This document describes the rules and techniques for auscultating the heart. There are 5 standard points for listening to heart sounds that correspond to the major heart valves. Two primary sounds can be heard - the first sound occurs during ventricular systole and the second during ventricular diastole. Various pathological sounds and murmurs can provide clues about cardiac abnormalities, such as extra sounds indicating ventricular dysfunction or murmurs localized to specific valves that may be stenotic or incompetent. Auscultation of the heart is an important part of the physical exam to evaluate cardiac rhythm, sounds, and detect any abnormalities.

1. Auscultation
of the Heart.

2. Rules of cardiac auscultation
 There are 5 standard
points of cardiac
auscultation, which
can be auscultated in
sequence. The
sequence of
auscultation of the
heart valves associated
with the frequency of
their damage.
 The first point is in the area of ​​the apical impulse or
along the left cardiac margin in the 5th intercostal space.
The mitral valve is auscultated there.
The first point

3. The second
point is in the
2nd intercostal
space at the right
margin of the
sternum (the
aortic valve).
The third point is in the 2nd
intercostal space, left of the sternum
(the pulmonary valve).
The second
point
The third
point

4.  The fourth
point is the
auscultation
point of the
tricuspid valve
on the base of
the sternal
xiphoid process.
 The fifth point (Botkin-Erb’s point) is an
additional auscultation point of the aortic valve (in the
3rd intercostal space at the left margin of the sternum).
The fourth point
The fifth
point

5. Auscultation places of cardiac valves do not always coincide
with their projection up on the anterior thoracic wall.
 The mitral
valve is
projected at the
site of junction
of the 3rd
costal cartilage
to the left
sternal margin.
 The tricuspid valve is projected onto the midline, which
connects the places of junction of the 3rd costal cartilage on the
left and the 5th costal cartilage on the right to the sternum.
The mitral valve
The tricuspid
valve

6.  The aortic
valves are
projected
along the
middle of the
sternum at the
third costal
cartilage
level.
The pulmonary trunk is projected onto the
2nd intercostal space left of the sternum.
The aortic
valves
The
pulmonary
trunk

7. Two primary cardiac sounds can be auscultated.
 The first sound
(I) coincides with the
origination point of
the ventricular systole
and is called a
systolic one. The
second sound (II)
coincides with the
start of diastole and is
called diastolic.
 A short pause between the sounds corresponding to the
duration of systole is called a systolic pause. A long
pause after the second sound is called a diastolic pause.
systolic
pause
diastolic
pause
systolic
sound
diastolic
sound
I II

8.  Sound I coincides with the apical impulse and the carotid
pulse; it is louder and more prolong; it occurs after a long
diastolic pause; it can be better auscultated in the auscultation
area of the mitral and tricuspid valves.
I
sound
II
sound
auscultation area of
the mitral and
tricuspid valves
cardiac
base

9.  Sound II can be better auscultated on the cardiac base; it
is shorter and higher; it arises after a short systolic pause; it
does not coincide with the apical impulse and the pulse on the
carotid artery.
I
sound
II
sound
auscultation area of
the mitral and
tricuspid valves
cardiac
base

10. Origin of sound I involves four components:
 1) Valvular: due to
fluctuations of the mitral and
tricuspid valves’ leaflets caused
by their tension during
ventricular closure (at the very
beginning of systole);
 2) Muscular: associated
with tension of the ventricular
myocardium in the early period
of blood ejection out of the
ventricles;
 3) Vascular: caused by vibrations of the walls of the aorta
and the pulmonary artery in the initial period of admission of the
ventricular blood;
 4) Atrial: due to fluctuations of the atria on contraction.
Atrial and vascular components generate sounds below the
threshold of hearing, so are of no significant value.
Valvular
Atrial
Muscular
Vascular

11. Origin of sound II involves two components:
 1) Valvular:
due to fluctuations
in the leaflets of the
semilunar valves of
the aorta and of the
pulmonary artery
during their closure
at the end of
ventricular systole;
 2) Vascular: associated with vibration of the walls of the
aorta and the pulmonary artery. Vibration arises because of
the fact that the last part of the ejected blood is kind of being
repelled from the already closed valves.
Valvular
Vascular

12. Auscultation of the heart provides determination of the
regular cardiac rhythm, heart rate, number of primary
sounds, their volume, tone, sound integrity, correlation of
sound volumes, as well as presence of extra sounds and
murmurs.
 During auscultation
over the apex of the
heart (1st point),
rhythmicity of heart
sounds is determined
at first.
 Prolongation of some diastolic pauses is characteristic for
extrasystoles, particularly ventricular and for disorders in cardiac
conduction. Chaotic alternation of diastolic pauses of varying duration
is typical for atrial fibrillation.

