Heart Sounds and Murmurs

S1

the first heart sound

heard when the atrioventricular (mitral and tricuspid) valves close

S2

The second heart sound

Heard when the semilunar (aortic and pulmonic) valves close

S3

an abnormal heart sound detected early in diastole as resistance is met to blood entering either ventricle

most often due to volume overload (rapid ventricular filling) associated with heart failure

This can be normal in children, pregnant women, and athletes

S4

an abnormal heart sound detected late in diastole as resistance is met to blood entering either ventricle during atrial contraction

most often caused by hypertrophy of the ventricle (non compliant or stiff ventricle)

4, 5, 6

What grades of murmurs are associated with a thrill?

aortic regurgitation

2nd left intercostal space

High pitch blowing

Early diastolic murmur Heard with the patient sitting up and leaning forward

aortic stenosis (L)

2nd R intercostal space

Mid systolic

Radiates to carotid

Have pt sit up and lean forward ***

tricuspid regurgitation

left lateral sternal border

Crescendo-decrescendo or rectangular

systolic murmur

tricuspid stenosis

L lateral sternal border

diastolic murmur, opening snap

Ventricular septal defect

RARE

Often w/ other murmurs/often rheumatic

patent ductus arteriosus

inferior to left clavicle continuous machine-like murmur

pulmonic regurgitation

2nd left intercostal space

decrescendo in early diastole

usually congenital and found in children

pulmonary stenosis

2nd intercostal space

mid-systolic ejection click

radiates to the back (L shoulder, L upper back/scapular region)

aortic regurgitation

3rd L intercostal space

high f blowing decrescendo diastolic murmur

potential S3 and Austin Flint

Mitral regurgitation

apex

blowing high pitch

systolic

radiates to the axilla

mitral stenosis

apex in LLD

mid diastolic

low pitch/rumbling

decrescendo, opening snap

pulmonary stenosis

Tetralogy of fallot causes which murmur? This is a hallmark finding (one of the four components).

systolic ejection murmur

Murmur associated with ASD? Occurs bc increased blood passing through a normal pulmonary valve.

fixed split

The murmur associated with ASD also causes pulmonary valve to close LATER than the aortic valve. What does this do to S2?

holosystolic murmur

Murmur associated with VSD? Occurs bc increased flow to the lungs, which can eventually cause severe pulmonary HTN that pressure in R heart overcomes pressure in L heart reversing the shunt (Eisenmenger syndrome).

congenital aortic stenosis

A congenitally stenotic valve increases workload on LV, leading to hypertrophy. This is a systolic ejection murmur.

COA murmur

A systolic ejection murmur best heard at the left infraclavicular area and/or left upper back (scapular region), caused by turbulent flow through a narrowed segment of the descending aorta. It may be accompanied by a continuous murmur from collateral circulation. Commonly associated with blood pressure disparity between upper and lower extremities and diminished femoral pulses.

Aortic Stenosis

Mitral Regurgitation

Pulmonic Stenosis

Tricuspid Regurgitation

VSD

Which murmurs get louder with squatting?

Squatting increases venous return (↑ preload) and increases afterload.

Hypertrophic cardiomyopathy (HCM)

Mitral valve prolapse (MVP)

Which murmurs get softer with squatting?

Hypertrophic cardiomyopathy (HCM)

Mitral valve prolapse (MVP)

Which murmurs get louder with standing or Valsalva?

Aortic Stenosis

Mitral Regurgitation

Pulmonic Stenosis

Tricuspid Regurgitation

VSD

Which murmurs get softer with standing of Valsalva?