This document describes the various types of heart sounds and murmurs. It discusses the first, second, third, and fourth heart sounds and their physiological causes. It then covers the characteristics and locations of systolic, diastolic, and continuous murmurs caused by various heart conditions like mitral regurgitation, aortic stenosis, ventricular septal defect, and patent ductus arteriosus. Key murmurs are described in detail including their timing in the cardiac cycle, quality, pitch, radiation points, and changes with maneuvers like inspiration.

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3. Omar Abdelaziz Abdelhady Abdelaziz
Medical Student
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5. First Heart Sound
The first heart sound (S1) is produced by
vibrations generated by closure of the mitral
and tricuspid valves . It corresponds to the
end of diastole and beginning of ventricular
systole
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6. Second Heart Sound
The second heart sound (S2) is produced by
the closure of the aortic and the pulmonary
valves at the end of systole.
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8. Normal Heart Sounds
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9. Third Heart Sound
The third heart sound (S3) is a low-pitched,
early diastolic sound audible during the rapid
entry of blood from the atrium to the
ventricle.
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10. Fourth Heart Sound
The fourth heart sound (S4) is a late diastolic
sound that corresponds to late ventricular
filling through active atrial contraction. It is a
low-intensity sound heard best with the bell
of the stethoscope.
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11. A third heart sound (S3) in early diastole
results from the impact of inflowing blood
against a distended ventricle.
The 4th heart sound (S4) results from atrial
contraction forcing blood into a stiff ventricle
in late diastole
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12. Pericardial friction rub
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13. Pericardial friction rub
A pericardial rub is highly specific for acute
pericarditis. It is generally heard over the left
sternal border.
This sound is usually continuous, and heard
diffusely over the chest.
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16. Physiology of murmur
Increased velocity
Decreased diameter
Decreased viscosity
blood flow across
incompetent valve
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Inspiration decreases the intrathoracic pressure
and increases the venous return to the right side
of the heart.
The murmurs generated from the right side of the
heart increase in intensity with inspiration.

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The intrathoracic pressure increases + venous
return to the right side of the heart decreases .
Blood in the lung is “forced” into the left heart so
murmurs arising from the left side of the heart
become more prominent.

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This causes a peripheral pooling and a net decrease in
venous return  Most murmurs are decreased in
intensity, except that of hypertrophic obstructive
cardiomyopathy (HOCM) and MVP (mitral valve
prolapse).

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Squatting causes an increase in the afterload
and venous return (ie, preload). The net effect
is an increase in intensity of all the murmurs,
except those associated with MVP and HOCM

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Increases the intrathoracic pressure
Decreases preload.
Most heart murmurs decrease in intensity,
except those of HOCM and MVP.

