1. DIFFERENTIAL DIAGNOSIS OF HEART SOUNDS

2. DIFFERENTIAL DIAGNOSIS OF HEART SOUNDS
In clinical cardiology:
Systole – period of ventricular contraction
Diastole – period of ventricular relaxation

3. What Is a Heart Murmur?
These are abnormal sounds produced by turbulent blood flow in the heart caused by:
Abnormal valve function: stenosis or regurgitation
Increased volume or velocity of blood flowing through a normal valve such as during pregnancy, severe anemia, athletes
Flow of blood through communications such as ASD, VSD

4. Main signs Timing: systolic, diastolic or systolo-distolic
Duration: e.g. pansystolic or late-systolic
Site of maximum intensity
Radiation
Grading
Character
Relation with posture
Relation with respiration

5. Timing of murmur
You need to be differentiated by palpating the carotid pulse during auscultation
Systole starts with the first heart sound (coincides with the carotid pulse) and ends on second heart sound. Murmurs heard during this period are called systolic murmurs
Diastole is the interval between second and first sound and it does not coincide with the carotid pulse. Murmurs heard during this period are called diastolic murmurs

6. Duration of murmur б-protosystolic в-mid-systolic
г-late-systolic (tele-systolic)
д-pansystolic
е- golosystolic
ж-presystolic
з-protodiastolic
и-systolo-diastolic

7. Area of maximum intensity
Murmur may be audible all over the precordium but the maximum intensity of murmur is heard where it originates

8. Radiation
Murmur radiate in the direction of blood flow to the specific sites from the precordium. Usually the systolic murmur radiates.
When the area of maximum intensity has been noted, the stethoscope should be moved radically from this point in different directions to observe whether the murmur is localized or radiating to other of chest wall.

9. Grading of systolic murmur
Grade
Feature
Grade 1/6
So faint or soft that it is heard only with special effort
Grade 2/6
Soft, but can be detected almost immediately by an experienced auscultator
Grade 3/6
Prominent but not loud; no trill
Grade 4/6
Loud; thrill just palpable
Grade 5/6
Very loud; thrill easily palpable
Grade 6/6
Very, very loud

10. Grading of diastolic murmur
Grade
Feature
Grade 1
Very soft (heard only in good circumstances)
Grade 2
Soft
Grade 3
Moderate
Grade 4
Loud or associated with palpable thrill

11. Dynamic maneuvers Relation with respiration:
Murmurs of left side become louder during
expiration and murmurs of right side become
louder during inspiration.
Relation with posture:
Diastolic murmur of mitral stenosis is best heard in left lateral position while the diastolic murmur of aortic regurgitation is best heard when the patient sits and leaning forward.

12. Dynamic maneuvers (2) Valsalva’s maneuver
Listen over the left sternal border during
the maneuver for changes in systolic
murmur of hypertrofhic cardiomyopathy

13. Functional (innocent) murmur
These SM are produced due to change in velocity or viscosity of blood.
These SM are present in the absence of heart abnormalities, disappear on exercise, do not radiate, thrill is never present and there is no change in the loudness of murmur with change of osture or respiration.
Causes are:
Anemia, polycytemia
Fever
Cirrhosis
Thyrptoxicosis
Hypertension

14. Some common structural causes of systolic murmur
Position where murmur is best heard
Ejection (mid) systolic
Aortic stenosis
Pulmonary stenosis
Atreal septal defect
HOCM
Aortic area
Left sternal border
Left sternal border II-III LIcostal
Pan-systolic
Mitral regurgitation
Tricuspidal regurgitation
Ventricular septal defect
Apex
Left sternal border III-IV L Icostal

15. Some common structural causes of systolic murmur
Position where murmur is best heard
Late systolic
HOCM
Mitral valve prolapse
Coarctation of aorta
Accentuated on standing
Apex
Left sternal border

16. Some common structural causes of dyiastolic murmur
Position where murmur is best heard
Mid-diastolic
Mitral stenosis
Tricuspid stenosis
Austin-Flint murmur
Apex , patient on left side, accentuated on exertion
Left sternal border, accentuated on inspiration
Apex
Ealy diastolic
Aortic regurgitation
Pulmonary regurgitation
Graham-Stell in pulmonary hypertention (due to MS)
Left sternal border (III LIC, II aortic area and apex
Right of sternum, louder on inspiration
Left sternal border

