Auscultation of the Heart and Bedside Maneuvers

S1 is best heard/louder at the _____________ (apex/base) S2 is best heard/louder at the _____________ (apex/base)

S1: Apex (Mitral Area/5LICS) S2: Base (2ICS)

S1 is due to closure of which heart valves? S2 is due to closure of which heart valves?

S1: Mitral and Tricuspid (AV valves) S2: Aortic and Pulmonic (Semilunar Valves)

VSD is associated with a loud ___________ (S1/S2) ASD is associated with a loud ___________ (S1/S2)

VSD: Loud S2 ASD: Loud S1

http://northwesternmedicalreview.com/pdf/maneuvers.pdf

http://northwesternmedicalreview.com/pdf/maneuvers.pdf

You are observing a 5-year-old child with the history of a mild tetralogy of fallot. While playing with a few other children in the patient receiving room, the child's lips turns blue and he stops his play and squats for almost 20 seconds and then resumes his play. You noticed that his lips are no longer cyanotic. What is the most likely physiologic mechanism of reduced cyanosis in this case? A. Increased systemic vascular resistance B. Decreased systemic vascular resistance C. Increased pulmonary vascular resistance D. Decreased pulmonary vascular resistance E. Dilation of the orifice of the pulmonary valve

A. Increased systemic vascular resistance

Name the diastolic heart sounds

AR, PR, MS, TS

Name the systolic heart sounds

AS, PS, MR, TR, VSD, MVP

Amyl Nitrate __________ (increases/decreases) afterload Phenylepinephrine __________ (increases/decreases) afterload

Amyl Nitrate decreases afterload Phenylepinephrine increases afterload

Which condition makes it impossible to have an S4 heart sound?

Atrial fibrillation Since genesis of a fourth heart sound requires an effective atrial contraction, it does not occur in patients with atrial fibrillation.

A patient suffers a myocardial infarction which results in mitral papillary muscle dysfunction. This patient will most likely have a murmur that is best auscultated at the: A Fifth intercostal space, lateral to right midclavicular line B Fifth intercostal space, lateral to left midclavicular line C Second intercostal space, left upper sternal border D Fourth intercostal space, lower left sternal border E Second intercostal space, right upper sternal border

B Fifth intercostal space, lateral to left midclavicular line The mitral valve is best heard in the 5th intercostal space at the left midclavicular line.

Expiration ___________ (increases/decreases) venous return to the right atrium

Decreases venous return to right atrium. Increases venous return to left side of heart https://iamjagjit.wordpress.com/2014/07/28/effect-of-maneuvers-on-heart-murmurs/#more-13

What type of Murmurs are increased in intensity by the Handgrip Murmur? Which are decreased?

Due to increased afterload, Ejection murmurs are decreased in intensity and Regurgitant murmurs are increased in intensity Inc: Mitral Regurg, Aortic Regurg, Ventricular Septal Defect Dec: Hypertrophic Cardiomyopathy, Aortic Stenosis, Mitral Stenosis (negligible effect)

Auscultation at the second intercostal space along the left upper sternal border is recommended to hear a murmur of the: A Intraventricular septum B Aortic valve C Mitral valve D Tricuspid valve E Pulmonary valve

E Pulmonary valve The pulmonic valve is best heard in the 2nd intercostal space at the upper left sternal border.

Hypertrophic Cardiomyopathy is characterized by __________(S3/S4) on physical exam Dilated Cardiomyopathy is characterized by __________(S3/S4) on physical exam

HCM: S4 - Dilated Cardiomyopathy: S3 -decreased ejection fraction => still a fair amount of blood in the LV after systole; during diastole the blood from the LA rushes into a relatively full LV creating the S3

What effect does the Isometric Handgrip maneuver have on Mitral Valve Prolapse

* * * *Increased intensity? *Later onset of click/murmur

Where is the Physiologic Splitting of S2 best heard?

