Heart sounds and murmur


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Auscultation of Heart - Presentation
By Dr.Vitrag Shah

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Heart sounds and murmur

  1. 1. www.medicalgeek.com Heart Sounds & Murmurs Dr.Vitrag Shah First year resident,MD Medicine April-2012 GMC,Surat
  2. 2. Dr.Vitrag Shah - www.medicalgeek.com
  3. 3. Dr.Vitrag Shah - www.medicalgeek.com
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  5. 5. Different areas for auscultation of heart Dr.Vitrag Shah - www.medicalgeek.com
  6. 6. I. Auscultatory Valve Area 1. MV: apex, fifth left intercostal space, medial to the midclavicular line 2. PV: second left intercostal space 3. AV: second right intercostal space 4. AV2: left third intercostal space(Neoaortic/Erb’s area) 5. TV: lower part of left sternal border 6. Other part Dr.Vitrag Shah - www.medicalgeek.com
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  8. 8. Auscultatory order  ApexPV AV AV2 TV Or  ApexTV AV2PV AVContent of auscultation 1. Heart rate 2. Heart rhythm 3. Heart sound 4. Heart murmurs Dr.Vitrag Shah - www.medicalgeek.com
  9. 9. Function of the valves Valves prevent the back flow of blood. The papillary muscles will not close the valves,they will maintain the closure of the valves. The importance of chordea tendinei attached to the papillary muscles is because during ventricular contraction the ventricle size decreases and the papillary muscle must contract to shorten the chordea tendinei to prevent the leakage of valves Dr.Vitrag Shah - www.medicalgeek.com
  10. 10. Heart sounds The bell and diaphragm of the stethoscope accentuate sounds of different pitches. The bell emphasizes low-pitched sounds such as normal heart sounds and the diastolic murmur of mitral stenosis. The diaphragm filters these sounds and helps to identify high-pitched sounds such as the early diastolic murmur of aortic regurgitation or a pericardial friction rub. Normal heart valves make a sound when they close but not when they open. The classic lub-dub sounds are caused by closure of the atrioventricular (mitral and tricuspid) valves followed by the outlet (aortic and pulmonary) valves. the first and second heart sounds extra heart sounds (third and fourth, heard in diastole) additional sounds, e.g. clicks and snaps pericardial rubs murmurs in systole and/or diastole. Dr.Vitrag Shah - www.medicalgeek.com
  11. 11. Cause of the heart sounds Slapping of the valves leaflets is not enough to generate a heart sound.The causes of the 1st heart sound: During systole the AV valves are closed & blood tries to flow back to the atrium back bulging the AV valves. But the taut chordae tendinae stop the back bulging and causes the blood to flow forward. This will cause vibration of the valves, blood & the walls of the ventricles which is presented as the 1st heart sound. Dr.Vitrag Shah - www.medicalgeek.com
  12. 12. The causes of the 2nd heartsound: During diastole, blood in the blood vessels tries to flow back to the ventricles cause the semilunar valves to bulge. But the elastic recoil of the arteries cause the blood to bounce forward which will vibrate the blood the valves and the ventricle walls. This is presented as the 2nd heart sound. Dr.Vitrag Shah - www.medicalgeek.com
  13. 13. Difference between the 1st and2nd heart sounds The 1st sound lasts longer because the AV valves are less taut than the semilunar valves which will enable them to vibrate for longer time.The 2nd heart sound had higher frequency due to The semilunar valves are more taut The great elastic coefficient of the taut arteries which provides the principle vibrations of the 2nd heart sound Dr.Vitrag Shah - www.medicalgeek.com
  14. 14. First heart sound The first heart sound (S1), lub, is caused by closure of the mitral and tricuspid valves at onset of ventricular systole and is best heard at the apex. Components of S1 Mitral Valve Closure  Best Heard: Apex Tricuspid Valve Closure  Best heard: Lower Left Sternal Boarder Dr.Vitrag Shah - www.medicalgeek.com
