventricle is stiff (v
entricular hypertrophy)
• Site – mitral area
• Timing – heard just before the 1st heart so
und in diastole
 Heart sounds
Function of Valves
• Open with a forward pressure gradient
– e.g. when LV pressure > the aortic pressure th
e aortic valve is open
• Close with a backward pressure gradient
– e.g. when aortic pressure > LV pressure the a
ortic valve is closed
 Heart sounds cont’
• The interval between aortic and pulmonary valve
closure during inspiration is frequently long enough
for the second sound to be reduplicated
(physiologic splitting of the second sound).
• Splitting also occurs in various diseases.
Normal physiological splitting of S2
• venous return in inspiration
• volume of right ventricle
• Delay emptying time and closure of
pulmonary valve
• Pooling of blood in pulmonary veins
• filling of left atrium makes aortic valve
closure slightly earlier than in expiration
 Splitting of the second heart sound
In Inspiration → ↑ negative intrathoracic pressure →
↑ venous return → delayed closure of the PV →
splitting of the second heart sound
 Paradoxical /reverse splitting
• In aortic stenosis
• Left ventricular filling takes a long time
• to empty.
• Closure of the aortic valve is delayed.
• in severe aortic stenosis, it is so delayed that
it follows the closure of the pulmonary valve
 Wide fixed splitting in ASD
• In atrial septal defect
• Left to right shunt delay right ventricular
emptying time
• Split does not change with phases of
respiration
• Wide and fixed split
 Heart sounds cont’
• the "slapping" together of the valve leaflets sets up
vibrations has been shown to cause little, if any, of
the sound, because the blood between the leaflets
cushions the slapping effect and prevents significant
sound.
• Instead, the cause is vibration of the taut valves
immediately after closure, along with vibration of
the adjacent walls of the heart and major vessels
around the heart.
•
 Duration and Pitch of the First and Second
Heart sounds
• The duration of each of the heart sounds is slightly
more than 0.10 second-the first sound about 0.14
second, and the second about 0.11 second. The
reason for the shorter second sound is that the
semilunar valves are more taut than the A-V valves, so
they vibrate for a shorter time than do the A-V valves.
• The second heart sound normally has a higher
frequency than the first heart sound because
– (1) the tautness of the semilunar valves is less
– (2) the greater elastic coefficient of the arterial walls
Brachial artery pressure curve
 Arterial pressure
.
• Systolic blood pressure- peak pressure
during systole in arterial blood
• Diastolic blood pressure- lowest pressure
during diastole in the arterial blood
• Pulse pressure- difference between SBP and
DBP
• Mean arterial pressure-average pressure
= DBP+1/3rd of pulse pressure
 Arterial Pressure Pulsations
• With each beat of the heart a new surge of
blood fills the arteries.
• Blood flow occurs continuously during
systole as well as diastole
• It is because the vessels are elastic, and
forward flow is continuous because of the
recoil during diastole of the vessel walls that
have been stretched during systole.
 Arterial Pressure Pulsations
• If distensibility of the arterial system is
absent , blood would flow through the
peripheral blood vessels only during cardiac
systole, and no flow would occur during
diastole.
• Two major factors affect the pulse pressure:
(1) stroke volume
(2) the compliance (total distensibility) of the
arterial tree
 Arterial Pressure Pulsations
• Greater the stroke volume, the greater the pulse
pressure.
• Conversely, the less the compliance of the arterial
system, the greater the rise in pressure for a given
stroke volume of blood pumped into the arteries
resulting higher pulse pressure
• 1.e the pulse pressure in old age rises to as much
as twice normal, because the arteries have
become hardened with arteriosclerosis and
therefore are relatively noncompliant.
Arterial Pressure Pulsations
 Arterial Pressure Pulsations
• An incisura (dicrotic notch) , a small oscillation on
the falling phase of the pulse wave caused by
vibrations set up when the aortic valve snaps shut ,
• This is caused by a short period of backward flow
of blood immediately before closure of the valve,
followed by sudden cessation of the backflow
• The pulmonary artery pressure curve also has a
dicrotic notch produced by the closure of the
pulmonary valves.
 Arterial pulse
• Blood forced into the aorta during systole not only
moves the blood in the vessels forward but also sets up
a pressure wave that travels along the arteries.
• The pressure wave expands the arterial walls as it
travels, and the expansion is palpable as the pulse.
• The rate at which the wave travels which is independent
of and much higher than the velocity of blood flow
• Consequently, the pulse is felt in the radial artery at the
wrist about 0.1 s at er the peak of systolic ejection into
the aorta
• With advancing age, the arteries become more rigid, and
the pulse wave moves faster.
 Arterial pulse cont’
• The strength of the pulse is determined by the pulse pr
essure and bears little relation to the mean pressure.
• The pulse is weak (“thready”) in shock.
• It is strong when stroke volume is large; for example, d
uring exercise or after the administration of histamine.
• When the pulse pressure is high, the pulse waves may
be large enough to be felt or even heard by the individ
ual (palpitation, “pounding heart”).
• When the aortic valve is incompetent (aortic insufficie
ncy), the pulse is particularly strong, and the force of s
ystolic ejection may be sufficient to make the head no
d with each heartbeat.
 Arterial pulse cont’
• The pulse wave is gradually reduces and almost no
pulsation in capillaries.
 Arterial pulse cont’

