Completed - Normal Second heart sound

The most difficult thing in auscultation is to identify the abnormalities of S2.

Physiology of Second heartsound

Two components for 2nd heart sound are- aortic and pulmonary
Aortic component it is the 1st component and loud one   heard in all areas
Pulmonary component - 2nd component and soft, heard only over pulmonary area.

Normal second heart sound

1. It is a high pitched sound with normal split - 2 components are separately heard during inspiration and as single component during expiration over the pulmonary area.
2. Distance between the 2 components during inspiration is 0.04 sec, during expiration is 0.02 sec. 
3. Human ear can appreciate, when the distance between the 2 components is 0.03 or more. 
4. Normal second heart sound is expressed as - normal in intensity and normal split with respiration.

Things to look for in S2:

Intensity
Splitting
A2 heard over aortic area and pulmonary area and the apex.
P2 heard over pulmonary area and 2-4 LICS only and not at the apex.
P2 heard over the apex only in pulmonary artery hypertension and in young.
Best site for S2 in COPD—epigastrium

Mechanism of continuous murmur

1.High pressure system communicating with low pressure system
Intracardiac

• RSOV to RV, RA ,Pulmonary artery.
• Coronary artery fistula to cardiac chamber.

Extracardiac

• PDA.
• Aorto pulmonary septal defect.
• Pulmonary AVF.
• Systemic AVF.
• Anomalous left coronary artery from pulmonary artery.

2.Narrowing of vessel

• Coarctation of aorta.
• Peripheral pulmonary artery stenosis.
• Carotid stenosis.

3.Increased blood flow through vessels

• Venous hum - Devil’s murmur - root of neck.
• Venous hum (Cruveilhier – Baumgarten murmur) - umbilicus - in portal hypertension.
• Intercostal arteries - Coarctation of aorta.
• Bronchopulmonary anastomoses.
• Pulmonary atresia and TOF.
• Internal mammary artery - Mammary Souffle in pregnancy.

What is Gallop rhythm

3 sounds heard during each cardiac cycle produce triple rhythm

Triple rhythm with sinus tachycardia produce Gallop rhythm imitating the sounds of galloping horse.
LV S3 gallop - is an important auscultatory sign of Left ventricular failure.
LVS3 is a sign of systolic dysfunction of ventricle.
Early S3 is heard in RVEMF -this is due to sudden limitation of ventricular filling.
Pericardial knock - An early S3 in constrictive pericarditis as in RV EMF.

S3 gallop is common in:

1. Dilated cardiomyopathy.
2. Decompensated aortic valve disease.
3. Decompensated hypertensive heart disease.

RV S3 is always pathological
It is heard at LLSB.
Inspiratory augmentation is  present.
This is  associated with tricuspid regurgitation.

Atrial gallop S1,S2, S4
Ventricular gallop S1, S2, S3

Quadruple Rhythm
Quadruple rhythm is the presence of 4 heart sounds
(S1, S2, S3 and S4).

Summation Gallop
Summation is the presence of S1,S2 with merged S3 and S4

Types of continuous murmur

 Continuous murmur with cyanosis

• TOF with PDA
• Pulmonary atresia with bronchopulmonary anastomoses
• Pulmonary AVF

Continuous murmur with systolic > diastolic component

• PDA
• Peripheral Pulmonaryartery stenosis
• Broncho pulmonary anastomoses

Continuous Murmurs with Diastolic Accentuation

• Rupture of sinus of Vakalva (RSOV)
• Coronary arteriovenous fistula
• Anomalous origin of left coronary artery from pulmonary artery (ALCAPA)
• Pulmonary arteriovenous fistula

Causes of fourth heartsound

 LV S4  causes

1. Systemic hypertension
2. AS (left ventricular hypertrophy)
3. LV myocardial infarction

RVS4  causes

1. Pulmonary hypertension
2. Pulmonary stenosis (Right Ventricular hypertrophy)
3. RV myocardial infarction.

Features of RVS4

1. Heard at LLSB
2. Inspiratory augmentation present
3. Associated with  a wave in JVP
4. Seen in PAH and pulmonary stenosis

Triple rhythm
S1+S2+S3/S4

Quadruple rhythm
S1,S2 + S3 + S4.