  15. 15. Abnormalities of intensity of thefirst heart soundQuiet Low cardiac output Poor left ventricular function Long P-R interval (first-degree heart block) Rheumatic mitral regurgitation , Calcified MSLoud Increased cardiac output Large stroke volume Mitral stenosis Short P-R interval Atrial myxoma (rare)Variable Atrial fibrillation Extrasystoles Complete heart blockDr.Vitrag Shah - www.medicalgeek.com
  16. 16. S1 Wide Splitting  RBBB  PVC from Left Ventricle Single Sound  Normal  LBBB  PVC from Right Ventricle  Paced Beats Dr.Vitrag Shah - www.medicalgeek.com
  17. 17. Second Heart Sound The second heart sound (S2), dub, is caused by closure of the pulmonary and aortic valves at the end of ventricular systole and is best heard at the left sternal edge. It is louder and higher-pitched than the first sound, and the aortic component is normally louder than the pulmonary one. Physiological splitting of the second heart sound occurs because left ventricular contraction slightly precedes that of the right ventricle so that the aortic valve closes before the pulmonary valve. This splitting increases at end-inspiration because the increased venous filling of the right ventricle further delays pulmonary valve closure. This separation disappears on expiration.Splitting of the second sound is best heard at the left sternal edge. On auscultation, you hear lub d/dub (inspiration) lub-dub (expiration). Dr.Vitrag Shah - www.medicalgeek.com
  18. 18. Abnormalities of the second heart soundQuiet Low cardiac output Calcific aortic stenosis Aortic regurgitationLoud Systemic hypertension (aortic component) Pulmonary hypertension (pulmonary component)Split Widens in inspiration (enhanced physiological splitting):  Right bundle branch block  Pulmonary stenosis  Pulmonary hypertension  Ventricular septal defectFixed splitting (unaffected by respiration):  Atrial septal defectWidens in expiration (reversed splitting):  Aortic stenosis  Hypertrophic cardiomyopathy  Left bundle branch block  Ventricular pacing Dr.Vitrag Shah - www.medicalgeek.com
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  20. 20. Physiological splitting of S2 Dr.Vitrag Shah - www.medicalgeek.com
  21. 21. Fixed splitting of S2 Dr.Vitrag Shah - www.medicalgeek.com
  22. 22. Reversed splitting of S2 Dr.Vitrag Shah - www.medicalgeek.com
  23. 23. Third heart sound A third heart sound (S3) is a low-pitched early diastolic sound best heard with the bell at the apex. It coincides with rapid ventricular filling immediately after opening of the atrioventricular valves and is therefore heard after the second as lub-dub-dum. 0.12~0.18 after S2, frequency  intensity. A third heart sound is a normal finding in children, in young adults and during pregnancy. A third heart sound is usually pathological after the age of 40 years. The most common causes are left ventricular failure, when it is an early sign, and mitral regurgitation. In heart failure S3 occurs with a tachycardia and S1 and S2 are quiet (lub-da-dub). Dr.Vitrag Shah - www.medicalgeek.com
  24. 24. Causes of a third heart soundPhysiological Healthy young adults Athletes Pregnancy FeverPathological Large, poorly contracting left ventricle Mitral regurgitation Dr.Vitrag Shah - www.medicalgeek.com
  25. 25. Fourth heart sound A fourth heart sound (S4) is less common. It is soft and low-pitched, best heard with the bell of the stethoscope at the apex. It occurs just before the first sound (da-lub-dub). 0.11 prior to S1 It is always pathological and is caused by forceful atrial contraction against a non- compliant or stiff ventricle. A fourth heart sound is most often heard with left ventricular hypertrophy (due to hypertension, aortic stenosis or hypertrophic obstructive cardiomyopathy). It cannot occur when there is atrial fibrillation. Both a third and a fourth heart sound cause a triple or gallop rhythm. Dr.Vitrag Shah - www.medicalgeek.com
  26. 26. Added Sounds Dr.Vitrag Shah - www.medicalgeek.com