*A2 is louder and is heard all over the heart *P2 is softer and is best heard at the pulmonic listening area (2nd ICS LSB) *Thus Physiologic Splitting of S2 is best heard here

S4

*AKA Atrial Gallop *Occurs in Late Diastole (immediately before systole) *Best heard with bell, over the apex of the heart, with patient in left lateral decubitus position *Always pathological *Result of a forceful atrial contraction (atrial kick) into a stiff or noncompliant ventricle that cannot expand further *Can be heard in any condition that causes reduced ventricular compliance (e.g Hypertrophy): Left Ventricular Hypertrophy, Aortic Stenosis, Systemic Hypertension, Coronary Artery Disease, Hypertrophic Cardiomyopathy, Ischemia *Right sided S4 indicate reduced ventricular compliance/hypertrophy of the right ventricle: Pulmonic Stenosis, Pulmonary arterial hypertension *Absent in Atrial fibrillation

S3

*AKA Ventricular Gallop *Occurs in Early Diastole (rapid filling phase) *Left sided S3 is best heard with bell, over the apex of the heart, with patient in left lateral decubitus position *Thought to be due to a sudden rush of blood entering a volume overloaded left or right ventricle (like a river emptying into an ocean) *Signifies either systolic dysfunction or increased ventricular preload (CHF, Mitral regurgitation) **First sign of left or right heart failure* **In the presence of heart failure, S3 is a bad prognostic sign* *Less commonly, valvular regurgitation and left to right shunts may also result in a S3 due to increased flow. *Athletes, pregnant women, and Children and adults up to age 35-40 may have a physiologic S3

What is a Fixed Split S2

Splitting of S2 that occurs both during inspiration and expiration to the same extent (recall that in persistent/widened split S2, inspiration was more prominent than expiration)

Which maneuver has the same effects on murmurs as that of the Strain Phase of Valsalva?

Standing up (Decreases Preload)

Closing of which Atrioventricular Valve is louder? Where is it easier to hear each?

The M1 sound is much louder than the T1 sound due to higher pressures in the left side of the heart M1 is best heard at apex T1 is softer and heard best at Lower Left Sternal Border (tricuspid area)

Which Semilunar Valve closes first?

The aortic valve closes first followed by the pulmonic valve (high pressure beds always close earlier). Aortic valve closure: A2 Pulmonic valve closure: P2

Which anatomical chest location is used to auscultate the aortic valve?

The aortic valve is best heard in the 2nd intercostal space at the upper right sternal border.

Which Atrioventricular Valve closes first?

The mitral valve closes first followed by the tricuspid (high pressure beds always close earlier). Mitral valve closure: M1 Tricuspid valve closure: T1

What is the effect of exhalation on S2

The opposite as inspiration. It delays A2 (more venous return to the left side) and anticipates P2 (less venous return to the right side), so that the interval between the two components becomes too narrow for being appreciated by the human ear

What is meant by the hangout interval?

The pulmonary valve remains open for some time even after the right ventricular pressure becomes equal to pulmonary artery pressure at end of systole. This time interval is known as the hangout interval Since the pulmonary vascular resistance is low compared to the systemic vascular resistance, it takes some time for the blood flow from the right ventricle to stop Hangout interval is shortened in cases of increased pulmonary vascular resistance such as pulmonary vasospasm, obliteration of pulmonary vessels etc (Due to increased systemic vascular resistance, the hangout interval for the aortic valve is negligible)

Which anatomical chest location is used to auscultate the pulmonary valve?

The pulmonic valve is best heard in the 2nd intercostal space at the upper left sternal border.

What is a cardiac thrill?

Thrills are vibratory sensations caused by the heart and felt on the body surface. Thrills are always associated with murmurs. (feels like sensation when kink garden hose)

Your patient is a 31-year-old woman who is diagnosed with mitral prolapse (MVP). Auscultation of her heart is significant for an audible mid-systolic click. Which of the following options is a more likely auscultation finding if she moves from seating to a standing position? A. The click gets closer to S1 and murmur duration gets longer B. The click gets closer to S1 and murmur duration gets shorter C. The click gets closer to S2 and murmur duration gets longer D. The click gets closer to S2 and murmur duration gets shorter E. The click's position and the murmur's duration will not change

A. The click gets closer to S1 and murmur duration gets longer

Handgrip on mitral stenosis? on pulmonary stenosis? tricuspid stenosis?

