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Cardiac Auscultation

Cardiac Auscultation. Jay L. Rubenstone, D.O., F.A.C.C. October 2012. 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

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Cardiac Auscultation

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  1. Cardiac Auscultation Jay L. Rubenstone, D.O., F.A.C.C. October 2012

  2. Techniques of Examination • Order of Exam • Aortic Area • Pulmonic Area • Tricuspid Area • Mitral Area

  3. 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

  4. 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

  5. Process of Ascultation *If Systolic or Diastolic Murmur Present, Note: • Location • Radiation • Intensity • Pitch • Quality

  6. Auscultation Timing • Systolic • Early • Mid • Late • Diastolic • Early • Mid • Late (or Presystolic)

  7. AuscultationLocation • Interspace • Centimeters from • Midsternal • Midclavicular • Or Axillary Lines

  8. AuscultationIntensity • 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 Thrill • Grade 5 Very Loud • Grade 6 May be Heard w/stethoscope off chest

  9. Auscultation • Radiation or Transmission • Pitch • High, Med, Low • Quality • Blowing • Rumbling • Harsh • Muscial

  10. Components of S1 • Mitral Valve Closure • Best Heard: Apex • Tricuspid Valve Closure • Best heard: Lower Left Sternal Boarder

  11. S1 • Wide Splitting • RBBB • PVC from Left Ventricle • Single Sound • Normal • LBBB • PVC from Right Ventricle • Paced Beats

  12. S1 • Increased Intensity • Short PR • Rapid HR • Atrial Fibrillation • Mitral Stenosis

  13. S 1 • Decreased Intensity • Mitral Stenosis (Immobile Leaflets) • Opposite of Causes of Increased Intensity

  14. S 2 • Two Components • Aortic Closure A2 • Pulmonic Closure P2 Best Heard at the Base

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

  16. S 2 • Loss of Splitting • Inaudible P2- • Adults with Increased Chest Diameter • Congenital (Tetralogy, Pulmonary Atresia Transposition) • Increased Pulmonary Valve Resistance-Pulmonary HTN • Eisenmenger’s Complex-Equal Pulmonary & Systemic Resistances

  17. S 2 • 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

  18. S 2 • Paradoxical Splitting- P2 before A2 • LBBB • Paced Beats • Increased Intensity • A2 Systemic HTN Dilated Aortic Root • P2 Pulmonary HTN Dilated Pulmonary Trunk

  19. Early Systolic Sounds • Ejection Sound- Usually High Frequency • Aortic Valve- Aortic Stenosis, Bicuspid Aortic Valve • Pulmonary Valve-Pulmonic Stenosis Vary with Respirations • Prosthetic Valves- Mechanical, Not Bioprosthetic

  20. Mid-Late Systolic Sounds • Click • High Frequency Sound Found in Mitral Valve Prolapse • Occurs Earlier with Valsalva Maneuver or Squatting to Standing

  21. Early Diastolic Sounds • Opening Snap of Mitral Stenosis (MS) • High Frequency-Left Lateral Decubitus Position, Apex • 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

  22. 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 Failure

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

  24. 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

  25. 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

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

  27. 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

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

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

  30. Normal Systolic Murmurs • Aortic Sclerosis • Most Common Innocent Murmur

  31. 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 Standing

  32. 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 Connection

  33. 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

  34. Early Diastolic Murmur • Graham Steell – • Murmur of Pulmonic Regurgitation as a Result of Pulmonary HTN • High Freq, Decrescendo Blowing Murmur Heard throughout Diastole

  35. 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

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

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

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

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

  40. Diastolic Murmurs • Venous Hum • Rough in quality not actually a hum • Hepatic • Internal Jugular • During Anemia, Fever, Pregnancy and Thyrotoxicosis

  41. 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 Pericardium • Confused with Hamman’s Sign in Post Open Heart Surgery (Crunch Sound from Mediastinal Air)

  42. Innocent or Normal Murmurs-Systolic • Vibratory Systolic Murmur (Still’s Murmur) • Pulmonic Systolic Murmur (Pulmonary Trunk)* • Mammary Soufflé* • Peripheral Pulmonic Systolic Murmur (Pulmonary Branches) • Supraclavicular or Brachiocephalic Systolic Murmur • Aortic Systolic Murmur *common in pregnancy

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