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HEART SOUNDS
by
Don Hudson, D.O., FACEP/ACOEP
Everything You need to Know About Heart
Sounds
• We have all heard the heart make the usual
sounds.
LUB----------DUB
• Lub is the first sound or S1
• Dub is the second heart sound or S2
So What is All of The Other Sounds
• The best way to understand the individual
sounds is to think about what is causing them
• First you need to concentrate on the total
sounds and then try to listen to the individual
component sounds
Systole
•
The time between the S1 and S2 sounds is:
Lub------------Dub
1. The ventricles contracting
2. Blood flowing from the heart to the lungs and
body
3. Blood flowing across the Pulmonic and Aortic
valves
Diastole
Dub----------Lub
The time between S2 and S1 is :
1. The blood is flowing from the atria to the
ventricles.
2. The blood flowing across the bicuspid and
tricuspid valves.
3. The atrial contraction also occurs now.
S1- What is it ?
The “lub” in the lub – dub.
• This sound is primarily because of the closing
of the bicuspid and tricuspid valves.
• Anatomically they are located between the atria
and the ventricles
• They close because the ventricles contract
• The Pulmonic and Aortic valves are opening
and blood is being forced into the arteries
S2- What is it ?
S2 is the “dub” in the lub- dub
• The sounds are because of the closing of the
Pulmonic and Aortic valves as the pressure
from the arteries is greater then the pressure in
the ventricles.
• This is the end of systole
What Kinds of Sounds Do You
Hear?
• Murmurs-usually indicate turbulence & they
range from 1 to 5 in loudness.
• Does it occur during diastole or systole?
• Does it crescendo (get progressively louder)?
• Does it decrescendo (get progressively
quieter)?
• Where do you hear it best? (Neck, Chest, Axilla)
Other Sounds
• Gallops- these are either S3 or S4 sounds.
• Rubs- pericardial or plural friction rubs and
usually indicated either pericarditis or possible
pleurisy ( must be careful to listen to both heart
and lung sounds)
• Rubs- sounds “sandpapery”
Other Sounds
• Clicks- only occur in systole and represent the
loud valve closing
• Diastolic Knock- occurs because of a abrupt
arrest of ventricular filling by a non-compliant
& constricting pericardium.
• Continuous Murmurs- indicate a constant shunt
flow throughout systole & diastole i.e.
Coarctation, or patent ductus arteriosus.
Anatomy of A Sound
• LUB-- DUB-------------LUB--DUB
• S1
S2 S3 S4 S1
S2
• Here is where you expect to hear the various
sounds
Now that you Hear the Sounds
(what does it mean?)
First Heart Sound (S1)
•
•
•
- Louder than usual - Mitral Stenosis
- Variable Atrial Fib./Complete Heart Block
-Diminished Mitral or Aortic Regurg.
Second Heart Sounds (S2)
(what does it mean)
Wide split sounds or fixed ( not moving with
respiration) may indicate:
• Atrial Septal Defect
• RBBB
• Pulmonic Stenosis
Extra Heart Sounds (S3 & S4)
(what do they mean to you)
• Third Heart Sound (S3)  Markedly
Diminished Left Ventricular Function
• (Almost always present with Myocardial
Ischemia or early after an AMI)
• Fourth Heart Sound (S4) Modestly
Diminished Left Ventricular Function
What Special Things Do You Need
To Hear These Sounds
•
•
•
•
•
•
Stethoscope
As quite an environment as possible
Proper positioning of the patient
Stethoscope must touch the skin
Patient history
Ability to observe the chest, abdomen & neck
Where Do You Listen?
• Left Ventricle Area- The apex of the heart is at
the 4th or 5th intercostal space (ICS) along the
midclavicular line (MCL).
• Right Ventricular Area- the 3rd to 5th ICS along
the left sternal border (LSB)
• Pulmonic Area- 2end ICS along LSB
• Aortic Area- 2end ICS along the right sternal
border (RSB)
Stethoscope Use
• The diaphragm of your stethoscope is most
useful for picking up high-pitched sounds i.e. S1,
S2, Aortic or Mitral Regurgitation Murmurs or
Friction Rubs.
• The Bell is most useful for picking up lowpitched sounds, S3, S4, or Mitral Stenosis.
The Most Important Things To Have In
Order To Hear These Sounds
Thank You For Your Patience
Practice, Practice, Practice
Patience to take time to listen
Time to listen to history
Expose the patient
Think
Reflect
Your patients will appreciate your efforts