Lecture Slides Presented at SIMS by Medical Unit SIMS Hospital

1. Heart Murmurs
Dr Nighat Majeed
Assistant professor medicine
Medical unit 11
SIMS/SHL Lahore

2. Heart sounds
• Two heart sounds.

3. First Heart sound
• Is produced due to closure of mitral and
tricuspid valves.
• Louder at the apex of heart.
• Two audible components,
mitral(M1),Tricuspid(T1).

4. First Heart sound
• Two audible components,
mitral(M1),Tricuspid(T1).
• Normal splitting in 85% of cases but both
components have equal pitch and intensity.
• Has equal loudness at apex and left sternal
border.

5. First Heart sound
• Increased intensity
• Mitral stenosis.
• Sinus rhythm with short PR interval(0.08 to
0.12 sec).
• Hyperkinetic circulatory state.

6. First Heart sound
Decreased intensity
• Mitral regurgitation.
• Aortic regurgitation.
• Shock.
• Myocardial infarction.
• Congestive failure.

7. First Heart sound
Variation in intensity
• Atrial fibrillation.
• AV dissociation.
• Complete AV block.
• Ventricular tachycardia.

8. First Heart sound
• Wide splitting of S1
• Due to mechanical delay in mitral and tricuspid
valve closure.
• Mitral stenosis,Ebstein,s anomaly,ASD.

9. The second Heart
sound(S2)
• Is produced due to closure of aortic and
pulmonary valves.
• The second heart sound consists of an aortic(A2)
and pulmonary component(p2).
• Increased intensity
• Systemic hypertension,pulmonary hypertension.
• Aortitis.
• Aortic regurgitation.

10. The second Heart
sound(S2)
Decreased intensity
• Pulmonary stenosis.
• Aortic stenosis.
Splitting
• Normal splitting of S2 into earlier A2 and later p2
component is heard best in the pulmonary area.
• Maximum normal split is about 0.03 sec in
expiration and 0.06 sec in inspiration.

11. The second Heart
sound(S2)
Narrow physiologic splitting
• Severe pulmonary hypertension.
Wide splitting of second heart
sound
• Caused by delayed p2, early A2.or a
combination of two.
• Activation of right ventricle e:g in left
ventricular pacing or ectopic beat.
• Complete right bundle branch block.

12. Wide splitting of S2
• Vavular pulmonary stenosis.
• Pulmonary hypertension.
• Pulmonary embolism.
• Atrial septal defect.
• Ventricular septal defect.
• Pulmonary insufficiency.

13. The second Heart
sound(S2)
Wide and fixed splitting
• The sound that do not split by more than 0.02
sec.
• Atrial septal defect.
• Right sided heart failure.
• Acute massive pulmonary embolism.
• Cardiomyopathy.
• Right bundle branch block wide but not fixed.

14. The second Heart
sound(S2)
Reversed or paradoxical splitting
1.Delayed closure of aortic valve
• Left bundle branch block.
• Right ventricular paced or ectopic beats.
• Left ventricular out flow tract obstruction.
2.Early closure of of pulmonary valve as
in WPW type B.

15. Abnormal or extra sounds
Third heart sound
• Occurs 0.12 to 0.18 sec after A2 coincide with
descending limb the v wave in jugular venous
pulse, soft low pitched sound,localized at apex.
• Can occur normally in children and young adults.
• Left sided S3 is caused by left ventricular failure,
a right sided S3 by the right ventricular failure.
• Mitral regurgitation.
• When S3 or S4 coincide this is called summation
gallop.

16. Fourth heart sound
Fourth heart sound S4
• Occurs 0.05 to 0.10 sec before S1.
• Also called atrial or presystolic gallops.
• Absent in atrial fibrillation.
• It is a soft, low pitched sound, heard with the bell
of stethoscope applied lightly to the chest wall,
best heard at the apex.
• S4 may be left sided or right sided.
• Indicative of myocardial contractility.

17. Fourth heart sound
Causes
• Decreased compliance of left ventricle
systemic hypertension.
Aortic stenosis,aortic insufficiency.
Cardiomyopathy.
• Acute myocardial infarction.
• Attacks of angina pectoris.
• AV blocks of varying degree.
• Hyperdynamic circulation.

18. Abnormal heart sounds
Pericardial Knock
• Diastolic filling sound.
• Occurs earlier than S3.
• Occurs in constrictive pericarditis.
• Coincide with the y descent of JVP.

19. Abnormal heart sounds
Opening snap(OS)
• Audible opening of mitral and tricuspid valve
when it is stenosed.
• Disappears when the valve become rigid, fixed,
or calcified.
• Persists after commissurotomy, audible both in
sinus rhythm and atrial fibrillation.
• OSMV is best heard at lower left sternal border
and at the apex.
• OSTV of tricuspid valve is best heard over the
lower end of sternum.

20. Abnormal heart sounds
(OS)
• OS is not affected by respiration.
• Occasionally heard in atrial septal defect.
• In severe MS A2-OS interval is very short,
administration of phenylephrine increases the A2-
OS interval, separate the OS from S2.

21. Abnormal heart sounds
(OS)
• Occurs between 0.04 and 0.12 sec after A2.
• Severity of mitral stenosis is estimated by A2-OS
interval.

22. Abnormal heart sounds
• Systolic sounds
Aortic and Pulmonary ejection sounds
• Occurs 0.04-0.09 sec after Ist heart sound.
• Occur in pulmonary stenosis and pulmonary
hypertension.
• Congenital aortic stenosis, aortic insufficiency,
coarctation of aorta, tetrology of Fallot.

