Heart sounds - Wikipedia

Heart sounds are the noises generated by the beating heart and the resultant flow of blood ... heart murmurs, adventitious sounds, and gallop rhythms S3 and S4. Heartsounds FromWikipedia,thefreeencyclopedia Jumptonavigation Jumptosearch Noisegeneratedbythebeatingheart Emily'sracingheartbeat Heartsoundsofa16yearoldgirlimmediatelyafterrunning,withaheartrateof186BPM.TheS1heartsoundisintensifiedduetotheincreasedcardiacoutput. Emily’sheartbeat Normalheartsoundsofa16yearoldfemaleatrest,asheardwithastethoscope. Problemsplayingthesefiles?Seemediahelp. Frontofthorax,showingsurfacerelationsofbones,lungs(purple),pleura(blue),andheart(redoutline).Thelocationsofbestauscultationforeachheartvalvearelabeledwith"M","T","A",and"P".Firstheartsound:causedbyatrioventricularvalves–Mitral(M)andTricuspid(T).Secondheartsoundcausedbysemilunarvalves–Aortic(A)andPulmonary/Pulmonic(P). Heartsoundsarethenoisesgeneratedbythebeatingheartandtheresultantflowofbloodthroughit.Specifically,thesoundsreflecttheturbulencecreatedwhentheheartvalvessnapshut.Incardiacauscultation,anexaminermayuseastethoscopetolistenfortheseuniqueanddistinctsoundsthatprovideimportantauditorydataregardingtheconditionoftheheart. Inhealthyadults,therearetwonormalheartsounds,oftendescribedasalubandadubthatoccurinsequencewitheachheartbeat.Thesearethefirstheartsound(S1)andsecondheartsound(S2), producedbytheclosingoftheatrioventricularvalvesandsemilunarvalves,respectively.Inadditiontothesenormalsounds,avarietyofothersoundsmaybepresentincludingheartmurmurs,adventitioussounds,andgalloprhythmsS3andS4. Heartmurmursaregeneratedbyturbulentflowofbloodandamurmurtobeheardasturbulentflowmustrequirepressuredifferenceofatleast30mmofHgbetweenthechambersandthepressuredominantchamberwilloutflowthebloodtonon-dominantchamberindiseasedconditionwhichleadstoLeft-to-rightshuntorRight-to-leftshuntbasedonthepressuredominance.Turbulencemayoccurinsideoroutsidetheheart;ifitoccursoutsidetheheartthentheturbulenceiscalledbruitorvascularmurmur.Murmursmaybephysiological(benign)orpathological(abnormal).Abnormalmurmurscanbecausedbystenosisrestrictingtheopeningofaheartvalve,resultinginturbulenceasbloodflowsthroughit.Abnormalmurmursmayalsooccurwithvalvularinsufficiency(regurgitation),whichallowsbackflowofbloodwhentheincompetentvalvecloseswithonlypartialeffectiveness.Differentmurmursareaudibleindifferentpartsofthecardiaccycle,dependingonthecauseofthemurmur. Contents 1Primaryheartsounds 1.1Firstheartsound 1.2Secondheartsound 2Extraheartsounds 2.1Thirdheartsound 2.2Fourthheartsound 3Murmurs 3.1Effectsofbreathing 3.2Interventionsthatchangemurmurs 4Otherabnormalsounds 5Surfaceanatomy 6Recordingheartsounds 7Seealso 8References 9Externallinks Primaryheartsounds[edit] Diagramshowingrelationsofopenedhearttofrontofthoracicwall.Ant.Anteriorsegmentoftricuspidvalve.AO.Aorta.A.P.Anteriorpapillarymuscle.In.Innominateartery.L.C.C.Leftcommoncarotidartery.L.S.Leftsubclavianartery.L.V.Leftventricle.P.A.Pulmonaryartery.R.A.Rightatrium.R.V.Rightventricle.V.S.Ventricularseptum. Normalheartsoundsareassociatedwithheartvalvesclosing: Firstheartsound[edit] Thefirstheartsound,orS1,formsthe"lub"of"lub-dub"andiscomposedofcomponentsM1(mitralvalveclosure)andT1(tricuspidvalveclosure).NormallyM1precedesT1slightly.Itiscausedbytheclosureoftheatrioventricularvalves,i.e.tricuspidandmitral(bicuspid),atthebeginningofventricularcontraction,orsystole.Whentheventriclesbegintocontract,sodothepapillarymusclesineachventricle.Thepapillarymusclesareattachedtothecuspsorleafletsofthetricuspidandmitralvalvesviachordaetendineae(heartstrings).Whenthepapillarymusclescontract,thechordaetendineaebecometenseandtherebypreventthebackflowofbloodintothelowerpressureenvironmentoftheatria.Thechordaetendineaeactabitlikethestringsonaparachute,andallowtheleafletsofthevalvetoballoonupintotheatriaslightly,butnotsomuchastoevertthecuspedgesandallowbackflowofblood.Itisthepressurecreatedfromventricularcontractionthatclosesthevalve,notthepapillarymusclesthemselves.ThecontractionoftheventriclebeginsjustpriortoAVvalvesclosingandpriortotheopeningofthesemilunarvalves.Thesuddentensingofthechordaetendineaeandthesqueezingoftheventriclesagainstclosedsemilunarvalves,sendbloodrushingbacktowardtheatria,andtheparachute-likevalvescatchtherushofbloodintheirleafletscausingthevalvetosnapshut.TheS1soundresultsfromreverberationwithinthebloodassociatedwiththesuddenblockofflowreversalbythevalves.ThedelayofT1evenmorethannormallycausesthesplitS1whichisheardinarightbundlebranchblock.[1] Secondheartsound[edit] Thesecondheartsound,orS2,formsthe"dub"of"lub-dub"andiscomposedofcomponentsA2(aorticvalveclosure)andP2(pulmonaryvalveclosure).NormallyA2precedesP2especiallyduringinspirationwhereasplitofS2canbeheard.Itiscausedbytheclosureofthesemilunarvalves(theaorticvalveandpulmonaryvalve)attheendofventricularsystoleandthebeginningofventriculardiastole.Astheleftventricleempties,itspressurefallsbelowthepressureintheaorta.Aorticbloodflowquicklyreversesbacktowardtheleftventricle,catchingthepocket-likecuspsoftheaorticvalve,andisstoppedbyaorticvalveclosure.Similarly,asthepressureintherightventriclefallsbelowthepressureinthepulmonaryartery,thepulmonaryvalvecloses.TheS2soundresultsfromreverberationwithinthebloodassociatedwiththesuddenblockofflowreversal.[1] SplittingofS2,alsoknownasphysiologicalsplit,normallyoccursduringinhalationbecausethedecreaseinintrathoracicpressureincreasesthetimeneededforpulmonarypressuretoexceedthatoftherightventricularpressure.AwidelysplitS2canbeassociatedwithseveraldifferentcardiovascularconditions,andthesplitissometimeswideandvariablewhereas,sometimeswideandfixed.ThewideandvariablesplitoccursinRightbundlebranchblock,pulmonarystenosis,pulmonaryhypertensionandventricularseptaldefects.ThewideandfixedsplittingofS2occursinatrialseptaldefect.PulmonaryS2(P2)willbeaccentuated(loudP2)inpulmonaryhypertensionandpulmonaryembolism.S2becomessofterinaorticstenosis.[1] Extraheartsounds[edit] Therarerextraheartsoundsformgalloprhythmsandareheardinbothnormalandabnormalsituations.[1] Thirdheartsound[edit] Thethirdheartsound,orS3israrelyheard,andisalsocalledaprotodiastolicgallop,ventriculargallop,orinformallythe"Kentucky"gallopasanonomatopoeicreferencetotherhythmandstressofS1followedbyS2andS3together(S1=Ken;S2=tuck;S3=y).[2] "lub-dub-ta"or"slosh-ing-in"Ifnew,indicatesheartfailureorvolumeoverload.[citationneeded] ItoccursatthebeginningofdiastoleafterS2andislowerinpitchthanS1orS2asitisnotofvalvularorigin.Thethirdheartsoundisbenigninyouth,sometrainedathletes,andsometimesinpregnancybutifitre-emergeslaterinlifeitmaysignalcardiacproblems,suchasafailingleftventricleasindilatedcongestiveheartfailure(CHF).S3isthoughttobecausedbytheoscillationofbloodbackandforthbetweenthewallsoftheventriclesinitiatedbybloodrushinginfromtheatria.Thereasonthethirdheartsounddoesnotoccuruntilthemiddlethirdofdiastoleisprobablythatduringtheearlypartofdiastole,theventriclesarenotfilledsufficientlytocreateenoughtensionforreverberation.