Hemorrhage

1. EXAMINATION OF THE HEART
Assoc. prof. Jozef Gonsorčík, MD. FESC
Department of cardiology UPJŠ LF & VÚSCH, a.s.

5. Viliam Harvey Rene Teofil Hyacint Laennec Willem Einthoven
....1616................1715.................1816.................1895....
Harvey Douglas Laennec Huerle Einthoven
....20 cent. world
Gallavardin Laubry Levine
Vaquez White Weber Luisada
Slovakia
prof. Sumbal prof. Haviar
prof. Jakubcová prof. Takáč

6. Focus on chest
1. Front medial line
2. Right sternal line
3. Right parasternal line
4. Right medioclavicular line
5. Right front axillary line
6. Left scapular line
7. Left paravertebral line
8. Back medial line

7. AUSCULTATION OF THE HEART
Projection on the chest:
Aortic valve
Pulmonary valve
Tricuspid valve
Mitral valve
Erb point

8. Heart sound
1 heart sound (S1)
 the normal S1 comprises mitral (M1) and tricuspid (T1) valve closure
 the M1 sound occurs slightly before T1
 best on cardiac apex
 is synchronous with carotid beat
 accentuated S1 – short PQ interval, moderate mitral stenosis,complete AV
block
 softer S1- LV systolic dysfunction, in the late stages of mitral stenosis, when
the leaflets are rigid and calcified, mitral regurgitation, long PR interval,
obesity, pericardial effusion
 split S1 - LBBB
st

9. Heart sound
2 Heart sound (S2)
 comprises aortic (A2) and pulmonic (P2) valve closure
 the components are best heard at the second left interspace in the supine
position
 split S2 - physiologic splitting, the A2-P2 interval increases during inspiration
and narrows with expiration
S1 S1
S2
SYSTOLE DIASTOLE
A2 P2 A2 + P2
S1 S1 S1 S1
INSPIRATION EXPIRATION
S2 S2
nd

10. Heart sound
Wide physiologic splitting of the S2 is seen in a
patient with complete right bundle-branch block
(RBBB).
fixed splitting - the A2-P2 interval is wide and remains unchanged during the
respiratory cycle (hemodynamically significant atrial septal defect)
Reversed (paradoxical) splitting - occurs as a consequence of a pathologic delay
in aortic valve closure, as may occur with complete LBBB, RV apical pacing,
severe aortic stenosis, hypertrofic - OCM, and myocardial ischemia
 accentuated S2 – component A2: arterial hypertension
– component P2: pulmonary hypertension, pulmonary embolism
S1 S1
S1 S1
S2
S2
P2 A2
P2+A2
INSPIRATION
EXPIRATION

11. Heart sound
3 heart sound (S3)
 abrupt ending of ventricular distension in the initial phase of diastole
 is greatly increased in patients over 40, in whom it often signifies left
ventricular systolic dysfunction /heart failure due to dilated left ventricle/ -
LVEDD >55 mm, EF< 40 %
4 heart sound (S4)
 its origin exactly relates to distension of the ventricle caused by atrial
systole
 reduced compliance of the ventricle (hypertrophy, fibrotic changes)
 At the apex of the patient on left side
rd
th
S1
S1
S1 S1 S1
S1
S2 S2 S2

12. Ventricular gallop Atrial, presystolic gallop
Quadruple rythm
Incomplete summation gallop
Summation gallop
Atrial diastolic gallop and ventricular diastolic gallop
recorded in an adult with severe calcific aortic stenosis.

13. Additional abnormal sounds
 diastolic opening snap of the mitral valve
 early systolic (ejection) click – non-calcified aortic stenosis
 late systolic click - mitral valve prolaps
 pericardial knock – in early diastole in constrictive pericarditis
 valvular prosthesis sounds

14. Cardiac murmurs
 result from audible vibrations caused by increased turbulence and are
defined by their timing within the cardiac cycle
 Organic
 Functional
 according to the mechanism are divided into ejection, regurgitant
and overflow
 murmurs characteristic:
1. location in timing – systolic, diastolic (early-, mid-, late-, proto-, holo-),
continuous
S1 S2 S1

15. Cardiac murmurs
2. point of maximum intensity
3. radiation
4. intensity is graded on a scale of 1 to 6
1/6 poorly audible
2/6 silent but recognizable
3/6 murmurs mid volume
- a palpable thrill is present with murmurs of grade 4/6 intensity or
higher
5. quality – crescendo, decrescendo, crescendo – decrescendo,
musical, rough, etc.

16. Systolic murmurs
• aortic stenosis
• pulmonary stenosis
• atrioventricular valve regurgitation
• ventricular septal defect
• aortic coarctation
• mitral valve prolaps
Aortic stenosis - a prominent aortic
valvular ejection sound (AVES), it is
followed by a crescendo–
decrescendo systolic ejection
murmur (SEM)
Holosystolic murmur – mitral valve regurgitation

17. Systolic murmurs
Late systolic murmur with a
prominent late systolic click
– mitral valve prolaps
Pansystolic murmur (PSM)
with late systolic
accentuation is secondary to
the prolaps of the mitral
valve.

18. Diastolic murmurs
aortic
regurgitation
pulmonary
regurgitation
mitral stenosis tricuspid
stenosis

19. Diastolic murmurs
Mitral stenosis - diastolic murmur
following loud opening snap (OS),
presystolic accentuation with sinus rythm
Aortic regurgitation - high-pitched
decrescendo murmur, which begins with
the second heart sound (S2)

20. Continuous murmurs & pericardial friction rub
 a continuous murmur implies a pressure gradient between two
chambers or vessels during both systole and diastole
 these murmurs begin in systole, peak near S2, and then continue
into diastole
• PDA
• Coronary & peripheral AV fistula
• Ruptured sinus of Valsalva aneurysm
S1 S1
S2
A pericardial friction rub is very specific for the diagnosis (acute
pericarditis/sicca), although its sensitivity is not as high, because the rub
may wax and wane over the course of an acute illness. This leathery or
scratchy, typically two- or three-component sound may also be
monophasic. S1 S1
S2