Professional Documents
Culture Documents
OF THE
HEART
Heart Sounds
Factors that decrease the intensity of the heart
sounds and murmurs:
1. mechanical ventilation
2. obstructive lung disease
3. obesity
4. pendulous breasts
5. pneumothorax
6. pericardial effusion
1. First Heart Sound (S1)
- mitral (M1) and tricuspid (T1) valve closure
- best heard: lower left sternal border
- splitting: complete RBBB
- intensity early rheumatic mitral stenosis,
hyperkinetic states, short P-R intervals
(<160 milliseconds)
- intensity late rheumatic mitral stenosis,
contractile dysfunction, -adrenergic
receptor blockers, long P-R intervals
(>200 milliseconds)
2. Second Heart Sound (S2)
- aortic (A2) and pulmonic (P2) valve closure
- A2 is normally louder than P2
- widening: complete RBBB
- splitting: A2-P2 interval during inspiration
and with expiration
- fixed splitting: ostium secundum ASD
- paradoxical splitting: complete left bundle
branch block, RV apical pacing, severe
aortic stenosis, HOCM, myocardial ischemia
- intensity of P2 relative to A2: pulmonary
artery hypertension
- best heard: 2nd left interspace
Systolic Sounds
1. Ejection sound
- high-pitched early systolic sound
- coincides in timing with the upstroke of
the carotid pulse
- associated with congenital bicuspid
aortic or pulmonic valve disease
- pulmonic valve disease: intensity with
inspiration (only right-sided cardiac
event to behave in this manner)
- best heard: lower left sternal border
Diastolic Sounds
1. Opening snap (OS)
- high-pitched early diastolic sound
- heard in mitral stenosis
- distance after S2
2. Pericardial knock (PK)
- high-pitched early diastolic sound
- abrupt cessation of ventricular
expansion after AV valve opening and to
the prominent y descent
- seen in the jugular venous waveform in
patients with constrictive pericarditis
3. Tumor plop
- low-pitched sound
- atrial myxoma (rare)
- arises from the diastolic prolapse of
tumor across the mitral valve
4. Third heart sound (S3)
- occurs during the rapid filling phase of
ventricular diastole
- may be normally present in children,
adolescents, young adults, pregnant
- indicates systolic heart failure in older
adults
- left-sided S3:
- low-pitched
- best heard over the LV apex,
- left lateral decubitus position
- right-sided S3:
- usually heard at the lower left
sternal border or in the
subxiphoid position
- supine
- louder with inspiration
5. Fourth heart sound (S4)
- occurs during the atrial filling phase of
ventricular diastole
- thought to indicate presystolic
ventricular expansion
- common in patients with accentuated
atrial contribution to ventricular filling
(e.g., LV hypertrophy)
Cardiac Murmurs
- result from audible vibrations caused by
increased turbulence
Grade
1
3
4
5
6
1. Systolic Murmurs
a. Early
- high-frequency
- begins with S1 and ends before S2
- decrescendo in configuration
- causes: acute severe MR, acute TR
with normal pulmonary artery
pressures ( intensity with
inspiration, may be audible at the
lower left sternal border)
b. Midsystolic
- high frequency
- begin after S1 and end before S2
- d/t blood flow through the semilunar
valves
- crescendo-decrescendo in
configuration
- causes: aortic stenosis, HOCM,
pulmonic stenosis, large ASD, leftto-right shunt
- isolated grade 1 or 2 midsystolic
murmur in the absence of
symptoms or other signs of heart
disease is a benign finding
c. Late
Dynamic Auscultation