Heart sounds and murmurs
Dr. Szathmári Miklós
Semmelweis University
First Department of Medicine
15. Oct. 2013.
Conditions for auscultation of the heart
•
•
•
•
Quiet room
Patient comfortable
Chest fully exposed
Examiner on the right side of the patient
Auscultation of the heart
Auscultation of the heart
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular
line)
Auscultation of the heart
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular line)
Auscultation of the heart
TRICUSPID VALVE
to right ventricle:
fourth intercostal space
(lower left sternal border)
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(lateral to left
midclavicular line)
Auscultation of the heart
TRICUSPID VALVE
to right ventricle:
fourth intercostal space
(lower left sternal border)
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular line)
Auscultation of the heart
PULMONARY VALVE:
Second intercostal space
(left upper sternal border)
TRICUSPID VALVE
to right ventricle:
fourth intercostal space
(lower left sternal border)
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular line)
Auscultation of the heart
PULMONARY VALVE
Second intercostal space
(left upper sternal border)
TRICUSPID VALVE
to right ventricle:
fourth intercostal space
(lower left sternal border)
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular line)
Auscultation of the heart
AORTIC VALVE (to aorta):
second intercostal space
(right upper sternal border)
- outflow
TRICUSPID VALVE
to right ventricle:
fourth intercostal space
(lower left sternal border)
PULMONARY VALVE
Second intercostal space
(left upper sternal border)
APEX –
MITRAL VALVE
to left ventricle
fifth intercostal space
(left midclavicular line)
The sounds ↔ The murmurs
are generated by the
beating heart, the valve
movements, and the
flow of blood through
the heart.
~ called a heartbeat.
are generated by
turbulent flow of blood,
which may occur inside
or outside the heart.
The sounds ↔ The murmurs
• Brief
• Discrete
• Characterized by
– Intensity (loudness)
– Frequency (pitch)
– Quality (timbre)
• Prolonged
• Characterized by
–
–
–
–
–
–
Intensity (loudness)
Frequency (pitch)
Configuration (shape)
Timing
Duration
Direction of radiation
Normal heart sounds
First heart sound
(S1)
Lub
Closure of the mitral
and tricuspidal valves
Start of the systole
Second heard sound
(S2)
Dub
Closure of semilunar
valves
Start of the diastole
Identification of heart sounds
The systolic sound (S1) longer, deeper and softer,
than S2 (beat-like, dobbanás-szerű). The
diastolic sound (S2) is shorter, higher, and sharp
(clicking-like, koppanás-szerű)
• The diastolic interval (S2 – S1) is longer, than
the systolic (S1-S2)
• The carotid artery pulse or apical impulse occur
in early systole, right after the first heart sound
• S1 is usually louder than S2 at the apex, and S2
is usually louder than S1 at the base.
Factors affecting the intensity of S1
Loud S1
Soft S1
• Short PR interval
• Tachycardia/hyperkinetic
state
• Mitral stenosis
• „Stiff” left ventricle
• Holosystolic mitral valve
prolapse
• Long PR interval
• Depressed LV
contractility
• Premature closure of
mitral valve (ac. AR)
• LBBB
• Extracardiac factors
Components of S2 (dub)
(1) closure of the aortic valve: The aortic
component (A2) is louder. It is heard
throughout of the precordium.
(2) closure of the pulmonary valve: The
pulmonic component (P2) is softer. It is heard
best in the 2nd and 3rd interspaces close to
the sternum. In this location you should search
for splitting of the second heart sound.
Splitting of the second heart sound
• Non-fixed
• Fixed
Lub-Drub
Splitting of the second heart sound
Non-fixed
Inspiration
negative intrathoracic pressure
increased blood return into the right side of the heart
the pulmonary valve stays open longer during ventricular systole
increased delay in the P2 component of S2 relative to the A2
•
•
physiological in younger people
During expiration, the interval between the two components normally
shortens and the S2 sounds becomes merged.
Splitting of the second heart sound
Fixed
Atrial (ASD) or ventricular septal defect (VSD)
left to right shunt
increases the blood flow to the right side of the heart
(independent of inspiration/expiration)
the pulmonary valve stays open longer during ventricular systole
Third heart sound S3
• = protodiastolic
(early diastolic) sound
• not of valvular origin
• occurs at the beginning/middle of diastole
• occurs when the left ventricle is not very compliant, and
at the beginning of diastole the rush of blood into the left
ventricle causes vibration of the valve leaflets and the
chordae tendinae.