Seen In:

• Cardiomyopathy
• Coronary artery disease

Summation gallop
S, S3 with merged S, & S4.

Causes of pathological S4

1. Hypertrophic cardiomyopathy
2. Systemic hypertension
3. Coronary artery disease
4. Myocardial infarction
5. Ventricular aneurysm.

S3 -Ventricular distension sound.
S4 -Atrial contraction sound.

Achronym

LV : Left Ventricular

AS : Aortic Stenosis

RV : Right Ventricular

S1 - First Heart Sound

S2 - Second Heart Sound

S3 - Third Heart Sound

S4 - Fourth Heart Sound

Method of Cardiac Auscultation

Patient is asked to be in supine position or in propped up position if orthopnoea present. The conventional sequence of auscultation of areas - Mitral area - tricuspid area - pulmonary area - aortic area - second aortic area

One should start auscultating mitral area with bell, then with diaphragm of stethoscope. For better appreciation, patient can be put in left lateral position.

Mitral area
Search for abnormality of S1 and presence of S3, S4, Opening snap and mitral systolic and diastolic murmur, conduction of systolic murmur to axilla

Tricuspid area 
You should look for diastolic and systolic murmurs of tricuspid valve disease, augmentation with inspiration in the sitting position is noticed

Pulmonary area 
Identify the abnormality of S2, alteration in intensity and split, ejection click, systolic, diastolic and continuous murmur

Aortic area 
Ask the patient to be in the sitting posture ,leaning forward and breath held in expiration. Look for intensity of aortic component of S2, aortic, systolic and early diastolic murmur

Second aortic area 
Sometimes aortic events are better heard in the 2nd aortic area and the position of the patient is as above. 

Third heart sound

S3 is a low pitched sound produced due to rapid deceleration of blood during inflow Into the leftventricle.It is also called as protodiastolic sound or ventricular gallop.S3 signifies diastolic overload of the ventricles. It occurs during the first rapid filling phase of cardiac cycle (in ventricular diastole).
Mechanism of S3 
More than normal amount of blood reaching the ventricle during rapid filling phase, produce stretch on myocardium - tense chordae and papillary muscle, it will produce S3
Pathogenesis of S3
Abnormally increased LVEDV due to increased transvalvular flow or diminished LV function.
Characteristics of S3

• Low pitched sound
• 0.12 sec after S2 in produced both in LV and RV

Physiological 3rd heart sound seen in children and adults upto 30 - 35 yrs.
Physiologic S3 is associated with functional murmur and venous hum and it disappears in standing position
What are the association of S3?
S3 commonly associated with the following

• Pulsus alternans 
• Narrow pulse pressure
• Heaving apex
• Other signs of LV/RV failure

Causes of third heartsound

Etiology of S3
Abnormal increase in transmitral flow

• Mitral regurgitation
• VSD
• PDA

Depression of ventricular function

• LV dysfunction—LV S3
• RV dysfunction—RV S3
• LV S3 and RV S3

LV S3 may be either physiological or pathological
RVS3 is always pathological.
Causes of physiological S3 

• Children
• Young adults (< 40 years)
• Athletes
• Pregnancy.
• Pathological 3rd heart sound
• Pathologic S3 persists in the standing position and is associated with other signs of LV dysfunction.
• LV S3 - MR, LVF
• RV S3 - TR, RV

Causes of pathological S3

• High output states
• Congenital heart diseasis ASD, VSD,
• Regurgitant lesions of aortic, mitral, tricuspid valves.
• Hypertrophic cardiomyopathy
• ischaemic heart diseases
• Constrictive pericarditis
• Systemic hypertension
• Pulmonary hypertension

Differentiating Features between Right and Left Ventricular S3
RV-S3                                              LVS3
Tncmpid area                                      MItral area
Increas esOn inspiration                  Increases on expiration

Causes of Fourth heartsound

Left ventricular S4 (LVS4)

• Systemic hypertension
• AS (left ventricular hypertrophy)
• LV myocardial infarction

Right ventricularS4 (RVS4)

• Pulmonary hypertension
• Pulmonary stenosis (Right Ventricular hypertrophy)
• RV myocardial infarction.

