Heart Sounds Flashcards
S1
Closure of mitral and tricuspid valves – beginning of systole
(long, soft, low-pitched sound)
S2
Closure of aortic and pulmonic valves – beginning of diastole
(short, sharp, high-pitched sound)
S3
Due to rapid ventricular filling – deceleration of blood against ventricular wall (volume overload)
- Physiologic: children and young adults
- Pathologic (‘S3/ventricular gallop’): ventricular volume overload (heart failure, mitral regurgitation)
S4
Due to atrial contraction against stiff ventricular wall (pressure overload)
- Physiologic: trained athletes
- Pathologic (‘S4/atrial gallop’): resistance to ventricular filling due to decreased compliance (ventricular hypertrophy, restrictive cardiomyopathy)
Points of auscultation
Pulmonic valve
2nd left intercostal space, parasternal
Points of auscultation
Aortic valve
2nd right intercostal space, parasternal
Points of auscultation
Mitral valve
5th left intercostal space, midclavicular line (apex)
Points of auscultation
Tricuspid valve
Over lower sternum
Timing in the cardiac cycle
Pan (holo) - systolic/diastolic murmur
Along the entire phase
Mitral regurgitation
Timing in the cardiac cycle
Early (proto) - systolic/diastolic murmur
Beginning of the phase
Aortic Regurgitation
Timing in the cardiac cycle
Mid (meso) - systolic/diastolic
Middle of the phase
Aortic stenosis
Timing in the cardiac cycle
Late (tele) - systolic/diastolic
End of the phase
Mitral stenosis
Timing in the cardiac cycle
Continuous murmur
During the entire cardiac cycle
Friction rub, VSD
Shape (configuration) of the murmur
Aortic stenosis
Crescendo-decrescendo murmur
first rises in intensity, then falls
Shape (configuration) of the murmur
Mitral regurgitation
Plateau murmur (the same intensity throughout)
Shape (configuration) of the murmur
Mitral stenosis
Crescendo murmur (intensity grows louder)
Shape (configuration) of the murmur
Aortic Regurgitation
Decrescendo murmur (intensity falls)
Location of maximal intensity (‘punctum maximum’)
Aortic murmurs
Loudest at the base
Location of maximal intensity (‘punctum maximum’)
Mitral murmurs
Loudest at the apex
Radiation - Where to
Aortic murmurs
Carotids
Radiation - Where to
Mitral murmurs
Axillary line
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 1
Very faint murmur, heard only after listener has ‘tuned in’; may not be heard in all positions
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 2
Quiet, but heard immediately after placing the stethoscope on the chest
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 3
Moderately loud
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 4
Loud, with palpable thrill
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 5
Very loud, with thrill; may be heard when the stethoscope is partly off the chest
Intensity on a ‘6-point-scale’ (Levine scale, 1933)
Grade 6
Very loud, with thrill;
may be heard with stethoscope entirely off the chest
Diastolic heart murmurs :
Mitral stenosis
Etiology
- Rheumatic heart disease
- Non-rheumatic etiology: congenital, degenerative calcification, endocarditis, carcinoid heart disease
Diastolic heart murmurs :
Aortic regurgitation
Etiology
- Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
- Annulus dilatation – aortic root disease: dilatative cardiomyopathy, atrial remodeling, aortic root dissection, Marfan’s syndrome
Graham Steell murmur
Early diastolic murmur due to pulmonary regurgitation from pulmonary hypertension, may be heard rarely
Opening snap of the mitral valve - When is it best heard
heard best at or medial to the apex in expiration
Diastolic heart murmurs:
Aortic regurgitation
Etiology
- Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
- Annulus dilatation – aortic root disease: dilatative cardiomyopathy, atrial remodeling, aortic root dissection, Marfan’s syndrome
Austin Flint Murmur
Mid-diastolic murmur heard at the apex due to antegrade flow
across a mitral valve orifice which has been narrowed by a combination of
rising LV pressure and jet of AR directed at the anterior MV leaflet
Traube’s sign
(‘pistol shot femora’) – loud systolic and diastolic bruit heard with stethoscope over femoral artery
Diastolic heart murmurs:
Mitral stenosis
Murmur Sound
- Mid-/late- diastolic
- Crescendo
- Apex
- Axilla
- Low-pitched
Diastolic heart murmurs:
Aortic regurgitation
Murmur Sound
- Early diastolic (duration of murmur correlated with severity of regurgitation)
- Decrescendo
- Left upper sternal border
- Left sternal area
- High-pitched
Systolic heart murmurs:
Mitral regurgitation
Etiology
- Valvular (leaflet) abnormality: endocarditis, degenerative, rheumatic
- Sub-valvular apparatus abnormality:
Chordal rupture, papillary muscle rupture, papillary muscle dysfunction - Annulus dilatation: dilatative cardiomyopathy, atrial remodeling, Marfan’s syndrome
Systolic heart murmurs:
Mitral regurgitation
Murmur Sound
- Holosystolic
- Plateau
- Apex
- Axilla
Systolic heart murmurs:
Aortic stenosis
Etiology
- Acquired: degenerative, rheumatic, Paget disease of the bone
- Congenital: bicuspid aortic valve
Systolic heart murmurs:
Aortic stenosis
Murmur Sound
Murmur
- Mid-systolic
- Crescendo-decrescendo
- Right upper sternal border (aortic area)
- Carotid
* Systolic ejection click may be heard (severe stenosis)
Systolic heart murmurs:
Aortic stenosis
Murmur Sound - If severity worsens
Murmur peaks later, extends later through systole, and may obscure S2
