CARDIAC
AUSCULTATION
J A Y
L .
R U B E N S T O N E ,
D . O . ,
F . A . C . C .
O C T O B E R
2 0 1 2
TECHNIQUES OF EXAMINATION
• Order of Exam
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Aortic Area
Pulmonic Area
Tricuspid Area
Mitral Area
PROCESS OF AUSCULTATION
At each auscultatory area:
1.
Concentrate on 1st Heart Sound
• note Intensity and Splitting
2.
Concentrate on 2nd Heart Sound
• note Intensity and Splitting
3.
Listen for Extra Sounds in Systole
• note Timing, Intensity, Pitch
PROCESS OF ASCULTATION
4.
Listen for Extra Sounds in Diastole
• note timing, intensity, pitch
5.
6.
7.
Listen for Systolic Murmurs*
Listen for Diastolic Murmurs*
Other Heart Sounds
PROCESS OF ASCULTATION
*If Systolic or Diastolic Murmur Present, Note:
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Location
Radiation
Intensity
Pitch
Quality
AUSCULTATION
TIMING
• Systolic
• Early
• Mid
• Late
• Diastolic
• Early
• Mid
• Late (or Presystolic)
AUSCULTATION
LOCATION
• Interspace
• Centimeters from
• Midsternal
• Midclavicular
• Or Axillary Lines
AUSCULTATION
INTENSITY
• Grade 1
• Grade 2
• Grade 3
with
• Grade 4
• Grade 5
• Grade 6
Very Faint
Quiet, but Heard Immediately
Moderately Loud, Not Associated
a Thrill
Loud, May Be Associated with a
Thrill
Very Loud
May be Heard w/stethoscope
off chest
AUSCULTATION
• Radiation or Transmission
• Pitch
• High, Med, Low
• Quality
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Blowing
Rumbling
Harsh
Muscial
COMPONENTS OF S1
• Mitral Valve Closure
• Best Heard: Apex
• Tricuspid Valve Closure
• Best heard: Lower Left Sternal Boarder
S1
• Wide Splitting
• RBBB
• PVC from Left Ventricle
• Single Sound
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Normal
LBBB
PVC from Right Ventricle
Paced Beats
S1
• Increased Intensity
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Short PR
Rapid HR
Atrial Fibrillation
Mitral Stenosis
S1
• Decreased Intensity
• Mitral Stenosis (Immobile Leaflets)
• Opposite of Causes of Increased Intensity
S2
• Two Components
• Aortic Closure A2
• Pulmonic Closure P2
Best Heard at the Base
S2
• Normal Splitting
• Best Heard At 2nd Left Intercostal Space
• During Inspiration there is Delayed Pulmonic Valve Closure
• Due to Increased Capacitance of Pulmonary Bed
S2
• Loss of Splitting
• Inaudible P2• Adults with Increased Chest Diameter
• Congenital (Tetralogy, Pulmonary Atresia Transposition)
• Increased Pulmonary Valve Resistance-Pulmonary HTN
• Eisenmenger’s Complex-Equal Pulmonary & Systemic Resistances
S2
• Persistent Splitting
• RBBB
• Pure MR
• Healthy Adolescents when in Supine Position
• Fixed Splitting
• Atrial Septal Defect- Due to Delayed Closure of Pulmonic Valve from
Increased Right-Sided Flow
S2
• Paradoxical Splitting- P2 before A2
• LBBB
• Paced Beats
• Increased Intensity
• A2
Systemic HTN
Dilated Aortic Root
• P2
Pulmonary HTN
Dilated Pulmonary Trunk
EARLY SYSTOLIC SOUNDS
• Ejection Sound- Usually High Frequency
• Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve
• Pulmonary Valve-Pulmonic Stenosis Vary with Respirations
• Prosthetic Valves- Mechanical, Not Bioprosthetic
MID-LATE SYSTOLIC SOUNDS
• Click
• High Frequency Sound Found in Mitral Valve Prolapse
• Occurs Earlier with Valsalva Maneuver or Squatting to Standing
EARLY DIASTOLIC SOUNDS
• Opening Snap of Mitral Stenosis (MS)
• High Frequency-Left Lateral Decubitus Position, Apex
• Occurs after S2, before S3
• MS More Severe with Short A2-OS Interval
• Precordial Knock
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Chronic Constrictive Pericarditis
Mitral Regurgitation
Atrial Myxoma
Older Model Prosthetic Mitral Valve
MID DIASTOLIC SOUNDS
• S3
• Occurs During Rapid Filling of Left
related to LV Volume
• Low Frequency Best Heard
Ventricle (LV)
• At the Apex w/Bell
• Pt in Left Lateral Decubitus Position
• Can Be Normal to Age 40???
