1. Cardiac Auscultation Jay L. Rubenstone, D.O., F.A.C.C. September 2007

2. Techniques of Examination Order of Exam –Aortic Area –Pulmonic Area –Tricuspid Area –Mitral Area

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

6. 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

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

8. Auscultation Timing Systolic –Early –Mid –Late Diastolic –Early –Mid –Late (or Presystolic)

9. Auscultation Location Interspace Centimeters from –Midsternal –Midclavicular –Or Axillary Lines

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

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

12. Components of S 1 Mitral Valve Closure –Best Heard: Apex Tricuspid Valve Closure –Best heard: Lower Left Sternal Boarder

13. S1S1 Wide Splitting –RBBB –PVC from Left Ventricle Single Sound –Normal –LBBB –PVC from Right Ventricle –Paced Beats

14. S1S1 Increased Intensity –Short PR –Rapid HR –Atrial Fibrillation –Mitral Stenosis

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

16. S 2 Two Components –Aortic Closure A 2 –Pulmonic Closure P 2 Best Heard at the Base

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

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

19. S 2 Persistent 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

20. S 2 Paradoxical Splitting- P 2 before A 2 –LBBB –Paced Beats Increased Intensity –A 2 Systemic HTN Dilated Aortic Root –P 2 Pulmonary HTN Dilated Pulmonary Trunk

22. 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

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

24. Early Diastolic Sounds Opening Snap of Mitral Stenosis (MS) High Frequency-Left Lateral Decubitus Position, Apex Occurs after S 2, before S 3 MS More Severe with Short A2-OS Interval Precordial Knock Chronic Constrictive Pericarditis Mitral Regurgitation Atrial Myxoma Older Model Prosthetic Mitral Valve

26. Mid Diastolic Sounds S 3 –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

27. 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

28. Diastolic Sounds Right Sided S 3, S 4 –Left Lower Sternal Boarder –Intensity Varies with Respiration due to Right Heart Filling (Carvallo’s Sign) Summation Gallop –Occurrence of an Over Lapping S 3 and S 4 due to Tachycardia

31. 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

32. 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)

33. Systolic Murmurs Aortic Valve Stenosis –Diamond Shaped, Crescendo-Decrescendo –Begins After S 1 or with Aortic Ejection Sound –Ends Before S 2 –2 nd Right Intercostal Space, Apex, can radiate to Neck –High Frequency, Harsh –Can be Musical in Quality at the Apex

34. Systolic Murmurs Pulmonic Stenosis –Similar to AS Except Relationship to P 2 –2 nd Left Intercostal Space

35. 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

36. Normal Systolic Murmurs Aortic Sclerosis –Most Common Innocent Murmur

37. Systolic Murmurs Mitral Valve Prolapse –High Frequency, Sometimes Honking, Crescendo Murmur –Usually Extends to S 2 –Classic Mid-Late Systolic Click Occurs Earlier with Valsalva & Squatting to Standing

38. Systolic Murmurs Holosystolic –Begins with S 1, Ends at S 2 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

40. 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

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

43. 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

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

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

46. 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

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

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

49. 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)

50. 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

51. Innocent or Normal Murmurs- Continuous Venous Hum Continuous Mammary Soufflé

52. 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