heart terms Ch 19

Varying intensity of S1 Examples

-Atrial fibrillation-irregularly irregular rhythm -Complete heart block with changing PR interval

Faint (Diminished) S1 Examples

-First- degree heart block (prolonged PR interval) -Mitral insufficiency -Severe hypertension-systemic or pulmonary

Accentuated S2 example

-systemic hypertension, ringing, or booming S2 -mitral stenosis, heart failure aortic or pulmonic stenosis

The S3 is usually abnormal in adults

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Diminished S2

1. A fall in systemic blood pressure causes a decrease in valve strength 2. Semilunar valves thickened and calcified, with decreased mobility

Accentuated S2

1. Higher closing pressure 2. Exercise and excitement increase pressure in aorta 3. Pulmonary hypertension 4. Semilunar Valves calcified but still mobile

Loud (Accentuated) S1

1. Position of AV valve at start of systole- wide open and no time to drift together 2. Change in valve structure-calcification of valve, needs increasing ventricular pressure to close the valve against increase atrial pressure

Varying intensity of S1

1. Position of AV valve varies before closing from beat to beat 2. Atria and ventricles beat independently

Faint (Diminished) S1

1. Position of AV valve- delayed conduction from atria to ventricles. Mitral valve drifts shut before ventricular contraction closes it. 2. Change in valve structure-extreme calcification, which limits mobility. 3. More forceful atrial contraction into noncompliant ventricle; delays or diminishes ventricular contraction

Onset of heart failure may be:

1. acute, as following a myocardial infarction when direct damage to the heart's contracting ability has occurred. 2. chronic, as with hypertension, when the ventricles must pump against chronically increased pressure.

Signs and symptoms of heart failure comes from two main mechanisms

1. the hearts inability to pump enough blood to meet the metabolic demands of the body. 2. the kidney's compensatory mechanisms of abnormal retention of sodium and water to compensate for the decreased cardiac output. This increases blood volume and venous return, which causes further congestion.

Fixed Split

A fixed split is unaffected by respiration; the split is always there. Example: Atrial septal defect, right ventricular failure

Left sternal border

A lift (heave) occurs with right ventricular hypertrophy, as found in pulmonic valve disease, pulmonic hypertension, and chronic lung disease. You feel a diffuse lifting impulse during systole at the left lower sternal border. It may be associated with retraction at the apex because the left ventricle is rotated posteriorly by the enlarged right ventricle.

Base

A thrill in the second and third left interspaces occurs with pulmonic stenosis and pulmonic hypertension

Base

A thrill in the second and third right interspaces occurs with severe aortic stenosis and systemic hypertension.

Ventricular Septal Defect (VSD)

Abnormal opening in septum between the ventricles, usually subaortic area. The size and exact position vary considerably. S: Small defects are asymptomatic. Infants with large defects have poor growth, slow weight gain; later look pale, thin, delicate. May have feeding problems; DOE; frequent respiratory infections; and when the condition is severe, heart failure.

Atrial Septal Defect (ASD)

Abnormal opening in the arterial septum, resulting usually in left-to-right shunt and causing large increase in pulmonary blood flow S: Defect is remarkably well tolerated. Symptoms in infants are rare; growth and development normal. Children and young adults have mild fatigue and DOE. O:Sternal lift often present. S2 has fixed split, with P2 often louder than A2. Murmur is systolic, ejection, medium pitch, best heard at base in second left interspace. Murmur caused not by shunt itself but by increased blood flow through pulmonic valve.

Midsystolic Click

Although it is systolic, this is not an ejection click. it is associated with mitral valve prolapse, in which the mitral valve lealets not only close with contraction but balloon back up into the left atrium. During ballooning, the sudden tensing of the valve leaflets and the chordae tendinae creates the click

Mitral Prosthetic Valve Sound

An iatrogenic sound, the opening of a ball-in-cage mitral prosthesis gives an early diastolic sound: an opening click just after S2. It is loud, is heard over the whole precordium, and is loudest at the apex and left lower sternal border.