• Can be Pathognomonic for Congestive Heart Failure
LATE DIASTOLIC SOUNDS
• S4
• During Atrial Phase of LV Filling
• Consequence of Ventricular Stiffness
• Absent in Atrial Fibrillation or Ventricular Pacing
• Low Frequency Sound Best Heart
• At the Apex
• Pt in Left Lateral Decubitus Position
• HTN, Aortic Stenosis, Ischemic Heart Disease
DIASTOLIC SOUNDS
• Right Sided S3, S4
• Left Lower Sternal Boarder
• Intensity Varies with Respiration due to Right Heart Filling
(Carvallo’s Sign)
• Summation Gallop
• Occurrence of an Over Lapping S3 and S4 due to Tachycardia
SYSTOLIC MURMURS
• Acute Mitral Regurgitation (MR) or Tricuspid
Regurgitation (TR)
• Mid Frequency
• Not Classic Murmur
• Ventricular-Septal Defect (VSD)
• High Frequency (diaphram)
• Atrial-Septal Defect (ASD)
• Pulmonary Outflow
• Not Defect Murmur
SYSTOLIC MURMURS
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Obstruction to Ventricular Outflow
Dilatation of Aortic Root or Pulmonary Trunk
Accelerated Flow into Aorta or Pulmonary Trunk
Innocent Murmurs
Some Forms of MR (Papillary Muscle Dysfunction)
SYSTOLIC MURMURS
• Aortic Valve Stenosis
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Diamond Shaped, Crescendo-Decrescendo
Begins After S1 or with Aortic Ejection Sound
Ends Before S2
2nd Right Intercostal Space, Apex, can radiate to Neck
High Frequency, Harsh
Can be Musical in Quality at the Apex
SYSTOLIC MURMURS
• Pulmonic Stenosis
• Similar to AS Except Relationship to P2
• 2nd Left Intercostal Space
NORMAL SYSTOLIC MURMURS
• Still’s Murmur
• Medium Frequency, Vibratory, Originating from Leaflets of Pulmonic
Valve
• Rapid Ejection into Aortic Root or Pulmonary Trunk
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Pregnancy
Anemia
Fever
Thyrotoxicosis
NORMAL SYSTOLIC MURMURS
• Aortic Sclerosis
• Most Common Innocent Murmur
SYSTOLIC MURMURS
• Mitral Valve Prolapse
• High Frequency, Sometimes Honking, Crescendo Murmur
• Usually Extends to S2
• Classic Mid-Late Systolic Click
• Occurs Earlier with Valsalva & Squatting to Standing
SYSTOLIC MURMURS
• Holosystolic
• Begins with S1, Ends at S2
• MRRadiates to Left Sternal Boarder, Base or Neck, More
Commonly Apex to Axilla
• TRCarvallo’s Sign (Inspiratory Variation)
• VSD-Across Precordium
• Patent Ductus Arteriosis (PDA)- Aorto-Pulmonary Connection
EARLY DIASTOLIC MURMUR
Aortic Regurgitation
• High Pitched, Decrescendo Murmur
• Best heard at
• Left Sternal Boarder with the diaphram w/Patient
Leaning Forward at End Expiration
• Acute, Severe AR Murmur
• Can be Short, Soft and Med Pitched
• Chronic, Sever AR• Murmur Usually Long, Loud, Blowing Decrescendo, High Frequency
EARLY DIASTOLIC MURMUR
• Graham Steell –
• Murmur of Pulmonic Regurgitation as a Result of Pulmonary HTN
• High Freq, Decrescendo Blowing Murmur Heard throughout Diastole
MID DIASTOLIC MURMUR
• Mitral Stenosis (MS)
• Follows Opening Snap
• Low Pitch Rumble
• Best Heard
• Apex over LV
• Using Bell of Stethoscope
• Pt in Left Lateral Decubitus Position
MID DIASTOLIC MURMURS
• Tricuspid Stenosis
• Similar to MS, except increases with Respiration (Carvallo’s Sign)
• Best Heard at Left Lower Sternal Edge
MID DIASTOLIC MURMURS
• Pulmonic Regurgitation
• Crescendo-Decrescendo Murmur when Primary Valvular
Abnormality and Not Associated with Pumonary HTN
DIASTOLIC MURMURS
• Late or Presystolic
• Follows Atrial Systole
• Implies Sinus Rhythm
• Can be present in MS or Complete Heart Block
• Austin Flint Murmur of Aortic Regurgitation
• Bubbling Quality, Short
• Consequence of Aortic Regurgitation impinging on Mitral Valve
DIASTOLIC MURMURS
• Continuous
• PDA (AortoPulmonary Connection)
• Rough Thrill
• A-V Fistulas
• Hemodialysis Shunt
• Aortic Valve Sinus to Right Ventricular Fistula
• Coronary Artery Fistulas
DIASTOLIC MURMURS
• Venous Hum
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Rough in quality not actually a hum
Hepatic
Internal Jugular
During Anemia, Fever, Pregnancy and Thyrotoxicosis
PERICARDIAL FRICTION RUB
• Three Phases
• Mid Systolic, Mid Diastolic, Pre Systolic
• Scratchy, Leathery
• Best Heard
• With Diaphragm of Stethoscope
• Left Sternal Boarder Leaning over at End Expiration
• Apposition of Abnormal Visceral and Parietal
Pericardium
• Confused with Hamman’s Sign in Post Open Heart
Surgery (Crunch Sound from Mediastinal Air)
INNOCENT OR NORMAL MURMURSSYSTOLIC
• Vibratory Systolic Murmur (Still’s Murmur)
• Pulmonic Systolic Murmur (Pulmonary Trunk)*
• Mammary Soufflé*
• Peripheral Pulmonic Systolic Murmur (Pulmonary
Branches)
• Supraclavicular or Brachiocephalic Systolic
Murmur
• Aortic Systolic Murmur
*common in pregnancy
INNOCENT OR NORMAL MURMURSCONTINUOUS
• Venous Hum
• Continuous Mammary Soufflé
CONCLUSIONS
• Consistent Approach to Auscultation
• Knowing What to Look For
• Follow Through on H&P
• Confirm or Eliminate Suspicions
• Knowing How to Find It
• Proper Utilization of Stethoscope
• Location and Quality of Heart Sounds & Murmurs