Notes on Heart Sounds and Murmurs

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Descriptions of Heart Sounds:

Heart Sound Cause
S4 Heart Sound: Aortic stenosis; Stiff and hypertrophied ventricles; hypertrophic cardiomyopathy; ventricular hypertrophy due to hypertension; ischemic heart damage due to acute myocardial infarction; immediately precedes S1 heart sound; ventricular gallop; left-sided S4 is heard best in left lateral decubitus position while expiring; right-sided S4 is heard best in the lower left sternal border while the patient lies in supine position; may be normal in children and young adults.
S3 Heart Sound: Aortic valve regurgitation; Congestive Heart Failure; dilated cardiomyopathy; mitral regurgitation; volume-overloaded left ventricle; heard best in left lateral decubitus position while expiring.
Harsh holosystolic murmur heard over tricuspid area (left lower sternal border). Pulse pressure is wide. Precordium is hyperkinetic, and there is a systolic thrill along the left sternal border. There is no apical pan systolic murmur of mitral regurgitation as in ostium primum defect. ECG shows left ventricular hypertrophy or biventricular hypertrophy and P waves may be notched or peaked; CXR shows enlarged left atrium, decreased pulmonary vascular markings, "boot-shaped" heart: Ventricular Septal Defect.
ST elevation + T inversion + unrecognizable QRS complexes: Ventricular fibrillation.
Water hammer pulse. Diastolic murmur in upper left sternal border (precordium); Marfan's Syndrome; early diastolic decrescendo murmur radiating to the apex; early high-pitched blowing diastolic murmur; diastolic decrescendo murmur at the right upper sternal border; wide pulse pressure; head bobbing with each heart beat; bounding pulse; often accompanied by diastolic "blowing" murmur (i.e., an aortic regurgitation murmur); Pulsus bisferiens; Corrigan pulse (rapid rise and fall of peripheral pulses): Aortic regurgitation/insufficiency.
Nonejection click and murmur that vary in timing depending on body position. Mid-systolic click over the cardiac apex with accompanying short systolic murmur if mitral regurgitation is present; murmur disappears with squatting. Asymptomatic in young people and often goes undiagnosed. Midsystolic click followed by late systolic murmur; "apical systolic murmur:" Mitral valve prolapse; loudest during valsalva maneuver.
Crescendo-decrescendo mid-systolic ejection murmur radiating to the neck; weak and late pulses; harsh systolic murmur; "diamond-shaped;" may be preceded by an opening click; pulsus parvus et tardus; slow-rising carotid pulse; paradoxical splitting of S2; delayed carotid upstroke with systolic ejection murmur at second intercostal space at the right sternal border; soft S2 without splitting may be present; systolic thrill; forceful apex beat: Aortic stenosis; may be due to age-related calcified aortic valve. Young adults with bicuspid aortic valve can also have this murmur.
Mid-systolic ejection murmur heard in pulmonic area; may be accompanied by wide fixed split S2; S1 may be a bit louder: Atrial Septal Defect.
Due to untreated streptococcal infection. Progressive SOB; bilateral basilar rales. Diastolic decrescendo murmur radiating to the axilla; Systolic murmur that is apical and holo- or pan-systolic radiating to left axilla; high-pitched blowing holosystolic murmur: Mitral regurgitation/insufficiency.
Loud S1 + diastolic murmur heard at apex; opening snap followed by delayed, rumbling late-diastolic decrescendo murmur; Rheumatic heart disease: Mitral stenosis or atrial myxoma.
Crescendo-decrescendo murmur; harsh systolic murmur heard along left middle to upper sternal border; pulmonary ejection click and a jugular a wave are seen with right ventricular outflow tract obstructive lesions: Pulmonary valve stenosis.
High-pitched diastolic murmur: Coarctation of the aorta.
Pulsus paradoxus: Exaggeration of normal physiology; pericarditis (enlarged heart, but not as enlarged as in hypertrophic cardiomegaly); drop in systolic BP during inspiration; also heard in pericardial tamponade; may be due to bacterial infection. Drop in systolic blood pressure greater than 12 mm Hg during inspiration. May be due to tension pneumothorax or severe asthma.
