Normal and abnormal Heart sounds (Murmurs).pptx

Normal and abnormal Heart sounds (Murmurs).pptx
Auscultation of heart sounds
How murmurs are produced
physiology of murmurs
Classification and types of murmurs
causes of murmurs

1. Normal and abnormal Heart sounds (Murmurs) By Dr. Irtaza Rehman (Author of The Extraordinary Life) Follow at

2. Learning Objectives To learn about the N ormal heart sounds To learn about the Abnormal heart sounds

3. Normal Heart sounds Produced by the closure of Atrio -ventricular valves (Mitral and tricuspid) and Semilunar valves (aortic & pulmonary)

4. Normal Heart sounds Sites for Auscultation

5. Normal Heart sounds Systole Systole Systole Diastole Diastole

6. Normal Heart sounds

7. S2: A2 (Aortic valve closure) Loud A2: Systemic Hypertension (High B.P will create louder noise) Low A2: Systemic Hypotension, Aortic regurgitation   (destruction of valve tissue and impairment of the valve closure mechanism) Normal Heart sounds

8. S2: P2 (Pulmonary valve closure) Loud P2: Pulmonary hypertension, ASD (Blood shunting from left to right atrium  right ventricle  Pulmonary artery  Loud P2) Low/soft P2: Pulmonary stenosis Normal Heart sounds

9. S1 splitting Normally T1 (Tricuspid closure) comes later than M1 due to slightly earlier closure of Mitral valve. But this splitting is very narrow, almost negligible. May not be present at all. So normally there is no splitting in S1. Normal Heart sounds

10. S1 splitting Delayed T1: RBBB (due to slower conduction on right heart, Tricuspid valve will close with further delay than Mitral valve) Normal Heart sounds

11. S1 splitting Reverse splitting: LBBB, Severe MS (as mitral valve will close with a delay after Pulmonary valve in both condition). M1T1 pattern will be reversed. T1  M1 Normal Heart sounds

12. S2 splitting S2 is normally split because the aortic valve (A2) closes before the pulmonary valve (P2 ) Split is more prominent in inspiration. Normal Heart sounds

13. S2 splitting Wide splitting: splitting gets wide and wider in inspiration. In RBBB, Pulmonary stenosis ( late movt of P.v ) Fixed splitting: Equal delay in both Ins & Exp. In ASD ( Blood shunting from left to right atrium  right ventricle  Pulmonary artery  Late closure of P.v ) Paradoxical splitting: Aortic valve moves slower. Aortic stenosis, LBBB) Normal Heart sounds

14. Third heart sound In early diastole Normally present in Kids, Young adults, athletes, pregnancy In older (congestive heart failure) Due to rapid ventricular filling during diastole Ventricular gallop

15. How to differentiate bw S3 and S2 Splitting? S3 S2 split Low pitch High pitch Heard by the Bell Heard by diaphragm At the Apex At the base Aortic area (5 th ICS MCC )

16. Fourth heart sound In late diastole Always pathological Heard at the Apex Low pitch HOCM, Hypertension, Acute MI When atria contracts in non compliant/stiff ventricles Atrial gallop

17. Murmurs Murmurs are extra or unusual sounds made by blood circulating through the heart's chambers or valves, or through blood vessels near the heart.

18. Murmurs are produced due to any sort of turbulence in normal blood flow across heart. Causes of turbulence: Increase velocity of blood Decrease diameter (ASD, VSD) Decreased diameter will inc. the velocity. Incompetent valves ( Valvular heart diseases) Decrease viscosity of blood (Anemia) Increase contractile strength of heart: Leads to hyperdynamic flow (Exercise, Fever, Sepsis, Pregnancy etc ) Murmurs

19. Murmurs HOW MURMURS CAN BE CLASSIFIED? Murmurs can be classified according to their: L ocation T iming Q uality R adiation I ntensity L earn T o Q uestion R epeatedly & I ntelligently

20. Location of murmurs Aortic valve : Right 2 nd ICS : A.S Pulmonic Valve: Left 2 nd ICS: P.S, P.R, ASD Tricuspid valve: Left 5 th ICS PSB: T.S, T.R, VSD Mitral valve: Left 5 th ICS MCL: M.R, M.S, MVP

21. Timings of Murmurs

22. Timings of Murmurs

23. Timings of Murmurs

24. Quality of Murmur A.R/MR  Blowing/Musical A.S/M.S  Rumbling/Harsh PDA  Machine like

25. Radiation of Murmurs While murmurs are usually most intense at one specific listening post, they often radiate to other listening posts or areas of the body. Aortic stenosis  To carotids Aortic regurgitation  To left sternal border Mitral regurgitation  To axilla

26. Intensity of Murmur

27. Terminology Regurgitation: Blood flow through a structure normally closed during systole. Stenosis: Blood flow through an abnormally narrowed structure/valve normally open in systole.

28. Important Common murmurs Aortic stenosis: Ejection systolic/Early systolic murmur Crescendo-decrescendo Diamond shaped Harsh

29. Aortic Regurgitation: Early diastolic Decrescendo Blowing Sharp S2 Important Common murmurs

30. Mitral stenosis: Mid diastolic Opening snap (opening of the mitral valve)   Loud S1 Rumbling Important Common murmurs

31. Mitral stenosis

32. Mitral regurgitation: Holosystolic / Pansystolic (Throughout systole) Blowing Radiated to axilla Important Common murmurs

33. Jazakumullahu Khair ♥ (May ALLAH swt reward you with goodness)