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INTERPRETATION OF HEART SOUNDS A Workshop: Review Your Knowledge and Build your Skills INTERPRETATION OF HEART SOUNDS Virginia Joslin, PA-C, MPH and Karen.

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Presentation on theme: "INTERPRETATION OF HEART SOUNDS A Workshop: Review Your Knowledge and Build your Skills INTERPRETATION OF HEART SOUNDS Virginia Joslin, PA-C, MPH and Karen."— Presentation transcript:

1 INTERPRETATION OF HEART SOUNDS A Workshop: Review Your Knowledge and Build your Skills INTERPRETATION OF HEART SOUNDS Virginia Joslin, PA-C, MPH and Karen Newell, PA-C, MMSc Emory DFPM www.emorypa.org

2 Workshop Goals: To enhance the learner’s knowledge and skills in heart sounds interpretation for improved clinical practice and performance on the Board Certification exam a) using physical exam techniques focusing on auscultation effectively and b) critically analyzing a narrative description of heart exam findings

3 Learner Objectives By the end of the workshop, the learner will be able to: 1. Describe the critical cardiac anatomy and physiology as it relates to heart sounds. 2. Utilize the stethoscope properly to maximize your ability to pick-up subtle sounds. 3. Recognize the common causes of heart murmurs. 4. Interpret heart sounds based on timing, location, radiation, pitch, and changes in quality with specific exam techniques. 5. Provide a differential diagnosis for the etiology of extra heart sounds. 6. Identify the heart abnormality or diagnosis, given a classic description of case presentation with risk factors, history and physical exam findings.

4 Organize your critical thinking skills! Case Presentation Mr. N. Trouble is a 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. On exam of the heart you note: an enlarged, hyperdynamic PMI displaced infero- laterally, a thrill over the apex, an S4, S3, and a grade IV/VI holosystolic murmur heard best with the diaphragm at the apex.

5 Case Presentation What is the most likely diagnosis? What is the likely cause of this condition in this patient?

6 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Surface Anatomy: Key Landmarks Sternal Angle MCL 2 ICS@LSB 5 ICS@ L. MCL Erb’s Point Erb’s Point

7 Heart wall layers and pericardium Inter-atrial and Inter- ventricular Septum Valves Chordae Tendineae and Papillary muscles Cardiac conduction system Other Relevant Cardiac Anatomy

8 Cardiac Conduction System Organizer of the cardiac physiological events

9 Emory University Physician Assistant Program Tricuspid Valve is closed Mitral Valve is closed A & P Valves Open -- M & T Valves Closed http://upload.wikimedia.org/

10 Emory University Physician Assistant Program M & T Valves Open -- P & A Valves Closed P A / http://upload.wikimedia.org/

11 12 3 4 56 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens with permission M & T open M & T closeA & P openA & P close

12 S4 A complete cycle of physiologic cardiac events Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens S1 EjCl Ventricular Pressure Atrial Pressure Aortic Pressure S1

13 Quiz Which valves are normally closed during systole? A. Aortic and Pulmonic B. Tricuspid and Mitral C. Aortic and Mitral D. Tricuspid and Pulmonic

14 Answer: B T&M valves During Systole: the Aortic and Pulmonic valves are OPEN The Tricuspid and Mitral valves are CLOSED

15 Cardiac Exam Inspect Palpate Auscultate

16 Normal Heart Sounds Valve Closure S1 (closure of Mitral and Tricuspid valves) S2 (closure of the Aortic and Pulmonic valves) High pitched: heard best with the Diaphragm Which is S1? S2? (location where best heard, rhythm, timing compared to the carotid pulse and JVP waves )

17 S2 S1 S2 = A P valves S1 = M T valves Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Base Apex

18 Split S2 with inspiration, heard best with diaphragm near 2 nd and 3 rd ICS at the LSB Normal Splitting of S2 with Inspiration Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens Expiration Inspiration

19 Quiz Upon auscultation of heart sounds, where is S2 normally heard the loudest? A. Base B. Apex C. Erb’s Point D. 2 nd ICS @ the LSB

