HEART SOUNDS

LEARNING OBJECTIVES: After end of this practical you must be able to: 1. Define precordium 2. Locate the different auscultatory areas on the precordium 3. Auscultate the heart sounds. 4. Describe the 1st & the 2nd heart sounds. 5. Describe the mechanism and causes of split of first and second heart sounds.

THE PRECORDIUM

The PRECORDIUM is defined as the anterior aspect of the chest wall that overlies the heart.

THE AUSCULTATORY AREAS

MITRAL AREA: This area corresponds to the apex beat of the heart. The first heart sound is best heard over the mitral area. Normally, this is present in the left fifth intercostal space half an inch medial to the midclavicular line. But in different pathological conditions the position of the apex changes. Therefore, the auscultatory area of the mitral valve changes with the position of the apex. PULMONARY AREA: This is an area half an inch in diameter with a centre in the left second intercostal space close to the parasternal line. AORTIC AREA: This is an area half an inch in diameter with a centre in the right second intercostal space close to the parasternal line. TRICUSPID AREA: This is an area half an inch in diameter with its centre on the left side close to the sternum towards its lower end.

AUSCULTATION
With the help of the stethoscope, auscultate the different areas in the following sequence: mitral area, pulmonary area, aortic area and tricuspid area. Use the diaphragm of the stethoscope to hear the heart sounds. In each area, the following points should be noted during auscultation.

First (S1) and Second (S2) Heart Sounds :

Note their quality, intensity, duration and character. S1 is better heard on the mitral area, and S2 is heard better over pulmonary and aortic area. The first and second heart sounds can be differentiated by their pitch and duration. The first heart sound is heard as lub and the second sound as dub. For beginners, it is difficult to differentiate these sounds. They can palpate the carotid artery in the neck while auscultating the heart sounds. The heart sound that coincides with the carotid pulsation is the first heart sound and the sound that follows the pulsation is the second heart sound.

First heart sound :

The first heart sound represents the beginning of systole. Causes: It occurs due to vibration set up by: Sudden closure of AV valves Rapid increase in tension in the ventricular muscles during isometric contraction acting on full ventricles. Turbulence created in the blood due to ventricular contraction. Character: It is soft sound heard as lub. Significance : It signifies the beginning of the ventricular systole and AV valve closure. Splitting : The first heart sound has two components: the mitral and the tricuspid components. The mitral valve closes slightly before the tricuspid valve. This gives rise to splitting of the first heart sound. But this splitting cannot be detected by auscultation, because both the components are very low pitched and merge into each other. Therefore, when splitting of the first heart sound is heard, it is always considered as pathological.

Second Heart Sound :

Causes :

The second heart sound is primarily caused by the closure of semilunar valves. Rushing of blood into the ventricles due to opening of the AV valves also contributes.

This is heard as Significance :

dub.

Second heart sound signifies the end of clinical systole and closure of semilunar valves &beginning of ventricular diastole. Splitting : Splitting of the second sound is due to the gap between the aortic and pulmonary components. It is easy to detect because aortic and pulmonary valve closure sounds are high pitched and can be separated. Aortic valve closure is audible in all areas whereas pulmonary valve closure is audible only in the pulmonary area. Splitting is most easily heard in children and may not be audible in elderly subjects. Mechanism of splitting : The splitting of the second heart sound is due to the separation between the closure of aortic and pulmonary valves. The closure of the pulmonary valve always follows the closure of aortic valve (aortic valve closes first). The spilitting is distinctly heard during inspiration. During inspiration more blood is drawn into the thorax. Therefore, venous return to right atrium increases. Therefore, left ventricular systole is shortened and A2 comes earlier. Therefore, during inspiration A2 occurs earlier and P2 occurs later. Hence, splitting of the second sound widens during inspiration. Exactly the opposite happens during expiration and splitting narrows.

Third Heart Sound :

Third heart sound is usually not heard in many healthy individuals. Sometimes it may be heard in children and in young adults. It is usually heard in conditions in which the circulation becomes hyperkinetic. The third sound can arise from either side of the heart, but, usually, it arises in the left ventricle. Causes: It is caused by the vibration setup in the ventricle during the early period of rapid ventricular filling. Significance : This is attributed to rapid ventricular filling. It is found in relatively hyperkinetic (hyper dynamic) circulation, in young persons, and where the mitral diastolic flow is increased as in mitral regurgitation.

Fourth Heart Sound :

This is also called atrial sound, because it is produced during atrial contraction. It is not heard in normal individuals. Presence of the fourth heart sound is always considered abnormal. The first and the second heart sounds can be heard with a stethoscope but the 3rd and the fourth heart sounds if present, can only be recorded by a phonogram/ echocardiogram.

MURMURS: Murmurs are abnormal sounds heard during the auscultation of the heart.
Murmurs occur due to turbulence in the blood flow at or near a valve, or an abnormal communication within the heart. When a murmur is present, the following points are carefully noted. 1) Timing and duration 2) Site of origin 3) Character 4) Radiation (Conduction) 5) Relation with respiration

HEART MURMURS VALVE Aortic or pulmonary Incompetence/regurgitati diastolic Mitral or tricuspid Incompetence/regurgitati systolic on on stenosis diastolic ABNORMALITY stenosis TIMING OF MURMUR systolic