Cardiac Auscultation Flashcards
a wave
- in late diastole, atrial contraction propels a final bolus of blood into each ventricle
- produces a brief further rise in atrial and ventricular pressures
c wave
- small rise in atrial pressure as tricuspid and mitral valves close and bulge into respective atria
v wave
- result of passive filling of the atria from the pulmonary and systemic veins during systole during which blood accumulates because the tricuspid and mitral valves are closed
causes of prominent a wave
- RVH or tricuspid stenosis
cause of prominent v wave
- tricuspid regurgitation
cause of prominent y wave
- constrictive pericarditis
S1
- produced by the closure of the mitral and tricuspid valves in early systole
- loudest near the apex
- high frequency sound - listen with diaphragm
S2
- results from closure of the aortic and pulmonic valves
- high frequency - listen with diaphragm
physiologic splitting of S2
- normally A2 and P2 are fused as one sound during expiration
- A2 and P2 are audibly separated during inspiration
physiologic mechanism behind physiologic splitting of S2
- inspiration causes an intrathoracic pressure to become more negative
- transient increase in capacitance and reduced resistance resulting in a temporary delay in the diastolic back pressure of the pulmonary artery responsible for pulmonic valve closure
- P2 is delay
description and common causes of paradoxical splitting of S2
- audible separation of A2 and P2 during expiration and fusion upon inspiration
- most common cause is LBBB, aortic stenosis, HCM, right ventricular pacemaker, right ventricular ectopic beat
description and common causes of fixed splitting of S2
- widened interval between A2 and P2 that persists unchanged through the respiratory cycle
- most common cause is atrial septal defect
- mid systolic murmur almost clinches the diagnosis
S3
- occurs in early diastole following opening of the AV valves
- dull, low pitched sound best heard with the bell
- left sided S3 heard at the apex, right sided at LLSB
- results from tensing of the chordae tendinae during rapid filling and expansion of the ventricle
- “Kentucky”
S4
- occurs in late diastole and coincides with the contraction of the atria
- sound generated by atria vigorously contracting against a stiffened ventricle
- dull, low pitched sound best heard with bell
- left sided S4 best heard at the apex, right sided S4 best heard at the LLSB
- “Tennessee”
pathology associated with an S4 sound
- decreased ventricular compliance
quadruple rhythm
- presence of all 4 heart sounds
summation gallop
- quadruple rhythm with tachycardia
dynamic ausculatory changes that occur with inspiration
- increase in venous return and flow to the right side of the heart
- all right sided pathological findings will increase in intensity during inspiration except the pulmonic ejection click
actions that decrease venous return
- squatting to standing
- valsalva
systolic murmur grading system
- 1: very faint, usually not heard at first
- 2: faint, but heard immediately
- 3: easily heard
- 4: easily heard with palpable thrill
- 5: very loud, stethoscope slightly off chest
- 6: very loud, stethoscope completely off chest
diastolic murmur grading system
- 1: very faint, usually not heard at first
- 2: faint, but heard immediately
- 3: easily heard
- 4: very loud
- no palpable thrills associated with diastolic murmurs
timing of a systolic murmur
- begins with or after S1 and ends at or before S2
timing a diastolic murmur
- begins with or after S2 and ends before the next S1
4 types of systolic murmurs
- aortic and pulmonic stenosis
- mitral and tricuspid regurg
4 types of diastolic murmurs
- aortic and pulmonic regurn
- mitral and tricuspid stenosis
2 major categories of systolic murmurs
- systolic ejection murmurs: AS, PS, HCM, most “innocent murmurs”
- holosystolic murmurs: TR, MR (except acute MR and MVP), VSD
characteristics of chronic MR
- holosystolic murmur
- does not get louder with inspiration
- best heard at apex, radiating to axilla
- gets louder with isometric grip and squatting or vasopressor agents (decreased venous return)
characteristics of acute MR
- early systolic decrescendo murmur
characteristics of MVP
- midsystolic click, late systolic murmur
- maneuvers that increase the volume of the LV (sudden squatting) delay the occurrence of prolapse in systole and cause the click and murmur to occur later and shorter
- if volume of blood in the LV is decreased (sudden standing), prolapse occurs more readily and the click and murmur occur earlier in systole
characteristics of TR
- holosytolic murmur
- gets louder during inspiration (Carvallo’s sign)
classic triad of severe TR
- Carvallo’s sign - louder during inspiration
- pulsatile JVD - prominent v waves
- pulsatile liver - regurgitant blood gets backed up into systemic veins
characteristics of VSD
- holosytolic murmur
- does not get louder with inspiration
- best heard at LLSB
- often harsh in quality
characteristics of AS
- aortic ejection click is hallmark for bicuspid aortic valve
- crescendo-decrescendo murmur
- radiates to the carotids
- pulsus parvus et tardus: delayed carotid upstroke
- gets louder with increased preload (squatting, amyl nitrate)
- gets softer with decreased preload (standing, Valsalva, isometric grip)
differentiating AS from MR
- AS gets louder after a PVC
- MR does not change intensity after PVCs
characteristics of HCM murmur
- crescendo-decrescendo
- louder with reduced preload (Valsalva, standing, amyl nitrate)
- softer with increased preload (isometric grip, squatting)
characteristics of pulmonic stenosis
- crescendo-decrescendo
- increases during inspiration
- does not radiate to carotids
4 causes of diastolic murmurs
- AR, PR
- MS, TS
characteristics of AR
- early diastolic murmur
- decrescendo
- high pitched
- “blowing”
- best heard with patient leaning forward
associated murmurs with AR
- systolic ejection murmur: high flow across valve
- Austin Flint murmur: diastolic rumble
Duroziez sign of AR
- systolic murmur heard over femoral artery when stethoscope is compressed proximally and a diastolic murmur over femoral artery when stethoscope is compressed distally
- most specific sign of severe AR
other signs of AR that are associated with high stroke volume
- wide pulse pressure
- Quincke’s pulse - phasic blanching of the nails
- Hill sign - popliteal SBP exceeds brachial SBP by > 60 mmHg
- Corrigan (water hammer) pulse - palpable abrupt upstroke and rapid fall of arterial pulsation
- Traube sign - pistol shot sound over femoral artery
- Mueller sign - pulsating uvula
characteristics of PR
- Graham Steel murmur
- early diastolic
- decrescendo
- high pitched, blowing
- louder with inspiration
- murmur due to deformity
- mid diastolic
- crescendo-decrescendo
- low pitched
characteristics of MS
- mid diastolic
- low pitched rumble
- best heard in left lateral decubitus position
- may have opening snap or accentuated S1
characteristics of TS
- sounds like MS except: gets louder during inspiration, best heard at LLSB
common cause of continuous murmurs
- PDA
- Beck’s triad
- hypotension
- JVD
- muffled or distant heart sounds
Virchow’s triad
- vascular injury
- hypercoagulability
- venous stasis
- high risk for DVTs
Kussmaul sign
- increase in JVD during inspiration
- often seen in restrictive pericarditis
