Heart sounds and murmurs

Dr Jain T Kallarakkal
MD, DM, FRCP

 Sounds produced by the heart during a cardiac
cycle
 Easily detected with a stethoscope or
phonocardiograph

 First heart sound - S1
 Second heart sound - S2
 Third heart sound - S3
 Fourth heart sound - S4

 S1: signals the onset of ventricular contraction
whish occurs 50-60 msec after the initiation of
ventricular systole frequency ranging from
100-120 Hz.
 Best heard at apex and lower left sternal
border
 Has mitral (M1) and tricuspid (T1)
components

 Small low frequency muscular vibrations
 Large high frequency vibrations of mitral
valve closure (M1)
 High frequency tricuspid valve closure (T1)
which occurs 20-30 msec after M1
 Small low frequency vibrations of accelerated
blood flow into great vessels

 Luisada: Sound produced by prominent
tensing of left ventricular walls, septum and
mitral valve apparatus
 Leatham: Sudden tensing of closed mitral
valve apparatus leading sudden deceleration of
blood setting the surrounding cardiac
structures into vibration

 Loud
 Soft
 Variable intensity

 Tachycardia or Hyper dynamic states
 Mitral / tricuspid stenosis
 Short PR interval
 Atrial myxoma
 Left to right shunts: Atrial septal defect, Ventricular septal defect,
Patent ductus arteriosus
 Ebstein’s anomaly
 Hypertension
 Thin chest wall

 Low cardiac output states
 Long PR interval
 Severe mitral / tricuspid regurgitation
 Calcified mitral stenosis
 Flail mitral leaflets
 Significant aortic stenosis
 Left bundle branch block

 Atrial fibrillation
 Extrasystoles
 Complete heart block
 Mobitz type I heart block
 Pulsus paradoxus

 Right bundle branch block
 Ventricular premature ectopic from left ventricle
 Left ventricular pacing
 Ideoventricular rhythm from left ventricle
 Wolss Parkinson White syndrome
 Tricuspid stenosis
 Ebstein’s anomaly

 Paced beats
 Ventricular premature ectopic from right
ventricle

 Left atrial myxoma
 Mitral stenosis
 Right ventricular pacing

 S2: Sudden deceleration of retrograde blood
flow in the aorta and pulmonary artery which
sets the cardiohemic system into vibration
 Best heard at the base
 Louder and high pitched than S1 (120-150Hz)
 Has aortic (A2) and pulmonary (P2)
components

 Hang out interval: Though the right and left
ventricular systoles are equal in duration, the
pulmonary artery incisura is delayed in
relation to the aortic incisura, primarily due to
a larger interval separating the pulmonary
artery incisura from the right ventricular
pressure compared with the same left sided
event. This internal is termed as hang out
interval

 Occurs because left ventricular contraction
slightly precedes that of right ventricular
contraction
 Hence aortic valve closes before pulmonary valve
 Increases at end inspiration because of increased
filling of right ventricle which further delays
pulmonary valve closure
 Disappears on expiration

 Loud A2: Systemic hypertension, Coarctation
of aorta, Ascending aortic aneurysm,
Tetrology of Fallot, Transposition of great
arteries
 Loud P2: Pulmonary artery hypertension,
Pulmonary artery dilatation

 Low cardiac output
 Aortic regurgitation
 Calcific aortic stenosis

 Right bundle branch block
 Pulmonary stenosis
 Pulmonary hypertension
 Ventricular septal defect
 Acute mitral regurgitation
Wide fixed split : Atrial septal defect

 Severe aortic stenosis
 Hypertrophic cardiomyopathy
 Ventricular pacing
 Chronic aortic regurgitation

 VSD: Single loud S2
 PDA: Close split S2
 ASD: Narrow fixed split S2

 Low pitched early diastolic sound
 Best heard at apex with bell
 Coincides with rapid ventricular filling (Lub-
Dub-Dum)
 0.12-0.18 seconds after S2
 Usually pathological in elderly

 Physiological: Children, Athletes, Pregnancy,
Fever
 Pathological: Left ventricular failure, Severe
mitral / tricuspid regurgitation, Severe aortic
regurgitation, Large left to right shunts

