HEART SOUNDS HEART SOUNDS

byby

Don Hudson, D.O., FACEP/ACOEPDon Hudson, D.O., FACEP/ACOEP

Everything You need to Know About Everything You need to Know About Heart SoundsHeart Sounds

• We have all heard the heart make We have all heard the heart make the usual sounds.the usual sounds.

LUB----------DUBLUB----------DUB

• Lub is the first sound or S1Lub is the first sound or S1

• Dub is the second heart sound or S2Dub is the second heart sound or S2

So What is All of The Other So What is All of The Other SoundsSounds

• The best way to understand the The best way to understand the individual sounds is to think about individual sounds is to think about what is causing themwhat is causing them

• First you need to concentrate on the First you need to concentrate on the total sounds and then try to listen to total sounds and then try to listen to the individual component sounds the individual component sounds

SystoleSystole

• The time between the S1 and S2 The time between the S1 and S2 sounds is:sounds is:

Lub------------DubLub------------Dub

1.1. The ventricles contractingThe ventricles contracting

2.2. Blood flowing from the heart to the Blood flowing from the heart to the lungs and bodylungs and body

3.3. Blood flowing across the Pulmonic and Blood flowing across the Pulmonic and Aortic valvesAortic valves

DiastoleDiastoleDub----------LubDub----------Lub

The time between S2 and S1 isThe time between S2 and S1 is : :

1.1. The blood is flowing from the atria The blood is flowing from the atria to the ventricles.to the ventricles.

2.2. The blood flowing across the The blood flowing across the bicuspid and tricuspid valves.bicuspid and tricuspid valves.

3.3. The atrial contraction also occurs The atrial contraction also occurs now.now.

S1- What is it ?S1- What is it ?

The “lub” in the lub – dub.The “lub” in the lub – dub.• This sound is primarily because of the This sound is primarily because of the

closing of the bicuspid and tricuspid valves.closing of the bicuspid and tricuspid valves.• Anatomically they are located between the Anatomically they are located between the

atria and the ventriclesatria and the ventricles• They close because the ventricles contractThey close because the ventricles contract• The Pulmonic and Aortic valves are The Pulmonic and Aortic valves are

opening and blood is being forced into the opening and blood is being forced into the arteriesarteries

S2- What is it ?S2- What is it ?

S2 is the “dub” in the lub- dub S2 is the “dub” in the lub- dub • The sounds are because of the The sounds are because of the

closing of the Pulmonic and Aortic closing of the Pulmonic and Aortic valves as the pressure from the valves as the pressure from the arteries is greater then the pressure arteries is greater then the pressure in the ventricles.in the ventricles.

•This is the end of systole This is the end of systole

What Kinds of Sounds Do What Kinds of Sounds Do You Hear? You Hear?

• Murmurs-usually indicate turbulence & they Murmurs-usually indicate turbulence & they range from 1 to 5 in loudness.range from 1 to 5 in loudness.

• Does it occur during diastole or systole?Does it occur during diastole or systole?• Does it Does it crescendocrescendo (get progressively louder)? (get progressively louder)?• Does it Does it decrescendodecrescendo (get progressively (get progressively

quieter)?quieter)?• Where do you hear it best? (Neck, Chest, Where do you hear it best? (Neck, Chest,

Axilla)Axilla)

Other SoundsOther Sounds

• GallopsGallops- these are either S3 or S4 - these are either S3 or S4 sounds.sounds.

• RubsRubs- pericardial or plural friction rubs - pericardial or plural friction rubs and usually indicated either pericarditis and usually indicated either pericarditis or possible pleurisy ( must be careful to or possible pleurisy ( must be careful to listen to both heart and lung sounds)listen to both heart and lung sounds)

• RubsRubs- sounds “sandpapery”- sounds “sandpapery”

Other SoundsOther Sounds

• ClicksClicks- only occur in systole and - only occur in systole and represent the loud valve closingrepresent the loud valve closing

• Diastolic Knock-Diastolic Knock- occurs because of a occurs because of a abrupt arrest of ventricular filling by a abrupt arrest of ventricular filling by a non-compliant & constricting non-compliant & constricting pericardium.pericardium.

