Heart Sound and Murmur Listening Guide
Lecture 5 · Advanced Cardiovascular & Peripheral Vascular Examination · 22 recordings
Press play on each recording, and listen for a few beats before reading what follows it. Every recording is a twenty-second excerpt from the University of Michigan Heart Sound and Murmur Library, the same library whose first recording the lecture plays on slide 36. What each sound is comes from the lecture slides, cited to the slide; a few recordings show findings the deck does not teach, and they are marked. The listening quiz asks the recordings the deck does teach, and each question links back here.
1 · How to listen
Ask the same questions every time (slide 49): is the murmur during diastole or systole? How long is it? Where is it loudest, and does it radiate? Is it crescendo or decrescendo? Are there any extra heart sounds present?
Timing comes first. A systolic murmur falls between S1 and S2 and a diastolic murmur falls between S2 and S1; palpating the carotid artery while you listen helps, because systolic sounds coincide with the carotid upstroke (slide 50). Systolic murmurs are named by where they sit in systole: midsystolic, pansystolic (holosystolic) or late systolic (slide 51). Diastolic murmurs are early, mid or late (slide 52), and they are less common and more difficult to hear than systolic murmurs (slide 76).
Choose the chest piece by pitch (slides 26 and 30). The bell picks up low-pitched sounds and is applied lightly; the diaphragm picks up high-pitched sounds (S1, S2, rubs, and the aortic and mitral regurgitation murmurs) and is pressed firmly. Listen in a quiet setting, isolate each sound in turn, and close your eyes to focus on it.
2 · Normal sounds and splitting of S2
S1 and S2 (slides 13, 14 and 34). S1, “lub”, is closure of the mitral and tricuspid valves; it is best heard with the diaphragm at the apex, and it precedes the carotid pulse. S2, “dub”, is closure of the aortic and pulmonic valves; it is best heard with the diaphragm at the base, and it follows the carotid pulse. S2 has two components: aortic (A2), usually louder, and pulmonic (P2).
Normal S1 and S2 · Apex, supine, bell
This is the recording the lecture itself plays on slide 36. In a normal heart nothing extra sounds in systole or diastole: only S1 and S2, repeating.
Physiologic splitting of S2 (slides 15 and 35). The two components of S2 are normally fused as one sound during expiration and audibly separated during inspiration. When both are heard during inspiration it is normal, and it is called physiologic splitting of S2. A single S2 is the fused sound of expiration.
Transient split S2 · Pulmonic area, supine, diaphragm
The split comes and goes with the breathing cycle: separate on inspiration, single on expiration.
Single S2 · Pulmonic area, supine, diaphragm
A single, unsplit S2, as heard when the two components are fused.
Pathologic splitting of S2 (slide 35). Splitting that is audible during expiration is pathologic and suggests heart disease.
Persistent split S2 · Pulmonic area, supine, diaphragm
The two components stay separate through the whole breathing cycle instead of fusing on expiration.
Split S1 (not taught in the deck) · Apex, supine, bell
Included from the library for completeness. The deck says only that splitting of S1 is usually not present (slide 34), so it is not asked in the quiz.
3 · Extra heart sounds
Early ejection sounds (slide 38). An early systolic ejection sound occurs shortly after S1, is high in pitch with a sharp clicking quality, and is best heard with the diaphragm. It coincides with the sudden pathologic halting of the aortic or pulmonic valve as it opens in early systole, and it indicates cardiovascular disease. A pulmonic ejection sound is best heard in the second and third intercostal spaces and decreases with inspiration; its causes include dilatation of the pulmonary artery, pulmonary hypertension and pulmonic stenosis. You will hear one with the pulmonic murmur in section 5.
The systolic click (slide 39). A click is usually caused by mitral valve prolapse. It falls in mid to late systole, is usually single but may be more than one, is high pitched and is best heard with the diaphragm. It is followed by a late systolic murmur from mitral regurgitation that crescendos up to S2.
