Heart Sounds & murmurs

Index: Red: important Grey: extra information Green: doctor’s notes yellow: numbers Purple: only in female slides Blue: only in male slides

Physiology 437 teamwork 2 OBJECTIVES

by the end of this lecture you will be able to: ▹ List the major types of normal ▹ Understand the physiological basis for the production of normal heart sounds ▹ Understand the pathophysiological basis for the production of heart murmurs. Heart Sounds Windows

3 ▹ Detected over anterior chest wall by 2 methods:- ▹ 4 heart sounds can be detected: 1. (). - 1st & 2nd heart sounds (usually audible). 2. Phonocardiography (sound recording device). - 3rd & 4th heart sounds (sometimes detected).

ONLY in male’s slides:

○ Ventricular Systole is between First and second heart sounds. ○ Ventricular diastole is between Second and First Heart sound.

▹ Aortic area: ▹ Mitral (bicuspid) area: 2nd Rt costal cartilage. 5th Lt intercostal space crossing mid-clavicular line, or 9cm (2.5-3 inches) from sternum. ▹ Pulmonary area: 2nd Lt intercostal space. ▹ Tricuspid area: lower part of sternum towards Rt side. S1 Due to closure of Recorded at the It marks Long in duration 0.15 sec. Of (25-35 Hz) Best heard at the A-V valves. beginning of the beginning low pitch (LUB). ~(25-45 Hz) Mitral & 4 ‘isovolumetric of Its is heavier when Tricuspid contraction ventricular compared to the 2nd areas. phase.’ systole. heart sound.

S2 Due to closure of Recorded at the Marks the Short in duration .. 50 Hz. Best heard at semilunar beginning of the beginning 0.11-0.125 sec. ~(0.12 sec) Of Aortic & valves. ‘isovolumetric of high pitch (DUB). Pulmonary relaxation phase’. ventricular areas. Soft & Sharp (compared to diastole. the 1st heart sound)

Splitting of the 2nd Heart Sound ▹ S2 splits physiologically into 2 sounds during inspiration = Physiological Splitting. ▹ This splitting occurs due to delay closure of pulmonary valve.

S1 S1 S1 S1 S1 S2 S2 S2 S2 S2 ONLY in male slides

▹ 5 Physiological splitting of S2 ▹ Fixed splitting of S2 1. During inspiration, the aortic valve closes before pulmonary valve → 1. Splitting of S2 is heard in both reduplication (physiologic splitting during inspiration and of S2. expiration, with the aortic 2. The increased venous return to valve closing before the the right side of the heart pulmonary valve. delays closure of the pulmonary 2. This is heard in cases of ASD.(atrial valve. The right ventricle has septic defect) more blood than usual to eject and it thus takes more time. 3. No splitting of the second heart sound is normally seen during Mitral : long black expiration. line Tricuspid: short black line ONLY in male slides

▹ 6 Wide splitting of S2 ▹ Paradoxical (reversed) splitting of S2 A split in the second heart sound during Reversed (paradoxical) splitting of the inspiration may become wider and the split second heart sound is typically heard may also be seen during expiration if: during expiration, with the pulmonary 1. There is a delay in the closing of the valve closing before the aortic valve. No pulmonic valve (as would be seen in right splitting is apparent during inspiration, bundle branch block due to delay in right since the pulmonary valve is closing ventricular depolarization and earlier (relative to the aortic valve) than contraction). normal. This may be caused by the following: 1. Delayed onset of left ventricular systole (example: left bundle branch block). 2. Prolonged left ventricular systole (examples: aortic 2. The aortic valve closes earlier than stenosis, severe hypertension, left-sided congestive normal (this is seen with either mitral heart failure). regurgitation or ventricular septal defect). 3. Early onset of right ventricular systole (example: Wolff-Parkinson White syndrome). Types of S2 Splitting… 7 Extra Figure 3rd Heart Sound =S3 4th Heart Sound =S4 8 ▹ Recorded during the ‘rapid filling ▹ Recorded during ‘atrial systole’ (just phase’ due to rush of blood before S1). into the ventricle. ▹ S4 is usually not audible (very low ▹ S3 is usually not audible (very low pitch.) pitch.) ▹ 0.04 sec. ▹ 0.05 sec. ▹ Frequency: < 20 Hz. ▹ Frequency: 20-30 Hz ▹ Heard in elderly (?). ▹ Heard in children (?). ▹ Best heard at Mitral area. ▹ Best heard at Mitral area.

ONLY in male slides: ○ Third and are low pitched sounds therefore not audible normally with stethoscope ○ S4 may be heard in elderly but is usually pathologic in the young.(opposite of S3) Significance of Heart Sound What make noise in the heart 9 Important for diagnosis of heart murmurs.

Closure of valves of the Increased intra-cardiac heart hemo-dynamics Abnormal extra heart sounds heard during the heartbeat cycle . Blood striking the left 1)Atrio-ventricular ventricle = (S3, S4) Produced by turbulence (abnormal patterns) of (Mitral & Tricuspid) blood flow through the heart & its valves. valves= (S1) •Increased flow across normal valves. Murmurs are longer than heart sounds. • Turbulent flow Semilunar (Aortic & through an abnormal Pulmonary) valves= valve. (S2) • Turbulent flow through septal defect.

