HEART SOUND

Dian Pratiwi
Cardiology Department
Chasan Boesoerie Hospital
The Origin of Heart Sounds

 Valvular theory
 Vibrations of the heart valves
during their closure
 Cardiohemic theory
 Vibrations of the entire
cardiohemic system: heart
cavities, valves, blood

Rushmer, R.F., Cardiovascular Dynamics,

4yh ed. W.B. Saunders, Philadelphia,
1976
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Heart Sounds
Heart sounds
 S1 – “lubb” caused by the closing of the AV valves
 S2 – “dupp” caused by the closing of semilunar valves
 S3 –associated with blood flowing into the ventricles
 S4 –associated with atrial contraction

Four heart sounds can be recorded by phonocardiography, but

normally only the first and the second heart sounds, are audible
through a stethoscope
Auscultation Areas
First heart sound

 occurs when the atrioventricular

(AV) valves close at the
beginning of ventricular
contraction

 generated by the vibration of the

blood and the ventricular wall

 is louder, longer, more in duration

than the second heart sound
Second heart sound

 occurs when aortic and

pulmonary semilunar valves close
at the beginning of ventricular
dilation

 generated by the vibration of the

blood and the aorta

 Aortic valve closes slightly before

pulmonary valve

 Splitting of S2
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 Distinguishing S1 vs S2
-Listen at apex, palpate carotid-S1 precedes
carotid pulse.
-Intensity of S1>S2 at apex (reverse at base).
 S1 occasionally splits with inspiration (.02-.03
seconds)…difficult to hearMV closes
before TV, accentuated with inspiration.
 S2 Splitting
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 Commonly heard in inspiration (separation of A2 and

P2 is .02-06 Sec).
 A2 normally precedes P2- accentuated in inspiration
because RV volume increases
 Fixed splitting: ASD.
 Paradoxical splitting: Aortic valve closure is delayed,
closes after pulmonic.
 P2 precedes A2 . During inspiration they move together, in
expiration they move apart.
 Examples: Aortic Stenosis, LBBB.
Splitting of 2nd Heart Sound
 3rd Heart Sound vs S3 Gallop
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 3rd heart sound: Low pitched sound, 0.1-0.2 sec post S2. May
be heard in young, healthy people. Reflects rapid inflow of
blood into normal, compliant LV.
 S3 gallop: abnormal “dull thud” in mid diastole. LV
dysfunction and dilation often present (CHF). Also heard with
MR, AR with volume overload.
 Pathophys:
 1. Sudden deceleration of blood flow into diseased, dilated & non
compliant ventricle.
 2. AR/MR- volume overload with rapid inflow of increased blood volume into
compliant LV.
 Best heard: bell at apex in LLD position.
 Timing: lub….du..dub
S1 S2 S3
 S4 Gallop
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 Almost always abnormal

 Short, low frequency, precedes S1 “presystolic
gallop”.
 Pathophys: Atrial contraction into non-compliant
ventricle.
 Conditions: LVH (HTN, AS), CHD (ischemia or
infarction).
 Best heard: bell at apex in LLD position.
 Timing: bu.lub….dub
S4 S1 S2
Heart Murmur

 Cardiac murmurs are abnormal heart sounds in the form of

noises resulting from turbulent blood flow,

 Murmurs may be:

 Systolic murmurs, if they occur during systole.
 Diastolic murmurs, if they occur during diastole

 Causes:
 Stenosis (narrowing) of heart valves
 Incompetence of heart valves
 Increase of blood flow or decrease of blood viscosity (as in anemia).
Two Basic Types of Valvular Diseases

valvular stenosis:
 narrowing of the valve

valvular insufficiency
(incompetence):
 valve is unable to close

fully; so there is
regurgitation
Phonocardiograms examples
 Murmurs: Grading Scale
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 Grade I- Very faint; barely audible. Often heard

only by experienced clinicians.
 Grade II- soft, but audible
 Grade III- moderately loud
 Grade IV- loud with associated thrill
 Grade V- very loud + thrill; audible with diaphragm
on end.
 Grade VI- very loud + thrill; audible with stethoscope
off chest.
 Murmurs: Radiation
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 Depends on direction of blood flow responsible for

the murmur, duration of and intensity of the murmur.
 Aortic outflow murmurs (AS) radiate from the cardiac
base/aortic area to base of neck or carotids.
 Most MR murmurs radiate to axilla.
 AR murmurs radiate down LSB
 Murmurs: Description
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 Intensity: see grading scale

 Quality: Blowing, harsh, grating, rumble.
 Pitch: High vs low pitched
 Timing: Early/mid/late systolic vs. holosystolic.
Early/mid diastolic.
 Configuration: Crescendo-decrescendo, decrescendo,
plateau, others.
Murmur Timing and Configurations
 Murmurs: Use of Maneuvers
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 Respiration: Inspiration RV filling/volume. Murmurs

arising from right side of heart (PS, PR, TR) get louder
during inspiration and reverse in expiration.
 Valsalva: Net effect is venous return to RV; RV
followed by LV volume.
 Squatting: venous return to heart;PVR and BP. Net
effect: LV and RV volumes.
 Murmurs: Use of Maneuvers
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 Rapid upright posture after squatting: venous return

to RV, PVR. Net effect:RV and LV volumes.
 Isometric exercise (handgrip):PVR and BP, CO/HR.
Net effect- makes murmurs of MR and AR louder.
Avoid in patients with myocardial ischemia and
ventricular arrhythmias.
 Murmurs: Maneuvers
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 Outflow murmurs across aortic and pulmonic valves (includes

AS, PS and innocent murmurs) get louder with maneuvers that
LV/RV volume and softer with LV/RV volume.
 Insufficiency Murmurs: AR, MR, TR act similarly to above.
 Exceptions: Murmur of MV prolapse and hypertrophic
cardiomyopathy get louder with maneuvers that LV volume
and softer with reverse physiology.
 Characteristic Systolic Murmurs
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 Innocent or functional murmurs: arise from pulmonic or aortic

outflow tracts in the presence of normal pulmonic/aortic valves.
Common in young, healthy individuals. Usually Grade I or
II, get louder with squatting and very soft or absent with
standing/valsalva. Mid-systolic, short.
 Aortic stenosis: harsh, often loud, best heard base/aortic
area, C/D (crescendo/decrescendo), radiate to neck/carotids.
Length of murmur correlates with severity of obstruction. Best
heard with diaphragm.
 Characteristic Systolic Murmurs
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 Mitral regurgitation: high pitched, blowing, best heard at

apex, holosystolic (if not acute), radiates to axilla. Best heard
with diaphragm.
 MV prolapse with MR: high pitched, blowing, best heard at
apex, mid to late systolic and often preceded by valve click.
Characteristic changes with maneuvers (see above). Best heard
with diaphragm.
 Pulmonic stenosis (congenital defect): harsh, best heard at
base/pulmonic area, C/D radiates down LSB. Louder in
inspiration.
 Characteristic Diastolic Murmurs
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 Aortic regurgitation/insufficiency: high pitched,

blowing, best heard along LSB, 2nd/3rd ICS,
decreshendo, begins with S2, radiates down LSB. Best
heard with diaphragm.
 Mitral stenosis: low pitched, rumbling, best heard at
apex, mid diastolic. Best heard with bell- easily
missed with diaphragm.
Thank You