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  28. 28. Pericardial Friction Rub  Three Phases ○ Mid Systolic, Mid Diastolic, Pre Systolic  Scratchy, Leathery  Best Heard ○ With Diaphragm of Stethoscope ○ Left Sternal Boarder Leaning over at End Expiration  Apposition of Abnormal Visceral and Parietal Pericardium  Confused with Hamman’s Sign in Post Open Heart Surgery (Crunch Sound from Mediastinal Air) It may be audible over any part of the precordium but is often localized. It is most often heard in acute viral pericarditis and sometimes 24-72 hours after myocardial infarction. Pericardial rubs vary in intensity over time, and with the position of the patient. A pleuro-pericardial rub is a similar sound that occurs in time with the cardiac cycle but is also influenced by respiration and is pleural in origin. Occasionally a crunching noise can be heard caused by air in the pericardium (pneumopericardium). Dr.Vitrag Shah - www.medicalgeek.com
  29. 29. Early Systolic Sounds Ejection Sound- Usually High Frequency  Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve  Pulmonary Valve-Pulmonic Stenosis Vary with Respirations  Prosthetic Valves- Mechanical, Not Bioprosthetic Dr.Vitrag Shah - www.medicalgeek.com
  30. 30. Mid-Late Systolic Sounds Click  High Frequency Sound Found in Mitral Valve Prolapse  Occurs Earlier with Valsalva Maneuver or Squatting to Standing Dr.Vitrag Shah - www.medicalgeek.com
  31. 31. Early Diastolic Sounds Opening Snap of Mitral Stenosis (MS) ○ High pitched-Left Lateral Decubitus Position, Apex. 0.04-0.12 sec after A2 (S3 occurs 0.12 sec after A2) ○ Occurs after S2, before S3 ○ MS More Severe with Short A2-OS Interval & softer OS or absent OS Paricardial Knock ○ Chronic Constrictive Pericarditis ○ Mitral Regurgitation ○ Atrial Myxoma ○ Older Model Prosthetic Mitral Valve Dr.Vitrag Shah - www.medicalgeek.com
  32. 32. Mechanism of OS Stenotic anterior mitral valve leaflet suddently bulging download into the left ventricular cavity like a dome, with a snapping sound when the mitral valve is rapidly opened during diastole. So OS is heard only if AML of mitral valve is mobile. OS occurs when movement of AMV suddenly stops, at point when LVP drops below that of LAP. Dr.Vitrag Shah - www.medicalgeek.com
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  34. 34. OS S2 S3Area Just inside 2nd & 3rd left ICS Only Apex apex/entire chest wallRelation to A2-OS interval A2-P2 interval Disappear ofposture wides on narrows on sitting standing standingIntensity on Remain Decreases -standing same/intensifiedRelation to A2-OS interval Split increase Nonerespiration constant on respiration throught respirationIntensity on Same - RVS3 Loadrespiration during inspirationA2-OS/A2- - A2-P2 interval A2-S3 interval isP2/A2-S3 shorter than A2- longer than A2-interval OS interval OS intervalPitch High(Best heard High Low (With Bell) with diaphtagm) Dr.Vitrag Shah - www.medicalgeek.com
  35. 35. Auscultation-Timing of A2 to OS Interval Say Timing Severity Other seconds of MS HS’s Prrr  0.06 Severe Pada .07-.08 Mod- severe Pata .08-.09 Mod Papa  0.10 Mild PK 0.1-0.110 Tu-  .12 A2-S3 huh 0.12-0.18 Dr.Vitrag Shah - www.medicalgeek.com
  36. 36. Gallop:1)Three or four sounds are spaced to audibly resemble the center of a horse, the extra sounds occurs after S2. Dr.Vitrag Shah - www.medicalgeek.com
  37. 37. • Protodiastolic gallop rhythm• S3 gallop, ventricular galloprhythm.• S1 + S2 + pathologic S3 Dr.Vitrag Shah - www.medicalgeek.com
  38. 38.  In early diastole, the blood through into ventricle from atrium in failing myocardium, the ventricular wall tension is poor, produce vibration. Reflex that the ventricular function Auscultation character of S3 gallop:  lower in pitch  After S2  Best hear at apex  Loudest at the end of expiration. Dr.Vitrag Shah - www.medicalgeek.com
  39. 39.  S3 gallop: differ from normal S3  Occur in severe organic heart disease  HR>100 bpm  The interval time between S1 and S2 are almost equal, mimicking quality, normal S3 is nearer from S2  Normal S3 will disappear in standing or sitting position Dr.Vitrag Shah - www.medicalgeek.com
