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1. Heart Sounds & Murmurs ____________ Color Index: Main Text Important Girl’s Slides Boy’s Slides Dr’s Notes Extra Info

2. Objectives Enumerate the different heart sounds Describe the cause and characteristic features of first and second heart sound (Normal Heart Sounds) Correlate the heart sounds with different phases of cardiac cycle Different examples of heart murmurs Define murmurs and their clinical importance Causes of abnormal heart sounds We Highly Recommend watching this video before studying this lecture

3. Heart sounds There are 4 heart sounds S1 S2 S3 S4 A udible with stethoscope (Lub-dub) I naudible in stethoscope under normal conditions because they are low frequency (pitch) sounds Two ways to detect heart sounds 1-Auscultation (stethoscope) 2-Phonocardiography (sound recording device) Ventricular systole is between S1 - S2 Ventricular diastole is between S2 - S1 Closing of the valves causes audible sounds. Ordinarily, no audible sounds occur when the valves open. Guyton

4. Areas of Auscultation Tricuspid area (S1) In the 4th left intercostal Mitral (bicuspid) area (S1) 5th left intercostal crossing mid-clavicular line, or 9 cm (2.5-3 inches) from sternum. Aortic area (S2) In the 2nd right costal cartilage Pulmonary area (S2) In the 2nd left intercostal space Girl’s Slides The areas for listening to the different heart sounds are not directly over the valves themselves. The aortic area is upward along the aorta because of sound transmission up the aorta, and the pulmonic area is upward along the pulmonary artery… etc Guyton

5. Heart sounds during the cardiac cycle

6. S1 (first heart sound) S2 (second heart sound) S-S-S-S ( S econd- S hort- S emilunar closure- S harp) Due to closure of A-V valves (Mitral & Tricuspid) Cause Due to closure of semilunar valves (Aortic & Pulmonary) at the beginning of the ‘isovolumetric contraction phase’ When is it recorded? at the beginning of the ‘isovolumetric relaxation phase’ beginning of ventricular systole What does it mark? the beginning of ventricular diastole, occurs at the end of systole LUB (low pitch) , Loud, heavier compared to S2. The sound you hear when you first feel the pulse is S1 Sound, pitch DUB (high pitch) , Soft, louder and sharp compared to S1. when the pulse disappears it is S2 Mitral and Tricuspid areas Best heard at? Aortic and Pulmonary areas 25-35 Hz frequency 50 Hz (0.15 sec) duration shorter (0.12 sec) AP= aortic, pulmonary MT= mitral, tricuspid

7. S3 (third heart sound) S4 (fourth heart sound) Rush of blood from Atria to Ventricle during rapid filling phase of Cardiac Cycle. It causes vibration in the blood. Cause Due to atrial systole causing rapid blood flow from atria to ventricle , vibration in the blood causing oscillations of ventricles during atrial contraction. during the ‘rapid filling phase’ at the beginning of middle third of ventricular diastole When is it recorded? recorded during atrial systole , occurs at the last one third of ventricular diastole. (just before S1) Heard in children and young slim adults (pathological in old age) Where is it heard? may be heard in elderly but is usually pathologic in the young. Can’t be heard in healthy people but it can be heard with pathologic problems (diastolic heart failure caused by systemic HT., aortic stenosis) usually not audible (very low pitch) Sound, pitch usually not audible (very low pitch) Mitral area Best heard at? Mitral area 20-30 Htz frequency < 20 Htz ( low pitch) (0.05 sec) duration (0.04 sec)

8. S2 Splitting physiological fixed wide Paradoxical 1- Physiological S2 Splitting ( normal) explanation: During inspiration , the aortic valve closes before pulmonary valve → reduplication (splitting of S2). No splitting of the second heart sound is normally seen during expiration. The increased venous return (VR) to the right side of the heart delays closure of the pulmonary valve. The right ventricle has more blood than usual to eject and it thus takes more time. No splitting of the second heart sound is normally seen during expiration S2 splitting types