20 S1 S1 = M&T valve closure Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Apex S2 Base S2= A&P valve closure S2 is loudest at the base of the heart since this sound results from the closure of the Aortic and Pulmonic valves o The pressures on the left side of the heart are higher than on the right, thus the Aortic valve closure sound predominates ( A / P **Answer: B S2

21 Which of the following best describes the normal splitting of S2? A. S2 is split into 2 components with expiration B. S2 is split into 2 components with inspiration C. Split S2 is heard best at the apex D. Split S2 is heard best at the aortic valve region

22 Answer: B If present, a split S2 is best heard near Erb’s Point (3 rd ICS @ LSB or over the Pulmonic valve area (2 nd ICS@LSB) and During Inspiration, venous return of blood to the right side of the heart, slows the right-sided physiologic events, causing a delay in the closure of the pulmonic valve. A Split S2 during expiration is pathological !

23 Abnormal Heart Sounds Discrete sounds: Split S2 (pathological) Gallops (S3 and S4) Clicks (ejection) Snaps (opening) Continuous sounds: Murmurs Friction Rubs PDA

24 Wide splitting Fixed splitting Paradoxical Splitting Adapted from Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Expiration Inspiration S2 P 2 A 2

25 What physiologic event normally occurs early in Systole? Extra Sounds in Systole: Ejection Clicks Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

26 What physiologic events normally occur early in Diastole? Extra Sounds in Diastole: Snaps Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

27 Extra sounds in early in Diastole: Gallops Early Diastolic Sound: S3 Heard best with the Bell Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

28 Late Diastolic Sound: Gallop Late diastolic sound: S4 Best heard with the Bell Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Summation Gallop ( S3+S4)

29 Quiz Which of the following best describes an ejection click? A. Occurs early in diastole and is best heard with the diaphragm B. Occurs late in diastole and is best heard with the bell C. Occurs early in systole and is a high pitched sound D. Occurs early in systole and is a low pitched sound E. A normal heard sound that occurs when the A&P valves open

30 Answer: C An ejection click is an abnormal heart sound, classically described as high-pitched, which occurs early in systole, when a stiff aortic or pulmonic valve opens Systole

31 Identify the Extra Heart Sound ! Is the extra sound continuous (murmur) or discrete(clicks, snaps, split S1or S2, Gallops, rubs) Is the extra sound in systole or diastole? Systole (between S1 and S2) Carotid pulse quickly follows S1 “A” wave (atrial kick) in the JVP is quickly followed by S1 Systole is shorter than diastole Which valve(A/P/T/M) location do you hear the sound best? Do you hear it better with the bell or the diaphragm (high [click, snap, split S1 or split S2] or low pitched [S3,S4])?

32 Discrete Sounds Which space between the heart sounds represents Systole ? Which bars represent S1? A B A B

33 Extra Sounds Systolic vs. Diastolic S2S1S2 DiastoleSystole  Carotid pulse “A” wave “V” wave

34 Systolic Extra Sounds S2 S1S2 DiastoleSystole Where heard best? Bell or diaphragm? Constant or varies with respiration? Apex/ diaphragm =Split S1 

35 Systolic Extra Sounds S2S1S2 DiastoleSystole Where heard best? Bell or diaphragm? Constant or varies with respiration? Base / diaphragm = Ej. click (A or P) 

36 Diastolic Extra Sounds S2 S1 S2 DiastoleSystole Where heard best? Bell or diaphragm? Constant or varies with respiration? Opening snap (location/pitch) vs. split S2 (location/pitch/varies with respiration) vs. S3 vs. S4 (location/pitch)

37 Causes of Murmurs ( turbulent flow ) Partial obstruction Dilated chamber Backward flow Shunting Increased output or increased stroke volume

38 Assessment of Murmurs Timing of the murmur Systolic Events Diastolic Events S1 _________S2_______________ S1 Systole Diastole

39 Location of the Murmur Best heard where ? Aortic Pulmonic Tricuspid Mitral (Apex) Radiates to where? R. Neck, L. Neck L. Axilla Back Sound follows the direction of flow AP M T

