Guided by Dr.

Alina mam

HEART
SOUND
seminar 14
By Nidhi R. Devangan
22019
CONTENT
Definition

Types of heart sound

Area of Ascultation

Which heart sound is heared in which area

Abnormal heart sound

Definition
Heart sounds are the sounds produced by mechanical
activities of heart during each cardiac cycle.
Heart sound are produced by :

1. Flow of blood through cardiac chambers

2. Contraction of cardiac muscle
3. Closure of valve of heart

Heart sounds are heard using a stethoscope or microphone.

These sound are also recorded graphically by phonocardiogram.
Heart sound heared by :

STETHOSCOPE
DIGITAL
PHONOCARDIOGRAM
Types of Heart sound
There are Four heart sounds are produced during each cardiac
cycle :
1. First heart sound
2. Second heart sound
3. Third heart sound
4. Fourth heart sound

It is recorded phonocardiographically but clinically in majority of the

cases only two heart sounds are usually audible.
These two sounds are more prominent and resemble the spoken
words 'LUB, (or LUBB) and 'DUBB (or DUP), respectively.
FIRST HEART SOUND (S1)
It is produced by the closure of the mitral
and tricuspid valves (M-1 & T-1
respectively). Normally the mitral valve
closes before the tricuspid valve by 20-30
msec. Hence S-1 is appreciated as a single
sound.
It is a high frequency sound and it is
timed with simultaneous palpation of
the carotid pulse.

S1 indicates the onset of systole.

SECOND HEART SOUND

It is normally has two components, produced by clo-sure

of the aortic valve (A₂) and pulmonary valve (P2).
Normally, it is a high frequency sound, heard better in the
aortic and pulmonary area.

It is normally split because the aortic valve closes before

the pulmonary valve. The A1 is normally louder than P₂.
During inspiration, the splitting of A1 P₂ becomes wider.
During expiration the splitting of A1 P2 is narrower and
S2 may be heard as a single sound.
THIRD HEART SOUND
Normally the third heart sound is a low frequency sound, heard
because of the first rapid filling phase of the ventricular diastole
when blood flows from the atria into the ventricles. It is heard best
with the bell of the stethoscope.

Right ventricular third heart

sound is located at the left
lower sternal border rather
than the apex and often
increases on inspiration. It
may radiate to right
supraclavicular fossa.
FOURTH HEART SOUND :
Fourth heart sound is an inaudible sound. It becomes audible in
pathological conditions only.
It is a low frequency sound. It occurs due to rapid emptying of
atrium into a non-compliant ventricle in late rapid filling phase
due to atrial contraction; heard best with the bell of stethoscope

NOTE:
S1 sound heard best at the apex of the heart.
S2 sound heard best at the aortic area.
S3 sound heard best at the apex of the heart
S4 sound heard best at the apex of the heart
Area of Chest Wall for Cardiac Ascultation
 Abnormal first heart sound :
1. Loud first heart sound :
Due to increased excursion of the AV valves leaflets away from each
other during their opening, there is a loud sound when they close
(similar to a door which when open to a wider angle, closes with a
louder sound).
A. Normal in children
B. Sinus tachycardia
C. Mitral and Tricuspid stenosis

2. Soft First Heart Sound:

Poor conduction of sound through chest wall :-
 1. Pericardial effusion
2. Emphysema
3. Thick chest wall
4. Obesity

3. Variable first heart sound :

Atrial fibrillation
Complete heart block
Mitral and tricuspid regurgitation.
A.V. dissociation

4. Widely split first heart sound:

Splitting of the first heart sound occurs when the Tricuspid valve closes
late as compared to Mitral Valve. Splitting is best heard in lower left
sternal border
 A. Electrical B. Mechanical

Right bundle branch block (RBBB) Tricuspid Stenosis (TS)

Ventricular premature contraction Right Atrial Myxoma
(VPCs) originat from LV Ebsteins anomaly ( sail sound)

5. Reverse Splitting of First Heart Sound:

It means when M-1 occours later than T-1.

