Heart Sounds Flashcards
what valves are open and closed during systole?
Mitral & Tricuspid (A-V) valves close
Aortic & Pulmonic valves open
what valves are open and closed during diastole?
Mitral & Tricuspid (A-V) valves open
Aortic & Pulmonic valves close
heart sounds are created by what two things?
the changing of intracardiac pressure
closing of heart valves
which part of the stethoscope can you hear low pitched sounds better?
what conditions/sounds could be heard?
bell - S3, S4, mitral stenosis
diaphragm - high pitched sounds - S1, S2, AR, MR, pericardial friction rub
how should the pt be positioned during a PE in general?
- Lying supine with their head at 30°
- Listen over all precordial areas with diaphragm
what position and post can you listen to S3, S4, and MS better? using what part of the stethoscope?
Left lateral decubitus
With the bell at the MV post
if you hear something at the aortic post, what position should they be and have the pt do? why?
- sit up, lean forward, and listen again with diaphragm after deep exhalation
- Helps distinguish aortic murmurs, esp. AR
what position Decreases venous return, arterial BP and stroke volume
standing
standing position affects which valvular disorders (3) how?
Increases MVP
increases outflow obstruction of HCM
decreases intensity of AS murmur
what position Increases venous return, LV volume, arterial BP?
squatting
squatting position affects which valvular disorders (3) how?
Decreases MVP
decreases obstruction of HCM
increases intensity of AS
which position is the same as standing? what does it do?
valsalva
increases intrathoracic pressure, leading to a reduction in preload to the heart
Produced by closure of the mitral valve
Marks the beginning of systole
what is this heart sound?
S1
Produced by closure of the aortic valve
Marks the end of systole and beginning of diastole
what is this heart sound?
S2
Result of opening of AV (dilated aorta, AS, or bicuspid AV) or PV (dilated pulmonary artery, pulm HTN, or pulmonic stenosis)
Immediately follows S1
what is this heart sound?
Ej (or Ec) - Ejection click
Caused by opening of MV, as in MS
Follows S2
what is this heart sound?
OS - opening snap
What abnormal heart sound
Occurs in early diastole
Dull, low pitched
S3 - “Kentucky” gallop
S3 - “Kentucky” gallop is best heard with (Bell/diaphragm) at where, with the pt in what position?
bell at apex
left lateral decubitus
S3 - “Kentucky” gallop is physiologic and pathologic in who? reason of pathology?
- Physiologic - kids, young adults, 3rd trimester of pregnancy
- Pathologic - older adults d/t change in ventricular compliance
- Specifically decreased myocardial contractility, CHF, and volume overload of ventricle
what abnormal heart sound
Occurs in late diastole, immediately before S1
Marks atrial contraction
Dull, low pitch heard
S4 - “Tennessee” gallop
S4 - “Tennessee” gallop’s dull, low pitch is heard best with (diaphagram/bell) at where, in what position?
bell at apex
left lateral decubitus
why does S4 occur?
- result of change in ventricular compliance
- D/t increased resistance to ventricular filling - Caused by HTN heart disease, CAD, AS and cardiomyopathy
where is S1 softer and louder than S2
Softer than at base
louder than at apex
what conditions make S1 sound diminished (3)
first degree AVB
mitral regurg
reduced LV contractility
when can variations in S1 be seen? (conditions)
S1 varies in a complete heart block and any irregular rhythm, such as A. Fib
when/where can split S1 be normal? abnormal?
- normal - along left lower sternal border where TV component is heard
- Abnormal - RBBB and in PVCs
where and how is S2 physiologic splitting best heard?
- 2nd and 3rd left intercostal space where pulmonic valve
- Accentuated by inspiration and disappears on expiration
when is pathologic S2 splitting heard? causes?