Aortic Prosthetic Valve Sounds

As sequela of modern technologic intervention for heart problems, some people now have iatrogenically induced heart sounds. The opening of mechanical aortic ball-in-cage prosthesis produces early systolic sound. This sound is less intense with a tilting disk prosthesis and is absent with a biologic tissue prostheses.

Pulmonic Regurgitation

Backflow of blood through incompetent pulmonic valve, from pulmonary artery to RV. Murmur has same timing and characteristics as that of aortic regurgitation, and is hard to distinguish on physical examination.

Tricuspid Regurgitation

Backflow of blood through incompetent tricuspid valve into RA. O: Engorged pulsating neck veins, liver enlarged. Lift at sternum if RV hypertrophy present, often thrill at left lower sternal border. Murmur: Soft, blowing, pansystolic, best heard at left lower sternal border, increases with inspiration.

Aortic Stenosis

Calcification of aortic valve cusps restricts forward flow of blood during systole; LV hypertrophy develops. S: Fatigue, DOE, palpation, dizziness, fainting, anginal pain O:Pallor, slow diminished radial pulse, low blood pressure, and auscultatory gap are common. Apical impulse sustained and displaced to left. Thrill in systole over second and third right interspaces and right side of neck. S1 normal, often ejection click present, often paradoxical split S2, S4 present with LV hypertrophy. Murmur: Loud, harsh, midsystolic, crescendodecrescendo, loudest at second right interspace, radiates widely to side of neck, down left sternal border, or apex.

Pulmonic Stenosis

Calcification of pulmonic valve restricts forward flow of blood. O: Thrill in systole at second and third left interspace, ejection click often present after S1, diminished S2 and usually with wide split, S4 common with RV hypertrophy. Murmur:Systolic, medium pitch, coarse, crescendo-decrescendo (diamond shape), best heard at second left interspace, radiates to the left and neck.

Tricuspid Stenosis

Calcification of tricuspid valve impedes forward flow into RV during diastole O: Diminished arterial pulse, jugular venous pulse prominent. Murmur: Diastolic rumble; best heard at left lower sternal border; louder in inspiration

Mitral Stenosis

Calcified mitral valve will not open properly, impedes forward flow of blood into LV during diastole. Results in LA enlarged and LA pressure increased. S: Fatigue, palpitations, DOE, orthopnea, occasional PND or pulmonary edema. O: Diminished, often irregular arterial pulse. Lift at apex, diastolic thrill common at apex. S1 accentuated; opening snap after S2 heard over wide area of precordium, followed by murmur. Murmur: Low-pitched diastolic rumble, best heard at apex, with person in left lateral position; does not radiate

Apex

Cardiac enlargement displaces the apical impulse laterally and over a wider area when left ventricular hypertrophy and dilation are present. This is volume overload, as in mitral regurgitation, and left-to-right shunts.

Paradoxical Split

Conditions that delay aortic valve closure cause the opposite of a normal split. In inspiration, P2 is normally delayed so with a paradoxical split, the sounds fuse. In expiration, you hear the split, in the order of P2A2. EXAMPLE: Aortic stenosis, Left bundle branch block, patent ductus arteriosus

Early diastolic Murmurs

Due to SL valve incompetence

Pansystolic Regurgitant Murmors

Due to backward flow of blood from area of higher pressure to one of lower pressure

Midsystolic Ejection Murmurs

Due to forward flow through semilunar valves

Opening snap

During presence of stenosis, AV valve is normally silent. Increasingly higher atrial pressure atrial pressure required to open the valve. The deformed valve opens with opening snap sound. Sharp and high pitched. Sound heard at S2 best heard with diaphragm. Opening snap usually not isolated sound. As a sign of mitral stenosis, opening snap usually ushers in the low-pitched diastolic rumbling murmur of that condition.