  40. 40.  Late diastolic gallop  S4 gallop, atrium gallop ○ At late diastole, related to atrial contraction. In LVEDP  compliance Artial contraction occur precede S1, far from S2 low-pitch; best heard at apex ○ Tensity: end of expiration(from LA) end of inspiration (from RA) Dr.Vitrag Shah - www.medicalgeek.com
  41. 41. • Occur in pressure overload,LVH, inmyocardial damaged , LV compliance, such as BP, IHSS, CHD. Dr.Vitrag Shah - www.medicalgeek.com
  42. 42.  Summation gallop  Overlapping of S3G and S4G while HR Dr.Vitrag Shah - www.medicalgeek.com
  43. 43. Mid Diastolic Sounds S3  Occurs During Rapid Filling of Left Ventricle (LV) related to LV Volume  Low Frequency Best Heard ○ At the Apex w/Bell ○ Pt in Left Lateral Decubitus Position  Can Be Normal to Age 40???  Can be Pathognomonic for Congestive Heart Failure Dr.Vitrag Shah - www.medicalgeek.com
  44. 44. Late Diastolic Sounds S4  During Atrial Phase of LV Filling ○ Consequence of Ventricular Stiffness  Absent in Atrial Fibrillation or Ventricular Pacing  Low Frequency Sound Best Heart ○ At the Apex ○ Pt in Left Lateral Decubitus Position  HTN, Aortic Stenosis, Ischemic Heart Disease Dr.Vitrag Shah - www.medicalgeek.com
  45. 45. Diastolic Sounds Right Sided S3, S4  Left Lower Sternal Boarder  Intensity Varies with Respiration due to Right Heart Filling (Carvallo’s Sign) Summation Gallop  Occurrence of an Over Lapping S3 and S4 due to Tachycardia Dr.Vitrag Shah - www.medicalgeek.com
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  47. 47. Murmurs (Latin word) Sudden deceleration of blood produces heart sounds while Heart murmurs are produced by turbulent flow (Raynold’s number >2000) across an abnormal valve, septal defect or outflow obstruction, or by increased volume or velocity of flow through a normal valve. Murmurs may occur in a healthy heart. These innocent murmurs occur when stroke volume is increased, e.g. during pregnancy, and in athletes with resting bradycardia or children with fever. Dr.Vitrag Shah - www.medicalgeek.com
  48. 48.  Mechanism  Blood velocity  Blood vascosity  Valve: narrowed or incompetent; organic or relative  Abnormal connection  Vibration of loose structure  Diameter of vessel or  Dr.Vitrag Shah - www.medicalgeek.com
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  50. 50. Points to be examined in murmur Timing Shape Intensity Duration Location of maximum intensity Character Pitch Radiation Variation with respiration Variation with position Variation with other maneuvers Best heard with bell or diaphram Dr.Vitrag Shah - www.medicalgeek.com
  51. 51. Common Murmurs andTimingSystolic Murmurs Aortic stenosis Mitral insufficiency Mitral valve prolapse Tricuspid insufficiencyDiastolic Murmurs Aortic insufficiency Mitral stenosis S1 S2 S1 Dr.Vitrag Shah - www.medicalgeek.com
  52. 52. Describing a heart murmur1. Timing  murmurs are longer than heart sounds  HS can distinguished by simultaneous palpation of the carotid arterial pulse  systolic, diastolic, continuous2. Shape  crescendo (grows louder), decrescendo, crescendo- decrescendo, plateau3. Location of maximum intensity  is determined by the site where the murmur originates  e.g. A, P, T, M listening areas Dr.Vitrag Shah - www.medicalgeek.com
  53. 53. Describing a heart murmur con’t:4. Radiation  reflects the intensity of the murmur and the direction of blood flow5. Intensity  graded on a 6 point scale ○ Grade 1 = very faint ○ Grade 2 = quiet but heard immediately ○ Grade 3 = moderately loud ○ Grade 4 = loud ○ Grade 5 = heard with stethoscope partly off the chest ○ Grade 6 = no stethoscope needed *Note: Thrills are assoc. with murmurs of grades 4 - 6 Dr.Vitrag Shah - www.medicalgeek.com