9. S2 Splitting 2-Fixed Splitting of S2 (Pathological) Splitting of S2 is heard both during inspiration and expiration , with the aortic valve closing before the pulmonary valve. This is heard in cases of Atrial Septal Defect. 3-Wide Splitting of S2 (Pathological) A split in the second heart sound during inspiration may become wider the split may also be seen during expiration due to: 1- There is a delay in the closing of the pulmonic valve (as would be seen in right bundle branch block due to delay in right ventricular depolarization & contraction). 2- The aortic valve closes earlier (before pulmonary) than normal (this is seen with either mitral regurgitation or ventricular septal defect). Wide splitting in case of delay in closing of the pulmonic valve Wide splitting in case of aortic valve closes earlier than normal

10. S2 S plitting 4-Paradoxical (Reversed) splitting of S2 typically heard during expiration , with the pulmonary valve closing before the aortic valve. No splitting is apparent during inspiration, since the pulmonary valve is closing earlier (relative to the aortic valve) than normal. This may be caused by the following: 1- Delayed onset of left ventricular systole (ex: left bundle branch block). 2- Prolonged left ventricular systole (ex: aortic stenosis, severe hypertension, left-sided congestive heart failure). 3- Early onset of right ventricular systole (example: Wolff-Parkinson White syndrome “WPW”).

11. what is turbulent blood flow? Normally in the body, blood flow is laminar . However, under certain conditions, the blood start flowing in all directions, mixing different layers and start producing sound . we call this type of blood flow(turbulent). Significance of Heart Sounds Important for diagnosis of heart murmurs Heart murmurs are abnormal, pathologic, extra/added heart sounds heard during the heartbeat cycle. Produced due to abnormal pattern of blood flow through the heart and its valves ( Turbulence ) and/or valvular abnormalities They are longer than normal heart sounds Closure of valves of the heart Increased intracardiac Hemodynamics (murmurs) Causes of Heart S ounds -Atrio-ventricular (Mitral & Tricuspid) valves= (S1) -Semilunar (Aortic & Pulmonary) valves= (S2) -Blood striking the left ventricle = (S3, S4) - increase flow across normal valves -Turbulent flow through an abnormal valve -Turbulent flow through septal defect murmurs Causes of Heart Sounds

12. Physiological vs. P athological M urmurs Heart Murmurs ( Types) Physiological Murmurs (innocent murmur) Pathological Murmurs Caused by increased flow through normal valves Caused by turbulent flow through abnormal valves or a septal congenital defect seen in: 1-Pregnancy 2-Hyperthyroidism 3-Anemia 4-Fever 5-Children Most common abnormalities of the valves are : 1- stenosis (Tight, narrowed valve): the valve does not open properly . 2- leaky / insufficiency ( regurgitation , incompetent, valve), the valve fails to close completely, and hence causing backflow or leaks of the blood across the insufficient valve. 3- A combination of stenosis and insufficiency. 4- Septal defect (as ventricular septal defect)

13. How to describe Heart Murmurs Timing (systolic or diastolic) Shape Location Radiation Intensity Pitch Quality Gallop: Three or four sounds are spaced to audibly resemble the pace of a horse, the extra sounds occurs after S2. In Boys Slides 1- Timing: Murmurs are described according to their position in the cardiac cycle: Systolic Diastolic Continuous (Discussed later) Systolic Murmur Diastolic Murmur

14. How to describe Heart Murmurs continued 1- Timing: Systolic Murmurs: Between S1 and S2 Classified as: Diastolic Murmurs: Between S2 and S1 Classified as: Mid (ejection systolic murmur (ESM) (A&P stenosis or M&T regurgitation ) Holosystolic (pansystolic) (M&T regurgitation or VSD) Early systolic Late systolic ( M&T regurgitation) Early diastolic (A or P regurgitation) Mid diastolic Late diastolic (presystolic) (M and T stenosis)

15. How to describe Heart Murmurs continued 2 - Shape: Murmurs are described according to the waxing & waning of the sound: Crescendo (increasing intensity) Decrescendo (decreasing intensity) Crescendo-decrescendo (Diamond- shaped); (increasing then immediate decreasing intensity). Plateau (uniform); the intensity of the murmur remains uniform throughout. 3- Location of maximum intensity: Determined by the site where the murmur Originates ; e.g. Aortic, Pulmonary, Tricuspid, & Mitral listening areas. 4- Radiation : Reflects intensity of the murmur & direction of blood flow. 5- Pitch (Frequency) : High, medium, low. 6- Quality: Blowing, harsh (hard) , resonant (rumbling) & musical.