[1] Itmayalsobearesultoftensingofthechordaetendineaeduringrapidfillingandexpansionoftheventricle.Inotherwords,anS3heartsoundindicatesincreasedvolumeofbloodwithintheventricle.AnS3heartsoundisbestheardwiththebell-sideofthestethoscope(usedforlowerfrequencysounds).Aleft-sidedS3isbestheardintheleftlateraldecubituspositionandattheapexoftheheart,whichisnormallylocatedinthe5thleftintercostalspaceatthemidclavicularline.Aright-sidedS3isbestheardatthelowerleftsternalborder.Thewaytodistinguishbetweenleftandright-sidedS3istoobservewhetheritincreasesinintensitywithinhalationorexhalation.Aright-sidedS3willincreaseoninhalation,whilealeft-sidedS3willincreaseonexhalation.[1] S3canbeanormalfindinginyoungpatientsbutisgenerallypathologicovertheageof40.ThemostcommoncauseofpathologicS3iscongestiveheartfailure.[1] Fourthheartsound[edit] Thefourthheartsound,orS4whenaudibleinanadultiscalledapresystolicgalloporatrialgallop.Thisgallopisproducedbythesoundofbloodbeingforcedintoastifforhypertrophicventricle.[1] "ta-lub-dub"or"a-stiff-wall" Itisasignofapathologicstate,usuallyafailingorhypertrophicleftventricle,asinsystemichypertension,severevalvularaorticstenosis,andhypertrophiccardiomyopathy.ThesoundoccursjustafteratrialcontractionattheendofdiastoleandimmediatelybeforeS1,producingarhythmsometimesreferredtoasthe"Tennessee"gallopwhereS4representsthe"Ten-"syllable.[2]Itisbestheardatthecardiacapexwiththepatientintheleftlateraldecubituspositionandholdinghisbreath.ThecombinedpresenceofS3andS4isaquadruplegallop,alsoknownasthe"Hello-Goodbye"gallop.Atrapidheartrates,S3andS4maymergetoproduceasummationgallop,sometimesreferredtoasS7.[1] AtrialcontractionmustbepresentforproductionofanS4.Itisabsentinatrialfibrillationandinotherrhythmsinwhichatrialcontractiondoesnotprecedeventricularcontraction.[1] Murmurs[edit] Phonocardiogramfromnormalandabnormalheartsounds. Heartmurmur Ventricularseptaldefectmurmurin14yearoldRachelMorrison'sheart,heardfromthemitralvalvearea. Problemsplayingthisfile?Seemediahelp. Mitralvalveprolapsemurmur Heartsoundsofa16-year-oldgirldiagnosedwithmitralvalveprolapseandmitralregurgitation.Auscultatingherheart,asystolicmurmurandclickareheard.Recordedwiththestethoscopeoverthemitralvalve. Problemsplayingthisfile?Seemediahelp. Functionalheartmurmur Heartsoundsofahealthyyoungwomanwithafunctional,physiologicalor"innocent"murmur.Recordedafterexercisewiththestethoscopeplacedoverthepulmonicvalvearea. Problemsplayingthisfile?Seemediahelp. Heartmurmursareproducedasaresultofturbulentflowofbloodstrongenoughtoproduceaudiblenoise.Theyareusuallyheardasawhooshingsound.Thetermmurmuronlyreferstoasoundbelievedtooriginatewithinbloodflowthroughorneartheheart;rapidbloodvelocityisnecessarytoproduceamurmur.Mostheartproblemsdonotproduceanymurmurandmostvalveproblemsalsodonotproduceanaudiblemurmur.[3] Murmurscanbeheardinmanysituationsinadultswithoutmajorcongenitalheartabnormalities:[3] Regurgitationthroughthemitralvalveisbyfarthemostcommonlyheardmurmur,producingapansystolic/holosystolicmurmurwhichissometimesfairlyloudtoapracticedear,eventhoughthevolumeofregurgitantbloodflowmaybequitesmall.Yet,thoughobvioususingechocardiographyvisualization,probablyabout20%ofcasesofmitralregurgitationdonotproduceanaudiblemurmur.