Murmurs

ONLY in male slides Physiological VS Pathological How to describe Heart Murmurs 10 Murmurs Physiological Murmurs: Pathological Murmurs: ▹ Timing (systolic or diastolic)

▹ Shape Increase blood flow across Turbulent flow through normal valves: abnormal valves, or septal defect…..Congenital? ▹ Location ONLY in male slides: e.g.:- e.g:- ▹ Radiation Gallop: ○ Pregnancy ○ Tight valve (stenosis) ○ Hyperthyroidism (narrowing): the valve does Three or four sounds ○ Anemia not open properly. ▹ Intensity are spaced to audibly ○ Fever ○ Leaky valve (regurgitation or resemble the pace of a ○ Children insufficiency): The valve fails ▹ Pitch horse, the extra to close completely, and sounds occurs after hence causing backflow or ▹ leaks of the blood across the Quality S2. insufficient valve. (Valvular insufficiency is also known as Regurgitation or Incompetency). ○ A combination of Stenosis and Insufficiency. 1- Timing Systolic murmur ○ Between S1 & S2 Murmurs are described according to ○ Classified as early, mid, late, holosystolic 11 their position in the cardiac cycle:

▹ Systolic. ▹ Diastolic. ▹ Continuous.

Diastolic murmur ○ Between S2 & S1 ○ Classified as early, mid, late 12 2- Shape Murmurs are described according to the waxing & waning of the sound.

Crescendo (grows louder) Decrescendo Decrescendo-crescendo > increasing intensity > decreasing intensity

Crescendo-decrescendo (diamond shaped) Plateau (uniform) > increasing then immediate decreasing > the intensity of the murmur remains intensity. uniform throughout.

Diamond-shaped murmur. Describing a Heart 13 Murmurs…..Cont

4- Location of maximum 3- Radiation intensity (of heart murmurs) Reflects intensity of the murmur & direction of Determined by the site blood flow. where the murmur originates; e.g. Aortic, Pulmonary, Tricuspid, &

Mitral listening areas. 14 5- Intensity Graded on a (6) point according to :

VI

Classification of murmurs by loudness

Grade one: Grade two: Grade three: Grade four: Grade five: Grade six: -Lowest -Low intensity -Medium -Medium -Loud intensity -Loudest intensity -Quiet but intensity intensity -Heard with intensity -Very faint heard -Moderately -Loud stethoscope -No immediately loud -Thrill partly off the stethoscope chest needed -Thrills -Thrills ONLY in male slides

15 5- Intensity…cont.

Grading Of Heart Murmurs

1 Soft murmur heard in quiet surroundings.

2 Soft murmur heard in noisy surroundings. A thrill is a slight 3 Prominent heard murmurs. palpable vibration felt 4 Loud murmur with a thrill. by the hand over the chest wall. 5 Loud murmur heard with edge of the steth tilted against the chest + thrill

6 Loud murmur heard 5-10 mm from the chest + thrill. Describing a Heart 16 Murmurs…..Cont

8- Others: 6-Pitch: i. Variation with respiration. ▹ High ○ Murmurs increasing with ▹ Medium expiration originate with left side ▹ Low (aortic or mitral) valves, while murmurs increasing in intensity with inspiration originate with tricuspid or pulmonary valves. 7- Quality: ii. Variation with position of patient. ▹ Blowing iii. Variation with special maneuvers: ▹ harsh ○ Valsalva (forced expiration) → (hard) Murmurs in length (duration) & ▹ resonant intensity (of most murmurs) (rumbling) & musical ONLY in female slides

17 Systolic Murmurs

▹ Early Systolic ▹ Mid Systolic ▹ Late Systolic ▹ Pansystolic (holosystolic)

Derived from harsh & turbulence in blood flow.

Associated with: 1) Increased flow across normal valve. 2) Increased flow into a dilated great vessel. 3) Increased flow across an abnormal valve, or narrowed ventricular outflow tract. ○ e.g. aortic /pulmonary stenosis. 4) Increased flow across an incompetent AV valve. ○ e.g. mitral/tricuspid regurgitation. 5) Increased flow across the inter-ventricular septum. ○ e.g. VSD. Common Systolic Murmurs and Timing 18 1) Aortic stenosis – ejection murmur. 2) Pulmonary stenosis – ejection murmur (+2nd split) 3) Mitral / Tricuspid regurgitation – holosystolic. 4) Mitral valve prolapse – mid-late systole. 5) Ventricular septal defect (VSD) – holosystolic. ONLY in female slides