Features of Right ventricularS4(RVS4)

• Heard at LLSB
• Inspiratory augmentation^
• Associated with  a wave in JVP
• Seen in PAH and pulmonary stenosis

Triple rhythm-S1+S2+S3/S4
Quadruple rhythm-S1, S2 + S3 + S4.
Seen In:

• Cardiomyopathy
• Coronary artery disease

Causes of pathological S4

• Hypertrophic cardiomyopathy
• Systemic hypertension
• Coronary artery disease
• Myocardial infarction
• Ventricular aneurysm.
• S3 Ventricular distension sound
• S4 Atrial contraction sound.

Fourth heart sound the Atrial sound

S4 signifies systolic overload of the ventricles.
It occurs during the last rapid filling phase of cardiac cycle (in ventricular diastole)
Which also coincides with the atrial systole.
Also called as presystolic or atrial gallop.
Physiology of S4
It is a low pitched sound in presystole heard just before 2nd heart sound.
Mechanism of S4
Fourth heart sound is produced due to forcible atrial contraction to fill the non-complaint ventricle in ventricular hypertrophy or infarct, this will produce stretch on myocardium which inturn produce tense chordae and papillary muscle to produce S4.
The fourth heart sound is due to increased left ventricular/right ventricular end-diastolic pressure
S4 is produced by a rapid emptying of the atrium into ventricle.
S4 is recordable, but inaudible in children adults.

What are the causes of Hemoptysis in cardiovascular diseases

The causes of Hemoptysis  in cardiovascular diseases are due to –

• Pulmonary edema it is characterised by pink frothy sputum
• Mitral stenosis - bronchopulmonary apoplexy due to rupture of bronchopulmonary venule
• Pulmonary artery hypertension (PAH ) as in Eisenmenger syndrome - Pulmonary infarct
• Infective endocarditis - Right Ventricular - VSD and tricuspid valvular endocarditis -vegetation results in Pulmonary infarct
• PDA with endarteritis produce vegetation embolise to form Pulmonary infarct
• Congestive heart failure may lead to DVT –which in turn can result in Pulmonary infarct
• Post myocardial infarction  will also lead to  DVT which inturn can result in Pulmonary infarct.

Causes of Fatigue in heart disease

Fatigue  in heart disease are due to the following

• Low output state - obstructive valvular lesion - Aortic stenosis
• Pulmonary artery hypertension(PAH)
• Diffused Myocardial damage - IHD, Cardiomyopathy
• Blood volume and electrolyte imbalance -Diuretics ,Beta blocker
• Super added anxiety and depression.

How to auscultate for S3 or S4 ?

• S3 or S4 is best heard at the cardiac apex with the bell of stethoscope placed lightly. 
• Sometimes, they are best heard with the patient turned to left lateral position  
• Often they are better felt than heard.
• They are low-pitched sounds.
• Left-sided S3 (LVF) is best audible at the apex during expiration while the right-sided S3 (RVF) is best heard at the lower left sternal border during inspiration.
• Handshould be placed very lightly over the skin. More pressure will tighten the skin and smother the low-frequency sounds. 

It is made for listening low-pitched sounds like.

• Murmur of MS and TS.
• S3 or S4.
• Foetal heart sounds.
• Venous hum.

Basics of cardiac auscultation

Auscultation is the most important part in cardiovascular examination. Doctor should gain the skill by experience obtained by constant repetition. Diagnosis of heart disease especially congenital and valvular heart disease, were done on the auscultatory finding before the advent of echocardiography.

Stethoscope was invented by Rene-Theophile-Hyacinthe Laennec.
Features of ideal stethoscope

• Ideal stethoscope should have tube length of 25 cm
• Double tube is better, the size of the tube - 0.3 cm, 
• Two chest pieces diaphragm with a diameter of 4 cm, bell with a diameter of 2.5 cm, and well fitting ear pieces. 
• Bell is used to hear low pitched sounds and murmurs (30 to 150 Hz), you should not press the bell too much since the skin will act as a diaphragm.
• Low pitched sounds and murmurs
• Third heart sound
• Fourth heart sound
• Mid diastolic murmurs.

Diaphragm of stethoscope is used for high pitched sounds and murmurs, this will filter out low pitched sounds of less than 300 Hz.

