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Heart Sounds

Heart Sounds. Auscultation. The stethoscope. The Bell Used to hear low-pitched sounds Used for mid-diastolic murmur of mitral stenosis or S3 in heart failure. The Diaphragm Filters out low-pitched sounds Highlights high-pitched sounds

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Heart Sounds

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  1. Heart Sounds Auscultation

  2. The stethoscope • The Bell • Used to hear low-pitched sounds • Used for mid-diastolic murmur of mitral stenosis or S3 in heart failure. • The Diaphragm • Filters out low-pitched sounds • Highlights high-pitched sounds • Used for analyzing high-pitched early diastolic murmur of aortic regurgitation. • The earpieces • Should fit comfortably and firmly • The tubing • Should be about 25 cm long. The tubing should be thick enough to reduce external sounds

  3. Positioning • Patients can be examined while lying supine, in the left lateral decubitus position, sitting, and leaning forward.

  4. Heart Sounds • First Heart Sound (S1) • Closure of mitral valve M1 and tricuspid valve T1 • Beginning of ventricular systole • Loudest at the apex and lower left sternal border. • The first heart sound can usually be heard easily with both the bell and the diaphragm • Second Heart Sound (S2) • Closure of aortic valve A2 and pulmonary valve P2 . • End of ventricular systole. • Loudest at the base. • For the second heart sound the diaphragm is used, with the stethoscope usually best placed at the base

  5. Heart Sounds systole S1S2 diastole systole S1S2 S4S3 diastole

  6. Abnormalities of the Heart Sounds • Alteration in Intensity. • Splitting. • Extra Heart Sounds. • Additional Sounds. • Murmurs.

  7. Alteration in Intensity Abnormal S1 Abnormal S2 Loud Second Heart Sound (aortic) Systemic hypertension Dilated aortic root Soft Second Heart Sound (aortic) Calcified aortic stenosis Loud Second Heart Sound (pulmonary) Pulmonary hypertension • Loud First Heart Sound • Hyperdynamic (fever, exercise) • Mitral stenosis • Short AV intervals like Wolff-Parkinson-White syndrome • Soft First Sound • Low cardiac output (rest, heart failure) • Severe mitral reflux (caused by destruction of valve) • long PR interval • Variable Intensity of First Sound • Atrial fibrillation • Complete heart block

  8. Splitting • Splitting: is unsynchronized closure of the heart valve • Physiological split of S2 • - Occurs in young adult • - Split during Inspiration due to delay in right ventricular emptying causing A2 closure occurs before P2. • Pathological Split of S2 • - Split during expiration (reversed split): aortic stenosis, left bundle branch block (LBBB) • Split during expiration and inspiration (fixed split): atrialspectal defect (ASD), ventricular septal defect (VSD) • Splitting of S1 into M1 and T1 is a normal finding on cardiac auscultation • Pathological splitting is heard in some disease conditions such as ASD.

  9. Extra Heart Sounds • Third Heart Sound (S3) • Lubb-dupp-da • - Slushingin SLOSH’-ing-in • - Caused by turbulent blood flow into ventricles and detected near end of first one-third of diastole (Rapid ventricular filling). • Fluid backing up , as in congestive heart failure, which is the most common cause of a S3. • S3 is low frequency and thus best heard with the bell of the stethoscope at the apex while the patient is in the left lateral decubitusposition. • Normal in children, young people, pregnancy, athletes, fever. • Abnormal. : ventricular fibrillation (VF), aortic regurgitation (AR), mitral regurgitation (MR), ventricular septal defect (VSD), patent ductusarteriosus (PDA), constrictive pericarditis.

  10. Extra Heart Sounds Fourth Heart Sound (S4) Da-lubb-dupp • Low frequency sound in late diastole • Caused by the atrial kick into a noncompliant ventricle. • Seen in patients with stiffened left ventricles, resulting from conditions such as hypertension (HTN), aortic stenosis (AS), ischemic or hypertrophic cardiomyopathy, acute MI. • In patient with mitral regurgitation, suggestive of acute onset of regurgitation due to the rupture of the chordatendinae that anchor the valvular leaflets. • It is heard best with the bell of the stethoscope at the apex.

  11. Additional Sounds • Opening snap: due to forceful opening of the mitral valve in MS. • Systolic ejection click: due to rapid opening of the stenotic A2 or P2. • Systolic nonejection click: due to rapid opening of M1 and T1 in MVP. • Prosthetic heart valves: .Artificial heart sounds • Pericardial friction rub. Pericardial Friction Rub A superficial scratching sound. Occurs at any time during the cardiac cycle. Sign of PERICARDITIS. Louder with sitting up and breathing out.

  12. Murmurs • Blood flow through a valve normally closed during systole (mitral or tricuspid valves). Regurgitation • Blood flow through a valve normally open in systole but abnormally narrowed (e.g. aortic or pulmonary). Stenosis • Increased blood flow through a normal valve High flow states like pregnancy, fever, anemia, hypothyroidism • Due to structural cardiac abnormality and increased flow: • Ventricular septal defect (VSD). • Atrialseptal defect (ASD).

  13. Murmurs Assessment • Timing. • Intensity. • Propagation. • Effect of certain maneuvers.

  14. Timing of Murmurs • Systolic Murmurs • Valvular • Mitral regurgitation • Tricuspid regurgitation • Aortic stenosis • Pulmonicstenosis • Mitral valve prolapse (MVP • - Abnormally thickened mitral valve • - Resulting in a mid-systolic click • after the click, a brief crescendo-decrescendo murmur • Nonvalvular • PDA • VSD

  15. Patent ductusarteriosus Congenital disorders in which the ductusarteriosus fail to close. There is abnormal blood flow between the pulmonary artery and the aortic artery. This murmur is best heard over the upper left sternal edge, associated with a thrill, and is characteristically continuous and machinery-like.

  16. Ventricular septal defect VSD is one of the most common congenital heart defects. It is usually best heard over the “tricuspid area”, or the lower left sternal border, with radiation to the right lower sternal border because this is the area which overlies the defect.

  17. Atrialseptal defect Congenital heart defect. This murmur is best heard over the “pulmonic area” of the chest, and may radiate to the back.

  18. Diastolic Murmurs • Valvular • Aortic regurgitation • Pulmonic regurgitation • Mitral stenosis • Tricuspid stenosis • Nonvalvular • - PDA

  19. Intensity of Murmurs

  20. Propagation of Murmur • MR Left axilla. • VSD Right sternal edge. • AS Carotid arteries.

  21. Effect of certain maneuvers A variety of physiological maneuvers that alter cardiovascular hemodynamic can be used to aid in characterization and differentiation of murmurs. Physiological Maneuvers: • Breathing • Valsalva maneuver. • Squatting. • Isometric exercise.

  22. Significant or not? - Consider the clinical scenario. - Presence of symptoms such as effort syncope, chest pain, palpitations, shortness of breath, or paroxysmal nocturnal dyspnea. - Some common variations of normal heart sounds without an underlying structural pathology.

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