1 Heart Sounds and Murmurs J.B. Handler, M.D. Physician Assistant Program University of New England

2 Abbreviations A- aortic P- pulmonic T- tricuspid M- mitral AV- atrioventricular SL- semi-lunar SB- sternal border ASD- atrial septal defect AR- aortic regurgitation AS- aortic stenosis TR- tricuspid regurgitation PVR- peripheral vascular resistance IO- interest only CHD- coronary heart disease MR- mitral regurgitation MS- mitral stenosis SEM- systolic ejection murmur MVP- mitral valve prolapse LBBB- left bundle branch block ICS- intercostal space RV- right ventricle LV- left ventricle LA- left atrium RA- right atrium PS- pulmonic stenosis PR- pulmonic regurgitation LLD-left lateral decubitus

3 Listening Points/Positions Aortic: “base”- 2 nd Rt ICS, SB Pulmonic: “base”- 2 nd Lt ICS, SB 3rd Lt ICS, SB Tricuspid: lower Lt sternal border(4-5ICS) Mitral: cardiac apex (LV) 5ICS, MCL Sitting, lying, left lateral decubitus (s3,4 gallops, and mitral stenosis) Internet sites for heart sounds:

Auscultation Areas

5 Heart Sounds S 1 - mitral/tricuspid valve closure. S 2 - aortic/pulmonic valve closure. Distinguishing S 1 vs S 2 -Listen at apex, palpate carotid-S 1 precedes carotid pulse. -Intensity of S 1 >S 2 at apex (reverse at base). -S 1 immediately precedes the PMI. S 1 occasionally splits with inspiration ( seconds)…difficult to hearMV closes before TV, accentuated with inspiration.

6 S 2 Splitting Commonly heard in inspiration (separation of A 2 and P 2 is Sec). A 2 normally precedes P 2 - accentuated in inspiration because RV volume increases, LV volume decreases………..why? Fixed splitting: ASD. Paradoxical splitting: Aortic valve closure is delayed, closes after pulmonic. P 2 precedes A 2. During inspiration they move together, in expiration they move apart. Examples: Aortic Stenosis, LBBB. IO

Splitting of 2 nd Heart Sound

8 3 rd Heart Sound vs S 3 Gallop 3 rd heart sound: Low pitched sound,.1-.2 sec post S 2. May be heard in young, healthy people. Reflects rapid inflow of blood into normal, compliant LV. S 3 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 S1S1 S2S2 S3S3

9 S 4 Gallop Almost always abnormal Short, low frequency, precedes S 1 “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 S4S1S2

10 Murmurs: Grading Scale 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.

11 Murmurs: Radiation 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

12 Murmurs: Description 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

14 Murmurs: Use of Maneuvers Respiration: Inspiration RV filling/volume. Murmurs arising from Rt 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.

15 Murmurs: Use of Maneuvers 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.

16 Murmurs: Maneuvers 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.

17 Characteristic Systolic Murmurs 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.

18 Characteristic Systolic Murmurs 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.

19 Characteristic Diastolic Murmurs Aortic regurgitation/insufficiency: high pitched, blowing, best heard along LSB, 2 nd /3 rd ICS, decreshendo, begins with S 2, 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.