The pulse in aortic insufficiency is called a

collapsing, Corrigan, or water-hammer pulse.
 Jugular venous pulse
• Atrial pressure fluctuates during cardiac cycle
• It gives rise to a characteristic pressure waves in
the internal jugular vein
 Jugular venous pulse
The atrial pressure changes are transmitted to the great veins,
producing three characteristic waves in the record of jugular
pressure waves
• 3 waves  a, c, v
• 2 descents  x & y descent.
 Atrial pressure changes and the
Jugular pulse cont’
a wave
• due to atrial systole.
• blood regurgitates into the great veins when the
atria contract. In addition, venous inflow stops,
and the resultant rise in venous pressure
contributes to the a wave.
 Atrial pressure changes and the
Jugular pulse cont’
c wave
• Due to the rise in atrial pressure produced by the
bulging of the tricuspid valve into the atria during
isovolumetric ventricular contraction.
v wave
• Due to the rise in atrial pressure before the
tricuspid valve opens during diastole.
 genesis of X descent

decreased Atrial pressure due to pulling down

of AV valves during right ventricular ejection
– ‘x’ descent in JVP
X
 genesis of “V” Wave

• Filling of Right atrium

• Passive rise in pressure in Right atrium as
venous return to the atrium continues
during ventricular systole while the TV is
closed

V
 Genesis of “Y” Descent
• TV Open
• Blood flows from right atrium to right
ventricle
• Pressure drops in right atrium

Y
 Atrial pressure changes and the
Jugular pulse cont’
• Th e jugular pulse waves are superimposed on the
respiratory fluctuations in venous pressure.
• Venous pressure falls during inspiration as a result
of the increased negative intrathoracic pressure
and rises again during expiration.
 Murmurs
• Murmurs, or bruits, are abnormal sounds heard in
various parts of the vascular system.
• The two terms are used interchangeably, though
“murmur” is more commonly used to denote noise
heard over the heart than over blood vessels.
• The blood flow is laminar, nonturbulent, and silent
• up to a critical velocity; above this velocity (such as
beyond an obstruction), blood flow is turbulent and
creates sounds.
• Blood flow speeds up when an artery or a heart valv
e is narrowed.
 Murmurs & Bruits

- Abnormal sounds
- Due to blood flow above a critical velocity
- Reynolds no. (Re) = ρDV/η >3000
→ Turbulent flow
- May be functional or innocent

1. Large volume of blood passing thru’ a normal ori

fice
2. Normal amount of blood passing thru’ a small or
ifice
 Valvular dysfunction

• Valve not opening fully

– stenotic
• Valve not closing fully
– insufficient/regurgitant/leaky
• Creates vibrational noise
– murmurs
 Murmurs cont’
• Main cause of cardiac murmurs is disease of the he
art valves.
• When the orifice of a valve is narrowed (stenosis), b
lood fl ow through it is accelerated and turbulent.
• When a valve is incompetent, blood flows through i
t backward ( regurgitation or insufficiency ), again t
hrough a narrow orifice that accelerates flow.
Pathological murmurs & bruits
 Arterial obstruction

 Narrowing of a valve – stenosis

 Incompetent valve → regurgitation/ insufficiency

 Abnormal connections between right and left he

art circulations

 PDA – patent ductus arteriosus

 Murmurs cont’
• The timing (systolic or diastolic) of a murmur due t
o any particular valve can be predicted from a know
ledge of the mechanical events of the cardiac cycle.
• Murmurs due to disease of a particular valve can ge
nerally be heard best when the stethoscope is direc
tly over the valve.
 Timing of Murmurs
• Aortic or pulmonary valve
• stenosis – mid (ejection) systolic
• murmur
• incompetence – early diastolic murmur
• Mitral or tricuspid valve
• stenosis – mid diastolic murmur
• incompetence – pan systolic murmur
 Timing of Murmurs
• Ventricular septal defect (VSD) – systolic
due to left to right shunt
• Atrial septal defect (ASD) – mid systolic
due to increased blood flow through a
normal pulmonary artery
• Patent ductus arteriosus(PDA) –
continuous murmur, both in systole and
diastole
 Murmurs cont’
Examples of vascular sounds outside the heart are
1.bruit heard over a large, highly vascular goiter,
2.bruit heard over a carotid artery when its lumen is
narrowed and distorted by atherosclerosis
3. murmurs heard over an aneurysmal dilation of one of
the large arteries, an arteriovenous (A-V) fistula, or a
patent ductus arteriosus.
 Heart murmurs caused by valvular lesions
cont’
• Systolic murmurs are also heard in anemic patients
as a result of the low viscosity of the blood and
associated rapid flow
Heart Murmurs Caused by Valvular Lesi
ons
 References

• Ganong 24e
• Guyton 12e