40 Other Qualities of Murmurs Intensity (Grade I – VI) Soft to loud (if thrill present, Grade is =/> IV) Pitch (high, medium, low) Musical Quality Rumbling Cooing Blowing (Regurgitant murmurs) Shape (change in intensity) Crescendo Decrescendo

41 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams & Wilkens Crescendo Decrescendo Crescendo- decrescendo Plateau Shape

42 Factors Changing Murmurs Respiration (increase venous return with inspiration; ↑ in intensity of the murmurs of T.S. and P.S., but ↓ in intensity with T.R. and P.R. Exercise (increase flow>>>> increased intensity) Position decubitus brings out mitral murmurs leaning forward brings out the murmur of AR Valsalva or Standing (decreases venous return) Squatting (increases venous return)

43 Physical Exam Pulses Pulses: : slow and delayed carotid pulse with severe AS; bounding with AR; Emory University Physician Assistant Program

44 Other PE Clues Pulses: bounding carotid pulse (AR) decreased, delayed carotid pulse(AS) decreased with outlet obstruction or weak(heart failure) Pulsus alternans with L.Ventricular failure Fundus: Roth spots, splinter hemorrhages (Endocarditis) Lungs: crackles (heart failure )

45 Physical Exam: Pulses Paradoxical pulse with constrictive percarditis/tamponade Femoral pulse delay and BP in legs < in arms (Coarctation of the aorta) Emory University Physician Assistant Program Rib notching

46 Physical Exam Skin, Nails Nail clubbing (chronic hypoxia) Petechiae, splinter hemorrhages – Endocarditis Osler’s nodes- finger tips - Endocarditis Janeway lesions- palms and soles- Endocarditis Pedal edema- Right heart failure Emory University Physician Assistant Program Janeway Lesion Osler Node aapredbook.aappublications.org

47 Other PE Clues General appearance: Tall, thin with long limbs (Marfan’s); Willowy, thin chest wall (Mitral Valve Prolapse) Head bobbing (Severe AR) Pale (Anemia) Blue (anoxia with congenital heart defects) Vitals: Low BP with dehydration, Severe Heart Failure, MI Pulse pressure wide (AR); narrow(AS) Tachycardia with infection Bradycardia with AV blocks Jugular veins: distended, elevated JVP (R heart failure, PericardialTamponade) Giant A wave (TS) Large v wave (TR) Point of maximal intensity(PMI): enlarged, displaced, hyperdynamic, sustained (L. Heart Failure, LVH, AS, AR, MR)

48 Physical Exam JVP JVP reflects RA pressure : ↑ JVP with R. Heart Failure, Constrictive Pericarditis, Cardiac Tamponade; Large A wave-with Tricuspid Stenosis, large V wave with Tricuspid Regurgitation Emory University Physician Assistant Program

49 Physical Exam Abdomen (ascites, pulsatile liver, hepatomegaly- R Heart Failure) Extremities – pedal/lower extremity edema(R heart failure), pale distally (Arterial Insufficiency) Emory University Physician Assistant Program

50 Quiz Which of the following valve abnormalities may cause an enlarged displaced PMI A. Mitral Stenosis B. Pulmonic Stenosis C. Aortic Stenosis D. Tricuspid Stenosis E. Ventricular Septal Defect

51 Answer: C Aortic Stenosis will cause left ventricular hypertrophy, enlarging (>2.5 cm) and displacing the PMI leftward and inferiorly from the normal location (L. 5 th ICS MCL) Mitral Stenosis will enlarge the left atrium Pulmonic Stenosis will enlarge the right ventricle (sternal lift) Tricuspid Stenosis will enlarge the right atrium and cause abnormalities (elevated, giant “A” wave) of the JVP VSD causes enlargement of the right ventricle due to the higher pressures in the left ventricle resulting in a left to right shunting of blood and eventually RVH. (sternal lift)