• It is heard best at the apex in the left lateral
position. It is louder on inspiration. Dull, low –
pitched.
Third heart sound S3
• normal in children and young adults, but disappears
before middle age.
• abnormal re-emergence of this sound late in life
indicates a pathological state:
– failing left ventricle as in dilated congestive heart
failure (CHF).
– This sound is called a protodiastolic or
ventricular gallop, a type of gallop rhythm
• lub-dub-T (Kentucky; S1-S2-S3)
Fourth heart sound S4
•
•
•
•
rare
sometimes audible in healthy children
in adult is called a presystolic (atrial) gallop.
corresponds to ventricular filling caused by atrial
contraction ("atrial kick")
• a sign of a pathologic state: LVH, AS, HT
• the sound of blood being forced into a
stiff/hypertrophic left ventricle.
• dub-de-lub (Tennessee; S2-S4-S1)
dub-de-lub
Tennessee
Extra heart sounds – the „clicks”
Systolic sounds
Diastolic sounds
Early
Mid/late
Early
Mid/late
Ejection clicks:
aortic
pulmonary
Mitral
valve
prolapse
Opening
snap
S3 and S4
High in pitch,
have a sharp,
clicking quality
A/P stenosis
Hypertension
Abnormal systolic
ballooning of part
of the mitral valve
into the left atrium
Mitral valve
stenosis
Sounds - summary
• S1 – closure of AV valves
• S2 – closure of semilunar valves
– Splitting (fixed-pathological, non-fixed-normal)
• S3 – rapid filling phase of ventricle
– Ventricular gallop - HF
• S4 – ventricular filling during atrial contraction
– Atrial gallop – LVH, AS, HT, CHD
• Extra sounds – clicks
– systolic: AS/PS/MVP
– Diastolic: OS
Murmurs
Loud murmurs essentially always reflect a problem
BUT
Most heart problems do not produce any murmur!
Gradations of murmurs
Grade
Grade 1
Grade 2
Grade 3
Grade 4
Grade 5
Grade 6
Description
Very faint, heard only after listener has "tuned
in"; may not be heard in all positions.
Quiet, but heard immediately after placing the
stethoscope on the chest.
Moderately loud.
Loud, with palpable thrill.
Very loud, with thrill. May be heard when
stethoscope is partly off the chest.
Very loud, with thrill. May be heard with
stethoscope entirely off the chest.
Shapes of the murmurs
• CRESCENDO
• DECRESCENDO
• CRESCENDODECRESCENDO
– diamond
• PLATEAU (EVEN)
Murmurs
„Physiologic”
Innocent
• Turbulent blood flow in
children & young adults
• Midsystolic
• Lower left sternal border
• Grade 1 to 2, medium
pitch, usually decreases or
disappears on sitting
• Anaemia, fever,
pregnancy, hyperthyroidism
• Midsystolic
• Aortic area
Pathologic
Pathologic murmurs
Systolic
Aortic stenosis
Mitral regurgitation
Diastolic
Aortic regurgitation
Mitral stenosis
Systolo-diastolic (continuous)
Pericardial friction rub
Patent ductus arteriosus
Interventions that influence the intensity
of heart murmurs and sounds
Respiration (inspiration) Right-sided murmurs increase
Valsalva manoeuvre
Most murmurs decrease in length and
intensity. Exceptions: systolic murmur of
HCM and mitral valve prolapse
Exercise
Most murmurs become louder (PS, MS,
AR, MR, VSD). Exception: systolic murmur
of HCM decreases with near max.
handgrip exercise.
Positional changes
With standing
Most murmurs diminish, exceptions: HCM
and MVP
Left lateral position
Left-sided S3 and S4 and mitral murmurs
are accentuated
Sitting and leaning
forward
Accentuate of murmurs of aortic stenosis
and aortic regurgitation
Pericardial friction rub
• It is a characteristic scratching, creaking, highpitched sound coming from the rubbing of both
layers of inflamed pericardium.
• It is the loudest in systole, but can often be heard
also at the beginning and at the end of diastole.
• It is very dependent on body position and
breathing, and changes from hour to hour.