17. Some common structural causes of systolic murmur
Position where murmur is best heard
Combined systolic and diastolic
Patent ductus arteriosus
Aortic stenosis and regurgitation
Left sternal edge

18. Types of Murmurs Innocent (harmless) murmurs
A person with an innocent murmur has a normal heart and usually has no other signs or symptoms of a heart problem. Innocent murmurs are common in healthy children.
Abnormal murmurs
A person with an abnormal murmur usually has other signs or symptoms of a heart problem. Most abnormal murmurs in children are due to congenital heart defects-heart defects present at birth. In adults, abnormal murmurs are most often due to heart valve problems caused by infection, disease, or aging.

19. Types of Murmurs Innocent murmurs Normal heart murmurs
Benign heart murmurs
Functional heart murmurs
Physiologic heart murmurs
Still's murmur
Flow murmur
Abnormal murmurs
Pathologic heart murmurs

20. Innocent Heart Murmurs
Innocent murmurs are heard when blood moves noisily through a normal heart. Sometimes these murmurs occur when:
Blood is flowing faster than usual through the heart and blood vessels attached to the heart.
An increased amount of blood is flowing through the heart.
Illnesses or conditions that can cause blood to flow faster than usual through the heart include:
Fever
Anemia
Too much thyroid hormone in the body (hyperthyroidism)
Innocent murmurs are sometimes due to changes to the heart resulting from heart surgery or from aging.

21. Abnormal Heart Murmurs
The most common cause of abnormal murmurs is congenital heart defects. Congenital heart defects occur when the heart, heart valves, or blood vessels attached to the heart do not develop normally before a baby is born.
Common defects that cause murmurs include:
Congenital septal defects, which are holes in the wall (septum) that separates the right and left sides of the heart. They account for more than half of abnormal murmurs in children.
Congenital valve defects, which include narrow valves that do not allow enough blood to flow through them and leaking valves that do not close properly.

22. Abnormal Heart Murmurs
Infections and other conditions that damage heart valves or other structures of the heart also may cause murmurs. Theses includes:
Rheumatic fever, a serious illness that can develop after a person has an untreated or incompletely treated infection caused by the bacteria that cause strep throat or scarlet fever. Rheumatic fever can lead to permanent damage to the heart. If your doctor diagnoses strep throat, be sure your child takes all of the antibiotics prescribed, even if he or she feels better before the antibiotics run out.
Endocarditis, an inflammation of the inner lining of the heart and valves that is usually caused by a bacterial infection. Endocarditis is a serious disease that can lead to permanent heart damage and other complications. Endocarditis usually occurs in an abnormal heart.
Calcification (hardening and thickening) of valves as a result of aging. The hardened and thickened heart valves do not work as they should.

23. PHYSIOLOGIC CLASSIFICATION OF SYSTOLIC MURMURS
A. Systolic ejection murmurs-forward flow across the left or right ventricular outflow tract.
B. Systolic regurgitate murmurs—regurgitates flow from a high-pressure chamber to a lower-pressure chamber
1. Pansystolic regurgitant murmurs (mitral and tricuspid regurgitation, ventricular septal defect, left ventricle to right atrial defect)
2. Early systolic regurgitant murmur (acute mitral regurgitation, tricuspid regurgitation secondary to isolated disease of the valve, small ventricular septal defect)
3. Mid and late systolic regurgitant murmurs (papillary muscle dysfunction, mitral and tricuspid valve prolapse)

24. PHYSIOLOGIC CLASSIFICATION OF DIASTOLIC MURMURS
A. Diastolic filling murmurs (rumbles)- forward flow across the atrio-ventricular valves.
Forward flow across a stenosed or obstructed atrioventricular valve (mitral or tricuspid stenosis, left or right atrial myxoma)
High flow across a normal atrioventricular valve (mitral flow rumble of a ventricular septal defect or patent ductus arteriosus, tricuspid flow rumble of an atrial septal defect, hyperkinetic states, complete heart block)

25. PHYSIOLOGIC CLASSIFICATION OF DIASTOLIC MURMURS
3. High flow across an incompetent atrio-ventricular valve without significant stenosis (flow rumble of mitral and tricuspid regurgitation)
4. Forward flow across a partially closed atrioventricular valve (presystolic murmur of mitral stenosis, Austin Flint murmur secondary to severe aortic or pulmonary regurgitation)
5. Combinations of 1 through 4