- Persists thru the respiratory cycle
- Delayed closure of the PV (PS, RBBB) or early closure of the AV (mitral regurg)
- ASD or RV failure
Murmurs are differentiated from extra heart sounds by their ____ ____
longer duration
Describing a murmur should include the following points: (7)
- Timing
- Shape
- Location of maximum
- Radiation
- Intensity
- Pitch
- Quality
murmur timing types
- Systolic
- Midsystolic
- pansystolic (holosystolic)
- late systolic - Diastolic
- Early
- mid-diastolic
- late diastolic - Continuous
- Both systolic & diastolic components - PDA, pericardial friction rub, venous hum
parts of murmur features
- Shape
- Crescendo
- Decrescendo
- Crescendo-decrescendo
- Plateau - Location of Maximal Intensity - Where murmur originates
- Radiation - direction of blood flow and intensity of murmur
features of murmur intensity
- Graded on a 6-point scale
- Influenced by thickness of chest wall and presence of intervening tissue
- Grades
- I - very faint, have to “tune in” to catch
- II - quiet, but can hear immediately with stethoscope
- III - moderately loud
- IV - loud, with palpable thrill
- V - very loud with thrill; may be heard with stethoscope partly off chest
- VI - very loud with thrill; may hear with stethoscope fully off chest
features of pitch and quality murmurs
- Pitch - High, medium, or low
- Quality - Blowing, harsh, rumbling or musical
- Be mindful of positioning
- Comment on positioning and whether murmur changes with certain maneuvers or with respirations
Pathologic
Arising from blood flow from a chamber of high pressure to one of low pressure through a valve that should be closed
what type of murmur
What conditions is it commonly heard?
Pansystolic (holosystolic)
Mitral regurgitation, tricuspid regurgitation, ventricular septal defect (VSD)
Most common heart murmur
May be innocent, physiologic, or pathologic
what type of murmur
Midsystolic
when is midsystolic murmur innocent?
- turbulent blood flow
- grade I-III murmur typically heard between 2nd - 4th L ICS w/ minimal radiation
- Disappears/decreases with sitting
- blowing, mid-systolic
- No other associated PE findings
how is midsystolic physiologic
- Similar to innocent, but may have signs of an underlying cause
- Normal blood turbulence enhanced by conditions that increase blood flow
- anemia, pregnancy, fever and hyperthyroidism
when is midsystolic pathologic? (sound, condition)
Harsh, mid-systolic murmur
Aortic stenosis, HCM, pulmonic stenosis
pathologic diastolic murmurs can be heard when? reasons?
-
early or mid-late
- Early decrescendo = regurgitation through incompetent semilunar valves, most often aortic regurg
- Mid-late diastolic = stenosis of AV valve, MC mitral stenosis
Produced by turbulence of blood flow in jugular veins
Common in kids
Characterized by a continuous murmur that is louder in diastole
Soft, low pitched
what type of murmur?
Venous hum
Venous hum is best heard where?
above the medial third of the clavicles with radiation into the 1st and 2nd intercostal spaces
A result of inflammation of the pericardium
what is this condition
pericardial friction rub
what 3 components can a pericardial friction rub have?
Atrial systole (diastole)
ventricular systole
ventricular diastole
what sound does a pericardial friction rub produce? describe features of this murmur
- High pitched, scratching/scraping noise
- Similar to rubbing the back of your stethoscope - Increases when leaned forward, exhales, and holds their breath
- Location varies
- Radiation is not typical
Congenital abnormality resulting in a channel between the aorta and pulmonary artery
patent ductus arteriosus
- Loudest in systole and fades in diastole
- Best heard at left 2nd intercostal space, radiating to left clavicle
- Harsh, machinery-like, medium pitched
- Typically associated with a thrill
what condition/murmur?
Patent Ductus Arteriosus
Transthoracic (TTE) 2D echocardiogram w/Doppler imaging gives info about what? it gives images of what?
- size of all 4 chambers
- regional and global systolic function
- chamber wall thickness
- Provides excellent images of valve motion, intracardiac masses, cardiac abnormalities / anomalies, and pericardial fluid
Non-invasive and requires no radiation or prep!
provides color flow, gives a visual image of blood flow velocities superimposed over anatomic 2D images
what is this diagnostic method?
doppler
Allows viewer to see turbulence from valvular stenosis or regurgitation
Also picks up any intracardiac defects
what diagnostic method?
Doppler
how to improve visualization of wall motion with doppler?
add contrast agents
another option that is used if surface sound transmission is poor for a TTE
what is this diagnostic method?
Transesophageal echocardiography (TEE) with Doppler ultrasound
benefits of TEE vs TTE
- better view of posterior heart structures, esp atria, atrial appendage, and A-V valves
- Better than a TTE for dx LAA thrombus - Prosthetic heart valves and intracardiac masses difficult to see on TTE
- helps define septal defects or a PFO
- detects aortic dissection and severe atherosclerosis of the ascending aorta
Cons of TEE
- NPO for 6-8 hrs prior
- risks include:
- Aspiration
- Throat irritation
- Esophageal perforation - IV sedation and a local anesthetic to reduce gag reflex
- has to be monitored during procedure (O2, HR, BP)
- Signed consent required
