Cardiac Auscultation Cardiac Auscultation

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					        Cardiac Auscultation

Jay L. Rubenstone, D.O., F.A.C.C.

                              October 2010
          Techniques of Examination

• Order of Exam
  –   Aortic Area
  –   Pulmonic Area
  –   Tricuspid Area
  –   Mitral Area
                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
                   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
                  Process of Ascultation

*If Systolic or Diastolic Murmur Present,
  –   Location
  –   Radiation
  –   Intensity
  –   Pitch
  –   Quality

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

• Interspace

• Centimeters from
  – Midsternal
  – Midclavicular
  – Or Axillary Lines
• 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
• Grade 5   Very Loud
• Grade 6   May be Heard w/stethoscope
            off chest

• Radiation or Transmission
• Pitch
  – High, Med, Low
• Quality
  –   Blowing
  –   Rumbling
  –   Harsh
  –   Muscial
                       Components of S1

• Mitral Valve Closure
  – Best Heard: Apex

• Tricuspid Valve Closure
  – Best heard: Lower Left Sternal Boarder

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

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

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

• Two Components
  – Aortic Closure A2
  – Pulmonic Closure P2

  Best Heard at the Base

• Normal Splitting
  – Best Heard At 2nd Left Intercostal Space
  – During Inspiration there is Delayed Pulmonic
    Valve Closure
     •Due to Increased Capacitance of Pulmonary Bed

• Loss of Splitting
  – Inaudible P2-
     •Adults with Increased Chest Diameter
     •Congenital (Tetralogy, Pulmonary Atresia
  – Increased Pulmonary Valve Resistance-
    Pulmonary HTN
  – Eisenmenger’s Complex-Equal Pulmonary &
    Systemic Resistances

• 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

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

• Ejection Sound- Usually High Frequency
  – Aortic Valve- Aortic Stenosis, Bicuspid Aortic
  – Pulmonary Valve-Pulmonic Stenosis Vary
    with Respirations
  – Prosthetic Valves- Mechanical, Not
           Mid-Late Systolic Sounds

• Click
  – High Frequency Sound Found in Mitral Valve
  – Occurs Earlier with Valsalva Maneuver or
    Squatting to Standing
                Early Diastolic Sounds

• Opening Snap of Mitral Stenosis (MS)
     •High Frequency-Left Lateral Decubitus Position,
     •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
                       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
                  Late Diastolic Sounds

• S4
  – During Atrial Phase of LV Filling
       •Consequence of Ventricular Stiffness
  – Absent in Atrial Fibrillation or Ventricular
  – Low Frequency Sound Best Heart
       •At the Apex
       •Pt in Left Lateral Decubitus Position
  – HTN, Aortic Stenosis, Ischemic Heart Disease
                        Diastolic Sounds

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

• Obstruction to Ventricular Outflow
• Dilatation of Aortic Root or Pulmonary
• Accelerated Flow into Aorta or Pulmonary
• Innocent Murmurs
• Some Forms of MR (Papillary Muscle
           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
          Systolic Murmurs

• Pulmonic Stenosis
  – Similar to AS Except Relationship to P2
  – 2nd Left Intercostal Space
          Normal Systolic Murmurs

• Still’s Murmur
     •Medium Frequency, Vibratory, Originating from
      Leaflets of Pulmonic Valve
• Rapid Ejection into Aortic Root or
  Pulmonary Trunk
          Normal Systolic Murmurs

• Aortic Sclerosis
  – Most Common Innocent Murmur
           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
           Systolic Murmurs

• Holosystolic
  – Begins with S1, Ends at S2
     •MR- Radiates to Left Sternal Boarder, Base or
      Neck, More Commonly Apex to Axilla
     •TR- Carvallo’s Sign (Inspiratory Variation)
     •VSD-Across Precordium
     •Patent Ductus Arteriosis (PDA)- Aorto-Pulmonary
              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
          Early Diastolic Murmur
– Graham Steell –
  •Murmur of Pulmonic Regurgitation as a Result of
   Pulmonary HTN
  •High Freq, Decrescendo Blowing Murmur Heard
   throughout Diastole
                 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
             Mid Diastolic Murmurs

• Tricuspid Stenosis
  – Similar to MS, except increases with
    Respiration (Carvallo’s Sign)
  – Best Heard at Left Lower Sternal Edge
             Mid Diastolic Murmurs

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

• Late or Presystolic
  – Follows Atrial Systole
     •Implies Sinus Rhythm
  – Can be present in MS or Complete Heart
  – Austin Flint Murmur of Aortic Regurgitation
     • Bubbling Quality, Short
     •Consequence of Aortic Regurgitation impinging
      on Mitral Valve
                       Diastolic Murmurs

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

• Venous Hum
  – Rough in quality not actually a hum
  – Hepatic
  – Internal Jugular
  – During Anemia, Fever, Pregnancy and
             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
– Confused with Hamman’s Sign in Post Open Heart
  Surgery (Crunch Sound from Mediastinal Air)
     Innocent or Normal Murmurs-
• Vibratory Systolic Murmur (Still’s Murmur)
• Pulmonic Systolic Murmur (Pulmonary Trunk)*
• Mammary Soufflé*
• Peripheral Pulmonic Systolic Murmur (Pulmonary
• Supraclavicular or Brachiocephalic Systolic
• Aortic Systolic Murmur
  *common in pregnancy
   Innocent or Normal Murmurs-

• Venous Hum
• Continuous Mammary Soufflé

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

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