Heart Sounds and Murmurs

Heart Sounds and Murmurs

Heart Sounds

S1

  • Mitral Valve Closing
  • Loudest at: Mitral area

S2

  • Aortic Valve Closing
  • Loudest at: Left upper sternal border

S3 (Ventricular Gallop)

  • Occurs in: Early diastole during rapid ventricular filling phase
  • Associated with: Increased filling pressures (e.g., mitral regurgitation, heart failure) and more common in dilated ventricles.
  • Normal: In children and young adults
  • Pathological: In older adults, especially in the presence of heart disease

S4 (Atrial Gallop)

  • Occurs in: Late diastole ("atrial kick")
  • Best Heard At: Apex with patient in left lateral decubitus position
  • Associated with: High atrial pressure and ventricular noncompliance (e.g., hypertrophy). It is always considered abnormal.

Heart Murmurs

Murmurs Overview: - Part of physical examinations providing crucial clues for underlying conditions. - Important in pathophysiology/physiology questions. - Commonly tested in examinations and virtual patient scenarios. - High discrimination index, essential for deeper understanding. - Ensure audio/headphone functionality prior to assessments.

Systolic Murmurs

  • Normal: Aortic open, mitral closed.
  • Abnormal: Aortic stenosis, mitral regurgitation.

Diastolic Murmurs

  • Normal: Aortic closed, mitral open.
  • Abnormal: Aortic regurgitation, mitral stenosis.

Valve Issues:


 - Stenosis: Valve not opening properly, leading to reduced forward flow.

- Regurgitation: Valve not closing properly, causing backflow.

Locations and Types of Murmurs 

Aortic Area

  • Systolic Murmur: Aortic stenosis, flow murmur (e.g., physiologic murmur), aortic valve sclerosis.

Pulmonic Area

  • Systolic Ejection Murmur: Pulmonic stenosis, flow murmur (e.g., PDA).

Tricuspid Area

  • Holosystolic Murmur: Tricuspid regurgitation, ventricular septal defect.
  • Diastolic Murmur: Tricuspid stenosis, atrial septal defect (ASD).

Mitral Area (Apex)

  • Holosystolic Murmur: Mitral regurgitation.
  • Systolic Murmur: Mitral valve prolapse.
  • Diastolic Murmur: Mitral stenosis.

Extra Heart Sounds: S3 and S4

S3
  • Ventricular gallop.
  • Associated with: Dilated ventricles – conditions include dilated cardiomyopathy and heart failure.
S4
  • Atrial gallop.
  • Associated with: Hypertrophic or infiltrated ventricles – seen in hypertrophic cardiomyopathy and restrictive cardiomyopathy.

Murmur Effects and Maneuvers

Basic Maneuvers
  • Inspiration: Increases the intensity of right heart sounds.
  • Hand Grip: Increases afterload, intensifies MR, AR, and VSD murmurs, decreases hypertrophic cardiomyopathy and AS murmurs.
  • Valsalva Maneuver (phase II), Standing: Decreases preload, intensifies hypertrophic cardiomyopathy murmur, and decreases most murmurs including AS.
  • Rapid Squatting: Increases venous return, preload, and afterload, intensifies AS, MR, and VSD murmurs, and reduces hypertrophic cardiomyopathy murmur.
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