16. Pathophysiology In Boys Slides Mitral Stenosis Increased Left Atrial Pressure Pulmonary Hypertension RV Dilation and Dysfunction Tricuspid Regurgitation Tricuspid Annulus Dilation Atrial Fibrillation Increased Left Atrium Size

17. How to describe Heart Murmurs continued 7- Intensity: Graded on a (6) points according to Levine scale: GRADING OF HEART MURMURS 1 Soft Murmur heart in quiet surroundings 2 Soft Murmur heart in noisy surroundings 3 Prominent heard murmur 4 Loud murmur with a thrill 5 Loud murmur heard with edge of steth tilted against the chest + thrill 6 Loud murmur heard 5-10 mm from the chest + thrill A thrill is a slight palpable vibration felt by the hand over the chest wall 8 - Others: i. Variation with respiration: Murmurs increasing with expiration originate with left side (aortic or mitral) valves, while murmurs increasing in intensity with inspiration originate with tricuspid or pulmonary valves. (decreased pressure of RA and increase pressure of pulmonary veins) ii. Variation with position of patient. (Standing decreases venous return) iii. Variation with special maneuvers: Valsalva ( forced expiration) decreases the intensity and duration of most murmurs. (Decrease venous return) valvular stenosis: • narrowing of the valve Valvular insufficiency (incompetence): • valve is unable to close fully; so there is regurgitation In Boys Slides In Girls Slides

18. Heart Murmurs Intensity In Boys Slides I / VI 1 out of 6 Need quiet room and trained ear to hear (Difficult to hear even by expert listeners) II / VI 2 out of 6 Audible to anyone who listens attentively (Usually audible by all listeners) III / VI 3 out of 6 Loud but not palpable (Easy to hear even by inexperienced listeners, but without a palpable thrill) IV / VI 4 out of 6 Loud and palpable; produces precordial thrill V / VI 5 out of 6 Audible with your stethoscope placed perpendicular to chest wall VI / VI 6 out of 6 Audible without a stethoscope

19. Common Systolic Murmurs and Timing Aortic stenosis – ejection murmur Pulmonary stenosis – ejection murmur Mitral/Tricuspid regurgitation – holosystolic Mitral valve prolapse – mid-late systolic Ventricular septal defect (VSD) – holosystolic S1 S1 S2

20. Systolic Murmurs In Boys Slides Derived from harsh and turbulence in blood flow Associated with: Increase in flow across normal valves Increase in flow into a dilated great vessel Increase in flow across abnormal valve, or narrowed ventricular outflow tract, e.g. Aortic/Pulmonary stenosis Increase in flow across an incompetent AV valve, e.g. Mitral/Tricuspid regurgitation Increase in flow across the interventricular septum, e.g. VSD (Ventricular septal defect)

21. Systolic Murmurs Ejection (Mid- Systolic) Murmurs: Most common kind of heart murmur. Usually crescendo-decrescendo . They may be: 1. Innocent: Common in children & young adults . 2. Hyper-dynamic states: e.g. pregnancy, anemia, fever & hyperthyroidism. 3. Pathological: Secondary to structural abnormalities: e.g. Aortic/pulmonary stenosis, hypertrophic Cardiomyopathy & mitral prolapse. Pan- Systolic (Holosystolic) Murmurs: Pathological murmur Begins immediately with S1 & continues up to S2 Heard with: • Mitral/tricuspid regurgitation. • Ventricular septal defect(VSD). Girl’s Slides

22. Systolic Murmurs Aortic Stenosis Mitral Regurgitation Cause Obstruction of flow from LV into ascending aorta Retrograde flow from LV into LA through an incompetent mitral valve Timing Mid-systolic murmur Holosystolic (plateau shaped) murmur. Location Best heard on aortic area , radiates along carotid arteries. Best heard at apex , radiates to left axilla. Character Harsh, loud, may have associated with thrill, “ejection click.” (can be felt by the hand on upper chest and lower neck) Soft, high-pitched, blowing Association Old age, bicuspid aortic valve, rheumatic fever. MV prolapse, or myxomatous degeneration, rheumatic heart disease, endocarditis Pictures Girl’s Slides

