semmelweis university first department of medicine 15. oct ... · 15/10/2013  · pericardial...

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)

APEX –

MITRAL VALVE

to left ventricle

fifth intercostal space

(left midclavicular line)

TRICUSPID VALVE

to right ventricle:

fourth intercostal space

(lower left sternal border)

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)

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

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

Second heard sound

(S2)

Dub

Closure of semilunar

valves

Start of the systole 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

• 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

Loud S1 Soft S1

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

• physiological in younger people

• During expiration, the interval between the two components normally shortens and the S2 sounds becomes merged.

Non-fixedInspiration

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

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

Ejection clicks:

aortic

pulmonary

Mitral

valve

prolapse

High in pitch,

have a sharp,

clicking quality

A/P stenosis

Hypertension

Early Mid/late

Opening

snap

S3 and S4

Mitral valve

stenosis

Abnormal systolic

ballooning of part

of the mitral valve

into the left atrium

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 Description

Grade 1 Very faint, heard only after listener has "tuned

in"; may not be heard in all positions.

Grade 2 Quiet, but heard immediately after placing the

stethoscope on the chest.

Grade 3 Moderately loud.

Grade 4 Loud, with palpable thrill.

Grade 5 Very loud, with thrill. May be heard when

stethoscope is partly off the chest.

Grade 6 Very loud, with thrill. May be heard with

stethoscope entirely off the chest.

Shapes of the murmurs

• CRESCENDO

• DECRESCENDO

• CRESCENDO-

DECRESCENDO

– diamond

• PLATEAU (EVEN)

Murmurs

• Turbulent blood flow in

children & young adults

• Midsystolic

• Lower left sternal border

• Grade 1 to 2, medium

pitch, usually decreases or

disappears on sitting

Innocent „Physiologic”

• Anaemia, fever,

pregnancy, hyper-

thyroidism

• Midsystolic

• Aortic area

Pathologic

Pathologic murmurs

Aortic stenosis

Mitral regurgitation

Systolic Diastolic

Aortic regurgitation

Mitral stenosis

Pericardial friction rub

Patent ductus arteriosus

Systolo-diastolic (continuous)

Interventions that influence the intensity

of heart murmurs and soundsRespiration (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, high-pitched 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.