26. PHYSIOLOGIC CLASSIFICATION OF DIASTOLIC MURMURS
B. Diastolic regurgitant murmurs—regurgitant flow across an incompetent semilunar valve:
1. Pandiastolic regurgitant murmurs (aortic regurgitation and pulmonic regurgitation secondary to pulmonary hypertension)
2. Abbreviated diastolic regurgitant murmurs (acute aortic regurgitation, minimal aortic regurgitation)
3. Delayed diastolic regurgitant murmur (organic pulmonic regurgitation)

27. PHYSIOLOGIC CLASSIFICATIONS OF CONTINUOUS MURMURS
A. Continuous murmurs caused by rapid blood flow
1. Venous hum
2. Mammary souffle
3. Hemiangioma
4. Hyperthyroidism
5. Acute alcoholic hepatitis
6. Hyperemia of neoplasm (hepatoma renal cell carcinoma, Paget's disease)

28. PHYSIOLOGIC CLASSIFICATIONS OF CONTINUOUS MURMURS
B. Continuous murmurs caused by high-to-low pressure shunts:
1.Systemic artery to pulmonary artery (patent ductus arteriosus,
aortopulmonary window, truncus arteriosus, pulmonary atresia,
anomalous left coronary, bronchiectasis, sequestration of the lung)
2. Systemic artery to right heart (ruptured sinus of Valsalva,
coronary artery fistula) Left-to-right atrial shunting (Lutembacher's
syndrome, mitral atresia plus atrial septal defect).
3. Venovenous shunts (anomalous pulmonary veins, portosystemic
shunts)|
4. Arteriovenous fistula (systemic or pulmonic)

29. What Are the Signs and Symptoms of Heart Murmurs?
Most people with heart murmurs do not have any other signs and symptoms of a heart problem. The murmur is usually innocent (harmless).
Some people with heart murmurs do have signs and symptoms of a heart problem. The signs and symptoms may include:
Blue coloring of the skin, especially on the fingertips and inside the mouth
Poor eating and failure to grow normally (in infants)
Fast breathing
Excessive sweating
Chest pain
Dizziness
Shortness of breath
Fainting
Fatigue (feeling very tired)
The signs and symptoms depend on the cause and the severity of the problem causing the murmur.

30. How Are Heart Murmurs Diagnosed?
Doctors use a stethoscope to listen to heart sounds and hear murmurs. They often notice innocent heart murmurs during routine checkups or physical exams.
Physical Exam
Doctors listen carefully to the heart with a stethoscope to help decide if a murmur is innocent or abnormal. They listen to the loudness, location, and timing of the murmur to classify and describe the sound. This helps the doctor begin to diagnose the cause of the murmur.

31. How Are Heart Murmurs Diagnosed?
The doctor also:
Takes a medical and family history
Does a complete physical exam, looking for signs of illness or physical problems (such as blue coloring of the skin, delayed growth, and feeding problems in an infant)
Asks about symptoms, such as chest pain, shortness of breath (especially with exercise), dizziness, or fainting

32. Tests
Chest x-ray. A chest x ray takes a picture of your heart and lungs. It can show if the heart is enlarged, and it can show some problems of the heart and lungs.
(С/Т)х100 (normal < 50%)

33. Tests
ECG.
This test is used to measure the rate and regularity of your heartbeat. The EKG can help rule out a variety of heart problems.
Will most likely do the followup testing. These tests might include:
An echocardigram, a test that uses ultrasound (sound waves) to allow doctors to view your heart as it pumps and relaxes.
The echocardiogram is more detailed than an x-ray image and shows the structure and function of the heart. In some cases, transesophageal echocardiography (TEE) might be needed to get a better view of the heart. In TEE, the doctor inserts an ultrasound probe down the throat into the esophagus after the patient is sedated.

34. Tests Cardiac catheterization and angiography.
Cardiac catheterization is a procedure in which a thin, flexible tube (catheter) is passed through an artery or vein in your upper thigh (groin) or in your arm to reach the heart, after you are sedated. This allows measurement of pressure inside the heart and blood vessels.
Angiography involves injecting a dye that can be seen by using x ray. This helps the doctor see the flow of blood through the heart and blood vessels.