13. Alternations in sound volumes may involve
one or two sounds and is manifested in their
amplification or attenuation.
 Volume
amplification in both
cardiac sounds is not
associated with cardiac
pathology. It is noted in
thyrotoxicosis and hard
muscular load.
thyrotoxicosis

14. Amplification of sound I at the apex
 is typical for mitral
stenosis. In this heart
defect, amplified sound I
over the apex has a
"slapping" nature. It is
associated, first, with a
more rapid contraction of
the left ventricle, which is
insufficiently filled with
blood during diastole.
 Second, vibrations of sclerosed walls of the mitral valve
add a crackling tint to the 1st sound. Amplification of
sound I is noted at onset of extrasystole.
mitral
stenosis
Normal
mitral valves’

15. Amplification of sound I at the apex
 In patients with complete
atrioventricular blockage,
sudden amplification of
sound I (cannon sound of
Strazhesko) can be
occasionally auscultated over
the heart apex due to
pronounced bradycardia. This
phenomenon associated with
random simultaneous
contractions of the atria and
ventricles.

16. Amplification or shock of sound II above the
aorta
 is noted in
increase of
blood pressure
in the systemic
circulation and
during aortic
atherosclerosis.
aortic
atherosclerosis

17. Amplification or shock of sound II over the
pulmonary trunk
 is caused by high pressure in the pulmonary
circulation (pulmonary hypertension).

18. Pathological attenuation of both the heart sounds is
noted in diseases with impaired contractility of the
ventricular myocardium (myocarditis, myocardial infarction,
etc.) or in the presence of pericardial effusion.
 If sound I
over the heart
apex is equal
in pitch to
sound II or is
lower,
attenuation of
sound I is
noted.
Normal
Pericardial
effusion

19.  The main causes of attenuation in
apical sound I are: mitral incompetence
(absence of period of valvular closure
during systole, attenuation of the muscular
and valvular components occurs); lesion of
the cardiac muscle (myocardial infarction,
myocarditis) with attenuation of the
contractile ability of the left ventricle;
 aortic valve incompetence
(absence of period of valvular closure
during systole, which leads to
attenuation of the muscular and valvular
components); constriction of the aortic
orifice (ventricular contractions become
slod, systole enhances and amplitude of
sound oscillation decreases).
mitral incompetence

20. Attenuation of sound II on the aorta
 occurs in the aortic
valve incompetence
(due to diminished role
of the valvular and
vascular components)
and in decreased blood
pressure (due to
diminished role of the
vascular component, as
in low blood pressure
the aortic leaflets close
with less force).
 In case of aortic valve destruction, aortic sound II
cannot be auscultated.

21. Attenuation of sound II over the
pulmonary trunk
 develops due to
pulmonary valve
incompetence,
constriction of the
pulmonary artery, as
well as due to the
right ventricular
failure (reduced
pressure in the
pulmonary
circulation).

22.  If duration of pauses
and sound pitch become
uniform, the resulting
rhythm is called
pendulum.
 If in similar conditions the
pitch of sound I is higher than
that of sound II, the rhythm is
called embryocardia. Such
sounds may occur in
myocardial infarctions or
acute cardiovascular failure.

23.  If instead of one cardiac
sound two fast
consecutive short sounds
are auscultated, this is
reduplication in
sound I or II.
 If both the parts of the
reduplicated sounds are not
perceived as two sounds
but produce an impression
of a heterogeneous sound.
It is termed sounds
splitting.
sound
I
sound I
osound II
r I
reduplication in
sound I
splitting of sound I

24.  Reduplication and
splitting of cardiac sounds
are associated with
asynchronous performance
of the left and right halves
of the heart.
 If atrioventricular valves do not close
simultaneously, reduplication (or
splitting) of sound I is auscultated, if
asynchronous closure occurs in the
semilunar valves of the aorta and the
pulmonary artery, sound II is auscultated.
reduplication in
sound I Sound II
atrioventricular valves do not
close simultaneously
reduplication in sound II
Sound I
semilunar valves of the aorta and the pulmonary
artery do not close simultaneously

25.  Pathological reduplication
or splitting of sound I over
the heart apex is auscultated in
the case of asynchronous onset
of systole in the left and right
ventricles in bundle-branch
block,
in pronounced hypertrophy or
in dilatation of the left or right
ventricles.

26.  Pathological
reduplication or
splitting of sound II
over the heart apex can
be auscultated in arterial
or pulmonary
hypertension or in bundle
branch block.

