Cardiac Auscultation

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Cardiac Auscultation

• Jay L. Rubenstone, D.O., F.A.C.C.
• September 2007

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Techniques of Examination

• Order of Exam
• Aortic Area
• Pulmonic Area
• Tricuspid Area
• Mitral Area

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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

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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

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Process of Ascultation

• If Systolic or Diastolic Murmur Present, Note
• Location
• Radiation
• Intensity
• Pitch
• Quality

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Auscultation Timing

• Systolic
• Early
• Mid
• Late
• Diastolic
• Early
• Mid
• Late (or Presystolic)

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AuscultationLocation

• Interspace
• Centimeters from
• Midsternal
• Midclavicular
• Or Axillary Lines

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AuscultationIntensity

• 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

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Auscultation

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

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Components of S1

• Mitral Valve Closure
• Best Heard Apex
• Tricuspid Valve Closure
• Best heard Lower Left Sternal Boarder

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S1

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

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S1

• Increased Intensity
• Short PR
• Rapid HR
• Atrial Fibrillation
• Mitral Stenosis

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S 1

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

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S 2

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

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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

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S 2

• Loss of Splitting
• Inaudible P2-
• Adults with Increased Chest Diameter
• Congenital (Tetralogy, Pulmonary Atresia
  Transposition)
• Increased Pulmonary Valve Resistance-Pulmonary
  HTN
• Eisenmengers Complex-Equal Pulmonary Systemic
  Resistances

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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

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S 2

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

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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

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Mid-Late Systolic Sounds

• Click
• High Frequency Sound Found in Mitral Valve
  Prolapse
• Occurs Earlier with Valsalva Maneuver or
  Squatting to Standing

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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

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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

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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

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Diastolic Sounds

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

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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

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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)

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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

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Systolic Murmurs

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

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Normal Systolic Murmurs

• Stills Murmur
• Medium Frequency, Vibratory, Originating from
  Leaflets of Pulmonic Valve
• Rapid Ejection into Aortic Root or Pulmonary
  Trunk
• Pregnancy
• Anemia
• Fever
• Thyrotoxicosis

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Normal Systolic Murmurs

• Aortic Sclerosis
• Most Common Innocent Murmur

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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

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Systolic Murmurs

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

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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

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Early Diastolic Murmur

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

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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

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Mid Diastolic Murmurs

• Tricuspid Stenosis
• Similar to MS, except increases with Respiration
  (Carvallos Sign)
• Best Heard at Left Lower Sternal Edge

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Mid Diastolic Murmurs

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

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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

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Diastolic Murmurs

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

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Diastolic Murmurs

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

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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 Hammans Sign in Post Open Heart
  Surgery (Crunch Sound from Mediastinal Air)

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Innocent or Normal Murmurs-Systolic

• Vibratory Systolic Murmur (Stills 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

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Innocent or Normal Murmurs-Continuous

• Venous Hum
• Continuous Mammary Soufflé

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Conclusions

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

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