• Continuous Murmurs-Continuous Murmurs- indicate a constant indicate a constant shunt flow throughout systole & diastole shunt flow throughout systole & diastole i.e. Coarctation, or patent ductus i.e. Coarctation, or patent ductus arteriosus.arteriosus.

Anatomy of A SoundAnatomy of A Sound

•LUB-- DUB-------------LUB--DUBLUB-- DUB-------------LUB--DUB• S1 S2 S3 S4 S1 S1 S2 S3 S4 S1

S2S2

• Here is where you expect to hear the Here is where you expect to hear the various soundsvarious sounds

Now that you Hear the Now that you Hear the Sounds Sounds (what does it mean?)(what does it mean?)

First Heart Sound (S1)First Heart Sound (S1)

• - Louder than usual -- Louder than usual - Mitral Stenosis Mitral Stenosis• - Variable- Variable Atrial Fib./Complete Heart Atrial Fib./Complete Heart

BlockBlock• -Diminished-Diminished Mitral or Aortic Regurg. Mitral or Aortic Regurg.

Second Heart Sounds Second Heart Sounds (S2)(S2)

(what does it mean)(what does it mean)

Wide split sounds or fixed ( not Wide split sounds or fixed ( not moving with respiration) may moving with respiration) may indicate:indicate:

• Atrial Septal DefectAtrial Septal Defect• RBBBRBBB• Pulmonic StenosisPulmonic Stenosis

Extra Heart Sounds (S3 Extra Heart Sounds (S3 & S4)& S4)

(what do they mean to you)(what do they mean to you)• Third Heart Sound (S3) Third Heart Sound (S3) Markedly Markedly

Diminished Left Ventricular FunctionDiminished Left Ventricular Function• (Almost always present with Myocardial (Almost always present with Myocardial

Ischemia or early after an AMI)Ischemia or early after an AMI)

• Fourth Heart Sound (S4)Fourth Heart Sound (S4) Modestly Modestly Diminished Left Ventricular FunctionDiminished Left Ventricular Function

What Special Things Do What Special Things Do You Need To Hear These You Need To Hear These

SoundsSounds

• StethoscopeStethoscope• As quite an environment as possibleAs quite an environment as possible• Proper positioning of the patientProper positioning of the patient• Stethoscope must touch the skinStethoscope must touch the skin• Patient historyPatient history• Ability to observe the chest, Ability to observe the chest,

abdomen & neckabdomen & neck

Where Do You Listen?Where Do You Listen?

• Left Ventricle Area-Left Ventricle Area- The apex of the The apex of the heart is at the 4heart is at the 4thth or 5 or 5thth intercostal intercostal space (ICS) along the midclavicular space (ICS) along the midclavicular line (MCL).line (MCL).

• Right Ventricular Area-Right Ventricular Area- the 3 the 3rdrd to 5 to 5thth ICS along the left sternal border (LSB)ICS along the left sternal border (LSB)

• Pulmonic Area-Pulmonic Area- 2end ICS along LSB 2end ICS along LSB• Aortic Area-Aortic Area- 2end ICS along the right 2end ICS along the right

sternal border (RSB)sternal border (RSB)

Stethoscope UseStethoscope Use

• The diaphragm of your stethoscope is The diaphragm of your stethoscope is most useful for picking up high-most useful for picking up high-pitched sounds i.e. S1, S2, Aortic or pitched sounds i.e. S1, S2, Aortic or Mitral Regurgitation Murmurs or Mitral Regurgitation Murmurs or Friction Rubs.Friction Rubs.

• The Bell is most useful for picking up The Bell is most useful for picking up low-pitched sounds, S3, S4, or Mitral low-pitched sounds, S3, S4, or Mitral Stenosis. Stenosis.

The Most Important Things To The Most Important Things To Have In Order To Hear These Have In Order To Hear These

SoundsSounds

Thank You For Your Thank You For Your PatiencePatience

Practice, Practice, PracticePractice, Practice, Practice

Patience to take time to listenPatience to take time to listen

Time to listen to historyTime to listen to history

Expose the patientExpose the patient

Think Think

ReflectReflect

Your patients will appreciate your Your patients will appreciate your effortsefforts