35. Mitral Regurgitation (MR)
Chronic MR
Rheumatic heart disease (50%)
Mitral valve prolapse
Disease that cause dilatation of left ventricle cavity cause dilatation of valve annulus and mild MR (called functional MR), such disease are:
Aortic valve disease
Acute rheumatic fever
Myocarditis
Dilated cardiomyopathy
Ischemic heart disease
Acute MR
Myocardial infarction (due rupture of chordae tendineae)
Infective endocarditis

36. Sign
Organic MR MR
Aetiology
Rheumatism,
Atherosclerosis,
Connective Tissue diseases
Myocarditis EH
Cardiosclerosis
Morphology
Valve change
Valve non change
1 heart sound
connectivity
Concerned
Non concerned
Loudness murmur
noise loud
low, faint

37. Depending on position of body
Noise constant, auscultate in any position of body
Noise non constant, disappear at change on position of body
Duration
Pan systolic or 2/3part
short, 1/3 – ½ of systole
Dependence of breath phases
Become louder during expiration
Weakens or disappears during expiration
On the left side
Becomes stronger
May disappear
Radiating
Widely over the precardium, axilla
Apex
1 heart sound
soft
No change

38. Innocent Systolic Murmurs
Pansystolic murmur

39. Sign Organic MR Mitral valve Prolapse (MVP) Common
Systolic murmur at apex, I heart sound low, faint
Aetiology
Rheumatism,
Atherosclerosis,
Connective Tissue diseases
Genetic disease, Marfan syndrome, Connective Tissue diseases
Complaints
breathlessness, heart pain, palpitation
Most patients are asymptomatic
S1 Connecti-
vity
Concerned
Non concerned

40. Duration SM
Pan-systolic
Late-systolic
Irradiation
Apex to axilla
Apex
Depending on position of body
Noise constant, auscultate in any position of body
weakens, disappears at change on position of body
Exertion
Become louder during expiration
Weakens
Additional
heart tones
No additional tones
Mid systolic click is present
ECHO
Valve structure is changed
Mitral
valve Prolapse

41. MVP

42. Pan-systolic M at the MR

43. Mid-systolic clik and late systolic M at the MVP

44. Late systolic M at the MVP

45. Sign
Organic MR
Aortic Stenosis
Common
Pan Systolic murmur, loud, harsh S1
Change
Normal or soft S2
Ascent on 2 lIC
Soft only P2 is audible
Localization
Apex
2 right IC, point Erba
Depending on position of body
Noise constant, auscultate in any position of body
On the right side, sitting while bending ahead
Irradiation
Apex to axilla
To the carotid artery, precardium to the apex

46. Phonocardiogram
Pansystolic. Ribbon like
Mid-systolic. Rhombus like
Systolic vibration
absent
present
ECHO
Left atrial cavity increase, mitral valve changes
Left ventricular cavity increase, aortic valve changes
ECG
LAH, LVH
LVH

47. Aortic stenosis- M ECHO

48. Aortic stenosis- B ECHO

49. III-IV left IC Hump Sign Aortic Stenosis Ventricular septal defect
Common
Systolic murmur, loud, harsh, increasing
Localization
2 right IC, point Erba
III-IV left IC
Depending on position of body
On the right side, sitting while bending ahead
Independent
Examination
Apex beat is strong
Hump
Palpation
Systolic vibration in jugular fossa
Left sternal boader and epigastria pulsation
ECG
ECHO
LVH
Left ventricular cavity increase, aortic valve changes
RVH
Interventricular septal defect

50. II left IC Hump Sign Aortic Stenosis Atrial septal defect Common
Systolic murmur, loud, harsh, increasing
Localization
2 right IC and point Erba
II left IC
Depending on position of body
On the right side, sitting while bending ahead
Independent
Examination
Apex beat is strong
Hump
Palpation
Systolic vibration in jugular fossa
Pericardial and epigastria pulsation
ECG
ECHO
LVH
Left ventricular cavity increase, aortic valve changes
RVH, RAH

51. Unaware, hereditary factor
Sign
Aortic Stenosis
HOCMP
Common
Systolic murmur, loud, harsh at point Erba, Irradiation clavicles, jugular fossa
Aetiology
Rheumatism,
Atherosclerosis,
syphilis, бактериальный infective endocarditis, congenital anomaly of valves and aortic
Unaware, hereditary factor
Ausculta
tion
I sound weakening
I sound non change or intensification
Connection with I sound
Not connected with heart sounds