  54. 54. Describing a heart murmur con’t:6. Pitch  high, medium, low depending upto high/medium/low velosity jet7. Quality  blowing, harsh, rumbling, and musical8. Others: i. Variation with respiration ○ Right sided murmurs change more than left sided ii. Variation with position of the patient iii. Variation with special maneuvers ○ Valsalva/Standing => Murmurs decrease in length and intensity EXCEPT: Hypertrophic cardiomyopathy and Mitral valve prolapse Dr.Vitrag Shah - www.medicalgeek.com
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  56. 56. Levine & Freeman’s Grading Grades of intensity of murmur  Grade 1 Heard by an expert in optimum conditions  Grade 2 Heard by a non-expert in optimum conditions  Grade 3 Easily heard; no thrill  Grade 4 A loud murmur, with a thrill  Grade 5 Very loud, often heard over wide area, with thrill  Grade 6 Extremely loud, heard without stethoscope Dr.Vitrag Shah - www.medicalgeek.com
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  58. 58.  Physiological maneuver 1) Change the body position - Left recumbent: MS - Sitting, leaning forward: AI - Squatting from standing, supine position, raising two legs may increase venous return, SV CO - Murmur of MI, AI - Murmur of IHSS Dr.Vitrag Shah - www.medicalgeek.com
  59. 59. 2) Respiration - Deep inspiration: thorax pressure venous return, pulmonary circulation clockwise rotation of heart make murmur of TI, TS ,PI - Expiration: - Valsalva maneuver: thorax pressure venous return M of IHSS Dr.Vitrag Shah - www.medicalgeek.com
  60. 60. 3) Exercise: - HR - Blood volume - Blood velocity make the murmur of MSLeft sided murmurs increases on expirationwhile right sided murmur increased onInspiration.Basal (Aortic & Pulmonary) murmurs increaseson sitting and leaning forward while apical (Mitral &Tricuspid) murmurs increases on left lateral position. Dr.Vitrag Shah - www.medicalgeek.com
  61. 61. Systolic MurmursDerived from increased turbulence associated with: 1. Increased flow across normal SL valve or into a dilated great vessel 2. Flow across an abnormal SL valve or narrowed ventricular outflow tract - e.g. aortic stenosis 3. Flow across an incompetent AV valve - e.g. mitral regurg. 4. Flow across the interventricular septum Dr.Vitrag Shah - www.medicalgeek.com
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  66. 66. Holosystolic vs Pansystolicmurmur A holosystolic murmur is one which lasts from the end of S1 to the beginning of S2. A pansystolic murmur is one which lasts from the beginning S1 to the end of S2, and therefore obscures these heart sounds. The difference between them is academic in terms of the diagnosis. Pansystolic murmurs are often louder and more significant. Dr.Vitrag Shah - www.medicalgeek.com
  67. 67. Diastolic Murmurs Almost always indicate heart disease Two basic types: The term early diastolic murmur is misleading because the murmur usually lasts throughout diastole, but it is loudest in early diastole. 1. Early decrescendo diastolic murmurs  signify regurgitant flow through an imcompetent semilunar valve ○ e.g. aortic regurgitation 2. Rumbling diastolic murmurs in mid- or late diastole  suggest stenosis of an AV valve ○ e.g. mitral stenosis Dr.Vitrag Shah - www.medicalgeek.com
  68. 68. Classification and causes of diastolic murmur Dr.Vitrag Shah - www.medicalgeek.com
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  71. 71. Continuous Murmurs Begin in systole, peak near s2, and continue into all or part of diastole.1. Cervical venous hum  Audible in kids; can be abolished by compression over the IJV2. Mammary souffle  Represents augmented arterial flow through engorged breasts  Becomes audible during late 3rd trimester and lactation3. Patent Ductus Arteriosus  Has a harsh, machinery-like quality4. Pericardial friction rub  Has scratchy, scraping quality Dr.Vitrag Shah - www.medicalgeek.com
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  75. 75. Non-Audible murmurs at apexand pulmonary area Dr.Vitrag Shah - www.medicalgeek.com
  76. 76. Functional Murmur: short and soft SEM Normal S1 and S2 Normal cardiac impulse No evidence for hemodynamic abnormality Dr.Vitrag Shah - www.medicalgeek.com