52 Systolic Murmurs Innocent and Physiological Murmurs Anemia, Pregnancy, Fever, Hyperthyroidism Normal Flow Direction through valves Aortic and Pulmonic Stenosis Idiopathic Hypertrophic Subaortic Stenosis Holosystolic Murmurs Backward Flow through incompetent valves or a Ventricular septal defect Mitral and Tricuspid Regurgitation Ventricular Septal Defect Backward flow around billowing valve leaflets; but closed valve Mitral Valve Prolapse

53 Low-grade flow murmurs Adapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Systolic Murmurs Still’s murmur (innocent): child usually 3-6 years, mid-systolic, vibratory, heard at left sternal border to apex, disappears or ↓ with sitting/standing

54 Best heard at the Aortic area; Ejection shaped murmur, radiates to the right clavicle/ neck; May have EjCl, Narrowed Pulse Pressure, diminished delayed carotid upstroke, S4 PMI abnormalities Adapted from: Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens

55 Best heard at the Pulmonic area, ejection type murmur, radiates to the left neck, ↑ in intensity with inspiration Might have: Ej Cl over the pulmonic area, right-sided S4, sternal lift, JVP abnormalities Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Split S2 with Inspiration

56 subaortic hypertrophy From: Mosby’s Guide to Physical Examination Seidel H, Ball J.Dains J, Benedict GW IHSS

57 Google images Other generalized Cardiomyopathies

58 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens The intensity of this murmur increases with the valsalva!

59 Other Systolic Murmurs Backward direction of flow at a competent mitral valve, but the mitral leaflets billow Mitral valve prolapse Click-murmur or Click alone or Murmur alone Confirm by auscultating over the Mitral region while standing and squatting, or change with the valsalva maneuver Valsalva/Standing lengthens the murmur; Squatting shortens it mitral valve leaflets chordae tendinae

60 Holo/Pansystolic Murmurs 1. Mitral Regurgitation (Apex, radiates to the L. axilla or scapula) 2. Tricuspid Regurgitation (LLSB, JVP abnormalities) 3. Ventricular Septal Defect (lower sternum, Sternal lift)

61 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens M&T areas close together, Both are “blowing”! Radiation direction! radiation Apex R sided

62 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens R-sided S4 +/- Sternal lift

63 Which of the following conditions would cause a holosystolic murmur? A. MS B. AS C. ASD D. MR E. AR

64 Answer: D Holosystolic murmurs include: Tricuspid Regurgitation Mitral Regurgitation Ventricular Septal Defect

65 Diastolic Murmurs Possibilities during ventricular filling:  Normal direction of flow through narrowed valves  Mitral and Tricuspid Stenosis  Backward flow through incompetent valves  Aortic and Pulmonic Insufficiency M T A P

66 Diastolic Decrescendo- Crescendo Murmur +/- Opening Snap Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Compare to Tricuspid Stenosis! Both have low-pitched murmurs, may have an OS TS: murmur ↑ with inspiration/squatting, +/- giant A wave

67 Diastolic Decrescendo Murmur Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Blowing murmur, heard from Aortic area to the apex, S4,+/- S3, PMI abnormalities, wide pulse pressure, bounding or pulsus alterans of the carotid pulse, +/- head bobbing. Murmur may intensify as the patient leans forward and exhales

68 Sounds heard in both Systole and Diastole Pericardial Friction Rub Patent Ductus Arteriosus Venous Hum

69 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens High pitched, scratchy, LLSB & apex, 3 components (2 in diastole), best heard with patient leaning forward

70 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott William s& Wilkens PDA Machinery like, in neonates, S2 may be masked

71 Bickley, Lynn S, Bate’s Guide to Physical Examination and History Taking. Lippincott Williams& Wilkens Continuous hum heard over the Jugular vein above the clavicle; sound disappears when the Jugular is compressed

72 Quiz 1.You hear this extra systolic sound clearly at the 2 nd & 3 rd left ICS with the diaphragm, but only with inspiration. ____ 2. You hear this extra early diastolic sound only with bell at the apex in both inspiration and expiration in a healthy child._____ 3.You auscultate an ejection murmur at the 2 nd ICS RSB, which radiates to the right neck. What is the timing of the murmur ? 4.The intensity of a systolic murmur heard best at the 2 nd ICS RSB seems to increase during the Valsalva maneuver. What is the likely heart abnormality? _____________