Early Systolic

Ejection click Aortic prosthetic valve sounds

Diastolic Rumbles of AV valves

Filling murmurs at low pressures, best heard with bell lightly touching skin

Tetralogy of fallot

Four compononets: 1. Right ventricular outflow stenosis. 2. VSD 3. Right ventricular hypertrophy 4. Overriding aorta. Result: shunts a lot of venous blood directly into aorta away from pulmonary system, so blood never gets oxygenated. S:Severe cyanosis, not in first months of life but develops as infant grows and RV outflow. (I.e., pulmonic) stenosis gets worse. Cyanosis with crying and exertion at first, then at rest. Uses squating posture after starts walking. DOE common. Development is slowed. O:Thrill palpable at left lower sternal border. S1 normal; S2 has A2 loud and P2 diminished or absent. Murmur is systolic, loud, crescendo-decrescendo.

Late Diastole

Fourth heart sound Pacemaker-induced sound

Loud (Accentuated) S1 -EXAMPLES

Hyperkinetic states where blood velocity is increased: exercise, fever, anemia, hyperthyroidism Mitral stenosis with leaflets still mobile.

Pericardial Friction Rub

Inflammation of the pericardium gives rise to a friction rub. The sound is high pitched and scratchy, like sandpaper being rubbed. It is best heard with the diaphragm, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium but usually is best heard at the apex and left lower sternal border, places where the pericardium comes in close contact with the chest wall. Timing may be systolic and diastolic. The friction rub of pericarditis is common during the 1st week after a myocardial infarction and may last only a few hours.

A right sided S4 is less common..

It is heard at the left lower sternal border and may increase with inspiration. It occurs with pulmonary stenosis or pulmonary hypertension.

Mid-/late systolic

Midsystolic (mitral) click

Split S1

Mitral and tricuspid components are heard separately

Split S1 Examples

Normal but uncommon

Early Diastole

Opening snap Mitral prosthetic valve sound

Patent Ductus Arteriosus PDA

Persistence of the channel joining left pulmonary artery to aorta. This is normal in the fetus and usually closes spontaneously within hours of birth S: usually no symptoms in early childhood; growth and development are normal O: Blood pressure has wide pulse pressure and bounding peripheral pulses from rapid runoff of blood into low-resistance pulmonary ed during diastole. Thrill often palpable at left upper sternal border. The continuous murmur heard in systole and diastole is called machinery murmur.

Fourth Heart Sound

S4 filling sound happens right after the S1. Very soft sound, very low pitch. Need a good bell. Heard best at apex, person in left lateral position.

Coarction of the Aorta: Clinical Data

S:In infants with associated lesions or symptoms, diagnosis occurs in first few months as symptoms of heart failure develop. For asymptomatic children and adolescents, growth and development are normal. Diagnosis usually incidental due to blood pressure findings. Adolescents amy complain of vague lower extremity cramping that is worse with exercise. O: Upper extremity hypertension over 20 mm HG higher than lower extremity measures is a hallmark of coarctation. Another important sign is absent or greatly diminished femoral pulses. A systolic murmur is heard best at the left sternal border, radiating to the back.

Coarction of the Aorta

Severe narrowing of descending aorta, usually at the junction of the ductus arteriosus and the aortic arch, just distal to the orgin of the left subclavian artery. Results in increased workload on left ventricle. Associated with defects of aortic valve in most cases, as well as associated patent ductus arteriosus; and associated ventricular septal defect.

