Jay L. Rubenstone, D.O., F.A.C.C. October 2012 Cardiac Auscultation Jay L. Rubenstone, D.O., F.A.C.C. October 2012

Techniques of Examination Order of Exam Aortic Area Pulmonic Area Tricuspid Area Mitral Area

Process of Auscultation At each auscultatory area: 1. Concentrate on 1st Heart Sound note Intensity and Splitting 2. Concentrate on 2nd Heart Sound 3. Listen for Extra Sounds in Systole note Timing, Intensity, Pitch

Process of Ascultation 4. Listen for Extra Sounds in Diastole note timing, intensity, pitch 5. Listen for Systolic Murmurs* 6. Listen for Diastolic Murmurs* 7. Other Heart Sounds

Process of Ascultation *If Systolic or Diastolic Murmur Present, Note: Location Radiation Intensity Pitch Quality

Auscultation Timing Systolic Diastolic Early Mid Late Late (or Presystolic)

Auscultation Location Interspace Centimeters from Midsternal Midclavicular Or Axillary Lines

Auscultation Intensity Grade 1 Very Faint Grade 2 Quiet, but Heard Immediately Grade 3 Moderately Loud, Not Associated with a Thrill Grade 4 Loud, May Be Associated with a Thrill Grade 5 Very Loud Grade 6 May be Heard w/stethoscope off chest

Auscultation Radiation or Transmission Pitch Quality High, Med, Low Blowing Rumbling Harsh Muscial

Components of S1 Mitral Valve Closure Tricuspid Valve Closure Best Heard: Apex Tricuspid Valve Closure Best heard: Lower Left Sternal Boarder

S1 Wide Splitting Single Sound RBBB PVC from Left Ventricle Normal LBBB PVC from Right Ventricle Paced Beats

S1 Increased Intensity Short PR Rapid HR Atrial Fibrillation Mitral Stenosis

S 1 Decreased Intensity Mitral Stenosis (Immobile Leaflets) Opposite of Causes of Increased Intensity

S 2 Two Components Aortic Closure A2 Pulmonic Closure P2 Best Heard at the Base

S 2 Normal Splitting Best Heard At 2nd Left Intercostal Space During Inspiration there is Delayed Pulmonic Valve Closure Due to Increased Capacitance of Pulmonary Bed

S 2 Loss of Splitting Inaudible P2- Adults with Increased Chest Diameter Congenital (Tetralogy, Pulmonary Atresia Transposition) Increased Pulmonary Valve Resistance-Pulmonary HTN Eisenmenger’s Complex-Equal Pulmonary & Systemic Resistances

S 2 Persistent Splitting Fixed Splitting RBBB Pure MR Healthy Adolescents when in Supine Position Fixed Splitting Atrial Septal Defect- Due to Delayed Closure of Pulmonic Valve from Increased Right-Sided Flow

S 2 Paradoxical Splitting- P2 before A2 Increased Intensity LBBB Paced Beats Increased Intensity A2 Systemic HTN Dilated Aortic Root P2 Pulmonary HTN Dilated Pulmonary Trunk

Early Systolic Sounds Ejection Sound- Usually High Frequency Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve Pulmonary Valve-Pulmonic Stenosis Vary with Respirations Prosthetic Valves- Mechanical, Not Bioprosthetic

Mid-Late Systolic Sounds Click High Frequency Sound Found in Mitral Valve Prolapse Occurs Earlier with Valsalva Maneuver or Squatting to Standing

Early Diastolic Sounds Opening Snap of Mitral Stenosis (MS) High Frequency-Left Lateral Decubitus Position, Apex Occurs after S2, before S3 MS More Severe with Short A2-OS Interval Precordial Knock Chronic Constrictive Pericarditis Mitral Regurgitation Atrial Myxoma Older Model Prosthetic Mitral Valve

Mid Diastolic Sounds S3 Occurs During Rapid Filling of Left Ventricle (LV) related to LV Volume Low Frequency Best Heard At the Apex w/Bell Pt in Left Lateral Decubitus Position Can Be Normal to Age 40??? Can be Pathognomonic for Congestive Heart Failure

Late Diastolic Sounds S4 During Atrial Phase of LV Filling Consequence of Ventricular Stiffness Absent in Atrial Fibrillation or Ventricular Pacing Low Frequency Sound Best Heart At the Apex Pt in Left Lateral Decubitus Position HTN, Aortic Stenosis, Ischemic Heart Disease

Diastolic Sounds Right Sided S3, S4 Summation Gallop Left Lower Sternal Boarder Intensity Varies with Respiration due to Right Heart Filling (Carvallo’s Sign) Summation Gallop Occurrence of an Over Lapping S3 and S4 due to Tachycardia