• High pitched sounds and murmurs
• First heart sound .
• Second heart sound
• Opening snaps
• Tumour plops
• Pericardial rubs, knocks
• Systolic murmurs
• Early diastolic murmurs.
• Clicks

The beginner will have difficulty in identifying the auscultatory findings. you should understand the physiological events in cardiac cycle,first identify the 1st and 2nd heart sounds for differentiating the systolic and diastolic phase and events occurring there in. Remembering the quality of sounds and murmurs is the easy method for the recognition of the findings, than the other features in description

Prosthetic heart sounds

Prosthetic aortic sounds

Opening sound in systole—Ejection click

Closing sound—S2

Prosthetic Mitral sounds

Opening sound in diastole—Opening snap

Closing sound—S1

Ball valve type       -Opening sound louder than closing soond

Tilting disc valve  -Only closure sound is heard

Bileaflet valve        -Closure sound well heard

Mitral prosthesis: The opening sound corresponds to opening snap and closing sound to S1

Aortic prosthesis: The opening sound corresponds to ejection click and closing sound to S2

What is Pericardial rub?

Pericardial rub is produced due to the sliding of the two inflamed layers of the pericardium.

Features of pericardial rub

• Site  -Left sternal border 3rd and 4th intercostal space usually best heard on the left side of lower sternum may be heard over the entire precordium
• This is triphasic with midsysiolic middiastolic and presystolic components. 
• They are evanescent and they may vary with time and posture. 
• Creaky/leathery ,scratching, grating or creaking in character and mimics the sound produced from husking machine
• Intensity of the sound increases when patient sits and leans forward (thus, always auscultate in sitting and leaning position of the patient).
• Sound increases by pressing the chest piece (diaphragm) of stethoscope.
• Sound continues even after holding the breath.
• It may be  associated with chest pain.
• Usually there is no transmission that is localised

Cause of pericardial rub

• Pericarditis and  pericardial effusion
• Viral pericarditis
• Pyogenic pericarditis
• Tuberculous pericarditis
• Acute myocardial infarction
• Dressler's syndrome
• Acute rheumatic fever
• SLE
• Rheumatoid arthritis
• Uremia.

Pericardial rub persist inspite of the effusion unlike in pleural effusion, because both layers of the pericardium dip deep into the AV groove which cannot be separated by the fluid in pericardial effusion  thus the rub is persisting.

In acute Myocardial infarction, pericardial rub indicates transmural infarction.

Differential diagnosis of pericardial rub

• Systolic murmur.
• Early diastolic murmur of aortic incompetence.
• Continuous murmur.
• Artefact.
• Hamman's sign.

What is hammans sign?

• It is a crunching, rhythmical sound heard over the precordium and is synchronous with the heart beat. 
• This sign is found in pneumomediastinum (or mediastinal emphysema). 
• The sound is best audible in left lateral position 
• Always search for subcutaneous emphysema meticulously in the presence of hamans sign.

What is pericardial knock

• Pericardial knock is a loud high frequency diastolic sound produced by the abrupt halt in early diastolic filling due to the nondistensible pericardial shell overlying the heart
• Seen in constrictive pericarditis
• Diastolic high pitched sound
• 0.08-0.10 sec after S2
• Mistaken for Opening snap.

Ejection and nonejection clicks

What is an Ejection Click
Vascular ejection click
Valvular ejection click
Non-ejection click

What is an Ejection Click

Ejection click is a sharp and high-pitched clicking sound heard immediately alter the first heart
This sound is due due to sudden opening of the aortic or pulmonary valve (semilunar valves), and are best audible  in aortic and pulmonary area respectively.
Its presence indicates that the stenosis is at the valvular' level and the stenosis (AS or PS) is of milder degree.
Significance of ejection click

• Presence of ejection click Implies a mobile valve. 
• Calcification causes an absent EC
• Valvular ejection click  indicates the site of the lesion, not the severity of the lesion
• Its presence indicates that the stenosis is at the valvular' level and the stenosis (AS or PS) is of milder degree.

Characteristics of ejection clicks

• High pitched sounds
• 0.05 sec after S1
• Valvular clicks are later and more audible

Types of click

• Vascular click
• Valvular click