  77. 77. Innocent or Normal Murmurs-Systolic Vibratory Systolic Murmur (Still’s Murmur) Pulmonic Systolic Murmur (Pulmonary Trunk)* Mammary Soufflé* Peripheral Pulmonic Systolic Murmur (Pulmonary Branches) Supraclavicular or Brachiocephalic Systolic Murmur Aortic Systolic Murmur *common in pregnancy Still’s Murmur ○ Medium Frequency, Vibratory, Originating from Leaflets of Pulmonic Valve Dr.Vitrag Shah - www.medicalgeek.com
  78. 78. Innocent or Normal Murmurs-Continuous Venous Hum Continuous Mammary Soufflé Dr.Vitrag Shah - www.medicalgeek.com
  79. 79. Changing murmurs Murmurs which change in character or intensity from moment to moment. Carey-coombs’ murmur Infective endocarditis Atrial Thrombus Atrial Myxomas Dr.Vitrag Shah - www.medicalgeek.com
  80. 80. The Carey Coombs murmur orCoombs murmur A clinical sign which occurs in patients with mitral valvulitis due to acute rheumatic fever. It is described as a short, mid-diastolic rumble best heard at the apex, which disappears as the valvulitis improves. It is often associated with an S3 gallop rhythm, and can be distinguished from the diastolic murmur of mitral stenosis by the absence of an opening snap before the murmur. The murmur is caused by increased blood flow across a thickened mitral valve. Dr.Vitrag Shah - www.medicalgeek.com
  81. 81. Named murmurs Carey Coombs murmur- Mid diastolic murmur, in rheumatic fever Austin Flint murmur- mid- late diastolic murmur,in Aortic Regurgitation. Graham- Steel murmur- high pitched, diastolic, inpulmonary regurgitation. Rytands murmur - mid diastolic atypical murmur, in Complete heart block. Docks murmur-diastolic murmur, Left Anterior Descending(LAD) artery stenosis. Mill wheel murmur- due to air in RV cavity following cardiac catheterization. Stills murmur- inferior aspect of lower left sternal border, systolic ejection sound,vibratory/musical quality,in subaortic stenosis, small VSD Gibson’s murmur: continous machinary murmur of PDA Dr.Vitrag Shah - www.medicalgeek.com
  82. 82. Gallaverdin Phenomenon: The Gallavardin phenomenon is a clinical sign found in patients with aortic stenosis. It is described as the dissociation between the noisy and musical components of the systolic murmur heard in aortic stenosis. The harsh noisy component is best heard at the upper right sternal border radiating to the neck due to the high velocity jet in the ascending aorta. The musical high frequency component is best heard at the cardiac apex. The presence of a murmur at the apex can be misinterpreted as mitral regurgitation. It is presumably due to high frequency vibrations traveling to the apex from the calcific aortic valve. However, the apical murmur of the Gallavardin phenomenon does not radiate to the left axilla and is accentuated by a slowing of the heart rate (such as a compensatory pause after a premature beat) whereas the mitral regurgitation murmur does not change. The sign is named after Louis Gallavardin, having been described by Gallavardin and Ravault in 1925. Dr.Vitrag Shah - www.medicalgeek.com
  83. 83. Dynamic AuscultationAll patients with a new murmur shouldundergo dynamic auscultation: Respiration:  right sided murmurs are louder during inspiration, expiration has the opposite effect Valsalva manoeuvre: Postural Changes Isometric exercise Squatting: Vasoactive agents – Amyl Nitrite Dr.Vitrag Shah - www.medicalgeek.com
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  88. 88. Respiration Expiration :A2,P2 of second Heart sound separated <30ms ;single sound Inspiration: Splitting interval widens ;A2,P2 heard as 2 distinct soundsDIASTOLIC & EJECTION SOUNDS: S3 & S4 from Rt ventricle;augment in inspiration ;diminish during exhalation. Opening Snap of MV- soft in inspiration;loud in exhalation Inspiration decreases intensity of ejection sounds in PS , No effect on aortic ejection sounds.MURMURS Inspiration: Diastolic murmur of TS,Pulmonary regurgitation murmur,systolic murmur of TR,pre-systolic murmur of Ebstein anomaly are accentuated Mid-systolic click, systolic murmur of MVP accentuated. Dr.Vitrag Shah - www.medicalgeek.com