[3] Stenosisoftheaorticvalveistypicallythenextmostcommonheartmurmur,asystolicejectionmurmur.Thisismorecommoninolderadultsorinthoseindividualshavingatwo-leaflet,notathree-leaflet,aorticvalve.[citationneeded] Regurgitationthroughtheaorticvalve,ifmarked,issometimesaudibletoapracticedearwithhighquality,especiallyelectronicallyamplified,stethoscope.Generally,thisisaveryrarelyheardmurmur,eventhoughaorticvalveregurgitationisnotsorare.Aorticregurgitation,thoughobvioususingechocardiographyvisualization,usuallydoesnotproduceanaudiblemurmur.[citationneeded] Stenosisofthemitralvalve,ifsevere,alsorarelyproducesanaudible,lowfrequencysoftrumblingmurmur,bestrecognizedbyapracticedearusinghighquality,especiallyelectronicallyamplified,stethoscope. Otheraudiblemurmursareassociatedwithabnormalopeningsbetweentheleftventricleandrightheartorfromtheaorticorpulmonaryarteriesbackintoalowerpressureheartchamber. GradationsofMurmurs[1] (Definedbasedonuseofanacoustic,notahigh-fidelityamplifiedelectronicstethoscope) Grade Description Grade1 Veryfaint,heardonlyafterlistenerhas"tunedin";maynotbeheardinallpositions.Onlyheardifthepatient"bearsdown"orperformstheValsalvamaneuver. Grade2 Quiet,butheardimmediatelyafterplacingthestethoscopeonthechest. Grade3 Moderatelyloud. Grade4 Loud,withpalpablethrill(atremororvibrationfeltonpalpation)[4] Grade5 Veryloud,withthrill.Maybeheardwhenstethoscopeispartlyoffthechest. Grade6 Veryloud,withthrill.Maybeheardwithstethoscopeentirelyoffthechest. Thoughseveraldifferentcardiacconditionscancauseheartmurmurs,themurmurscanchangemarkedlywiththeseverityofthecardiacdisease.Anastutephysiciancansometimesdiagnosecardiacconditionswithsomeaccuracybasedlargelyonthemurmur,relatedphysicalexamination,andexperiencewiththerelativefrequencyofdifferentheartconditions.However,withtheadventofbetterqualityandwideravailabilityofechocardiographyandothertechniques,heartstatuscanberecognizedandquantifiedmuchmoreaccuratelythanformerlypossiblewithonlyastethoscope,examination,andexperience.Anotheradvantagetotheuseoftheechocardiogramisthatthedevicescanbehandheld.[5] Effectsofbreathing[edit] Heartbeatwhileholdingbreath Heartsoundsofa16-year-oldgirlwithmitralregurgitationholdingherbreath. Problemsplayingthisfile?Seemediahelp. Inhalationdecreasesintrathoracicpressurewhichallowsmorevenousbloodtoreturntotherightheart(pullingbloodintotherightsideoftheheartviaavacuum-likeeffect).Therefore,right-sidedheartmurmursgenerallyincreaseinintensitywithinhalation.Thedecreased(morenegative)intrathoracicpressurehasanoppositeeffectontheleftsideoftheheart,makingitharderforthebloodtoexitintocirculation.Therefore,left-sidedmurmursgenerallydecreaseinintensityduringinhalation.Increasingvenousbloodreturntotherightsideoftheheartbyraisingapatient'slegstoa45-degreewhilelyingsupineproducessimilareffectwhichoccursduringinhalation.Inhalationcanalsoproduceanon-pathologicalsplitS2whichwillbehearduponauscultation.[citationneeded] Withexhalation,theoppositehaemodynamicchangesoccur:left-sidedmurmursgenerallyincreaseinintensitywithexhalation.[citationneeded] Interventionsthatchangemurmurs[edit] Mainarticle:Heartmurmur Thereareanumberofinterventionsthatcanbeperformedthataltertheintensityandcharacteristicsofabnormalheartsounds.Theseinterventionscandifferentiatethedifferentheartsoundstomoreeffectivelyobtainadiagnosisofthecardiacanomalythatcausestheheartsound.