Diminished S2 Examples

Shock Aortic or pulmonic stenosis

Mitral Regurgitation

Stream of blood regurgitates back into LA during systole through incompetent mitral valve. In diastole, blood passes back into LV again along with new flow; results in LV dilation and hypertrophy S: Fatigue, palpitation, orthoppnea, PND O: Thirll in systole at apex. Lift at apex. Apical impulse displaced down and to left. S1 diminished, S2 accentuated, S3 at apex often present. Murmur: Pansystolic, often loud, blowing, best heart at apex, radiates well to left axilla

Aortic Regurgitation

Stream of blood regurgitates back through incompetent aortic valve into LV during diastole. LV dilation and hypertrophy due to increased LV stroke volume. Rapid ejection of large stroke volume into poorly filled aorta, then rapid runoff in diastole as part of blood pushed back into LV S: Only minor symptoms for many years, then rapid deterioration: DOE, PND, angina, dizziness O: Bounding "water-hammer" pulse in carotid, brachial and femoral arteries. Blood pressure has wide pulse pressure. Pulsations in cervical and suprasternal area, apical impulse displaced to left and down, apical impulse feels brief. Murmur starts almost simultaneously with S2: soft high pitched, blowing diastolic, decrescendo, best heard at third left interspace at base, as person sits up and leans forward, radiates down

The third sound-Respiratory Variation

The S3 does not vary in timing with respirations; the split S2 does

The third sound-Location

The S3 is heard at the apex or left lower sternal border; the split S2 at the base.

The third sound-Pitch

The S3 is lower pitched; the pitch of the split S2 stays the same

Apex

The apical impulse is increased in force and duration but is not necessarily displaced to the left when left ventricular hypertrophy occurs alone without dilation. This is pressure overload, as found in aortic stenosis or systemic hypertension.

Ejection Click

The ejection click occurs early in systole at the start of ejection because it results from opening of the semilunar valves. Normally, the SL valves open silently, but int he presence of stenosis (e.g., aortic stenosis, pulmonic stenosis), their opening makes a sound. It is short and high pitched, with a click quality, and is heard better with the diaphragm. The aortic ejection click is ehard at the second right interspace and apex and may be loudest at the apex. Its intensity does not change with respiration. The pulmonic ejection click is best heard in the second left interspace and often grows softer with inspiration.

Mid-Diastole

Third heart sound Summation SOund (S3 + S4)

Summation Sound

When both pathologic S3 and S4 are present, a quadruple rhythm is heard. Often, in cases of of cardiac stress, one response is tachycardia. During rapid rates, the diastolic filling time shortens and the S3 and S4 move closer together. They sound superimposed in mid-diastole, and you hear one loud, prolonged, summated sound, often louder than either S1 or S2.

Wide Split

When the right ventricle has delayed electrical activation, the split is very wide on inspiration and is still there on expiration EXAMPLE: right bundle branch block (which delays P2)

Third heart sound

Your S3 is the ventricular filling sound that occurs in early diastole during rapid filling phase. It sounds after S2 but later than an opening snap would be. It is a dull soft sound, and it is low pitched, like "distant thunder." heard at apex, with bell held lightly with person in left lateral position.

The pathologic S3

also called a ventricular gallop or an S3 gallop, and it persists when sitting up. The S3 indicates decreased compliance of the ventricles, as in heart failure.

Orthopnea

cannot breathe while lying down

Dyspnea

early symptom from pulmonary congestion

Ascites

fluid in peritoneal cavity

During Heart failure cough is

frothy pink or white sputum

Physiologic S3

heard frequently in children and young adults; it occasionally may persist after age 40 years, especially in women. The normal S3 usually disappears when the person sits up.

S3 is one of the earliest signs of?

heart failure

Pathologic S4

is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle (coronary artery disease, cardiomyopathy) and with systolic overload (after load), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions. It is heard best at the apex, in the left lateral position.

Physiologic S4

may occur in adults older than 40-50 years with no evidence of cardiovascular disease, especially after exercise.

During heart failure decreased cardiac output..

occurs when the heart fails as a pump, and the circulation becomes backed up and congested.

The S3 also occurs with conditions of?

volume overload, such as mitral regurgitation and aortic or tricuspid regurgitation. The S3 is also found in high cardiac output states in the absence of heart disease, such as hyperthyroidism, anemia, and pregnancy. When the primary condition is corrected, the gallop disappears.