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Heart sounds and murmurs

Prof Anura Weerasinghe

Objectives
Heart sounds (including murmurs) & their
genesis
Correlation of heart sounds with cardiac
events

Genesis
Heart sounds
Sudden changes in the rate of flow create
vibrations which can be heard.

Murmurs
Due to turbulent blood flow

Bruits
noise heard over blood vessels

Thrill
Vibration as perceived by the sense of touch

Rene Laennec invented the stethoscope.


(1781 1826)

Heart sounds
Closing of the valves is associated with audible
sounds
No audible sounds occur when valves open
The first heart sound
associated with closure of the atrioventricular valves

The second heart sound


associated with closure of the semilunar valves

1st ---systole--- 2nd ---Diastole --- 1st


lub
dub
lub

Splitting of heart sounds


The mitral valve closes slightly before the
tricuspid valve. But the splitting of the first
heart sound is difficult to be detected by
auscultation.
Normally pulmonary valve closure always
follows aortic valve closure and the splitting
is widest during inspiration. Splitting can be
heard with the stethoscope as they are highpitched sounds.
Pulmonary valve closure is normally heard only in pulmonary
area and a short distance down the left sternal edge.

Guyton 246

3rd and 4th heart sounds


3rd heart sound
heard about 1/3 of the way through diastole
associated with rapid ventricular filling
may be physiological in healthy young people

4th heart sound


associated with atrial contraction

Those sound are detected by


phonocardiography

Murmurs as a result of diseases


of the valves
Narrowed (stenosis)
Blood flow through it in the normal direction
produces the murmur

Incompetent (insufficiency)
Blood flow backward through it produces the
murmur (regurgitation)

Heart murmurs
Valve

Abnormality

Timing of
murmur

Aortic or
pulmonary

Stenosis

Systolic

Insufficiency

Diastolic

Stenosis

Diastolic

Insufficiency

systolic

Mitral or
tricuspid

Congenital heart diseases


Acyanotic
Ventricular septal defect
Pan systolic murmur over the precordium

Atrial septal defect


Ejection systolic murmur over the PA due to
increased blood floor through the normal pulmonary
valve

Patent ductus arteriosus


Continuous murmur

Cyanotic
Fallots tetrology

Patent Ductus Arteriosus

Guyton 250

Guyton 251

Fallots tetralogy
VSD
PS
Overrding of the aorta
RV hypertrophy

Guyton 246

Objectives
Heart sounds (including murmurs) & their
genesis
Correlation of heart sounds with cardiac
events