Heart Sounds and Murmurs

What is a Grade 1 cardiac murmur?

Very faint, may not be heard in all locations.

What is a Grade 2 cardiac murmur?

Quiet, but heard immediately when the stethoscope is on the chest.

What is a Grade 3 cardiac murmur?

Moderately loud.

What is a Grade 4 cardiac murmur?

Loud, may have a palpable thrill or vibration.

What is a Grade 5 cardiac murmur?

Very loud, definite thrill present, heard with light application of the stethoscope.

What is a Grade 6 cardiac murmur?

Very loud, may be heard with the stethoscope lifted off the chest.

What does S1 represent?

Closure of the atrioventricular valves.

What does S2 represent?

Closure of the semilunar valves.

What sound does S1 make?

LUB.

What sound does S2 make?

DUB.

Where is S1 heard loudest?

At the apex or mitral area.

What determines the loudness and timing of S1?

Distance between valve leaflets, leaflet mobility, and rate of rise of ventricular pressure.

What does A2 represent?

Aortic valve closure.

What does P2 represent?

Pulmonary valve closure.

When is S2 normally fused?

During expiration.

When does S2 normally split?

During inspiration.

Which valve normally closes first during inspiration?

Aortic valve (A2).

What happens to P2 during inspiration?

It is delayed.

What happens to A2 during inspiration?

It occurs earlier.

What is physiological splitting?

Normal splitting of S2 during inspiration.

What is widened splitting?

A wider than normal separation of A2 and P2.

What can cause widened splitting?

Right bundle branch block or pulmonic stenosis.

What is fixed splitting?

A widened S2 split that does not change with respiration.

What can cause fixed splitting?

A left-to-right shunt causing right-sided volume overload.

What is paradoxical splitting?

Reversed A2 and P2, heard during expiration and disappearing during inspiration.

What causes paradoxical splitting?

Delayed left ventricular contraction and late aortic valve closure.

What are ejection clicks associated with?

Aortic or pulmonary valve stenosis.

When do ejection clicks occur?

During systole as stenotic valves open.

What causes mid-to-late systolic clicks?

Mitral or tricuspid valve prolapse.

What is an opening snap?

A sharp, high-pitched diastolic sound caused by rigid valve leaflets opening.

What conditions cause an opening snap?

Mitral stenosis or tricuspid stenosis.

What is S3 also called?

Ventricular gallop.

When does S3 occur?

Early diastole.

What does S3 sound like?

Low-pitched rumbling.

When can S3 be normal?

In children and young adults.

What can an abnormal S3 indicate?

Volume overload in a dilated ventricle.

What is S4 also called?

Atrial gallop.

When does S4 occur?

Late diastole.

What causes S4?

Atrial contraction against a stiff ventricle.

What does S4 indicate?

Poor left ventricular compliance.

What conditions are commonly associated with S4?

Left ventricular hypertrophy or ischemia.

What does S4 correspond with?

Atrial kick (A-kick).

What is a quadruple beat?

The presence of S1, S2, S3, and S4.

What is a summation gallop?

Fusion of S3 and S4 during tachycardia.

What is a pericardial knock?

An early diastolic sound caused by sudden stopping of ventricular filling.

What condition causes a pericardial knock?

Severe constrictive pericarditis.

What is a heart murmur?

A sound created by turbulent blood flow.

Is laminar blood flow normally loud or quiet?

Quiet.

What are the three timing categories of murmurs?

Systolic, diastolic, and continuous.

What can cause a heart murmur?

Obstruction, increased flow, regurgitation, or a shunt.

What are the seven ways to describe a murmur?

Timing, intensity, pitch, shape, location, radiation, and response to maneuvers.

How are systolic murmurs graded?

Grades 1 through 6.

How are diastolic murmurs graded?

Grades 1 through 4.

What is a Grade 1 murmur?

Very faint and may not be heard in every location.

What is a Grade 2 murmur?

Quiet but heard immediately with a stethoscope.

What is a Grade 3 murmur?

Moderately loud.

What is a Grade 4 murmur?

Loud and may have a palpable thrill.

What is a Grade 5 murmur?

Very loud with a definite thrill, heard with light stethoscope contact.

What is a Grade 6 murmur?

Very loud and may be heard with the stethoscope lifted off the chest.

What is a thrill?

A palpable vibration associated with a murmur.

What does murmur pitch describe?

Sound frequency, either high or low.

What does murmur radiation describe?

The direction a murmur travels.

Where does aortic stenosis commonly radiate?

To the carotid arteries.

What does the Valsalva maneuver do to most murmurs?

Makes them quieter.

Which murmurs are exceptions to the usual Valsalva response?

HOCM and mitral valve prolapse.

What is a phonocardiogram?

A graphical display of heart sounds.

What does column height represent on a heart sound graph?

Intensity.

What does column width represent on a heart sound graph?

Duration.

When does systole occur?

Between S1 and S2.

When does diastole occur?

Between S2 and the next S1.

What shape is a crescendo-decrescendo systolic murmur?

Diamond shape.

What does a crescendo-decrescendo murmur do?

Gets louder and then quieter.

What shape is a murmur that maintains intensity throughout systole?

Block shape.

What is a decrescendo murmur?

A murmur that starts loud and gradually becomes quieter.

Why can early diastolic murmurs start loud?

The pressure gradient is greatest at the beginning.

What sound is associated with stenotic AV valve leaflets opening?

Opening snap.

What signs can appear during a physical exam of heart disease?

JVD, ankle edema, and ascites.

What symptoms may a patient with heart disease report?

Shortness of breath and dyspnea on exertion.

What does DOE stand for?

Dyspnea on exertion.

What does JVD stand for?

Jugular venous distention.