Auscultation of The Heart Dr. R Auscultation of The Heart Dr. R. Tandon Sitaram Bhartia Institute, New Delhi

First Sound (S1) Due to closure of MV/TV Accentuated, diminished or variable intensity Wide split – Rt. BBB.

First Sound (S1) Accentuated : Loud M1 Tachycardia Short PR interval Mitral stenosis VSD, PDA. LVH Loud T1 : ASD, TAPVC Tricuspid Stenosis

First Sound (S1) Diminished :- S2 > S1 at apex.  LV contractility 1° AVB AR

First Sound (S1) Variable Intensity Comp. AVB Atrial fibrillation.

Second Sound Normal :- Two components A2 & P2 A2 louder than P2 Insp.; split S2; A2-P2 Exp. : Single S2 A2 all over the precordium P2 - 2-3 ULSB

Second Sound Abnormalities : A2 or P2 Intensity : Increased or decreased Timing : Early or late

Second Sound Splitting :- Normal. W&V - PS, PAPVC - IAS, MR, VSD W&F - ASD, TAPVC, Rt. BB, WPW(A) Single - A2 or P2 or A2 + P2 Paradox - AS, PDA, LVF, Lt. BB, WPW (B)

Third Sound (S3) End of early diast. filling. Dull, 50 to 100 msec after S2. Normal in children and young adults Abnormal above 40 yrs. Left or right sided.

Fourth Sound Abnormal if audible. Rt. / Lt. sided Rt. / Lt. atrial hypertension (high RV/LV edp). Audible intermittently in comp. AVB. Acute MR - S4+.

Systolic Clicks (x) Loud sharp sounds Ejet. or Non-eject. Eject – Aortic, pulmonary – single. Non-eject - MV / TV prolapse - single or multiple.

Systolic Clicks Aortic : Constant, early Heard all over the precard Bicuspid AoV. Dilated Asc, Ao Syst. hypertension, aneurysms Fallot’s physiology, PTA. Disapear - fibrosis, calcification.

Systolic Clicks Pulmonary :- PS or PAH at ULSB. PS - Valvar PS - Audible in expirat. only -  severity - closer to SI PAH - PVOD - Constant

Systolic Clicks Non-Ejection : MVPS Single or multiple. Mid systolic but can be early - radiates to base and neck Late murmur ±

A2 P2 S1 X Syst. m.

Opening Snap Mitral, diast. sound 40-120 msec after A2 A2-OS interval - severity Disappears in immobile valves Tricuspid OS drowned in MSm.

Murmur Systolic - Pansystolic. Ejection systolic Diastolic * Semilunar valves - Regurgitant m. Early diastolic m. * Atriovent. Valves - Functional m. - Obstructive m. Delayed diast. (Middiast.) Late diast. (Presyst.) Continuous

S1 X A2 ES. m. AR. m.

S1 X A2 P2 ES. m. PR m.

S1 X A2 P2 ES. m. PR. m.

S1x S2 S1 x Cont. m.

S1x S2 S1 Cont. m.

Auscultation Clinical Utility :- Murmurs present. Murmurs absent.

Auscultation Clinical Utility :- Murmurs absent Myocardial disease - Primary – DCM, RCM, HCM - Secondary to CAD Pericardial disease Utility of S3, S4, S2, S1

Auscultation Clinical Utility :- Murmurs present Cong. Ht. Dis. Rh. Ht. Dis. PMD - DCM – MR/TR HOCM - Outflow m. - MR. m. Post M.I. - MR / VSD.

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