Heart Murmurs

Dr Nighat MajeedAssistant professor

medicineMedical unit 11

SIMS/SHL Lahore

Heart sounds

• Two heart sounds.

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).

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.

First Heart sound

• Increased intensity• Mitral stenosis.• Sinus rhythm with short PR interval(0.08

to 0.12 sec).• Hyperkinetic circulatory state.

First Heart sound

Decreased intensity• Mitral regurgitation.• Aortic regurgitation.• Shock.• Myocardial infarction.• Congestive failure.

First Heart sound

Variation in intensity• Atrial fibrillation.• AV dissociation.• Complete AV block.• Ventricular tachycardia.

First Heart sound

• Wide splitting of S1

• Due to mechanical delay in mitral and tricuspid valve closure.

• Mitral stenosis,Ebstein,s anomaly,ASD.

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.

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.

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.

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

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.

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.

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.

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.

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.

Abnormal heart sounds

Pericardial Knock• Diastolic filling sound.

• Occurs earlier than S3.

• Occurs in constrictive pericarditis.• Coincide with the y descent of JVP.

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.

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.

Abnormal heart sounds (OS)

• Occurs between 0.04 and 0.12 sec after A2.

• Severity of mitral stenosis is estimated by A2-OS interval.

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.

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.

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.

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.

Heart Murmurs

• Classification• Innocent (animals).

• Functional (anemia, tachycardia, hyperthyroidism, high output cardiac states).

• Pathological.

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.

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).

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.

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.

Heart Murmurs

Systolic murmurs• Early systolic ejection murmur Are flow murmurs(decrescendo or kite

type).

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.