J.B. Handler, M.D.
Physician Assistant Program
University of New England
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A- aortic
P- pulmonic
T- tricuspid
M- mitral
AV- atrioventricular
SL- semi-lunar
SB- sternal border
ASD- atrial septal defect
AR- aortic regurgitation
AS- aortic stenosis
TR- tricuspid regurgitation
PVR- peripheral vascular resistance
IO- interest only
CHD- coronary heart disease
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MR- mitral regurgitation
MS- mitral stenosis
SEM- systolic ejection murmur
MVP- mitral valve prolapse
LBBB- left bundle branch block
ICS- intercostal space
RV- right ventricle
LV- left ventricle
LA- left atrium
RA- right atrium
PS- pulmonic stenosis
PR- pulmonic regurgitation
LLD-left lateral decubitus
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Aortic: “base”- 2 nd Rt ICS, SB
Pulmonic: “base”- 2 nd Lt ICS, SB
3rd Lt ICS, SB
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Tricuspid: lower Lt sternal border(4-5ICS)
Mitral: cardiac apex (LV) 5ICS, MCL
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Sitting, lying, left lateral decubitus (s3,4 gallops, and mitral stenosis)
Internet sites for heart sounds: http://www.cardiologysite.com
http://www.blaufuss.org/
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S
1
S
2
- mitral/tricuspid valve closure.
- aortic/pulmonic valve closure.
Distinguishing S vs S
-Listen at apex, palpate carotid-S carotid pulse.
1 2
1 precedes
-Intensity of S
1
-S
1
>S
2 at apex (reverse at base).
immediately precedes the PMI.
S
1 occasionally splits with inspiration
(.02-.03 seconds)…difficult to hear  MV closes before TV, accentuated with inspiration.
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IO
2
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Commonly heard in inspiration
(separation of A
A
2
2 and P normally precedes P
2
2 is .02-06 Sec).
- accentuated in inspiration because RV volume increases,
LV volume decreases………..why?
Fixed splitting: ASD.
Paradoxical splitting: Aortic valve closure is delayed, closes after pulmonic.
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P
2 precedes A
2 .
During inspiration they move together, in expiration they move apart.
Examples: Aortic Stenosis, LBBB.
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nd

rd
3
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3 rd heart sound: Low pitched sound, .1-.2 sec post S
2
. May be heard in young, healthy
people. Reflects rapid inflow of blood into normal, compliant LV.
S
3
gallop: abnormal “dull thud” in mid diastole.
LV dysfunction and dilation often present (CHF).
Also heard with MR, AR with volume overload.
Pathophys: 1. Sudden deceleration of blood flow into diseased, dilated & non compliant ventricle.
2. AR/MR- volume overload with rapid inflow of increased blood volume into compliant LV.
Best heard: bell at apex in LLD position.
Timing: lub….du..dub
S
1
S
2
S
3
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4
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Almost always abnormal
Short, low frequency, precedes S
1
“presystolic gallop”.
Pathophys: Atrial contraction into noncompliant ventricle.
Conditions: LVH (HTN, AS), CHD
(ischemia or infarction).
Best heard: bell at apex in LLD position.
Timing: bu.lub….dub
S4 S1 S2
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Grade I- Very faint; barely audible. Often heard only by experienced clinicians.
Grade II- soft, but audible
Grade III- moderately loud
Grade IV- loud with associated thrill
Grade V- very loud + thrill; audible with diaphragm on end.
Grade VI- very loud + thrill; audible with stethoscope off chest.
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Depends on direction of blood flow responsible for the murmur, duration of and intensity of the murmur.
Aortic outflow murmurs (AS) radiate from the cardiac base/aortic area to base of neck or carotids.
Most MR murmurs radiate to axilla.
AR murmurs radiate down LSB
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Intensity: see grading scale
Quality: Blowing, harsh, grating, rumble.
Pitch: High vs low pitched
Timing: Early/mid/late systolic vs. holosystolic. Early/mid diastolic.
Configuration: Crescendo-decrescendo, decrescendo, plateau, others.
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Respiration: Inspiration  RV filling/volume. Murmurs arising from Rt side of heart (PS, PR, TR) get louder during inspiration and reverse in expiration.
Valsalva: Net effect is  venous return to
RV;  RV followed by  LV volume.
Squatting:  venous return to heart;
 PVR and BP. Net effect:  LV and RV volumes.
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Rapid upright posture after squatting:
 venous return to RV,  PVR. Net effect:  RV and  LV volumes.
Isometric exercise (handgrip):  PVR and
BP,  CO/HR. Net effect- makes murmurs of MR and AR louder. Avoid in patients with myocardial ischemia and ventricular arrhythmias.
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Outflow murmurs across aortic and pulmonic valves (includes AS, PS and innocent murmurs) get louder with maneuvers that  LV/RV volume and softer with  LV/RV volume.
Insufficiency Murmurs: AR, MR, TR act similarly to above.
Exceptions: Murmur of MV prolapse and hypertrophic cardiomyopathy get louder with maneuvers that  LV volume and softer with reverse physiology.
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Innocent or functional murmurs: arise from pulmonic or aortic outflow tracts in the presence of normal pulmonic/aortic valves. Common in
young, healthy individuals. Usually Grade I or II, get louder with squatting and very soft or absent with standing/valsalva. Mid-systolic, short.
Aortic stenosis: harsh, often loud, best heard base/aortic area, C/D (crescendo/decrescendo), radiate to neck/carotids. Length of murmur correlates with severity of obstruction. Best heard with diaphragm.
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Mitral regurgitation: high pitched, blowing, best heard at apex, holosystolic (if not acute), radiates to axilla. Best heard with diaphragm.
MV prolapse with MR: high pitched, blowing, best heard at apex, mid to late systolic and often preceded by valve click. Characteristic changes with maneuvers (see above). Best heard with diaphragm.
Pulmonic stenosis (congenital defect): harsh, best heard at base/pulmonic area, C/D radiates down LSB. Louder in inspiration.
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Aortic regurgitation/insufficiency: high pitched, blowing, best heard along
LSB, 2 nd /3 rd ICS, decreshendo, begins with S
2
, radiates down LSB. Best heard with diaphragm.
Mitral stenosis: low pitched, rumbling, best heard at apex, mid diastolic. Best heard with bell- easily missed with diaphragm.
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