Heart sounds

1. Heart Sounds
Dr.Sara Sadiq

2. What we hear ?
• We have all heard the heart make the usual sounds.
LUB----------DUB
• Lub is the first sound or S1
• Dub is the second heart sound or S2
-----------------------------------------------------------------------
S1 S2 S1

3. First heart sound S1
The “lub” in the lub – dub.
• This sound is primarily because of the closing
of the mitral and tricuspid valves.
• Anatomically they are located between the
atria and the ventricles.
• Correlates with the carotid pulse
• Loudest at the cardiac apex
• Time: 0.14 sec

4. Second heart sound S2
S2 is the “dub” in the lub- dub
• The sounds are because of the closing of the
Pulmonic and Aortic valves.
• This is the end of systole.
• Loudest at the base of the heart
• May have a split sound
• Duration: 0. 11 sec

5. • Base (R/L 2nd ICS)
• S2 louder than S1
• Apex
• S1 louder than S2
• Normal physiologic S2 Split
• Best heard at pulmonic area during
inspiration

6. Auscultation Areas

7. Auscultation Areas

9. Note during auscultation
• Rate
• Rhythm
• S1- Apex S2 – Base
• Other sounds?
• Murmurs

10. S3 Third heart sound
• also called a protodiastolic gallop or ventricular gallop
• Caused by rush of blood from Atria to Ventricle during rapid filling phase
of Cardiac Cycle.
• It occurs at the middle third of diastole after S2.
• The third heart sound may present in childrens, some trained athletes, and
sometimes in pregnancy
• The commonest causes are left ventricular failure and mitral regurgitation
• It is best heard with the bell-side of the stethoscope at the apex of the
heart .
• Time: 0.1 sec

11. S4 fourth heart sound
• called a presystolic gallop or atrial gallop.
• Occurs at the last one third of Diastole [Just before S1]
• Produced due to Atrial contraction which causes rapid flow of blood from Atria
to Ventricle and vibration in the blood.
• It is a sign of a pathologic state, (left ventricular hypertrophy, hypertension,
aortic stenosis)
• It is best heard with the bell-side of the stethoscope at the apex of the heart .

12. Here is where you expect to hear the various sounds
LUB-- DUB-------------LUB—DUB
S1 S2 S3 S4 S1 S2

13. Heart Sounds
• S1 – onset of the ventricular contraction
• S2 – closure of the semilunar valves
• S3 – ventricular gallop
• S4 – atrial gallop
• Other – opening snap, ejection sound
• Murmurs

14. S3 S4
• low-pitched sound
• usually heard at the apex of the heart.
• caused by rapid filling and stretching
of the left ventricle when the left
ventricle is somewhat noncompliant.
• characteristic of volume overloading,
such as in CHF (especially left-sided
heart failure), tricuspid or mitral valve
insufficiency.
• a dull, low-pitched postsystolic atrial
gallop
• best heard at the apex in the left lateral
position.
• occurs with reduced ventricular
compliance and is present in
conditions such as aortic stenosis,
hypertension, hypertrophic
cardiomyopathies, and coronary artery
disease.
• less specific for CHF than S3.

15. Heart Sound Occurs during: Associated with:
S1 Isovolumetric contraction Closure of mitral and tricuspid valves
S2 Isovolumetric relaxation Closure of aortic and pulmonic valves
S3 Early ventricular filling
Normal in children; in adults,
associated with ventricular dilation
(e.g. ventricular systolic failure)
S4 Atrial contraction
Associated with stiff, low compliant
ventricle (e.g., ventricular hypertrophy

16. Heart Murmurs
• Murmurs are abnormal sounds produced due to abnormal flow of
blood [turbulent blood flow] through abnormal heart valves e.g..
stenosis or incompetence.
• Stenosis  narrow or stiff, valve that does not open completely.
• Incompetent  valve which does not close properly and remains
open.
16

17. 17

19. Characteristics of cardiac murmur
1. Timing
• murmurs are longer than heart sounds
• systolic, diastolic, continuous
2. Shape
• crescendo (grows louder), decrescendo, crescendo-decrescendo,
plateau
3. Location of maximum intensity
• is determined by the site where the murmur originates

20. Characteristics of cardiac murmur
4) Radiation
• reflects the intensity of the murmur and the direction of blood flow
5. Intensity
• Grade I : barely audible
• Gr II : audible but quiet and soft
• Gr III : moderated loud, without thrust or thrill
• Gr IV : loud, with thrill
• Gr V : louder with thrill, steth on chest wall
• Gr VI : loud enough to be heard before steth on chest

21. Systolic Murmur
lub whoosh dub lub whoosh dub
Systolic murmur are produced during the systole of the
ventricle, between 1st and 2nd heart sound

22. Diastolic Mumur
whoosh lub dub whoosh lub dub whoosh
Diastolic murmur are produced during the diastole of the
ventricle, between 2nd and 1st heart sound

23. Aortic or pulmonary Stenosis  Systolic Murmur

24. Aortic or pulmonary Insufficiency Diastolic Murmur

25. Mitral or tricuspid Stenosis  Diastolic Murmur

26. Mitral or tricuspid Insufficiency Systolic Murmur

27. Valve Abnormality Timing of Murmur
Aortic or pulmonary Stenosis Systolic
Insufficiency Diastolic
Mitral or tricuspid Stenosis Diastolic
Insufficiency Systolic
Heart Murmurs

28. • Systolic types:
Pan systolic murmurs,
Ejection murmurs,
Late systolic murmurs.
• Diastolic types:
Early diastolic murmurs
Mid diastolic murmurs

29. • Thrill:
• a palpable murmur
• Bruits:
• Vascular murmur
• sounds made by turbulent blood flow
• Heard over blood vessels with constricted lumens.
• Carotid and femoral are routinely assessed for bruits

30. THANK
YOU