A. Electrical
Left Bundle Branch Block (RBBB) B. Mechanical
Ventricular premature
contraction (VPC) originating Severe Mitral Stenosis (MS)
from RV Left Atrial Myxoma
Abnormally Splitting of S-2 :
A. Widely Split Second Heart Sound:
a. Electrical b. Mechanical
1. RBBB 1. Atrial septal defect (ASD)
2. Left Ventricular Premature 2. VSD
Beat 3. Pulmonary stenosis
B. Reverse Splitting of Second heart sound:

A single S2 during inspiration and split S2 during expiration is called

Reverse Split of S2. It occurs since pulmonary valve closes earlier than
Aortic Valve.

a. Electrical
1. LBBB
2. Right VPB
3. Wolf-Parkinson-White
Syndrome
2. Hypertrophic Obstructive
b. Mechanical
. Cardiomyopathy (HOCM)
1. Aortic stenosis 3. Hypertension
 C. Single Second Heart Sound :
a. Diminished Intensity of A2 or P2 b. P2 synchronous with A2.
1. Aortic Stenosis 1. VSD
2. Pulmonary Stenosis 2. Single ventricle
3. Pulmonary atresia
4. Tetrology of fallot
The third heart sound is heard in following conditions :

1. Normal up to 30 years and in 5. Myocardial infarction

children, atheletes and pregnancy 6. Dilated cardiomyopathy
2. Mitral Regurgitation 7. Congestive Cardiac Failure .
3. Tricuspid Regurgitation
. (CCF)
Mechanism:
In MR and TR during systole some blood goes back into the atria
and hence there is increased flow into the ventricles during the first
rapid filling phase resulting in the third heart sound.
In heart failure there is increased atrial pressure and hence increased
first rapid filling results in the third heart sound.
Fourth Heart sound (S4) heard in the following
conditions
1. Elderly > 60 years.
2. AS, HOCM
3. PS
4. Pulmonary or systemic hypertension
5. MR, AR, TR
6. Myocardial infarction
Gallops :
Triple Rhythm : 3 audible hert sound - S1+S2+S3/ S4
Quadruple Rhythm : 4 audible heart sound S1+S2+S3+S4
Summation Gollap : S3 & S4 are merged due to tachycardia
S1+S2+(S3 & S4).
 ABNORMAL HEART SOUND :
1. Murmur
Abnormal sound heard on auscultation of the heart caused
by vibration of the valve or the wall of heart or great
vessels due to turbulent blood flow in/near the heart.
Murmurs are classified as systolic, diastolic and continuous
murmurs.
Causes of Murmur :
Normal blood flow is laminar. Turbulence occurs when laminar
flow is disrupted.
Murmurs are due to structural abnormality of the heart and/or
increased flow across normal cardiac structures
 Murmurs are either Organic, Functional , or innocent
1. Organic murmurs - by intrinsic cardiac diseases
.

2. Functional murmurs - by perturbations which are present

in the circulation but which are due to non- cardiac
causes.
3. Innocent murmurs cardiac or non- cardiac sources but are
not due to a recognized disease
Organic murmur
a. Systolic Murmur: are those which occur between the first
heart sound and second heart sound and
last during part or whole of systole.
 1. Mid - systolic or ejection 2. Late systolic murmurs
systolic murmurs Mitral valve prolapse ( MVP)
Aortic stenosis

3. Pan systolic / holosystolic murmurs

1. Mitral Regurgitation
2. Tricuspid Regurgitation
3. Ventricular septal defect
 4. Early systolic murmurs
1. Acute severe Mitral Regurgitation
2. Acute severeTricuspid
Regurgitation

b. Diastolic murmur:
are those which occur between the second heart sound and the
first heart sound, during any part of diastole.
1. Early diastolic murmurs : Aortic and Pulmonary regurgitation
2. Mid diastolic murmurs : Mitral stenosis, Tricuspid stenosis
3. late diastolic or presystolic : left and right mitral myxoma
murmurs
c. Continuous murmurs : in systole and diastole
1. patent ductus Arteriosus
2. Arteriovenous fistula
3. Venou 'hum'

2. Opening Snap
1. Mitral and Tricuspid Stenosis
It is a high pitched, loud snapping or clicking, sharp sound
Best heard at lower sternal border with diaphragm of the steth.
This is heard midway between the second and third heart
sounds and occur in early daistole.
3. Systolic Ejection Click
They are produced due to opening of semilunarvalves.
They are high pitched, click-like sounds that come immediately
after the first heart sound that occurs in early systole.
They are due to excessive ejection of blood from the ventricles
into the blood vessels.
1. Pulmonary Ejection Click : This is best heard during expiration
Dilatation of pulmonary artery
2. Aortic Ejection Click :
This is transmitted to the apical area.
Aortic aneurysm
Aortic regurgitation
3. Midsystolic Click/Non-ejection click
Produced by prolapse of AV valve leading to tensing of chordae
tendineae. Clauses: Mitral valve prolaps
Tricuspid valve prolaps
4. Pericardial Rub :
Causes : Pericarditis due to - Acute MI
Imflamation of pericardium - sac like structure surrounding the
heart .
5. Pericardial Knock :
Heard in diastole in a case of constrictive pericarditis due to
abrupt restriction of diastolic filling of ventricle due to the
adherent pericardium.
Reference Book-