An important point to mention is that handgrip and Amyl nitrate have a negligible effect on mitral stenosis since both maneuvers do not affect ventricular filling which is important in such murmurs. ????? TRUE?

What are the four cardiac auscultation points

Aortic, Pulmonic, Tricuspid, and Mitral areas Start with Aortic which is on the right side of the heart and then continue in a clockwise fashion *Mnemonic: All Patients Trust Me Aortic: 2nd Intercostal Space; Upper Right Sternal Border Pulmonic: 2nd Intercostal Space; Upper Left Sternal Border Tricuspid: 4th Intercostal Space; Lower Left Sternal Border Mitral: 5th Intercostal Space; Left of Midclavicular Line

A patient with a history of intravenous drug abuse develops vegetations on the tricuspid valve. Auscultation of this valve should be conducted in which location? A Second intercostal space, right upper sternal border B Fourth intercostal space, lower left sternal border C Fourth intercostal space, lower right sternal border D Fifth intercostal space, lateral to midclavicular line E Second intercostal space, left upper sternal border

B Fourth intercostal space, lower left sternal border The tricuspid valve is best heard in the 4th intercostal space at the lower left sternal border.

A 77-year-old patient presents with syncope, angina, and dyspnea. Echocardiography reveals a calcified heart valve. At which of the following locations would one most likely auscultate the murmur associated with this lesion? A Second intercostal space, left B Second intercostal space, right C Fourth intercostal space, right D Fifth intercostal space, left E Fourth intercostal space, left

B Second intercostal space, right Syncope + Angina + Dyspnea = typical presentation of Aortic Stenosis The aortic valve is best heard in the 2nd intercostal space at the upper right sternal border.

A healthy 4-year-old girl is brought for a well-child examination. A grade 2/6 systolic ejection murmur is heard along the upper left sternal border. S2 is widely split and does not vary with respiration. A soft mid-diastolic murmur is heard along the lower left sternal border. Examination shows no other abnormalities. Which of the following is the most likely diagnosis? A) Aortic stenosis B) Atrial septal defect C) Coarctation of the aorta D) Mitral valve prolapse E) Patent ductus arteriosus F) Pulmonary stenosis G) Tetralogy of Fallot H) Transposition of the great arteries I) Ventricular septal defect J) Normal heart

B) Atrial septal defect

After Valsalva maneuver the intensity of cardiac murmur of a patient is increased. This is most likely indicative of which of the following anomalies? A. Tricuspid regurgitation B. Atrial septal defect C. Mitral valve prolapse D. Mitral stenosis E. Pulmonic stenosis

C. Mitral valve prolapse Most murmurs decrease their intensities after Valsalva maneuver (i.e. with decreased preload) with the exception of the murmurs of hypertrophic cardiomyopathy (sub-aortic left ventricular outflow obstruction) and mitral valve prolapse (MVP).

A 24-year-old woman with no history of cardiovascular disease has a routine physical examination before starting a new job. Cardiac auscultation revealed that her second heart sound had a noticeable split during inspiration. What change in heart function contributes to the splitting of the second heart sound upon inspiration in this patient? A. Left ventricular afterload increases B. Left ventricular preload increases C. Right ventricular afterload decreases D. Right ventricular afterload increases E. Right ventricular preload decreases

C. Right ventricular afterload decreases Inspiration increases RV preload, decreases LV preload, decreases RV afterload (impedance)

What causes a Persistent/Widened Split S2?

