SYSTOLIC & DIASTOLIC SOUNDS

VISRUTH M KUMAR

SYSTOLIC SOUNDS
EJECTION SOUND/ EJECTION CLICK:
Opening of stenosed semilunar valves(AS,PS), aortic prosthesis, dilatation of aorta/pul. artery, PAH/sys. HTN Closely foll. S1, sharp, high-pitched, early systole Aortic EC: aortic area, conducted all over precordium, no change with resp. Pulmonic EC: pulmonary area only, increases with expiration

 NON-EJECTION CLICK/ MID-SYSTOLIC CLICK:

MVP, TVP, aneurysm of IA/IV septum, Ebstein s anomaly, severe AR MVP: @LLSB & apex later than ejection sound

DIASTOLIC SOUNDS
OPENING SNAP:
AV valve stenosis(MS/TS), mitral prosthesis , MR/TR, ASD/VSD, PDA

Brief, high-pitch, early diastole After A2, A2-OS interval ~0.04 to 0.12s MS: b/w LLSB & apex, radiate to base, all over precordium standing position due to elevated left atrial pressure A2-OS interval inversely relatd to mean LAP

 Soft/Absent OS in MS:
mild & severe(extreme clockwise rotation of heart) MS calcific MS congenital MS MS with AS/AR

A2-OS: mid-precordium long interval(30-150ms) wider on standing narrows on inspiration A2-P2: pulmonary area short interval(<30ms) narrows on standing widens on inspiration

 TUMOR PLOP:
Left/right atrial myxoma ~ timing of OS Low-pitched

HEART MURMURS
VISRUTH M KUMAR

What is a heart murmur?

Audible vibration produced by turbulent flow of blood from a narrow to a wide channel through large blood vessels or valves during the cardiac cycle Heard best over point where channel widens or beyond narrowing in the direction in which blood is flowing

 Exercise or severe anemia (increases blood flow) may cause murmurs to appear Polycythaemia (thickening of blood) may cause murmur to disappear Pathological heart murmur is one associated with a structural or functional abnormality of the heart

Describing a heart murmur

1. Timing murmurs are longer than heart sounds can distinguished by simultaneous palpation of the carotid pulse systolic, diastolic, continuous 2. Shape/Configuration crescendo, decrescendo, crescendo-decrescendo, plateau 3. Location of maximum intensity determined by the site where the murmur originates e.g. A, P, T, M areas

Describing a heart murmur

4. Radiation reflects the intensity of the murmur and the direction of blood flow 5. Intensity graded on a 6 point scale Grade 1 = very faint Grade 2 = quiet but heard immediately Grade 3 = moderately loud Grade 4 = loud with thrill Grade 5 = heard with stethoscope partly off the chest with thrill Grade 6 = audible without stethoscope with thrill * Thrill is always pathological

Describing a heart murmur

6. Pitch High (MR, TR, AR) --- BEST HEARD BY DIAPHRAGM Low (TS, MS) --- BEST HEARD BY BELL 7. Quality Blowing(MR, AR), harsh(AS, PS, VSD) & , rumbling, and musical 8. Others: i. Variation with respiration Left heart murmurs(AR, MR) are accentuated in expiration Right heart murmur(PR, TR, TS) in inspiration ii. Variation with position of the patient iii. Variation with special maneuvers
Valsalva/Standing => Murmurs decrease in length and intensity EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse

Heart Valves
May be narrowed (stenosed) May be enlarged / incompetent (leaky) Stenotic murmur occurs when a valve is meant to be fully open and is not Regurgitant murmur occurs when a valve is meant to be closed and is not

SYSTOLIC MURMURS
HOLOSYSTOLIC (PANSYSTOLIC):
MR,TR,VSD Begin with S1 upto S2 Plateau Flow b/w 2chambers having widely diff. pressures throughout systole (LV & LA/RV) MR: loudest @apex; radiate to LSB & base :posterior leaflet Axilla & back :anterior leaflet

 TR: loudest @LLSB; not radiate VSD: loudest @LLSB TR+PAH PSM increases during inspiration

 MID SYSTOLIC (EJECTION SYSTOLIC):

AS,PS,ASD Shortly after S1, ends before S2 Blood ejected across aortic/pulmonary outflow tracts Crescendo-decrescendo (N) SL valves high output states, ejection to dilated vessel beyond valve

PS: 2nd LICS; radiate to left chest & back AS: 2nd RICS; radiate to carotid ASD: @ULSB Gallavardin phenomenon: AS murmur absent over sternum, reappear @apex(mistaken as MR) Hypertrophic Cardiomyopathy: @LLSB & apex; no carotid radiation Calcified AS A2 soft; length & config. difficult to determine

 EARLY SYSTOLIC:
Begins with S1, ends in mid-systole Decrescendo Heard: Large VSD + PAH Muscular VSD TR in absence of PAH a/c MR with non-compliant LA

 LATE SYSTOLIC: Papillary muscle dysfunction (infarction/ischemia or LV dilatation; common in MI) MVP @apex; high-pitched; moderate loud

DIASTOLIC MURMURS
EARLY DIASTOLIC:
AR, PR
With or shortly after S2 Ventricular pressr. falls below aortic/pul Decrescendo, high-pitched AR: faint, @left sternal edge; sits leaning forward, breath in expiration Radiation to left SB(VALVULAR PATHOLOGY), to right sternal edge(AORTIC ROOT PATHOLOGY) PR: @RUSB, on inspiration

 MID DIASTOLIC:
MS, TS Early ventricular filling Loud(III/IV)-slight AV valve stenosis Soft/absent-severe stenosis [CO reduced] Prolonged MDM index of severity MS: @apex, left side supine, increase on mild exercise; low-pitched; follow OS, no radiation TS: @LLSB; inspiration

 MDM flow murmur in Large L-R shunts(VSD,ASD) severe MR/TR, PDA Austin-Flint murmur: MDM/pre-systolic in c/c severe AR appears to originate @ ant. MV leaflet(due to its displacement), when blood enters LV simultnsly from aorta & LA

 PRE SYSTOLIC: MS, TS Ventricular filling foll. atrial contraction Crescendo, peak at time of loud S1 Atrial myxoma: MDM/pre systolic

CONTINOUS MURMUR
Begins with S1, peak near S2, continue into all/part of diastole

Heard:
PDA [if PAH present, diastolic portion absent] SCA-pul. art anastomosis Systemic, pulmonary(only systolic) & coronary fistula Commun. b/w sinus of Valsalva & right heart Anomalous origin of Lt. coronary art from pul. Artery COA heard @ back Surgical

 Innocent murmur mammary souffl Innocent cervical venous hum: @rt. SCF medially, @diastole, absent on same-side IJV compression In pericardial friction rub

FLOW MURMURS
ASD: ESM @ pul area PAH: Graham Steell murmur(functional PR)-EDM AR: ESM @ aortic area(functional AS) a/c severe AR: MDM @ apex