52. Sign Aortic Stenosis HOCMP Irradiation
Irradiation clavicles, jugular fossa
Not irradiation clavicles, jugular fossa
Depending on position of body
Noise constant, auscultate in any position of body, non disappear after body position change
Murmur increases at test Val salve
ECG
LVH
Q wave in V1-6, deep, narrow
ECHO
Valve structure is changed
Thickness of IVS is >1 cм (2-3см), LV cavity is decreased
X-ray
Aorta is enlarged in ascending aortic part, strong pulsation
Little or not presence of heart shadow enlargement

53. Middle valve aortic stenosis

54. IVSD- early systolic murmur

55. IVSD- pan systolic murmur

56. ASD- loud, tricuspid component of I sound and II sound splitting

57. Differential diastolic murmurs
description
organic
functional
Aetiology
mitral or tricuspid stenosis, left or right atrial myxoma, ductus arteriosus
functional tricuspid stenosis, atrial septal defect
Loudness
loud
low
Duration
long
short
Depending on position of body
Noise constant, auscultate in any position of body
weakens, disappears at change on position of body
Mechanism
Diastolic filling murmurs
Diastolic regurgitate murmurs

58. Proto diastolic murmurs

59. Presystolic and pandiastolic murmurs

60. Signs
Aortic insufficiency (AI)
Mitral stenosis (МS)
Types of DM
True proto diastolic
Different types of DM
Relationship with II sound
Starts immediately with II sound
Starts some time from II sound (after QS – sound)
Duration
Timbre
Prolonged
Soft, quiet
Short
Rather harsh
Localization
Body position
III – IV i/c place at left side
Vertical position
Apex of heart
Horizontal position
II sound
II sound in aortic zone is decreased,
II sound in pulmonary zone is not changed
II sound in aortic zone is not changed,
II sound in pulmonary zone is increased

61. АI Signs МS I sound Is not changed or weakened Flapping I sound
Extra sound
Pre systolic murmur of Astine-Flint
OS sound
ECG
RVH
RAH and RVH
ECHO
Aortic valve changes, aortic regurgitation, LV cavity increases
Mitral valve changes, area of mitral aperture decreases, LA and RV increase

62. АR

64. МS

65. Signs Mitral stenosis (МS) Myxoma of left atrial Common
I sound increased, can be present in III sound at QS zone, diastolic murmur
Aetiology
Reumatism
Tumor cause is unknown
Auscultation
OS sound appears in 0,06-0,12 sec after II sound
III extra sound can present but appears later than in 0,12 sec after II sound
Types of DM
Often pre systolic
Often mid systolic, seldom pre systolic
Sound stability
Murmur is stable, can be heard at intake and at body position on the left side
Murmur is unstable, can be heard at sitting and standing position, sometimes disappears when position is changed
ECHO
Valve is changed
Valve is not changed, tumor is present in left atrial

66. Signs МS
Cor Pulmonale
Common
DM - left side of sternum, epigastria and pre cardiac pulsation, accent II sound at pulmonary artery, heart boundaries enlarge to the right тона
Aetiology
Reumatism
COPD
Auscultation
OS sound appears in 0,06-0,12 sec after II sound
Dull heart sounds
Types of DM
Often pre systolic
Proto diastolic (Graham-Still)
Sound stability
Murmur is stable, can be heard at intake and at body position on the left side
Murmur is unstable, can disappear after treatment

67. Signs МS
Cor Pulmonale
Dependence on breath phases
Can be heard on outward breath
Can be heard at intake and breath delay at standing
ECG
LAH and RVH
RAH and RVH
ECHO
Mitral valve is changed, LA and RV increased
Mitral valve is not changed, pulmonary artery is enlarged, pulmonary regurgitation, RA and RV increased
X-ray
LA is increased, mitral heart configuration
Bulging of truncus pulmonary artery, signs of main disease are present

68. DIFFERENTIAL DIAGNOSIS OF HEART SOUNDS

69. DIFFERENTIAL DIAGNOSIS OF HEART SOUNDS
CONDITION EXPIRATION INSPIRATION NOTES

70. VARIATIONS OF REGURGITANT MURMURS

71. DIASTOLIC FILLING MURMUR (RUMBLE OF MITRAL STENOSIS)