Conditions that delay Right Ventricular Emptying leading to exaggerated delay in pulmonic valve closure Pulmonic Stenosis, Right Bundle Branch Block (RBBB)

A 58-year-old man presents to the emergency room with shortness of breath for 2 days. He has three-pillow orthopnea but no paroxysmal nocturnal dyspnea. He denies chest pain, palpitations, dizziness, and cough. His blood pressure is 170/90 mmHg and his heart rate is 130/min. He has jugular venous distension. Heart examination reveals a high-pitched extra heart sound that appears to be louder than an isolated S3 or S4 gallop. It occurs in diastole, is best heard with the bell of the stethoscope, and is palpable. Lung examination reveals crackles at the bases; the patient has 1+ bilateral peripheral edema. Which of the following is the most likely cause of his abnormal heart sound? A. It is a ventricular gallop B. It is an atrial gallop C. It is quadruple rhythm D. It is a summation gallop E. It is a diastolic murmur

D. It is a summation gallop At a heart rate > 120 beats per minute, the diastolic period is shortened. This causes the third and fourth sound to be superimposed, creating a single loud sound.

A 55-year-old man with a 10-year history of poorly controlled hypertension has had increasing dyspnea for the past 3 days. Last night he slept sitting in a chair. Vital signs are Pulse 110/min Respirations 30/min and regular Blood pressure, sitting 120/80 mm Hg The apical impulse is felt 2 cm lateral to the midclavicular line in the sixth intercostal space. Over the apex, there is an early diastolic low frequency sound after S2. The sound is most likely A) A midsystolic click B) An opening snap C) A pericardial rub D) A splitting of S2 E) An S3

E) An S3 S3 is an early diastolic sound and heard best with the bell in the LLD position at the apex increasing dyspnea + signs of orthopnea (sleeping in a chair) suggest CHF Laterally displaced PMI past midclavicular line suggests ventricular dilation from long standing hypertension

A variety of physiological maneuvers are used to evaluate and differentiate heart murmurs. Squatting is among the commonly used maneuvers. Which of the following physiological findings commonly results from squatting? A. Increase in venous return to the right heart B. Increase in venous return to the left heart C. Increase in peripheral vascular resistance D. Reflex bradycardia E. All of the above findings result from squatting

E. All of the above findings result from squatting All of them result from squatting. Squatting primarily increases venous return to the right heart and then to the left heart. It increases the systemic blood pressure and as a result it is often accompanied by reflex bradycardia

You are examining a female patient with an audible systolic murmur. To confirm your clinical suspicion you asked her to firmly grip your hand. This maneuver reduced the murmur intensity. Which of the following conditions is she most likely suffering from? A. Mitral regurgitation B. Mitral stenosis C. Ventricular septal defect D. Aortic regurgitation E. Aortic stenosis

E. Aortic stenosis

A three-year old male patient who has just been diagnosed with tetralogy of Fallot (TOF) presents to your office for a routine well-child checkup. His condition presented when his parents noticed that he was squatting frequently and seemed to be in distress. After having been given a referral for a pediatric cardiologist, they were informed that the squatting helps to compress the femoral arteries which increases systemic vascular resistance and decreases the right to left shunting present in TOF. When auscultating the heart on physical exam, what is the most likely characteristic of the heart sounds? A. Fixed splitting of S1 B. Fixed splitting of S2 C. Normal splitting of S2 D. Paradoxical splitting of S2 E. Wide splitting of S2

E. Wide splitting of S2 Pulmonic Stenosis of TOF => Wide Splitting

Which maneuvers cause the click of mitral valve prolapse to move earlier in systole? later?

Earlier: Standing, Valsalva, Amyl Nitrate Later: Squatting, Leg Raise, Handgrip The midsystolic click occurs earlier (closer to S1) or later (closer to S2) depending upon the volume of the left ventricle. Increasing preload or increasing afterload (increasing LV volume) cause the click to occur later Decreasing preload or decreasing afterload (decreasing LV volume) cause the click to earlier

During which part of the cardiac cycle does the S3 heart sound occur?

Early Diastole (immediately following S2 during phase of rapid passive ventricular filling)

Where is Erb's Point and what is it's clinical significance?

