2. OBJECTIVES
by theend ofthislecture you will be able to:
▹ Listthemajor types ofnormal heartsounds
▹ Understand the physiological basis forthe production ofnormal heartsounds
▹ Understand the pathophysiological basis forthe production ofheart murmurs.
2
3. HeartSoundsWindows
3
▹ Aorticarea:
2ndRtcostalcartilage.
▹ Pulmonary area:
2ndLt intercostalspace.
▹ Mitral (bicuspid) area:
5thLt intercostal space crossing mid-clavicularline, or
9cm (2.5-3inches) fromsternum.
▹ Tricuspid area:
lowerpartof sternumtowardsRtside.
▹ Detectedoveranteriorchestwall by 2methods:-
1. Auscultation (Stethoscope).
2. Phonocardiography (sound recording device).
▹ 4heartsoundscan be detected:
- 1st&2ndheartsounds(usually audible).
- 3rd&4thheartsounds(sometimesdetected).
ONLY in male’s slides:
○ VentricularSystole is between
Firstand secondheartsounds.
○ Ventriculardiastole is between
Second and FirstHeart sound.
4. 4
S1 Due toclosure of
theA-Vvalves.
Recorded atthe
beginning of the
‘isovolumetric
contraction
phase.’
Itmarks
beginning
of
ventricular
systole.
Long in duration0.15sec. O
f
low pitch(LUB).
Itsis heavier when
compared tothe 2nd
heart sound.
(25-35Hz)
~(25-45Hz)
Best heard at
Mitral &
Tricuspid
areas.
S2 Due toclosure of
semilunar
valves.
Recorded atthe
beginning of the
‘isovolumetric
relaxation phase’.
Marks the
beginning
of
ventricular
diastole.
Short in duration ..
0.11-0.125sec. ~(0.12sec) Of
high pitch (DUB).
Soft&Sharp (compared to
the1stheartsound)
50Hz. Best heard at
Aortic &
Pulmonary
areas.
S1
S1 S1 S1 S1
S2 S2 S2 S2
S2
Splittingofthe2ndHeartSound
▹ S2 splits physiologically into 2sounds during inspiration =
Physiological Splitting.
▹ Thissplitting occurs due todelay closure of pulmonary valve.
5. ▹ Physiological splitting ofS
2
1. During inspiration, the aortic valve
closes beforepulmonary valve →
reduplication (physiologic splittingof
S2.
2. The increased venous return to
therightsideoftheheart delays
closure ofthe pulmonary valve.
The rightventricle has more blood
thanusualtoeject and itthus
takesmore time.
3. No splittingofthesecondheart
sound is normally seen during
expiration.
5 ▹ FixedsplittingofS2
1. SplittingofS2isheard in both
during inspiration and expiration,
with the aortic valve closing
beforethe pulmonary valve.
2. Thisisheard in cases ofASD.(atrial
septic defect)
ONLY in male slides
Mitral: longblack
line
Tricuspid: short
black line
6. ▹ WidesplittingofS2
Asplitin the second heartsound during
inspiration may become wider and the split
may also be seen during expiration if:
1. Thereisa delayin theclosingofthe
pulmonic valve (as would be seen in right
bundlebranch block due todelayin right
ventricular depolarization and contraction).
2. The aorticvalve closes earlierthan normal
(thisisseen witheithermitral regurgitation or
ventricular septal defect).
6 ▹ Paradoxical(reversed) splittingofS2
Reversed(paradoxical)splitting ofthe
secondheartsound istypicallyheard
during expiration, with the pulmonary valve
closingbeforetheaorticvalve. No splitting is
apparent during inspiration, sincethe
pulmonary valve is closing earlier(relative
tothe aortic valve) than normal.
Thismay be causedby thefollowing:
1. Delayed onset o
f left ventricular systole (example: left
bundle branch block).
2. Prolonged left ventricular systole (examples: aortic
stenosis, severe hypertension, left-sided congestive heart
failure).
3. Early onset o
f right ventricular systole (example: Wolff-
Parkinson White syndrome).
ONLY in male slides
8. 3rdHeartSound=S3
▹ Recorded duringthe ‘rapid filling
phase’duetorushof blood
intotheventricle.
▹ S3isusuallynotaudible (verylow
pitch.)
▹ 0.05sec.
▹ Frequency: 20-30Hz
▹ Heardin children (?).
