Heart Sounds

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"lub," or first sound, is produced by closing of the AV valves during isovolumetric contraction of the ventricles. The "dub," or second sound, is produced by closing of the semilunar valves when the pressure in the ventricles falls below the pressure in the arteries. The first sound is thus heard when the ventricles contract at systole, and the second sound is heard when the ventricles relax at the beginning of diastole.

The first sound may be heard to split into tricuspid and mitral components, particularly during inhalation. Closing of the tricuspid is best heard at the fifth intercostal space (between the ribs), just to the right of the sternum; closing of the mitral valve is best heard at the fifth left intercostal space at the apex of the heart (fig. 13.14). The second sound also may be split under certain conditions. Closing of the pulmonary and aortic semilunar valves is best heard at the second left and right intercostal spaces, respectively.

Heart Murmurs

Murmurs are abnormal heart sounds produced by abnormal patterns of blood flow in the heart. Many murmurs are caused by defective heart valves. Defective heart valves may be congenital, or they may occur as a result of rheumatic endocarditis, associated with rheumatic fever. In this disease, the valves become damaged by antibodies made in response to an infection caused by streptococcus bacteria (the same bacteria that produce strep throat). Many people have small defects that produce detectable murmurs but do not seriously compromise the pumping ability of the heart. Larger defects, however, may have dangerous consequences and thus may require surgical correction.

In mitral stenosis, for example, the mitral valve becomes thickened and calcified. This can impair the blood flow from the left atrium to the left ventricle. An accumulation of blood in the left atrium may cause a rise in left atrial and pulmonary vein pressure, resulting in pulmonary hypertension. To compensate for the increased pulmonary pressure, the right ventricle grows thicker and stronger.

Clinical Investigation Clues

Closing of the AV and semilunar valves produces sounds that can be heard by listening through a stethoscope placed on the chest. These sounds are often verbalized as "lub-dub." The

Remember that Jason has mitral stenosis. What does this mean? What effects could it have?

Could the mitral stenosis, the ventricular septal defect, or both, be responsible for Jason's chronic fatigue?

Valves are said to be incompetent when they do not close properly, and murmurs may be produced as blood regurgitates through the valve flaps. One important cause of incompetent AV valves is damage to the papillary muscles (see fig. 13.10). When this occurs, the tension in the chordae tendineae may not be sufficient to prevent the valve from everting as pressure in the ventricle rises during systole.

Heart and Circulation

Aortic area

Tricuspid area

Pulmonic area

Aortic area

Tricuspid area

Heart Listening Positions

Pulmonic area






â–  Figure 13.14 Routine stethoscope positions for listening to the heart sounds. The first heart sound is caused by closing of the AV valves; the second by closing of the semilunar valves.

Murmurs also can be produced by the flow of blood through septal defects—holes in the septum between the right and left sides of the heart. These are usually congenital and may occur either in the interatrial or interventricular septum (fig. 13.15). When a septal defect is not accompanied by other abnormalities, blood will usually pass through the defect from the left to the right side, due to the higher pressure on the left side. The buildup of blood and pressure on the right side of the heart that results may lead to pulmonary hypertension and edema (fluid in the lungs).

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  • carl
    How to listen to heart sounds with stethoscope?
    8 years ago
  • laurie
    What is the first sound of the closing heart?
    8 years ago
  • Eberardo Boni
    What is the first human heart sound?
    8 years ago
  • marcho
    Where is the tricuspid area?
    8 years ago
  • mungo
    Where to put stetoscope to listen mitral valve?
    8 years ago
  • Susanne
    Where to listen to breath sounds with stethoscope?
    8 years ago
  • henry
    Where to Hear Heart Sounds?
    7 years ago

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