Erb's Point is located at the 3rd intercostal space at the left sternal border ****

Describe the Valsalva Maneuver and when should one note the change in murmur? What is one way to instruct the patient to perform a Valsalva Maneuver?

Forced expiration against a closed glottis and the change in murmur should be noted at the end of the strain (i.e at 20 seconds) It can be easily accomplished by having the patient "bear down as if having a bowel movement,"

Why is the murmur of Aortic Stenosis decreased during the Isometric Handgrip maneuver?

Handgrip increases afterload (by the compression of the arteries of the arm), and therefore decreases ejection of blood by the LV (decreased outflow) and lessens the intensity of Aortic Stenosis

Why is the murmur of Hypertrophic Cardiomyopathy decreased during the Isometric Handgrip maneuver?

Handgrip increases afterload and therefore decreases ejection of blood by the LV and as a result Left Ventricular Volume is increased which decreases outflow obstruction

With the patient in the left lateral decubitus position, a late diastolic sound is heard best with the bell at the apex. Which of the following is the most likely explanation for this auscultatory finding? A) Aortic insufficiency B) Aortic stenosis C) Mitral insufficency D) Mitral stenosis E) Opening snap F) Pulmonic insufficiency G) Pulmonic stenosis H) S3 I) S4 J) Tricuspid insufficiency

I) S4 S4 is a late diastolic sound and heard best with the bell in the LLD position at the apex Long-standing, poorly controlled hypertension as well as the current elevated pressures suggest that he should have a noncompliant ventricle and likely has some degree of diastolic dysfunction

What cardiac parameters does rapid squatting alter?

Increases Preload (squeezes abdominal venous contents into chest) and Afterload/PVR (by compressing femoral and iliac arteries) It also causes an Increase in left ventricular diameter (decreases obstruction in HOCM),

What cardiac parameters does the straight leg raise alter?

Increases Venous Return/ Preload

Which cardiac parameters does Handgrip alter?

Increases afterload by increasing Peripheral Vascular Resistance (PVR)

Inspiration ___________ (increases/decreases) right sided murmurs and Vice Versa Expiration ___________ (increases/decreases) right sided murmurs and Vice Versa

Inspiration increases right sided murmurs and decreases left sided murmurs Expiration increases left sided murmurs and decreases right sided murmurs Mnemonic: RILE: Right- Inspiration; Left -Expiration

Inspiration ___________ (increases/decreases) venous return to the right atrium Can you give the mechanism why?

Inspiration increases venous return/preload *Decrease in right atrial pressure *More negative intrathoracic pressure (Both contribute to increased venous return/preload)

What is the significance of S2 physiologically split at the apex?

It suggests Pulmonary Hypertension, with P2 so loud to transmit downward

In Left Heart Failure, the intensity of S3 increases with _____________ (inspiration/expiration) In Right Heart Failure, the intensity of S3 increases with _____________ (inspiration/expiration)

Left: Expiration Right: Inspiration

The stethoscope has two different heads to receive sound, the bell and the diaphragm. Which is used to detect low-frequency sounds and which is used to detect high-frequency sounds?

Low: Bell High: Diaphragm *Mnemonic: Bell rhymes with Hell which is low

Split S1

Narrowly Split: A normal phenomenon that is best heard at the Lower Left Sternal Border (tricuspid area; tricuspid closes after mitral) Widely Split: It usually indicates a delayed closure of the tricuspid valve, most commonly because of a right bundle branch block (RBBB)

Where is the PMI normally located? What does a PMI lateral to the midclavicular line suggest?

Normally the PMI is located just medial to the midclavicular line at 5th ICS PMI lateral to the midclavicular line or below the sixth intercostal space suggests left ventricular enlargement(hypertrophy/dilation)

Describe the mechanism of Physiologic Splitting of S2?