▹ Bestheard atMitralarea.
▹ Recorded during ‘atrial systole’ (just
beforeS1).
▹ S4is usuallynotaudible (verylow
pitch.)
▹ 0.04sec.
▹ Frequency: <20Hz.
▹ Heardin elderly(?).
▹ Bestheard atMitralarea.
8
4thHeartSound=
S
4
ONLY in male slides:
○ Thirdand Fourth heartsound are low pitched sounds thereforenotaudible normally with
stethoscope
○ S4may be heard in elderlybutis usually pathologic in theyoung.(oppositeofS3)
9. Significanceof HeartSound
9 Importantfordiagnosisof heartmurmurs.
Abnormalextraheartsounds heard during the
heartbeatcycle .
Produced by turbulence (abnormal patterns)of
blood flowthrough theheart &itsvalves.
Murmursare longer thanheartsounds.
Whatmakenoiseintheheart
Closureofvalvesofthe
heart
Increased intra-cardiac
hemo-dynamics
1)Atrio-ventricular
(Mitral & Tricuspid)
valves=(S1)
Semilunar (Aortic &
Pulmonary) valves=
(S2)
Blood striking the left
ventricle =(S3, S4)
•Increased flow across
normal valves.
• Turbulent flow
through an abnormal
valve.
• Turbulent flow
through septal defect.
Murmurs
ONLY in male slides
10. Physiological VSPathological
Murmurs
1
0
Physiological Murmurs: Pathological Murmurs:
Increase blood flow across
normal valves:
Turbulent flow through
abnormal valves, or septal
defect…..Congenital?
e.g.:-
○ Pregnancy
○ Hyperthyroidism
○ Anemia
○ Fever
○ Children
e.g:-
○ Tight valve (stenosis)
(narrowing): the valve does
not open properly.
○ Leaky valve (regurgitation or
insufficiency): The valve fails to
close completely, and hence
causing backflow or leaks ofthe
blood across the insufficient
valve. (Valvular insufficiency is
also known a
s Regurgitation or
Incompetency).
○ Acombination ofStenosis
and Insufficiency.
HowtodescribeHeartMurmurs
▹ Timing (systolic or diastolic)
▹ Shape
▹ Location
▹ Radiation
▹ Intensity
▹ Pitch
▹ Quality
ONLY in male slides:
Gallop:
Threeor foursounds
arespacedtoaudibly
resemble thepace ofa
horse, theextra sounds
occurs after S2.
11. 1
-Timing
1
1 Murmurs are described according to
theirpositionin the cardiac cycle:
▹ Systolic.
▹ Diastolic.
▹ Continuous.
Systolicmurmur
○ BetweenS1&S2
○ Classifiedas early, mid, late, holosystolic
Diastolicmurmur
○ BetweenS2&S1
○ Classifiedas early, mid, late
16. DescribingaHeart
Murmurs…..Cont
1
6
6-Pitch:
▹ High
▹ Medium
▹ Low
7-Quality:
▹ Blowing
▹ harsh
(hard)
▹ resonant
(rumbling)
&musical
8-Others:
i. Variation with respiration.
○ Murmurs increasing with expiration
originate with leftside (aortic or mitral)
valves, while murmurs increasing
in
intensitywith inspirationoriginatewith
tricuspid or
pulmonary valves.
ii. Variation with position ofpatient.
iii. Variation with specialmaneuvers:
○ Valsalva (forcedexpiration) →
Murmurs inlength(duration) &
intensity(ofmostmurmurs)
17. SystolicMurmurs
▹ EarlySystolic
▹ Mid Systolic
▹ Late Systolic
▹ Pansystolic (holosystolic)
1
7
Derivedfromharsh &turbulence in blood flow.
Associatedwith:
1) Increased flowacross normal valve.
2) Increased flowinto a dilated greatvessel.
3) Increased flowacross an abnormal valve, or narrowed ventricular outflowtract.
○ e.g. aortic /pulmonary stenosis.
4) Increased flowacross an incompetent AVvalve.
○ e.g. mitral/tricuspid regurgitation.
5) Increased flowacross the inter-ventricular septum.
○ e.g. VSD.
ONLY in femaleslides
18. Common SystolicMurmursandTiming
1
8
1) Aortic stenosis– ejection murmur.
2) Pulmonarystenosis– ejection murmur (+2ndsplit)
3) Mitral/ Tricuspid regurgitation– holosystolic.
