Normal and abnormal Heart sounds (Murmurs).pptx Auscultation of heart sounds How murmurs are produced physiology of murmurs Classification and types of murmurs causes of murmurs

1. Normal and
abnormal Heart
sounds (Murmurs)
By Dr. Irtaza Rehman
(Author of The Extraordinary Life)

3. Learning Objectives
• To learn about the Normal heart sounds
• To learn about the Abnormal heart sounds

4. Normal Heart sounds
• Produced by the closure
of Atrio-ventricular
valves (Mitral and
tricuspid) and Semilunar
valves (aortic &
pulmonary)

5. Normal Heart sounds
Sites for Auscultation

7. Normal Heart sounds
Systole Systole Systole
Diastole Diastole

9. • S2: A2 (Aortic valve closure)
• Loud A2: Systemic Hypertension (High B.P will
create louder noise)
• Low A2: Systemic Hypotension, Aortic
regurgitation (destruction of valve tissue and
impairment of the valve closure mechanism)
Normal Heart sounds

10. • S2: P2 (Pulmonary valve closure)
• Loud P2: Pulmonary hypertension, ASD (Blood
shunting from left to right atrium  right
ventricle  Pulmonary artery  Loud P2)
• Low/soft P2: Pulmonary stenosis
Normal Heart sounds

11. • S1 splitting
• Normally T1 (Tricuspid closure) comes later
than M1 due to slightly earlier closure of Mitral
valve.
• But this splitting is very narrow, almost
negligible. May not be present at all.
• So normally there is no splitting in S1.
Normal Heart sounds

12. • S1 splitting
• Delayed T1: RBBB (due to slower conduction on
right heart, Tricuspid valve will close with
further delay than Mitral valve)
Normal Heart sounds

13. • S1 splitting
• Reverse splitting: LBBB, Severe MS (as mitral
valve will close with a delay after Pulmonary
valve in both condition). M1T1 pattern will be
reversed.
• T1  M1
Normal Heart sounds

14. • S2 splitting
• S2 is normally split
because the aortic valve (A2)
closes before the pulmonary
valve (P2)
• Split is more prominent in
inspiration.
Normal Heart sounds

15. • S2 splitting
• Wide splitting: splitting gets wide
and wider in inspiration. In RBBB,
Pulmonary stenosis ( late movt of
P.v)
• Fixed splitting: Equal delay in both
Ins & Exp. In ASD (Blood shunting
from left to right atrium  right
ventricle  Pulmonary artery 
Late closure of P.v)
• Paradoxical splitting: Aortic valve
moves slower. Aortic stenosis,
LBBB)
Normal Heart sounds

16. Third heart sound
• In early diastole
• Normally present in Kids,
Young adults, athletes,
pregnancy
• In older (congestive heart
failure)
Due to rapid
ventricular
filling during
diastole
Ventricular gallop

17. How to differentiate
bw S3 and S2 Splitting?
S3 S2 split
◦ Low pitch High pitch
◦ Heard by the Bell Heard by diaphragm
◦ At the Apex At the base Aortic area
(5th ICS MCC)

18. Fourth heart sound
• In late diastole
• Always pathological
• Heard at the Apex
• Low pitch
• HOCM, Hypertension, Acute MI
When atria
contracts in non
compliant/stiff
ventricles
Atrial gallop

19. Murmurs
• Murmurs are extra or unusual sounds made by
blood circulating through the heart's chambers
or valves, or through blood vessels near the
heart.

20. • Murmurs are produced due to any sort of turbulence
in normal blood flow across heart.
• Causes of turbulence:
i. Increase velocity of blood
ii. Decrease diameter (ASD, VSD) Decreased diameter will inc. the velocity.
iii. Incompetent valves ( Valvular heart diseases)
iv. Decrease viscosity of blood (Anemia)
v. Increase contractile strength of heart: Leads to hyperdynamic flow
(Exercise, Fever, Sepsis, Pregnancy etc)
Murmurs

21. Murmurs
HOW MURMURS CAN BE CLASSIFIED?
Murmurs can be classified according to their:
1. Location
2. Timing
3. Quality
4. Radiation
5. Intensity
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22. Location of murmurs
• Aortic valve : Right 2nd ICS : A.S
• Pulmonic Valve: Left 2nd ICS: P.S, P.R, ASD
• Tricuspid valve: Left 5th ICS PSB: T.S, T.R, VSD
• Mitral valve: Left 5th ICS MCL: M.R, M.S, MVP

23. Timings of Murmurs

24. Timings of Murmurs

25. Timings of Murmurs

26. Quality of Murmur
• A.R/MR  Blowing/Musical
• A.S/M.S  Rumbling/Harsh
• PDA  Machine like

27. Radiation of Murmurs
• While murmurs are usually most intense at one
specific listening post, they often radiate to other
listening posts or areas of the body.
• Aortic stenosis  To carotids
• Aortic regurgitation  To left sternal border
• Mitral regurgitation  To axilla

28. Intensity of Murmur

29. Terminology
• Regurgitation: Blood flow through a
structure normally closed during systole.
• Stenosis: Blood flow through an abnormally
narrowed structure/valve normally open in
systole.

30. Important Common murmurs
• Aortic stenosis:
• Ejection systolic/Early systolic murmur
• Crescendo-decrescendo
• Diamond shaped
• Harsh

31. • Aortic Regurgitation:
• Early diastolic
• Decrescendo
• Blowing
• Sharp S2
Important Common murmurs

32. • Mitral stenosis:
• Mid diastolic
• Opening snap (opening of the mitral valve)
• Loud S1
• Rumbling
Important Common murmurs

33. Mitral stenosis

34. • Mitral regurgitation:
• Holosystolic/Pansystolic (Throughout systole)
• Blowing
• Radiated to axilla
Important Common murmurs

36. Jazakumullahu Khair ♥
(May ALLAH swt reward you with goodness)