Crescendo-decrescendo murmur; syncope; intraventricular septal hypertrophy. Outflow obstruction, arrhythmias, ischemia may lead to syncope. Repeated dyspnea, ejection-type systolic murmur decreases with squatting. Autosomal dominant. Pulsus bisferiens (biphasic pulse) - two strong systolic peaks of aortic pulses from left ventricular ejection separated by a midsystolic dip. Crescendo-decrescendo murmur at left lower sternal border; abnormal mitral leaflet motion. Murmur increases in intensity during Valsalva maneuver due to decreased preload and decreased filling of the left ventricle. Hypertrophied IV septum causes outflow obstruction. Harsh systolic murmur in aortic area at right upper sternal border: Hypertrophic obstructive cardiomyopathy; angina; cardiac ischemia.
To-and-fro murmur in the second intercostal space; a loud S2, bounding peripheral pulses, and a wide pulse pressure, labored breathing; Continuous machine-like murmur: Patent ductus arteriosus.
Widely split fixed S2 + midsystolic ejection murmur over left upper sternal border: Patent foramen ovale.
High-pitched blowing holosystolic murmur; heard at the lower left parasternal area; varies with respiration; becomes louder with inspiration; prominent jugular pulse: Tricuspid regurgitation (could be due to Ebstein anomaly or IV drug abuse).
Diastolic murmur that increases with inspiration: Tricuspid stenosis (rare murmur).
Sudden tearing chest pain radiating to the back; early decrescendo-type diastolic murmur at the left sternal border; normal heart enzymes: Aortic dissection.
Cough and clear nasal discharge; poor feeding, blood pressure is 80/60 mm Hg in the arms and 84/64 mm Hg in the legs; grunting, nasal flaring, and intercostal retractions; pale and mottled skin. Scattered crackles and expiratory wheezes are heard on auscultation. A grade 4/6 systolic murmur is heard across the precordium radiating to the carotid arteries. An x-ray of the chest shows cardiomegaly and pulmonary edema. An ECG shows left axis deviation with tall T waves in leads V4 through V6.: Infant aortic stenosis.
Holosystolic or diastolic murmur near fourth intercostal space at the mid-clavicular line; complication of tetralogy of Fallot surgical repair, Rheumatic fever or infective endocarditis. Systolic thrill palpated at the left sternal border; murmur increases with inspiration and decreases with Valsalva maneuver. An extra heart sound is heard after diastole and a widely split second heart sound: Pulmonary regurgitation.
Decrescendo murmur. Hazy aortic knob with increased mediastinal width (mean mediastinal width = 6.31 cm. Source: Aortic dissection.
Precordial hyperactivity, loud S2, weak pulse: Hypoplastic left heart syndrome.
Infant with harsh systolic murmur and "tet spells": Tetralogy of Fallot.
An accentuated first heart sound, wide and fixed splitting of the second heart sound, pulmonary ejection systolic murmur due to increased flow across the pulmonary valve, and a rumbling mid-diastolic murmur at the lower left sternal border (due to increased flow across the tricuspid valve) suggest atrial septal defect. The presence of left axis deviation (LAD) and left ventricular hypertrophy (LVH) in the ECG: Ostium Primum ASD.
Wide fixed splitting of the second heart sound and a pulmonary ejection systolic murmur produced by increased flow of blood through the pulmonary valve. Cardiomegaly is mild. Pulmonary second sound is accentuated. Ostium secundum defect is generally located at the fossa ovalis. ECG shows right axis deviation and right ventricular hypertrophy: Ostium Secundum ASD.
Vibratory musical low- to medium-pitched midsystolic murmur heard best at the left lower sternal border with minimal radiation; especially when the child has increased cardiac output due to fever or anxiety: Most common innocent murmur in young children (age 3-7); Still's murmur due to vibration of the papillary muscles or chordae tendineae.
Continuous murmur at the right upper sternal border and can radiate to the upper left sternal border or into the right lower neck. It varies in intensity between grades II to III/VI. The murmur's intensity is decreased by moving the head to a position of maximal rotation, by compressing the jugular vein above the clavicles, or by placing the patient in a supine position. It varies in intensity between grades II to III/VI. The murmur's intensity is decreased by moving the head to a position of maximal rotation, by compressing the jugular vein above the clavicles, or by placing the patient in a supine position: A venous hum is a common innocent murmur frequently heard in children between 3 and 8 years of age. It occurs due to the turbulence created by venous return from the head and neck into the jugular vein.