[citationneeded] Otherabnormalsounds[edit] Clicks–Heartclicksareshort,high-pitchedsoundsthatcanbeappreciatedwithmodernnon-invasiveimagingtechniques.[citationneeded] Rubs–Thepericardialfrictionrubcanbeheardinpericarditis,aninflammationofthepericardium,thesacsurroundingtheheart.Thisisacharacteristicscratching,creaking,high-pitchedsoundemanatingfromtherubbingofbothlayersofinflamedpericardium.Itistheloudestinsystole,butcanoftenbeheardatthebeginningandattheendofdiastole.Itisverydependentonbodypositionandbreathing,andchangesfromhourtohour.[citationneeded] Surfaceanatomy[edit] Theaorticarea,pulmonicarea,tricuspidareaandmitralareaareareasonthesurfaceofthechestwheretheheartisauscultated.[6] Heartsoundsresultfromreverberationwithinthebloodassociatedwiththesuddenblockofflowreversalbythevalvesclosing.Becauseofthis,auscultationtodeterminefunctionofavalveisusuallynotperformedatthepositionofthevalve,butatthepositiontowherethesoundwavesreverberate.[citationneeded] Aorticvalve(toaorta) rightsecondintercostalspace upperrightsternalborder Pulmonaryvalve(topulmonarytrunk) leftsecondintercostalspace upperleftsternalborder Erb'spoint Leftthirdintercostalspace leftsternalborder Tricuspidvalve(torightventricle) leftfourth,fifthintercostalspaces lowerleftsternalborder Mitralvalve(toleftventricle) leftfifthintercostalspace leftmidclavicularline Recordingheartsounds[edit] Usingelectronicstethoscopes,itispossibletorecordheartsoundsviadirectoutputtoanexternalrecordingdevice,suchasalaptoporMP3recorder.Thesameconnectioncanbeusedtolistentothepreviouslyrecordedauscultationthroughthestethoscopeheadphones,allowingforamoredetailedstudyofmurmursandotherheartsounds,forgeneralresearchaswellasevaluationofaparticularpatient'scondition.[citationneeded] Seealso[edit] Pulse Precordialexamination Benignpediatricheartmurmur Iambicpentameter,ametreinpoetrythatfollowsasimilarrhythmtothehumanheartbeat Pulsatiletinnitus–hearingaheartbeatsoundinoneorbothears Souffle(heartsound) References[edit] ^abcdefghijLeng,S;Tan,R;Chai,R;Wang,C(2015)."Theelectronicstethoscope".BioMedicalEngineeringOnLine.14(1):66.doi:10.1186/s12938-015-0056-y.PMC 4496820.PMID 26159433.Retrieved30June2021. ^ab"Techniques–HeartSounds&MurmursExam–PhysicalDiagnosisSkills".depts.washington.edu.UniversityofWashingtonSchoolofMedicine. ^abc"AorticRegurgitation".TheLecturioMedicalConceptLibrary.October2020.Retrieved30June2021. ^"thrill".Archived2011-05-27attheWaybackMachineMedlinePlusMedicalDictionary. ^Bernstein,Lenny(2016-01-02),"Heartdoctorsarelisteningforcluestothefutureoftheirstethoscopes",WashingtonPost,archivedfromtheoriginalon2016-01-09. ^Mallinson,T(2017)."Asurveyintoparamedicaccuracyinidentifyingthecorrectanatomiclocationsforcardiacauscultation".BritishParamedicJournal.2(2):13–17.doi:10.29045/14784726.2017.2.2.13. Externallinks[edit] HeartSounds–HeartMurmurs.practicalclinicalskills.com vtePhysiologyofthecardiovascularsystemHeartCardiacoutput Cardiaccycle Cardiacoutput Heartrate Strokevolume Strokevolume End-diastolicvolume End-systolicvolume Afterload Preload Frank–Starlinglaw Cardiacfunctioncurve Venousreturncurve Wiggersdiagram Pressurevolumediagram Ultrasound Fractionalshortening=(End-diastolicdimension End-systolicdimension)/End-diastolicdimension Aorticvalveareacalculation Ejectionfraction Cardiacindex Leftatrialvolume Heartrate Cardiacpacemaker Chronotropic(Heartrate) Dromotropic(Conductionvelocity) Inotropic(Contractility) Bathmotropic(Excitability) Lusitropic(Relaxation) Conduction