First heart sound S1

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
Its maximum intensity is at the apex
S1 abnormalities

Loud S1 Soft S1

Mitral stenosis Mitral regurgitation

Tachycardia Heart failure
/hyperkinetic status Obesity
Shock
Pericardial effusion
Second heart sound S2
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
 S2 components:
Has two components A2 and P2
Inspiration decreases intrathoracic pressure,
increases RV filling
RV is relatively weak, and an increase in filling
results in slower emptying
 Inspirationdelays P2, causing audible splitting of S2
 P2 localized to pulmonary area while A2 audible all over the
pericardium with max. intensity at aortic area
S2
 S2 abnormalities

Loud P2 Loud A2

Pulmonary hypertension Systemic hypertension

SoftP2 Soft A2

Pulmonary stenosis Aortic stenosis

Aortic regurgitation
 Split abnormalities
 Wide splitting Fixed splitting
Delay pulmonic closure: Atrial septal defect
RBBB
Pulmonary hypertension
Pulmonic stenosis
Early aortic closure:
MR
Reversed splitting
Lf bundle branch block
Sever aortic stenosis
S2
 Systole
The time between the S1 and S2 sounds is:
Lub------------Dub

The ventricles contracting

Blood flowing from the heart to the lungs and
body
Blood flowing across the Pulmonic and Aortic
valves
Diastole
The time between S2 and S1 is :
Dub----------Lub

The blood is flowing from the atria to the

ventricles.
The blood flowing across the bicuspid and
tricuspid valves.
The atrial contraction also occurs now
 Third heart sound S3
 Is a low pitched early diastolic sound best heard with the bell
at the apex.
 also called ventricular gallop
 Occure with rapid ventricular filling after the AV valves open.
 It is best heard with the bell-side of the stethoscope at the apex
of the heart
 Causes
 Normally in Children and during pregnancy
 Pathological
LVF
MR
Fourth heart sound S4
 Low pitched sound occurs at late diastole due to
atrial contraction if ventricles are non complaint.
Just before S1
 Called a presystolic gallop or atrial gallop
 It is always pathological
 Causes:
Hypertension
Cardiomuopathy
AS
Ejection systolic murmur
Pansystolic systolic murmur
Mid-Diastolic murmur