23. Heart sounds Abnormal
• Systolic sounds
• Systolic clicks
• Can occur any time during the systole, but are
more common during mid and late systole.
• Indicative of mitral valve prolapse.

24. Abnormal heart sounds
Systolic sounds
Pericardial friction rub
• It is a rough, scratchy sound,louder on
inspiration.
• It has a systolic, diastolic and presystolic
components.
• Pericardial friction rub should be differentiated
from pleuropericardial friction rub and from the
sound of mediastinal emphysema.

25. Heart Murmurs
Produced due to
• Increased flow through normal or abnormal
valve.
• Forward flow through a deformed or narrowed
valve.
• Backward or regurgitant flow through
incompetent valves or septal defects.
• Vibration of loose structures in the heart.
• Continuous flow through intracardiac or extra
cardiac shunts or collateral vessels.

26. Heart Murmurs
• Classification
• Innocent (animals).
• Functional (anemia, tachycardia,
hyperthyroidism, high output cardiac states).
• Pathological.

27. Classification
• Murmurs can be described by six features
• Timing: whether the murmur is a systolic or
diastolic murmur.
• Shape: intensity over time; murmurs can be
crescendo, decrescendo or crescendo-
decrescendo.
• Location: where the heart murmur is
auscultated best(six places). At parasternal area
2nd right intercostal space, 2nd - 5th left
intercostal spaces, and 5th mid-clavicular
intercostal space.

28. Classification
• Intensity: Refers to the loudness of the
murmur, and is graded on a scale from 0-6/6.
• Pitch: low, medium or high and is determined
by whether it can be auscultated best with the
bell or diaphragm of a stethoscope.
• Quality: Blowing, harsh, rumbling and musical.
• Radiation: where the sound of the murmur
radiates(sound radiates in the direction of the
blood flow).

29. Heart Murmurs
Types of murmurs
• Systolic:Begins with or after S1 and ends
before,at S2.
• Diastolic:Begins with or after S2 and ends
before S1.
• Continuous:Begins in systole,continues
through S2 without interruption, and ends some
time in diastole.

30. Heart Murmurs
Systolic murmurs
• Midsystolic ejection murmur are caused by
normal or increased forward flow through right or
left ventricular outflow tracts.They are of variable
in intensity high pitched,noisy, harsh and
crescendo-decrescendo(diamond shaped) in
character.
• Found in Aortic stenosis.
• Pulmonary stenosis.
• Dilatation of aorta or pulmonary artery.

31. Heart Murmurs
Systolic murmurs
• Early systolic ejection murmur
Are flow murmurs(decrescendo or kite type).

32. Heart Murmurs
Systolic regurgitant murmurs
• They are caused by flow from high to low
pressure chambers or vessels.
Mitral regurgitation.
Tricuspid regurgitation.
Ventricular septal defect.
Mitral valve prolapse.
They are classified as pansystolic, early systolic,
late systolic.

33. Heart Murmurs(diastolic)
• They are classified as early diastolic, mid
diastolic or late diastolic.
• Early diastolic murmurs are caused by
incompetence semilunar valves
Aortic regurgitation.
Pulmonary regurgitation.

34. Heart Murmurs(diastolic)
• Mid and late diastolic murmurs
are caused due to stenosis of atrioventricular
valves or increased flow through these valves.
Mitral stenosis.
tricuspid stenosis.

35. Continuous murmurs
• Occurs
• Extra cardiac or intracardiac shunts.
• Flow through narrowed or collateral vessels
• Increased flow through vascular
structures(PDA).
• Machinery murmur of crescendo decrescendo
type found in PDA.

36. Description of murmur
• Levine and Harvey
• Grade 1:very faint, heard only after listener has
"tuned in"; may not be heard in all positions.
• Grade 2:Faint, Quiet, but heard immediately.
• Grade 3:Moderately loud.
• Grade 4:Loud. with palpable thrill (i.e., a tremor
or vibration felt on palpation)
• Grade 5:very Loud. with thrill. May be heard
when stethoscope is partly off the chest
• Grade 6:Loudest possible.

37. Interventions that change
murmur sounds
• Inspiration: Increase the amount of
blood filling into the right ventricle, thereby
prolonging ejection time. This will affect
the closure of the pulmonary valve. This
finding, also called Carvallo's Maneuver.

38. Interventions that change
murmur sounds
• Abrupt standing:decreases the
murmur of aortic stenosis, mitral
stenosis, tricuspid stenosis and
increases the murmur of idiopathic
hypertrophic subaortic stenosis.
• Hand grip.

39. Interventions that change
murmur sounds
Amyl nitrite:
• Decreases the murmur of mitral regurgitation
and increases all other murmurs.
Methoxamine:
• Decreases the murmur of mitral stenosis,and
idiopathic hypertrophic aortic stenosis and
• Increases the murmur of aortic regurgitation,
tricuspid regurgitation,mitral valve prolapse and
mitral regurgitation.

40. Interventions that change
murmur sounds
valsalva maneuver:
• Increases:Hypertrophic obstructive
cardiomyopathy (HOCM), idiopathic hypertrophic
subaortic stenosis and mitral valve prolapse.
• Decreases:aortic stenosis,pulmonary stenosis,
mitral regurgitation and tricuspid regurgitation.
Positioning of the patient: positioning
patients in the left lateral position will allow a
murmur in the mitral area to be more
pronounced.

41. Interventions that change
murmur sounds
Positioning of the patient: positioning
patients in the left lateral position will allow a
murmur in the mitral area to be more
pronounced.
Squatting:decreases the murmur of idiopathic
hypertrophic subaortic stenosis and increases
the murmur of Fallot,s tetrology and all other
murmurs.