Conductionsystem Cardiacelectrophysiology Actionpotential cardiac atrial ventricular Effectiverefractoryperiod Pacemakerpotential Electrocardiography Pwave PRinterval QRScomplex QTinterval STsegment Twave Uwave Hexaxialreferencesystem Chamberpressure Centralvenous Right atrial ventricular pulmonaryartery wedge Left atrial ventricular Aortic Other Ventricularremodeling Vascularsystem/HemodynamicsBloodflow Compliance Vascularresistance Pulse Perfusion Bloodpressure Pulsepressure Systolic Diastolic Meanarterialpressure Jugularvenouspressure Portalvenouspressure Criticalclosingpressure RegulationofBP Baroreflex Kinin–kallikreinsystem Renin–angiotensinsystem Vasoconstrictors Vasodilators Autoregulation Myogenicmechanism Tubuloglomerularfeedback Cerebralautoregulation Paraganglia Aorticbody Carotidbody Glomuscell vteMedicalexaminationandhistorytakingMedicalhistory Chiefcomplaint Historyofthepresentillness Systemsreview Nursingassessment Allergies Medications Pastmedicalhistory Familyhistory Socialhistory Psychiatrichistory Progressnotes Mnemonics SAMPLE OPQRST SOAP COASTMAP PhysicalexaminationGeneral/IPPA Inspection Auscultation Palpation Percussion Vitalsigns Temperature Heartrate Bloodpressure Respiratoryrate HEENT Eyeexamination Ophthalmoscopy Swinginglighttest Hearing Weber Rinne Respiratory Respiratorysounds Cardiovascular Cardiacexamination Peripheralvascularexamination Heartsounds Other Abdominojugulartest Ankle-brachialpressureindex Abdominal Liverspan Rectalexamination Bowelsounds Musculoskeletal Kneeexamination Hipexamination Shoulderexamination Elbowexamination GALSscreen Neurological Mentalstatus Mini–mentalstateexamination Cranialnerveexamination Upperlimbneurologicalexamination Neonatal Apgarscore BallardMaturationalAssessment Gynecological Well-womanexamination Vaginalexamination Breastexamination Sports Athleticheartsyndrome Suddencardiacdeath RED-S Assessmentandplan Medicaldiagnosis Differentialdiagnosis vteSignsandsymptomsrelatingtothecirculatorysystemChestpain Referredpain Angina Levine'ssign Auscultation Heartsounds SplitS2 S3 S4 Galloprhythm Heartmurmur Systolic Functionalmurmur Still'smurmur Diastolic Pulmonaryinsufficiency GrahamSteellmurmur Continuous CareyCoombsmurmur Mitralinsufficiency Presystolicmurmur Pericardialfrictionrub Heartclick Bruit carotid Pulse Tachycardia Bradycardia Pulsusparadoxus doubled Pulsusbisferiens Pulsusbigeminus Pulsusalternans Other Palpitations Apexbeat Cœurensabot Jugularvenouspressure CannonAwaves Hyperaemia Shock Cardiogenic Obstructive Hypovolemic Distributive SeefurtherTemplate:Shock CardiovasculardiseaseAorticinsufficiency Collapsingpulse DeMusset'ssign Duroziez'ssign Müller'ssign AustinFlintmurmur Mayne'ssign Otherendocardium endocarditis:Roth'sspot Janewaylesion/Osler'snode Bracht–Wachterbodies Pericardium Cardiactamponade/Pericardialeffusion:Beck'striad Ewart'ssign Other rheumaticfever: Anitschkowcell Aschoffbody EKG Jwave Gallavardinphenomenon VasculardiseaseArterial aorticaneurysm Cardarelli'ssign Oliver'ssign pulmonaryembolism Rightheartstrain radialarterysufficiency Allen'stest pseudohypertension thrombus LinesofZahn Adson'ssign arteriovenousfistula Nicoladoni–Branhamsign Venous Friedreich'ssign Caputmedusae Kussmaul'ssign Trendelenburgtest superiorvenacavasyndrome Pemberton'ssign 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