27. Physiological reduplication or splitting of
sounds I or II can be associated with the
respiratory phases.

28. Extra tones arise during a diastolic pause.
 They include: the
third (III) and fourth
(IV) sounds, the
opening sound of the
mitral valve and the
pericardial sound.
 Sound III is auscultated as a short, low, dull sound
following the second sound in early diastole.
Sound I
Sound II
diastole
systole

29. Sound
IV
 Sound IV is a low-
frequency sound that
occurs at the end of
diastole prior to the first
sound.
 Their origination leads to a three-component rhythm. If extra sound (IV) precedes the
first sound, the rhythm is called presystolic gallop. It is caused by enhanced contraction of
the dilated left atrium and by decreased tonicity of the myocardium. If the extra sound is
auscultated tone after sound II (sound III), the gallop rhythm is called protodiastolic. Its
occurrence is indicative of a sharp weakening in cardiac contractility.
Sound I
Sound II
diastole
systole
Sound I Sound I
Sound
III
Protodiastolic gallop Presystolic gallop

30. mitral click
 Sound of the mitral valve opening (mitral click) is a sign of mitral
stenosis. It arises immediately after the sound II. The best place for its
auscultation is the apex of the heart, in the patient’s position on the left side,
on exhalation. It is perceived as a short sound resembling a click.
 Occurrence of the mitral click is associated with the tension
of the fused leaflets in the mitral valve. It occurs during their
protrusion into the cavity of the left ventricle during valve
opening at the onset of diastole. It goes together with "flapping”
sound I. Loud sound I, sound II tone, as well as a mitral click,
which are auscultated at the heart apex, produce a "fout-ta-ta-
rou" rhythm.
"fout-ta-ta-rou" rhythm

31.  Pericardium sound is a short, loud sound resembling a mitral
click. It is not combined with clapping sound I. It is auscultated at the
heart apex in patients with adhesive pericarditis.
 It is registered after
sound II and is
associated with vibration
in the pericardium
during rapid ventricular
dilation in early diastole.
Pericardium
sound

32. Cardiac murmurs
 Cardiac
murmurs are
subdivided into
intracardiac, i.e.
generated inside
the heart, and
extracardiac
which are
generated outside
the heart.
 Intracardiac murmurs are subdivided into organic
and functional. Depending on the phase of the cardiac
cycle systolic and diastolic murmurs are distinguished.
Cardiac murmurs
extracardiac intracardiac
organic functional
pericardial
rub
pluropericardial
murmur

33. Organic intracardiac murmurs
 Organic intracardiac
murmurs are caused by
morphological changes in the
cardiac valves.
 Organic cardiac murmurs
are louder, continuous, with
areas of ​​irradiation, stable.
Organic murmurs occur due
to impairment or constriction
of the valve orifice.
 The murmur in stenosis of the valve is produced by turbulent
convolution of blood when passing through constricted orifices
during systole or diastole of the heart.

34.  Valve incompetence develops due to deformation and
partial destruction, valves cannot close completely the
corresponding orifice. A narrow slit remains, through which
blood may partly flow in the opposite direction.

35. Functional murmurs
 Functional murmurs are not
associated with organic
pathology of the heart. They
appear in dysfunction of the
papillary muscles, change in
the rheological properties of
blood and increase in blood
flow.
 They can be
auscultated in healthy
people, patients with
fever, hyperthyroidism,
anemia or malnutrition.

36.  Functional murmurs can be
auscultated within a limited
area, usually at the apex or at
the pulmonary trunk; they do
not propagate anywhere; they
have a small volume.
 They are always systolic; non-persistent (they appear
and disappear, depending on position of the body or
breathing phase). They attenuate on deep inspiration
and amplify by the end of exhalation.
Functional systolic
murmurs

37. Cardiac murmurs arising between sounds I and II are
called systolic, while murmurs, emerging after sound II are
diastolic.
 Diastolic murmurs are heard in
stenosis of the mitral or tricuspid
valves, in the incompetence of the
aortic valves and the valves of the
pulmonary artery failure.
 They are heard at the
points of auscultation of
these valves.

38.  There are three varieties
of diastolic murmur:
protodiastolic – at the onset
of diastole, immediately after
sound II;
 mesodiastolic - in mid-diastole; presystolic - at the end of
diastole preceding sound I. In some cases, murmur may last
throughout the diastole.
Mesodiastolic
murmur
Presystolic murmur

39.  If the
incompetence of
the pulmonary
artery valves is
relative
(stretched aortic
orifice caused by
dilatation of the
right ventricle),
 the diastolic murmur in the 2nd intercostal space left
of the sternum is called the Graham-Still’s murmur.
Graham-
Still’s
murmur.