Heart Sounds cheat sheet:

If you can't memorize all those descriptions, just remember this:

Mitral/tricuspid valves can't open (stenosis): diastolic murmur.

Mitral/tricuspid valves can't close (regurgitation/insufficiency/prolapse): (holo)-systolic murmur. NOTE: only tricuspid regurg murmurs increase intensity during inspiration; mitral regurg and ventricular septal defect murmurs do not.

Aortic/pulmonary valves can't open (stenosis): systolic murmur.

Aortic/pulmonary valves can't close (regurgitation/insufficiency/prolapse): diastolic murmur.

Additional Notes on Heart Sounds :

Right-sided murmurs increase on inspiration and left-sided murmurs increase on expiration. The bell of a stethoscope is well-suited to detect low frequency sounds like the S3, while the diaphgram is best for hearing high-pitched sounds like S1 and S2.

Valsalva maneuver and standing: most murmurs diminish except hypertrophic cardiomyopathy and mitral valve prolapse.

Squatting and passive leg raising: most murmurs become louder except hypertrophic obstructive cardiomyopathy and mitral valve prolapse. Note that lying down attenuates the murmur of hypertrophic obstructive cardiomyopathy.

Handgrip exercise: murmurs of mitral regurgitation, ventricular septal defect, aortic regurgitation become louder; murmurs of hypertrophic obstructive cardiomyopathy and aortic stenosis decrease.

Pulmonary regurgitation increases with inspiration and decreases with Valsalva maneuver.

Murmurs in pregnancy: systolic murmurs are found in 90% of women and need no workup; diastolic murmurs are bad and an echo would be needed to further evaluate them.

Heart Sounds drawn on the Cardiac Cycle:

Heart sounds drawn on cardiac cycle

Additional Reading:

Basic Cardiology

1. Electrical Activity of the Heart
2. Heart Muscle Mechanics
3. Heart Sounds and Murmurs
4. Additional FAQ on Heart Sounds and Murmurs
5. Cardiac Conduction Diagram
6. Blood Pressures in Cardiac Chambers
7. What is Pulsus Paradoxus?
8. FAQ on Heart Murmurs and Mechanisms of Turbulent Flow
9. Notes on Fetal Circulation
10. FAQ on Ischemic Myocardial Infarction
11. FAQ on Electrocardiograms / ECG / EKG
12. FAQ on Cardiac Conduction
13. The Heart as a Pump, the Cardiac cycle and Cardiac Output
14. What are the most common causes of aortic stenosis?
15. What is Pulseless Electrical Activity?
16. Causes and Complications of Arteriovenous Fistulas
17. CHADS2 Score for Atrial Fibrillation Stroke Risk
18. How to Reduce Blood Pressure without Medications?
19. Types of Shock
20. Locations of Heart Murmurs on Chest Wall
21. Types of Heart Blocks

Electrocardiogram (EKG/ECG) Topics

1. EKG Chest Leads
2. EKG Limb Leads
3. Quick 12-Lead ECG/EKG Format

Cardiology Videos

1. Video of Cardiology Examination in a Clinical Setting

Medical Images

Useful Medical Images & Diagrams (link opens in a new window)

Related Topics

1. Thorax Anatomy
2. Vascular Disorders
3. Heart Disorders
4. Histology of the Cardiovascular System
5. Jugular Venous Distention Workup
6. ER Chest Pain Workup
7. Cardiac Examination for Internal Medicine
8. FAQ on Blood Pressure
9. FAQ on principles of fluid and flow dynamics of Blood

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