  89. 89. Valsalva Maneuver Deep inspiration followed by forced exhalation against a closed glottis for 10-20 secs. Phase 1:transient rise in systemic arterial pressure. Phase 2:decrease in systemic venous return,systolic pressure & pulse pressure; reflex tachycardia. Phase 3:abrupt transient decrease in arterial pressure. Phase 4: overshoot of systemic arterial pressure & reflex bradycardia. Dr.Vitrag Shah - www.medicalgeek.com
  90. 90. Phase 2: S3 & S4 attenuated. A2-P2 interval narrows Systolic murmurs of AS & PS;MR,TR diminish. Diastolic murmurs of AR &PR;TS,MS-soften. Lt ventricular volume decreases;systolic murmur of HOCM amplifies ;click,late systolic murmur of MVP begins earlier.Phase 3: Sudden increase in systemic venous return;wide split of S2;augmentation of murmurs & filling sounds Rt side heart.Phase 4:Murmurs & filling sounds Lt side return to control & transiently increase. Dr.Vitrag Shah - www.medicalgeek.com
  91. 91. Postural changes & Exercise: Lying from standing/passive elevation of both legs : Widening of S2 split Augmentation of Rt S3 & S4; Lt S3,S4 Systolic murmurs of PS,AS,MR,TR& VSD augmented Lt ventricular EDV increased;systolic murmur of HOCM diminished & mid-systolic click,late systolic murmur of MVP are delayed /attenuated. Dr.Vitrag Shah - www.medicalgeek.com
  92. 92. Squatting Increase in venous return & systemic resistance simultaneously;Stroke volume and arterial pressure rise-transient reflex bradycardia. Augmentation of S3 & S4 (both ventricles) Systolic murmurs of PS & AS ;diastolic murmurs of TS & MS become louder.(Rt sided preceding Lt) Elevated arterial pressure;increases blood flow through Rt ventricular outflow tract in TOF Systolic murmur of VSD increases. The combtn of increase in arterial pressure and increase in venous return increases Lt ventricular size which decreases obstruction to outflow;intensity of HOCM murmur ;mid-systolic click,late systolic murmur of MVP delayed. Dr.Vitrag Shah - www.medicalgeek.com
  93. 93. Left Lateral recumbent position Accentuates S1,S3,S4 from Lt side of the heart. OS,murmurs of MS,MR;Mid-systolic click and late systolic murmur of MVP.Isometric Exercise Increase in systemic vascular resistance,arterial pressure,HR,CO,Lt ventricular filling pressure and heart size. S3 & S4 on Lt side is accentuated. Systolic murmur of AS decreases.(reduced pr gradient across aortic valve.) Diastolic murmur of AR,systolic murmur of MR ,VSD increase in intensity. Diastolic murmur of MS –louder. Systolic murmur of HOCM decreases & systolic click, late systolic murmur of MVP is delayed.(increase in LV volume) Dr.Vitrag Shah - www.medicalgeek.com
  94. 94. Amyl Nitrite Marked vasodilatation;redtn in systemic arterial pressure;reflex tachycardia;increase in CO and HR S1 augmented;A2 diminished OS of mitral and tricuspid valve become louder A2/OS interval shortens S3 augmented Systolic murmurs of AS,PS,HOCM,TR and functional systolic murmurs are accentuated. Dr.Vitrag Shah - www.medicalgeek.com
  95. 95. Murmur Analysis with Dynamic Auscultation Dr.Vitrag Shah - www.medicalgeek.com
  96. 96. Back to the Basics1. When does it occur - systole or diastole2. Where is it loudest - A, P, T, MI. Systolic Murmurs: 1. Aortic stenosis - ejection type 2. Mitral regurgitation - holosystolic 3. Mitral valve prolapse - late systoleII. Diastolic Murmurs: 1. Aortic regurgitation - early diastole 2. Mitral stenosis - mid to late diastole Dr.Vitrag Shah - www.medicalgeek.com
  97. 97. Summary A. Presystolic murmur  Mitral/Tricuspid stenosis B. Mitral/Tricuspid regurg. C. Aortic ejection murmur D. Pulmonic stenosis (spilling through S20 E. Aortic/Pulm. diastolic murmur F. Mitral stenosis w/ Opening snap G. Mid-diastolic inflow murmur H. Continuous murmur of PDA Dr.Vitrag Shah - www.medicalgeek.com
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  105. 105. THANK YOUDr.Vitrag Shah - www.medicalgeek.com