40. Organic systolic murmurs are subdivided into
ejection murmurs and regurgitation murmurs
depending on mechanism of their origination.
 Systolic murmur of regurgitation
arises during ventricular systole due to
retrograde blood flow through the
non-completely closed orifice from
the cavity with high pressure
(ventricular) to the cavity with low
pressure (atrial).
 It is noted in mitral and
tricuspid incompetence.
mitral
incompet
ence

41.  Systolic ejection
murmur occurs when
blood flows through a
constricted orifice in
the area of ​​the aortic
valve or the
pulmonary valve.

42.  All organic
murmurs can be
conducted from
the place of their
origin to other
points. Thus,
systolic murmur
on the mitral
incompetence is
conducted (along
the blood flow)
 upwards to the left atrium and left, towards the
axillary area (due to hypertrophy and dilatation of the
left ventricle).
axillary area

43.  Systolic murmur in aortic stenosis is
conducted along the flow of blood to the
subclavian, carotid arteries and to the
interscapular region.
carotid
arteries
subclavian
arteries

44.  Systolic murmur in tricuspid valve
incompetence is conducted upwards, along the
left sternal edge.
Systolic murmur in
tricuspid valve
incompetence

45.  In aortic incompetence a reverse flow of blood from the aorta
into the left ventricle during diastole can lift the front leaflet of the
mitral valve.
 This creates an obstacle to blood ejection from the left atrium
into the left ventricle, which contributes to functional mitral
stenosis. It is manifested by a gentle diastolic Flint’s murmur at
the apex of the heart.
Functional mitral stenosis.
Flint’s
murmur

46.  Depending on their tone
murmurs may be blowing,
harsh, sawing, scraping,
whistling and resonant cooing;
 Depending on their duration
murmurs may be short and
prolonged, lasting throughout
the whole systolic or diastolic
pause;
 Depending on their volume murmurs
may be soft and loud.
 Depending on dynamics in loudness
murmurs may be subsiding and enhancing.

47. Potential lesions of several valves with various types of
impairment (stenosis and insufficiency) or of one valve should be
taken into account.
 In the first case,
systolic or diastolic
murmurs are
identified in the
auscultation points of
all the affected
valves. In the second
case, systolic and
diastolic murmurs are
auscultated only at
one point.

48. Extracardiac murmurs
 Extracardiac murmurs
auscultated in the cardiac
area, include pericardial rub
murmur and pluropericardial
murmur. Pericardial rub
murmur arises in fibrinous
pericarditis, uremia and
dehydration.
 Layers of the pericardium
become rough and dry. The murmur
is well auscultated in the area of
absolute dullness of the heart; it does
not propagate at the left sternal edge
or over the base of the heart.

49.  The murmur can be auscultated during both systole and
diastole. It is amplified during pressing the thorax by a
stethoscope.
 It is better auscultated in patient standing or
sitting position with the trunk bent forward. It
subsides at the height of inspiration.

50.  Sometimes
pleurocardial
murmur is
auscultated at the
left contour of the
heart. It originates in
the inflamed section
of the pleura, which
is adjacent to the
heart.
 This murmur intensifies in a deep breath, and
subsides or disappears after expiration or holding
breath.

51. Auscultation of vessels should be performed
without exerting pressure with phonendoscope,
otherwise stenotic noise may appear.
 The carotid artery is auscultated along the internal
margin of the sternocleidomastoid muscle, at the level
of the superior margin of the thyroid cartilage.

52.  The subclavian artery is auscultated in the Morenheim’s
fossa, and the femoral artery is auscultated under the crural
arch in the patient lying position.
subclavian artery
Morenheim’s
fossa

53.  Murmurs in the arteries are auscultated in case of their
dilatation (aneurysm), constriction of the arteries or
acceleration of blood flow inside the arteries.
constriction of the
arteries

54.  Murmurs can be
also conducted to
arteries from the heart
(aortic stenosis). In
patients with aortic
failure Traube’s dual
sound is identified
over large vessels
during diastole.
 If the femoral artery is compressed, by a
phonendoscope - dual murmur of Vinogradov-Duroziez
is identified (as a result of reversed blood flow).

55.  In patients with
anemia, during
auscultation of the
jugular vein in a
vertical position,
“nun’s murmur” is
identified over the
sternal edge of the
clavicle on the right.
 It is mediated by accelerated blood
flow through the jugular vein. The
murmur may enhance during
inspiration, compression of the neck
with a stethoscope or turning the head
to the left.
point of
auscultation
“nun’s murmur”

56. Thank
you for
the
attention!