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33. Systolic Murmurs
Systolic murmurs occur during the ventricular
contraction. They can result from
(1) leakage across the abnormal atrioventricular
valves.
(2) ventricular outflow tract obstruction.
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34. A- Early Systolic Murmurs
Early systolic murmurs are produced by
• Acute mitral regurgitation
• or in VSD with pulmonary hypertension.
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35. Acute mitral regurgitation mumurs
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36. Acute mitral regurgitation mumurs
Acute MR can occur in the setting of an acute
MI, infective endocarditis, chordal rupture in
patients with MVP, or blunt chest wall trauma.
They are blowing in nature and decrescendo
in character.
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37. Small muscular VSD alone
and a large VSD with
pulmonary hypertension
Can also produce an early systolic murmur.
These murmurs are soft and blowing and
audible at the left lower sternal border.
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38. B- Mid to Late systolic
Murmurs
These murmurs are usually associated with
ventricular outflow tract obstruction
• Aortic stenosis murmurs
• Pulmonary stenosis murmur
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39. Aortic stenosis murmurs
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40. Aortic stenosis murmurs
It is usually a harsh murmur which is
crescendo- decrescendo in configuration and
high pitched.
Most audible at the right upper sternal border
with breath held at end expiration.
Usually radiates to the carotid arteries.
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41. Aortic stenosis murmurs
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43. Aortic stenosis murmurs
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44. Pulmonary stenosis murmur
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45. Pulmonary stenosis murmur
It is best audible at the left second ICS Lt
upper sternal border . It is crescendo-
decrescendo in configuration, and may be
associated with a systolic click that becomes
softer with inspiration.
And usually with S2 split
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46. Pulmonary stenosis murmur
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47. C- Holosystolic Murmurs
These murmurs last throughout ventricular
systole. they are typically produced by
emptying of the high-pressure ventricle during
systole into chambers that have lower
pressure at that time .
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48. Mitral regurgitation murmur
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49. Mitral regurgitation murmur
The murmur of MR is blowing and high
pitched
Best heard at the apex with radiation to the
axilla or the base of the heart.
It is usually plateau in configuration.
S1 muffled
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50. Mitral regurgitation murmur
The MR murmur is increased during
expiration, passive leg raising & squatting
And decreased in intensity with inspiration.
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51. Mitral regurgitation murmur
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52. Tricuspid regurgitation murmur
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53. Tricuspid regurgitation murmur
The murmur of TR is best heard at the left
lower sternal border.
It is a blowing high-pitched murmur that
increases in intensity with inspiration (Carvallo
sign)
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54. VSD
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55. VSD
VSD with normal pulmonary arterial
pressures, a holosystolic murmur can be heard
over the left lower sternal border at the level
of the third and fourth ICSs. This murmur
depends on the orifice size of the septal
defect. The smaller the defect, the greater the
intensity of the murmur.
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56. VSD
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58. Functional systolic ejection murmurs
They are associated with increased blood flow
across the semilunar valves (aortic/
pulmonary). Some of the conditions are
associated with functional murmurs include
anemia, thyrotoxicosis, pregnancy, fever and
exercise.
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60. Diastolic Murmurs
Diastolic murmurs are audible during
ventricular diastole and caused by either
• (1) Regurgitation across the aortic or
pulmonary valve or
• (2) Stenotic AV valves.
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61. A- Early diastolic murmurs
Early diastolic murmurs are produced by
either
• Aortic regurgitation or
• Pulmonary regurgitation.
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62. Aortic regurgitation murmur
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63. Aortic regurgitation murmur
Soft, high-pitched sound
Most audible at the left sternal border or the
right second ICS just to the right of sternum,
with the patient leaning forward at end
expiration
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64. Aortic regurgitation murmur
The murmur radiates to the left lower sternal
border if it is due to primary valve disease.
The murmur increases in intensity during
expiration and decreases in intensity with
hand grip, squatting and Valsalva,
The S2 is usually muffled with AR
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65. Aortic regurgitation murmur
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66. Pulmonary regurgitation murmur
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67. Pulmonary regurgitation murmur
The murmur of pulmonary regurgitation is
best audible at the pulmonary area. The
character, quality, and pitch of the murmur
vary depending on the presence or absence of
pulmonary hypertension.
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69. B- Mid- to late
Diastolic murmurs
These murmurs are produced by the blood
flow across stenotic AV valves.
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70. Mitral Stenosis murmur
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71. Mitral Stenosis murmur
low-pitched, mid-diastolic, rumbling murmur
with presystolic accentuation.
Best heard with the bell of the stethoscope
placed over the cardiac apex with the patient
in the left lateral position
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72. Mitral Stenosis murmur
The murmur of MS is increased in intensity
with expiration and maneuvers that increase
cardiac output, such as exercise.
The duration of murmur corresponds to the
period in which the LA-LV diastolic pressure
gradient is maintained.
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73. Mitral Stenosis murmur
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74. Tricuspid Stenosis murmur
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75. Tricuspid Stenosis murmur
TS produces a low-pitched, mid-systolic
rumbling murmur, best audible at the left third
ICS/left sternal border and xiphoid process.
The murmur increases in intensity with
inspiration and decreases in intensity during
expiration and with Valsalva maneuver.
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76. Other causes of Diastolic murmurs
Atrial myxoma
Carey Coombs murmur
States of increased flow across
AV valves
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78. Continuous Murmurs
These murmurs are audible in systole and
diastole, although their intensity usually varies
during systole and diastole. They result from a
communication between a high-pressure
arterial and low-pressure venous chamber or
vessel.
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79. Patent Ductus Arteriosus
(PDA) Murmur
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80. Patent Ductus Arteriosus
(PDA) Murmur
Continuous murmurs result from
an abnormal communication
between the aorta and the
pulmonary artery. The aortic
pressure is always higher.
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81. Patent Ductus Arteriosus
(PDA) Murmur
The murmur is blowing, high
pitched, and best audible at the
left upper sternal border near the
left second ICS
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