P2 normally closes after A2 (more separation than M1 and T1) because the pulmonary circulation offers so little resistance/impedance that flow continues for a short period even after completion of systole (hangout interval) With inspiration, P2 closure is delayed even more and the split is audible. *This happens during inspiration when increased venous return to the right side of the heart delays the closure of the pulmonic valve (increased VR -> increased RV filling -> increased RV stroke volume -> increased RV ejection time -> delayed closure of pulmonic valve) (major effect) *Decreased return to the left side of the heart hastens the closure of the aortic valve further separating A2 and P2 (minor effect) *Furthermore, inspiration decreases impedance in the pulmonary circuit and prolongs the hangout interval, further separating A2 and P2

What is a Persistent/Widened Split S2?

Persistent (widened) splitting occurs when both A2 and P2 are audible (split) during the entire respiratory cycle however STILL more marked in inspiration

Persistent/Wide Split S2 occur in conditions that delay _____________ closure such as ________________ Paradoxical Split S2 occur in conditions that delay _____________ closure such as ________________

Persistent/Wide Split S2: Delay pulmonic valve closure/RV emptying; RBBB, Pulmonic Stenosis Paradoxical Split S2: Delay aortic valve closure/LV emptying; LBBB, Aortic Stenosis

What are the four patterns of splitting seen with S2?

Physiologic, Fixed, Wide, and Paradoxical

Name 2 conditions that can produce a right sided S4; Name 3 conditions that can cause a left sided S4

Right sided S4 indicates reduced ventricular compliance/hypertrophy of the RV -Pulmonic Stenosis, Pulmonary arterial hypertension Left sided S4 indicates reduced ventricular compliance/hypertrophy of the LV -Aortic Stenosis, Hypertrophic cardiomyopathy, Systemic hypertension

Which heart sounds (S1-4) are detected using the diaphragm? bell?

S1 and S2 : Diaphragm S3 and S4: Bell

______ (S1/S2) marks the beginning of systole ______ (S1/S2) marks the end of systole

S1: beginning of systole S2: end of systole *The time period between S1-S2 = systole *The time period between S2 and the next S1 = diastole

A ________ (long/short) PR interval results in an accentuated S1 while a ________ (long/short) PR interval results in a soft S1

Short PR interval: Accentuated S1 Long PR interval: Soft S1 *Intensity of S1 varies inversely with length of PR Interval*

What causes a Fixed Split S2

Shunting of blood from left to right that results in increased right heart volume resulting in consistent delay in pulmonic valve closure regardless of inspiration Atrial Septal Defect

What is the effect of Valsalva maneuver on left ventricular volume and how does this affect the intensity of murmur in HOCM?

Valsalva decreases preload. It decreases the ventricular volume. The outflow gets more obstructed due to thick interventricular septum. The murmur intensity increases due to passage of blood through a narrowed outlet.

Which cardiac parameters does Valsalva (strain phase) alter?

Valsalva increases intrathoracic pressure and causes a drop in venous return It also causes a reduction in left ventricular diameter (increases obstruction in HOCM), and a fall in cardiac output.

What is the intensity of S1 in atrial fibrillation?

Variable. This is due to the irregular ventricular rate, which may catch the A-V valves widely open, partially closed, or in between

Squatting is a characteristic position assumed by patients with Tetralogy of Fallot. Why does squatting cause relief of cyanosis in Tetralogy?

With prolonged squatting the lower arteries (e.g. femoral) are compressed. This maneuver raises the afterload or systemic vascular resistance. As a result of increased TPR (afterload) the left ventricular pressure also increases. The rise in left ventricular pressure acts as an impediment to free flow of the right ventricular volume through the ventricular septal defect into the left ventricle. This increases the pulmonary flow and allows for more oxygenation of the blood.

Physiologic Splitting of S2 is most commonly seen in which patient demographic?

Young, healthy individuals A physiologic S2 split occurs in 60% of subjects younger than 30 and 30% of those older than 60.