23. Diastolic Murmurs Almost always indicate heart disease. Soft, blowing, rumbling, gurgle Two basic types: • Mid-or late (pre-systolic) diastolic murmurs: Suggest stenosis of mitral or tricuspid valves. • Early decrescendo diastolic murmurs: Signify regurgitant flow through an incompetent semilunar valve , e.g. aortic/pulmonary regurgitation. Girl’s Slides

24. Diastolic Murmurs Aortic Regurgitation Mitral Stenosis Cause Retrograde flow from aorta into LV through incompetent aortic cusps Obstruction of flow from LA to LV (Valve becomes narrowed , thickened & calcified) Timing Diastolic ( early ) murmur. Diastolic (mid-diastolic, or pre-systolic) murmur Location Best heard at 2nd-4th left intercostal spaces Best heard at apex Character High-pitched , blowing , decrescendo Low pitched (heard with bell) (usually weak and of very low frequency) Association Aortic root degeneration, rheumatic heart disease, VSD with aortic valve prolapse (kids). Rheumatic fever Pictures

25. Continuous Murmurs Ventricular septal defect Patent ductus arteriosus Cause A congenital condition associated with abnormal blood flow between the left ventricle and the right ventricle Failure of closure of duct between pulmonary artery & aorta Timing Holosystolic murmur , may be diastolic murmur due to turbulent flow through mitral valve Continuous murmur Location Best heard at tricuspid area Best heard at upper left sternal border Character A medium pitched murmur fills all of systole Machine-like (continuous murmur ) Association Volume overload of right ventricle Left to right shunt, cyanosis Pictures Girl’s Slides

26. MCQs Answers: 1. C 2. B 3. D 4. B 5. D Q1: T he 1st heart sound S1 is due to? A- closure of the semilunar valves B- ventricles oscillations C-closure of A -v valve D-The rapid filling Q2: When is 3rd heart sound heard? A- late ventricular diastole B-rapid filling phase C-atrial systole D- isovolumetric relaxation phase Q3: Which heart sound marks the beginning of ventricular diastole? A- S1 B-S4 C-S3 D-S2 Q4: What is the most common kind of heart murmurs? A- Pan-Systolic Murmurs B- Ejection Murmurs C- Diastolic Murmurs D- Continuous Murmurs Q5: Where are mitral stenosis murmurs best heard? A- Upper left sternal border B- Tricuspid area C- Aortic area D- Apex

27. SAQs Q1: When would you hear the abnormal heart sounds ? Q2: List 5 differences between first and second heart sounds? Q3: Describe the murmurs associated with Mitral Regurgitation, where they’re best heard and where do they radiate? A: S3: at the beginning of middle third of diastole S4: at the last one third of ventricular diastole A: Slide 6 A: Soft, high-pitched, blowing, b est heard at apex, radiates to left axilla.

28. Team Leaders Team Members Othman Aldraihem Abdulaziz Alqahtani Abdullah Alshahri Saad Al Hammad Mohammed Aldawsari Ahmad Almarshed Rayan Alahmari Abdulrahman Binbakhit Abdulaziz Alymni Faisal Alkhunein Abdullah Alqarni Raid Almadi Mohammad Alrashed Abdulrahman bin Ateeq Amer Alghamdi Mishal Alsuwayegh Nawaf alturki Hussam Aleid Raid Almadi Mohammed AlShehri Nouf Aldhalaan Amani Alotaibi Shahed Bukhari Shahad Aljeri Maha Alkoryshy Alhnouf Hadi Mayssam Aljaloud Hissa Alshiqari Mashael Albugami Renad Alayidh Ghada Binsalmah Razan Alsulami Shaden Albassam Razan Almanjomi Reem Alhazmi Dhai Hamdan Shahad Alaskar Haifa Almuddahi Reema Alquraini Deema Aljuribah Kadi Khalid Aldossari Farah Alhalafi Saleh Aldeligan Qusai Alsultan Raghad Alkhudair Raghad Alnadeef Editing File THANK YOU [email protected] Theme was done by Mohammad Alrashed Special Thanks to Saif Alotaibi ! Thanks for Team441 !