 Soft and low pitched
 Pre systolic or atrial gallop
 Best heard at apex with bell
 0.11 seconds prior to S1
 Caused by atrial kick into a non compliant
ventricle

 Always pathological
 LVH (Hypertension, Aortic stenosis,
Hypertrophic obstructive cardiomyopathy)
 Coronary artery disease
 Cannot occur in atrial fibrillation

 Three or four sounds resembling the center of
a horse
 S3 gallop
 S4 gallop
 Summation gallop

 Scratchy leathery high pitched sound
 Best heard at end inspiration leaning over
 Three phases: mid systolic, mid diastolic and
pre systolic
 Confusing with Hamman’s sign

 Viral pericarditis
 Pyogenic pericarditis
 Tuberculous pericarditis
 Dressler’s syndrome
 Acute rheumatic fever
 Systemic lupus erythematosus / Rheumatoid arthritis
 Uremia

 Ball valves: Opening sound louder than
closing sound
 Tilting disc valves: Only closure sound heard
 Bileaflet valves: Closure sound well heard

 Usually high frequency
 Ejection sound
 Seen with bicuspid aortic valve, pulmonic
stenosis and mechanical prosthetic valves

 High frequency
 Click
 Seen with mitral valve prolapse
 Occurs earlier with Valsalva maneuver or
squatting

 Opening snap: seen with mitral stenosis.
Occurs when movement of anterior mitral
leaflet suddenly stops at point when LV
pressure drops below left atrial pressure
 Pericardial knock: seen with chronic
constrictive pericarditis

 Mitral stenosis
 Tricuspid stenosis
 Severe mitral regurgitation
 Atrial septal defect
 Large ventricular septal defect
 Tetrology of Fallot

 Abnormal or ectopic heart sound
 Produced by turbulent flow across an
abnormal valve, septal defect or outflow
obstruction
 Also occur when stroke volume is increased

 Where best heard
 Systolic or diastolic
 Timing and character
 Intensity
 Pitch
 Best heard with bell or diaphragm
 Conducted or not
 Variation with respiration
 Variation with posture
 Dynamic auscultation

 I – Very soft
 II – Soft
 III – Loud
 IV – Loud with thrill
 V – Very loud with thrill
 VI – Very loud even heard when stethoscope is
slightly away from chest wall

 Occur during whole or part of systole
 Early systolic murmurs: Small ventricular septal defect, Acute
severe mitral regurgitation, Acute severe tricuspid regurgitation
 Ejection systolic murmurs: Atrial septal defect, aortic stenosis,
pulmonary stenosis, severe aortic regurgitation, Hypertrophic
obstructive cardiomyopathy
 Late systolic murmurs: Mital valve prolapse, Tricuspid valve
prolapse, Papillary muscle dysfunction
 Pan systolic murmurs: mitral regurgitation, tricuspid regurgitation,
Ventricular septal defect

 I – Very soft
 II – Soft
 III – Loud
 IV – Loud with thrill

 Early diastolic murmurs: Aortic regurgitation,
Pulmonary regurgitation
 Mid diastolic murmurs: Mitral stenosis,
Tricuspid stenosis
 Late diastolic murmurs: Mitral stenosis,
Tricuspid stenosis, Atrial myxoma

 Patent ductus arteriosus
 Aorto pulmonary window
 Tricuspid / pulmonary atresia
 Anomalous left coronary artery from
pulmonary artery
 Pericardial friction rub
 Mammary soufflé
 Rupture of sinus of Valsalva
 Venous hum

 Usually ejection systolic murmur
 Normal S1 and S2
 Normal cardiac impulse
 No hemodynamic abnormality

 Carey-coomb’s murmur
 Infective endocarditis
 Atrial thrombus
 Atrial myxoma

 Carey-coomb’s murmur – Acute rheumatic
valvulitis
 Austin Flint murmur – Chronic aortic
regurgitation
 Graham Steel murmur
 Ritan’s murmur – in complete heart block
 Docks murmur
 Mill wheel murmur
 Stills murmur
 Gibson’s murmur – Patent ductus arteriosus
murmur

Heart sounds and murmurs

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Heart sounds and murmurs