First Heart Sound (S1)

Produced by closure of mitral valve and tricuspid valve in early systole

Best heard at the apex of the heart. High frequency diaphragm
Actually the mitral valve closes before tricuspid valve, separated by only 0,01s
heard as a single sound
3 factors determine the intensity of S1:
1) The distance separating the leaflets of the open valves at the onset of
ventricular contraction described by PR interval in the ECG period
between onset of atrial and ventricular contraction. When atrial contraction
occurs, the valve will open. As the ventricle contracts, the leaflets are drifted
back together and forced to shut
2) Mobility of the leaflets
3) The rate of ventricular pressure
Accentuated S1 short PR interval valve leaflets dont have sufficient time to
drift back together forced to shut from relatively wide distance. Examples: mild
stenosis, tachycardia
Reduced intensity of S1 first degree AV block delays of the ventricular
contraction valves have additional time to float back together softer sound

Second Heart Sound (S2)
Results from the closure of aortic and pulmonic valves has aortic (A2) and
pulmonic (P2) components
The components of S2 vary with the respiratory cycle fused during expiration and
separated during inspiration physiologic splitting
At inspiration more negative intrathoracic pressure capacitance of
intrathoracic pulmonary vessels temporary delay in diastolic back pressure of the
pulmonary artery for the closure of pulmonary valve delayed P2
Inspiration more negative intrathoracic pressure capacitance of pulmonary
vein venous return to LA and LV SV shortens valve closure
Intensity of S2 depends on the velocity of blood coursing back toward the valves from
aorta and pulmonary artery and the suddenness with which that motion is arrested by
the closing of the valves
Hypertension accentuated S2 because the pressure is each great artery is higher blood velocity
Severe aortic or pulmonary valve stenosis valve commissures are nearly fixed in position diminished S2
There are 3 types of abnormal splitting of S2:











Extra Systolic Heart Sounds
Early Extra Systolic Heart Sounds (Ejection Clicks)
Occurs shortly after S1 coincide with the opening of the aortic or pulmonic valves
Sharp, high pitched, best heard with diaphragm placed over the aortic and pulmonic areas
Aortic and pulmonic stenosis deformed valve leaflets reach their maximal level of ascent into the great artery before the blood
ejection reach their elastic limits decelerate abruptly ejection click
Dilatation of the root of the aorta or pulmonary artery sudden tensing of the root with onset of blood flow into vessel ejection click
Aortic ejection click: heard both at the base and apex of the heart, doesnt vary during respiration
Pulmonic ejection click: heard only at base, intensity diminishes during inspiration

Mid or Late Extra Systolic Heart Sounds
Result of systolic prolapsed of the mitral or tricuspid valves leaflets bulge abnormally into the atrium
Loudest over the mitral or tricuspid regions

Extra Diastolic Heart Sounds
Opening Snap
Resulting from the opening of mitral and tricuspid valves
Sharp, high-pitched, timing doesnt vary with respiration
In mitral stenosis heard best between the apex and left sterna border, just after A2
Can be confused with P2. With careful auscultation, 3 sounds occurring in rapid successions A2, P2, OS
Third Heart Sound (S3)
Occurs in early diastole, following the opening of AV valves, during the ventricular rapid filling phase
Dull, low-pitched, best heard with bell
Production of S3 results from tensing of the chordae tendinae during rapid filling and expansion of the ventricle
Normally found in children and young adults, abnormal in middle-aged or older adults
When abnormally heard volume overload because CHF/ transvalvular flow that accompany advanced mitral/tricuspid regurgitation
Pathologic S3 ventricular gallop
Fourth Heart Sound
Occurs in late diastole, coincides with the contraction of atria
Generated by the left or right atrium vigorously contracting against a stiffened ventricle
Thus, the presence of S4 usually indicates a in ventricular compliance ventricular hypertrophy or myocardial ischemia
Dull, low-pitched sound, best heard with bell
Also known as atrial gallop
Quadruple Rhythm or Summation Gallop
Patients with S3 and S4, in conjunction with S1 and S2 produce quadruple beat
If patient with quadruple rhythm develops tachycardia shorter diastole duration S3 and S4 coalesce summation gallop
Pericardial Knock
Uncommon, high-pitched
Hallmark of constrictive pericarditis
Appears early in diastole, soon after S2, later than OS, louder and earlier than ventricular gallop
Results from abrupt cessation of ventricular filling in early diastole