Ejection (Mid- Systolic) Murmurs: Pan-Systolic (Holosystolic) Murmurs: Most common kind of . Usually Pathological murmur. crescendo-decrescendo. Begins immediately with S1 & continues up to S2 They may be: Heard with: 1) Innocent: Common in children & young adults. ▹ Mitral/tricuspid regurgitation. 2) Physiological: Can be detected in ▹ Ventricular septal defect (VSD) hyper-dynamic states. ○ e.g. anemia,pregnancy, fever & hyperthyroidism. 3) Pathological: Secondary to structural CV abnormalities. ○ e.g. Aortic/pulmonary stenosis, Hypertrophic cardiomyopathy & mitral prolapse. ONLY in female slides Systolic Murmurs Video of (Heart Murmurs) 19 Duration (12) mins Aortic Stenosis Mitral Prolapse Mitral Regurgitation

Cause Obstruction of flow from LV into Bulging of 1 or 2 mitral valve Retrograde flow from LV into LA ascending aorta. leaflets into LA during LV systole. through an incompetent mitral valve.

Timing Mid-systolic murmur. Mid-late systolic murmur. Holosystolic murmur.

Location Best heard on aortic area, radiates Best heard at the apex. Best heard at apex, radiates to left along carotid . axilla.

Character Harsh, loud, may have associated Mid systolic click. Soft, high-pitched, blowing. with thrill, “ejection click.”

Association Old age, bicuspid aortic valve, ~5% normal population, MV prolapse, or myxomatous . asymptomatic, ? Sudden death. degeneration, rheumatic heart disease, . In Summary 20 Common Diastolic Diastolic Murmurs Murmurs & Timing

▹ Almost always indicate heart disease. ▹ Soft, blowing, gurgle Two basic types: 1. Aortic regurgitation → early diastole. 1. Early decrescendo diastolic murmurs: 2. Mitral stenosis → mid to late Signify regurgitant flow through an incompetent (pre-systolic) diastole. semilunar valve. e.g. aortic/pulmonary regurgitation.

2. Rumbling diastolic murmurs in mid- or late diastole: Suggest stenosis of an AV valve. e.g. mitral/tricuspid stenosis. ONLY in female slides Diastolic Murmurs 21 Aortic Regurgitation Mitral Stenosis

Cause Retrograde flow from aorta into LV through Obstruction of flow from LA to LV (Valve incompetent aortic cusps. becomes narrowed, thickened & calcified).

Timing Diastolic (early) murmur. Diastolic (mid-diastolic, or pre-systolic) murmur.

Location Best heard at 2nd-4th left intercostal spaces. Best heard at apex.

Character High-pitched, blowing, decrescendo. Low pitched (heard with bell).

Association Aortic root degeneration, rheumatic Rheumatic fever. heart disease, VSD with aortic valve prolapse (kids). 22 Murmurs of Ventricular Septal Defect & Patent Ductus Arteriosus

Ventricular Septal Defect Patent ductus arteriosus ONLY in female slides

23 Murmurs of Ventricular Septal Defect VS Patent Ductus Arteriosus

Ventricular septal defect Patent ductus arteriosus

Cause A congenital condition associated with abnormal Failure of closure of duct (ductus arteriosus) between blood flow between the left ventricle and the right pulmonary & aorta ventricle

Timing Holosystolic murmur, may be diastolic murmur due Continuous murmur to turbulent flow through mitral valve

Location Best heard at tricuspid area Best heard at upper left sternal border

Character A medium pitched murmur fills all of systole Machine-like.

Association Volume overload of right ventricle Left to right shunt, cyanosis ONLY in female slides

24 Summary

A. . ○ Mitral/Tricuspid stenosis. B. Mitral/Tricuspid regurge. C. Aortic ejection murmur. D. Pulmonic stenosis (spilling through S2 ). E. Aortic/Pulm. diastolic murmur. F. Mitral stenosis w/ Opening snap. G. Mid-diastolic inflow murmur. H. Continuous murmur of PDA. Summary 25 Summary Special thanks for 436 team

26 27 Quiz

1. Closure of AV valves causes which sound? 4. S1 sound is soft at which condition? A- S3 A- B- S2 B- C- S4 D- S1 5. This sound is usually heard in children: A- S1 2. Aortic regurgitation is best heard at which location? B- S2 A- apex of heart C- S3 B- pulmonary area D- S4 C- 2-4 left intercostal spaces D- aortic area 6. Which heart sound has long duration: A- S1 1.D 3. 4th lead of ECG (V4) is on the same location of: B- S2 2.C A- aortic area C- S3 3.B B- mitral areas D- S4 4.B C- pulmonary area 5.C D- tricuspid area 6.A 28 Quiz

7. physiological splitting of S2 sound is heard at: A- inspiration only B- both inspiration and expiration C- expiration only

8. which of the following causes a mid-late systolic murmur? A- aortic regurgitation B- aortic stenosis C- mitral regurgitation D- mitral prolapse

9. which valvular abnormality causes the disappearance of pressure difference between LA and LV? A- aortic regurgitation 7.A B- aortic stenosis 8.D C- mitral regurgitation 9.C D- mitral stenosis

Thank you for checking our work 29 Team Leader: Male Team: Female Team:

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