1. The First Heart Sound (S1) Chapter 7
Ara G. Tilkian, MD, FACC
Instructor
Patricia L. Thomas, MBA, RCIS

2. Outline Components of S1 How to recognize S1 at Rapid Heart Rate
Physiological Splitting of S1
Differential Diagnosis
S1 as a Single Sound
Factors Influencing the Intensity of S1

3. Components of S1 Marks the mitral (M1)and tricuspid (T1) closure
Loudest heart sound
High frequency components
Vibrations set up in the valve cusps, chordae, papillary muscles and ventricular walls before aortic ejection

4. Where to Listen
Listen with the diaphragm & bell of the stethoscope at the apex & 4th left intercostal space

5. How to Recognize S1 at Rapid Heart Rates
During Auscultation
Slow Heart Rates
Defines the onset of systole which is of shorter duration than diastole
Rapid Heart Rates > 130 b/m
Palpate the Carotid artery: S1 precedes the palpable arterial upstroke
S2 immediately follows this pulse

7. Differential Diagnosis
Sounds of the Cardiac Cycle In Perspective
Pathological Splitting of S1
The S4-S1 Combination
S1 Followed by an Ejection Sound
The Presystolic Murmur-S1 Combination

8. Sounds of the Cardiac Cycle in Perspective

9. Physiological Splitting of S1

10. Factors Influencing the Intensity of S1
Any condition that increases the force of ventricular contraction
Shortens, the PR interval
Brings the heart closer to the chest wall makes S1 louder (loud in children and young adults)
When heart rate is normal, a loud S1 should alert the examiner of a possible short PR interval.
Ventricular Contractility
Pathological alteration of the cardiovascular system

11. Ventricular Contractility
Influence by the contractility of the Left Ventricle than by the Right Ventricle
Enhanced Contractility
S1 is accentuated (anemia, fever, pregnancy, exercise, anxiety)
Poor Contractility
Decrease in the rate of pressure rise in the left ventricle, the first sound softens. (MI, cardiomypathies, shock)

12. The PR Interval Reflects AV conduction time
The time between atrial and ventricular contraction
The shorter the PR interval, the louder the first heart sound (mitral valve leaflets are wide open and deep within the ventricle when contraction begins causing the leaflets to close forcefully.
The longer the PR interval, the softer the first sound
The PR interval directly influences the position of valve leaflets at the onset of ventricular systole

14. Mitral Stenosis
Mobile mitral cusp, one of the first and most consistent diagnostic clues is a typically loud and slapping heart sound.
The loud S1 of mitral stenosis is caused by the closure of the mitral valve occurring on the steep upslope of the LV pressure curve during isometric contraction.
Short PR interval

17. Aortic Insufficiency S1 is diminished or absent in patients
Mitral valve may be prematurely closed when systole begins because of a long PR interval or high Lvedp
Pressures within the aorta a ventricle approach each other during diastole, isovolumic systole is either short or absent, causing a softening of S1

19. Mitral Regurgitation S1 absent or weak
Valve leaflets may fail to seal the AV opening during ventricular systole because of structural defects or widening of the valve ring.
Dissipation of LV pressure and the LA
Decrease in the rate of rise of LV pressure weakens the intensity of S1

20. The heart has been sectioned to reveal the mitral valve as seen from above in the left atrium. The mitral valve demonstrates the typical "fish mouth" shape with chronic,

21. Left Atrial Myxoma
S1 is loud in patients with mobile myxoma of the LA because of a delay in mitral valve closure
Echocardiography can provide a definitive diagnosis
Mechanism is similar to a short PR interval when the mitral leaflets are widely opened immediately before the onset of ventricular systole

23. THE END OF CHAPTER 7
Tilkian, Ara MD Understanding Heart Sounds and Murmurs,
Fourth Edition, W.B. Sunders Company. 2002, pp