Mid-systolic click · Apex, supine, bell
S3, the ventricular gallop (slide 40). S3 is heard after S2, early in diastole, with the cadence Ken-TUC-ky (lub-dub-dee). It is low pitched and best heard with the bell at the apex with the patient in the left lateral decubitus position. It is physiologic in children, young adults and the last trimester of pregnancy, and pathologic in adults over 40, where it comes from high left ventricular filling pressures; causes include decreased myocardial contractility, heart failure, ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts.
S3 gallop · Apex, left lateral decubitus, bell
S4, the atrial gallop (slide 42). S4 is heard just before S1, with the cadence Ten-nes-SEE (dee-lub-dub). It is dull, low pitched and best heard with the bell at the apex in the left lateral decubitus position. It is normal in trained athletes and older people; it is more often due to ventricular hypertrophy or fibrosis that makes the ventricle stiff, and causes include hypertensive heart disease, aortic stenosis, and ischemic and hypertrophic cardiomyopathy.
S4 gallop · Apex, left lateral decubitus, bell
The opening snap (slide 44). An opening snap is a very early diastolic sound caused by abrupt deceleration as a stenotic mitral valve opens. It is high pitched with an obvious snap, heard best with the diaphragm just medial to the apex and along the lower left sternal border, and it can be mistaken for the pulmonic component of S2. You will hear it with its murmur in section 5.
4 · Murmurs by timing
A murmur is a sound made by turbulent blood flow over a heart valve, and it sounds like a swoosh (slide 46).
Midsystolic murmur (slides 51 and 66–68). It sits in the middle of systole, between S1 and S2, with a gap on either side; its shape is crescendo-decrescendo, like a diamond. Innocent murmurs are midsystolic; the pathologic ones include aortic stenosis, pulmonic stenosis and hypertrophic cardiomyopathy.
Mid-systolic murmur · Apex, supine, bell
Late systolic murmur (slides 39 and 51). It starts late in systole and builds up to S2; in mitral valve prolapse it follows a mid to late systolic click.
Late systolic murmur · Apex, supine, bell
Holosystolic (pansystolic) murmur (slides 72–74). It begins immediately with S1 and continues to S2. It is pathologic: blood flows from a chamber of high pressure to one of lower pressure through a valve or structure that should be closed. Mitral regurgitation is loudest at the apex and radiates to the left axilla; tricuspid regurgitation is loudest at the lower left sternal border and does not reach the axilla.
Holosystolic murmur · Apex, supine, bell
Also in the library: an early systolic murmur, which the deck does not teach and the quiz does not ask.
Early systolic murmur (not taught in the deck) · Apex, supine, bell
Early diastolic murmur: aortic regurgitation (slides 52 and 77). It is a high-pitched, blowing decrescendo murmur at the aortic area, and it may be mistaken for breath sounds. It is heard best with the patient sitting and leaning forward, holding the breath after exhaling. Pulmonic regurgitation is also an early diastolic, high-pitched decrescendo murmur, but it sits at the pulmonic area (slide 78).
Early diastolic murmur · Aortic area, sitting, bell
Mid to late diastolic murmur: mitral stenosis (slide 79). It is a low-pitched, decrescendo rumble at the apex, heard with the bell with the patient in the left lateral decubitus position. You will hear it after the opening snap in section 5.
5 · Sounds and murmurs together
Aortic stenosis (slide 67). A harsh midsystolic crescendo-decrescendo murmur at the aortic area that often radiates to the carotids, down the left sternal border and even to the apex.
Systolic murmur with an absent S2 · Aortic area, sitting, bell
The library labels this recording a systolic murmur with an absent S2; the deck does not mention an absent S2, so the description above is the deck’s.
Systolic and diastolic murmurs (not taught in the deck) · Aortic area, sitting, bell
A murmur in both phases at the aortic area. The deck teaches the systolic murmur of aortic stenosis and the diastolic murmur of aortic regurgitation separately, so this recording is not asked in the quiz.
Mitral valve prolapse: click, then a late systolic murmur (slide 39). A mid to late systolic click followed by a late systolic murmur from mitral regurgitation that crescendos up to S2.
Systolic click with a late systolic murmur · Apex, left lateral decubitus, bell
S3 with a holosystolic murmur (slides 40 and 74). Ventricular volume overload from mitral regurgitation is one cause of an S3, and mitral regurgitation is a holosystolic murmur, so the two are heard together.