________________ (systole/diastole) is always longer Except when the heart rate exceeds _____________ beats/min

summ *Because of this, there is usually a longer pause after S2*

What is a Paradoxical Split S2

A paradoxical split S2 heart sound occurs when the splitting is heard during expiration and DISAPPEARS during inspiration, the opposite of the physiologic split S2

What causes a Paradoxical Split S2

A paradoxical split S2 occurs in any setting that delays the closure of the aortic valve, such as severe aortic stenosis, hypertrophic obstructive cardiomyopathy (HOCM) or in the setting of a left bundle branch block (LBBB).

Summary of Maneuvers

*Inspiration increases preload to the right side of the heart and therefore increases intensity of right heart sounds *Expiration increases preload to the left side of the heart and therefore increases intensity of left heart sounds *Remember the mnemonic RILE *Maneuvers that increase preload: Squatting, Leg Raise *Maneuvers that decrease preload: Standing up, Valsalva (strain) *Maneuvers that increase afterload: Hand Grip, Transient Arterial Occlusion, Phenylepinephrine *Maneuvers that decrease afterload: Amyl Nitrate *Important to note that Squatting also increases afterload *As a general rule increasing preload increases flow to the heart and increases intensity of almost all types of murmurs. In contrast, decreasing preload reduces the intensity of valvular murmurs *Exception to this rule is Mitral Valve Prolapse and Hypertrophic Cardiomyopathy *Handgrip decreases both Aortic Stenosis and Hypertrophic Cardiomyopathy *Due to increased afterload, Ejection murmurs are decreased in intensity and Regurgitant murmurs are increased in intensity in Handgrip *Handgrip and Amyl Nitrate have a negligible effect on MS ??? *The midsystolic click occurs earlier (closer to S1) or later (closer to S2) depending upon the volume of the left ventricle. *Increasing preload or increasing afterload (increasing LV volume) cause the click to occur later *Decreasing preload or decreasing afterload (decreasing LV volume) cause the click to earlier *Earlier: Standing, Valsalva, Amyl Nitrate Later: Squatting, Leg Raise, Handgrip *

Match the characteristic heart sound with the cardiac pathology *Persistent/Wide Split S2 *Variable Intensity of S1 *Split S2 detected at apex of heart *Fixed Split S2 *Increased/Booming S1 *Impossible to hear S4 *Split S1 *Paradoxical Split S2

*Persistent/Wide Split S2: RBBB, Pulmonic Stenosis *Variable Intensity of S1: Atrial Fibrillation *Split S2 detected at apex of heart: Pulmonary Hypertension *Fixed Split S2: ASD *Increased/Booming S1:Early Mitral Stenosis *Impossible to hear S4: Atrial Fibrillation *Split S1: RBBB *Paradoxical Split S2: LBBB, Aortic Stenosis, HOCM

Summary of S1

*S1 results from closure of mitral and tricuspid valves *Best heard at mitral area (apex) *M1 is louder and occurs slightly early *T1 is softer and is best heard at tricuspid listening area (LLSB) *RBBB causes widely split S1 *Split S1 is best heard at LLSB *Mild to moderate Mitral Stenosis results in loud S1; Severe Mitral Stenosis results in soft S1 *Intensity of S1 varies inversely with length of PR Interval *A fib causes variable intensity of S1

S3 vs S4

*S3: Early Diastole; S4: Late Diastole *S3 can be physiologic or pathologic; S4 is always pathologic *S3 is due to ventricular dysfunction or increased ventricular preload *S3 requires a very compliant ventricle; S4 is due to an abnormally stiff ventricle/ decreased ventricular compliance (from hypertrophy or fibrosis) *S3 = Ventricular Gallop; S4 = Atrial Gallop *S3 indicates systolic dysfunction; S4 indicates diastolic dysfunction *Both (left sided S3 and S4) are best heard with the bell at the apex of the heart in the left lateral decubitus postion

An 80-year-old with a past history of myocardial infarction is found to have left bundle branch block on ECG. He is asymptomatic with blood pressure 130/80, lungs clear to auscultation, and no leg edema. On cardiac auscultation, the most likely finding is A) Fixed (wide) split S2 B) Paradoxical (reversed) split S2 C) S3 D) S4 E) Opening snap F) Midsystolic click

