++
Loud: Mitral stenosis (MS), short PR interval, hyperkinetic heart, thin chest wall (Fig. 110-2). Soft: Long PR interval, heart failure, mitral regurgitation, thick chest wall, pulmonary emphysema.
++
++
Normally A2 precedes P2 and splitting increases with inspiration; abnormalities include:
++
Widened splitting: Right bundle branch block, PS, mitral regurgitation
Fixed splitting (no respiratory change in splitting): Atrial septal defect
Narrow splitting: Pulmonary hypertension
Paradoxical splitting (splitting narrows with inspiration): Aortic stenosis, left bundle branch block, heart failure
Loud A2: Systemic hypertension
Soft A2: Aortic stenosis (AS)
Loud P2: Pulmonary arterial hypertension
Soft P2: Pulmonic stenosis (PS)
++
Low-pitched, heard best with bell of stethoscope at apex, following S2; normal in children; after age 30–35, indicates LV failure or volume overload.
++
Low-pitched, heard best with bell at apex, preceding S1; reflects atrial contraction into a noncompliant ventricle; found in AS, hypertension, hypertrophic cardiomyopathy, and coronary artery disease (CAD).
++
High-pitched; follows S2 (by 0.06–0.12 s), heard at lower left sternal border and apex in MS; the more severe the MS, the shorter the S2–OS interval.
++
High-pitched sounds following S1 typically loudest at left sternal border; observed in dilation of aortic root or pulmonary artery, congenital AS or PS; when due to the latter, click decreases with inspiration.
++
At lower left sternal border and apex, often followed by late systolic murmur in mitral valve prolapse.
++
May be “crescendo-decrescendo” ejection type, pansystolic, or late systolic; right-sided murmurs (e.g., tricuspid regurgitation) typically increase with inspiration (Fig. 110-3; Tables 110-1 and 110-2).
++
++
++
++
Early diastolic murmurs: Begin immediately after S2, are high-pitched, and are usually caused by aortic or pulmonary regurgitation.
Mid-to-late diastolic murmurs: Low-pitched, heard best with bell of stethoscope; observed in MS or TS; less commonly due to atrial myxoma.
Continuous murmurs: Present in systole and diastole (envelops S2); found in patent ductus arteriosus and sometimes in coarctation of aorta; less common causes are systemic or coronary AV fistula, aortopulmonary septal defect, ruptured aneurysm of sinus of Valsalva.
++
For a more detailed discussion, see O’Gara PT, Loscalzo J: Physical Examination of the Cardiovascular System, Chap. 267, p. 1442, in HPIM-19.