S3 with a holosystolic murmur · Apex, left lateral decubitus, bell
S4 with a mid-systolic murmur (slides 42 and 67–70). The dull S4 just before S1 is followed by a murmur in the middle of systole; aortic stenosis and hypertrophic cardiomyopathy are causes of an S4 and are midsystolic murmurs.
S4 with a mid-systolic murmur · Apex, left lateral decubitus, bell
Opening snap with a diastolic murmur: mitral stenosis (slides 44 and 79). The snap of a stenotic mitral valve opening is followed by the low-pitched mid to late diastolic murmur of mitral stenosis, heard with the bell at the apex.
Mitral opening snap with a diastolic murmur · Apex, left lateral decubitus, bell
Ejection sound with a mid-systolic murmur: pulmonic stenosis (slides 38 and 68). A pulmonic ejection sound comes right after S1 and is high pitched; pulmonic stenosis is a midsystolic crescendo-decrescendo murmur at the pulmonic area, and it is one cause of the ejection sound.
Ejection systolic murmur with a single S2 and an ejection click · Pulmonic area, supine, diaphragm
Midsystolic murmur with physiologic or pathologic splitting of S2 (slides 35 and 66–68). Listen for two things separately: the murmur sits in the middle of systole, and the split of S2 either comes and goes with breathing (physiologic) or stays audible during expiration (pathologic, suggesting heart disease).
Ejection systolic murmur with a transient split S2 · Pulmonic area, supine, diaphragm
Ejection systolic murmur with a persistent split S2 · Pulmonic area, supine, diaphragm
6 · Every recording at a glance
| Recording | Where it was recorded | What to hear | Slides |
|---|---|---|---|
| Normal S1 and S2 | Apex, supine | Two sounds repeating, nothing extra | 13, 14, 34 |
| Transient split S2 | Pulmonic area | S2 splits on inspiration and fuses on expiration (physiologic) | 15, 35 |
| Persistent split S2 | Pulmonic area | S2 stays split on expiration (pathologic) | 35 |
| Mid-systolic click | Apex, supine | Sharp, high-pitched sound in mid to late systole (mitral valve prolapse) | 39 |
| S3 gallop | Apex, left lateral decubitus | Low-pitched sound after S2 (Ken-TUC-ky) | 40 |
| S4 gallop | Apex, left lateral decubitus | Dull sound just before S1 (Ten-nes-SEE) | 42 |
| Mid-systolic murmur | Apex, supine | Murmur in the middle of systole, gaps at both ends | 51, 66–68 |
| Late systolic murmur | Apex, supine | Murmur that starts late and builds up to S2 | 39, 51 |
| Holosystolic murmur | Apex, supine | Murmur from S1 all the way to S2 | 72–74 |
| Click, then late systolic murmur | Apex, left lateral decubitus | Mitral valve prolapse | 39 |
| S3 with holosystolic murmur | Apex, left lateral decubitus | Volume overload from mitral regurgitation | 40, 74 |
| S4 with mid-systolic murmur | Apex, left lateral decubitus | Dull sound before S1, then a midsystolic murmur | 42, 67–70 |
| Opening snap with diastolic murmur | Apex, left lateral decubitus | Mitral stenosis | 44, 79 |
| Systolic murmur, aortic area | Aortic area, sitting | Aortic stenosis: harsh, midsystolic, radiates to the carotids | 67 |
| Early diastolic murmur | Aortic area, sitting | Aortic regurgitation: high-pitched, blowing, decrescendo | 77 |
| Ejection sound with mid-systolic murmur | Pulmonic area | Pulmonic stenosis | 38, 68 |
Recordings and licence
All recordings are from the Heart Sound & Murmur Library, produced by the Learning Resource Center, Office of Medical Education, University of Michigan, by Richard D. Judge and Rajesh Mangrulkar, and licensed under Creative Commons Attribution-ShareAlike 3.0. Copyright The Regents of the University of Michigan. Each recording here is shortened to a twenty-second excerpt (an adaptation), converted to a smaller mp3 and shared under the same licence. The lecture deck embeds the library’s first recording on slide 36.