B) Paradoxical (reversed) split S2 Normally, the second heart sound (S2) is composed of aortic closure followed by pulmonic closure. Because inspiration increases blood return to the right side of the heart, pulmonic closure is delayed, which results in normal splitting of S2 during inspiration. Paradoxical splitting of S2, however, refers to splitting of S2 that is narrowed instead of widened with inspiration consequent to a delayed aortic closure. Paradoxical splitting can result from any electrical or mechanical event that delays left ventricular systole. Thus, aortic stenosis and hypertension, which increase resistance to systolic ejection of blood, delay closure of the aortic valve. Acute ischemia from angina or acute myocardial infarction also can delay ejection of blood from the left ventricle. The most common cause of paradoxical splitting—left bundle branch block—delays electrical activation of the left ventricle. Right bundle branch block results in a wide splitting of S2 that widens further during inspiration. An S3 is typically heard with congestive heart failure, an S4 with hypertension, an opening snap with mitral stenosis, and a midsystolic click with mitral valve prolapse.

How is a left sided S3 best detected?

Best heard with bell, over the apex of the heart, with patient in left lateral decubitus position

A 27-year-old man comes to the physician because of a 1-week history of shortness of breath with exertion, paroxysmal nocturnal dyspnea, and swelling of his feet. He has not had chest pain or palpitations. He has been healthy except for a "bad cold" 1 month ago that resolved spontaneously after 10 days. His temperature is 37 C (98.6 F), blood pressure is 90/60 mm Hg, pulse is 120/min, and respirations are 24/min. Examination shows jugular venous distention to 8 cm. Bilateral basilar crackles are heard. Cardiac examination shows a diffuse, laterally displaced point of maximal impulse. There is a normal S1 and S2 and an S3. Examination shows 2+ pretibial edema bilaterally. An ECG shows no abnormalities. Echocardiography is most likely to show which of the following? A) Asymmetric septal hypertrophy B) Bicuspid aortic valve with stenosis C) Diffuse hypokinesia and dilation of the ventricles D) Dyskinesia of the left ventricular apex E) Mitral valve prolapse

C) Diffuse hypokinesia and dilation of the ventricles Dx: Dilated cardiomyopathy secondary to viral myocarditis Hypokenesis is heart wall movement impairment that may reduce the heart's ability to pump adequately Dyskinesia of the apex = uncoordinated movement; suggestive of infarction?

Fixed Split S2 and VSD?

fixed splitting means when there is no variation of S2 splitting with inhalation which normally occurs. normally; s1 is produced by closure of mitral and tricuspid valves and s2 by closure of pulmonic and aortic valves..producing 2 components of s2 i.e a2 and p2..normally a2 precedes p2,but on inspiration p2 precedes a2,means pulmonic valve is taking longer to shut,n that is because on inspiration the blood flow to the right heart(RA and RV) increases, making the pulmonic valve to take longer to close. In ASD: on inspiration the increased blood flow towards RA which occurs normally, is there, but every time the amount of blood equalizes between RA and LA due to the septal defect.now the blood entering the RV equals to the blood entering LV regardless inspiration or expiration..hence producing fixed splitting. Now VSD: it is a defect between the two ventricles..normally the pressure of LV is more than the Pressure in RV, so initially the direction of the shunt will be left to right. the blood entering the RA wud be more than LA on inspiration which happens normally and this mechanism is not disturbed in VSD ,as the defect is between ventricles not atria.. so more blood coming in RA during inspiration, goes to RV.. but what happens there, it is a left to right shunt ! so even more blood wud be entering RV. so the closure of pulmonic valve would be even more delayed. so there wont be any fixed splitting... but when the disease get worsen with RV hypertrophy and the shunt get reversed, then there might be some fixed splitting ,but by that tym u get murmurs of regurgitation of pulmonic and aortic valve. So we don't hear 1 ************************ CLEAN UP

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