73 1. PHYSIOLOGIC SPLIT S2 2. S3 3.SYSTOLE 4. IHSS NOTE: AORTIC STENOSIS IS ALSO BEST HEARD AT THE 2 ND ICS OF THE RSB, RADIATES TO THE RIGHT NECK. VALSALVA MANEUVER DECREASES THE BLOOD FLOW BACK TO THE HEART INCLUDING TO THE LEFT VENTRICLE, ↓ ING THE INTENSITY OF THE MURMUR OF AS, BUT ↑ ING THE MURMUR OF IHSS (AREA OF HYPERTROPHY BULGES INTO THE OUTFLOW TRACT CAUSING TURBULENCE Answers

74 Case Presentations 33 y. o. pregnant female with a new systolic murmur Grade 2/6 mid-peaking ejection murmur heard best at the left sternal border unchanged during respiration no other abnormal heart findings

75 Physiological Murmur Increase blood volume and flow through the aortic valve with pregnancy

76 26 y.o. I.V. drug abuser with fever and a new systolic murmur Systolic Murmur AS, PS MR, TR (holosystolic), VSD MVP Fever suggests infection! Look for Roth spots, petechea, splinter hemorrhages, Osler nodes, Janeway lesions Drug abuse most commonly effects Right heart valves ( T/P) ( forward or backward flow?) The murmur increases with inspiration, is heard best at 2 nd LICS at the SB, radiates to the Left clavicle/neck and is mid-peaking

77 Pulmonic Stenosis

78 18 y.o. basketball “phenom” with episodes of C/P associated with palpitations, SOB. You auscultate a systolic murmur ! Systolic Murmur AS, PS MR, TR ( holosystolic), and MVP You wisely auscultate at the apex and hear a click- murmur. You have the patient squat and the murmur decreases in intensity and shortens. Upon standing the murmurs gets louder and longer. Q: Would you like to order any additional test?

79 Symptomatic Mitral Valve Prolapse

80 Neonate with a Holosystolic murmur Three causes of Holosystolic/Pansystolic Murmurs MR (Heard best at the Mitral valve(apex) area, radiates to __?; may have an S4 and enlarged PMI) TR (Heard best at the Tricuspid area, decreases in intensity with inspiration) Check the JVP for elevation, large “v” wave VSD (radiates widely across the sternum, may have a sternal lift)

81 In a Neonate, VSD is most common ! Note: The size of the defect does not correlate with the intensity of the murmur

82 Mr. N. Trouble S: 64 y.o. homeless man with a history of worsening chest pain and DOE for the last 3 months. He has developed a nonproductive cough and orthopnea without fever. O: On PE of the heart you note: an enlarged, hyperdynamic PMI displaced inferiorly and leftward, a thrill over the apex, an S4, S3,and a grade IV/VI holosystolic murmur, heard best with the diaphragm at the apex.

83 Mr. N. Trouble A: D.Dx. MR, TR, VSD Clues on history : homeless, C/P with DOE, orthopnea and nonproductive cough Clues on physical exam: LVH, at least a Grade IV/VI holosystolic/pansystolic murmur heard best at the apex. Which of the three valves abnormalities in your D.Dx is most likely, and what condition is the result of the valve problem?

84 Mitral Regurgitation Mitral Regurgitation Auscultate at the axilla to confirm! He has developed CHF.

85 Helpful Web Resources http://www.blaufuss.org/tutonline.html http://www.medstudents.com.br/cardio/heartsounds/heartsou.htm http://www.auscultation.com/ http://www.medstudents.com.br/cardio/heartsounds/heartsou.htm http://filer.case.edu/~dck3/heart/listen.html - Murmurs http://texasheart.org/Education/CME/explore/events/eventdetail_5469.cf m http://texasheart.org/Education/CME/explore/events/eventdetail_5469.cf m Visit our website: www.emorypa.org or call us at 404 727-7825www.emorypa.org


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