Systolic Murmurs Acute Mitral Regurgitation (MR) or Tricuspid Regurgitation (TR) Mid Frequency Not Classic Murmur Ventricular-Septal Defect (VSD) High Frequency (diaphram) Atrial-Septal Defect (ASD) Pulmonary Outflow Not Defect Murmur

Systolic Murmurs Obstruction to Ventricular Outflow Dilatation of Aortic Root or Pulmonary Trunk Accelerated Flow into Aorta or Pulmonary Trunk Innocent Murmurs Some Forms of MR (Papillary Muscle Dysfunction)

Systolic Murmurs Aortic Valve Stenosis Diamond Shaped, Crescendo-Decrescendo Begins After S1 or with Aortic Ejection Sound Ends Before S2 2nd Right Intercostal Space, Apex, can radiate to Neck High Frequency, Harsh Can be Musical in Quality at the Apex

Systolic Murmurs Pulmonic Stenosis Similar to AS Except Relationship to P2 2nd Left Intercostal Space

Normal Systolic Murmurs Still’s Murmur Medium Frequency, Vibratory, Originating from Leaflets of Pulmonic Valve Rapid Ejection into Aortic Root or Pulmonary Trunk Pregnancy Anemia Fever Thyrotoxicosis

Normal Systolic Murmurs Aortic Sclerosis Most Common Innocent Murmur

Systolic Murmurs Mitral Valve Prolapse High Frequency, Sometimes Honking, Crescendo Murmur Usually Extends to S2 Classic Mid-Late Systolic Click Occurs Earlier with Valsalva & Squatting to Standing

Systolic Murmurs Holosystolic Begins with S1, Ends at S2 MR- Radiates to Left Sternal Boarder, Base or Neck, More Commonly Apex to Axilla TR- Carvallo’s Sign (Inspiratory Variation) VSD-Across Precordium Patent Ductus Arteriosis (PDA)- Aorto-Pulmonary Connection

Early Diastolic Murmur Aortic Regurgitation High Pitched, Decrescendo Murmur Best heard at Left Sternal Boarder with the diaphram w/Patient Leaning Forward at End Expiration Acute, Severe AR Murmur Can be Short, Soft and Med Pitched Chronic, Sever AR- Murmur Usually Long, Loud, Blowing Decrescendo, High Frequency

Early Diastolic Murmur Graham Steell – Murmur of Pulmonic Regurgitation as a Result of Pulmonary HTN High Freq, Decrescendo Blowing Murmur Heard throughout Diastole

Mid Diastolic Murmur Mitral Stenosis (MS) Follows Opening Snap Low Pitch Rumble Best Heard Apex over LV Using Bell of Stethoscope Pt in Left Lateral Decubitus Position

Mid Diastolic Murmurs Tricuspid Stenosis Similar to MS, except increases with Respiration (Carvallo’s Sign) Best Heard at Left Lower Sternal Edge

Mid Diastolic Murmurs Pulmonic Regurgitation Crescendo-Decrescendo Murmur when Primary Valvular Abnormality and Not Associated with Pumonary HTN

Diastolic Murmurs Late or Presystolic Follows Atrial Systole Implies Sinus Rhythm Can be present in MS or Complete Heart Block Austin Flint Murmur of Aortic Regurgitation Bubbling Quality, Short Consequence of Aortic Regurgitation impinging on Mitral Valve

Diastolic Murmurs Continuous PDA (AortoPulmonary Connection) Rough Thrill A-V Fistulas Hemodialysis Shunt Aortic Valve Sinus to Right Ventricular Fistula Coronary Artery Fistulas

Diastolic Murmurs Venous Hum Rough in quality not actually a hum Hepatic Internal Jugular During Anemia, Fever, Pregnancy and Thyrotoxicosis

Pericardial Friction Rub Three Phases Mid Systolic, Mid Diastolic, Pre Systolic Scratchy, Leathery Best Heard With Diaphragm of Stethoscope Left Sternal Boarder Leaning over at End Expiration Apposition of Abnormal Visceral and Parietal Pericardium Confused with Hamman’s Sign in Post Open Heart Surgery (Crunch Sound from Mediastinal Air)

Innocent or Normal Murmurs-Systolic Vibratory Systolic Murmur (Still’s Murmur) Pulmonic Systolic Murmur (Pulmonary Trunk)* Mammary Soufflé* Peripheral Pulmonic Systolic Murmur (Pulmonary Branches) Supraclavicular or Brachiocephalic Systolic Murmur Aortic Systolic Murmur *common in pregnancy

Innocent or Normal Murmurs- Continuous Venous Hum Continuous Mammary Soufflé

Conclusions Consistent Approach to Auscultation Knowing What to Look For Follow Through on H&P Confirm or Eliminate Suspicions Knowing How to Find It Proper Utilization of Stethoscope Location and Quality of Heart Sounds & Murmurs