4) Mitralvalve prolapse– mid-latesystole.
5) Ventricularseptaldefect(VSD)– holosystolic.
Ejection (Mid-Systolic) Murmurs:
Most commonkind of heart murmur.Usually
crescendo-decrescendo.
They may be:
1) Innocent: Commonin children & young adults.
2) Physiological:Can be detected in
hyper-dynamic states.
○ e.g. anemia,pregnancy, fever &
hyperthyroidism.
3) Pathological: Secondary to structural CV
abnormalities.
○ e.g. Aortic/pulmonary stenosis,
Hypertrophic cardiomyopathy & mitral
prolapse.
Pan-Systolic (Holosystolic) Murmurs:
Pathological murmur.
Begins immediatelywith S1 &continuesup to S2 Heard
with:
▹ Mitral/tricuspid regurgitation.
▹ Ventricular septal defect (VSD)
ONLY in femaleslides
19. SystolicMurmurs
1
9
Aortic Stenosis MitralProlapse MitralRegurgitation
Cause Obstruction offlowfrom LV into
ascending aorta.
Bulging of1or 2mitral valve leaflets
into LA during LV systole.
Retrograde flow from LV into L
A
through an incompetent mitral
valve.
Timing Mid-systolic murmur. Mid-late systolic murmur. Holosystolic murmur.
Location Best heard on aorticarea, radiates
along carotid arteries.
Best heard atthe apex. Best heard atapex, radiates to left
axilla.
Character Harsh, loud, may have associated
with thrill, “ejection click.”
Mid systolic click. Soft, high-pitched, blowing.
Association Old age, bicuspid aortic valve,
rheumatic fever.
~5%normal population,
asymptomatic, ?Sudden death.
MV prolapse, or myxomatous
degeneration, rheumatic heart
disease, endocarditis.
ONLY in femaleslides
Video of(Heart Murmurs)
Duration (12)mins
20. DiastolicMurmurs
▹ Almostalways indicateheart disease.
Two basic types:
1. Earlydecrescendodiastolic murmurs:
Signifyregurgitant flowthrough an incompetent
semilunar valve.
e.g. aortic/pulmonary regurgitation.
2. Rumblingdiastolicmurmursinmid-orlatediastole:
Suggest stenosisof an AVvalve.
e.g. mitral/tricuspid stenosis.
20
InSummary
Common Diastolic
Murmurs&Timing
▹ Soft,blowing, gurgle
1. Aorticregurgitation →early diastole.
2. Mitralstenosis→mid tolate
(pre-systolic) diastole.
21. 2
1
Aortic Regurgitation MitralStenosis
Cause Retrogradeflow from aorta into LV through
incompetent aortic cusps.
Obstructionof flowfromLA toLV (Valve
becomes narrowed, thickened &calcified).
Timing Diastolic (early) murmur. Diastolic (mid-diastolic, or pre-systolic)
murmur.
Location Best heard at2nd-4th leftintercostalspaces. Best heard atapex.
Character High-pitched, blowing, decrescendo. Low pitched (heard with bell).
Association Aortic root degeneration, rheumatic
heart disease, VSD with aortic valve prolapse
(kids).
Rheumatic fever.
DiastolicMurmurs
ONLY in femaleslides
23. Murmursof VentricularSeptalDefectVSPatentDuctusArteriosus
23
Ventricular septal defect Patent ductus arteriosus
Cause A congenital condition associated with abnormal
blood flow between the leftventricle and the right
ventricle
Failure ofclosure ofduct (ductus arteriosus)between
pulmonary artery&aorta
Timing Holosystolic murmur, may be diastolic murmur due to
turbulent flow through mitral valve
Continuous murmur
Location Best heard at tricuspid area Best heard atupper leftsternal border
Character Amedium pitched murmur fillsall of systole Machine-like.
Association Volume overload ofright ventricle Left to right shunt, cyanosis
ONLY in femaleslides
24. Summary
A. Presystolic murmur.
○ Mitral/Tricuspid stenosis.
B. Mitral/Tricuspid regurge.
C. Aorticejection murmur.
D. Pulmonic stenosis (spilling through S2 ).
E. Aortic/Pulm. diastolic murmur.
F. Mitralstenosisw/Opening snap.
G. Mid-diastolic inflowmurmur.
H. Continuousmurmurof PDA.
24
ONLY in femaleslides
