Systolic murmurs, diastolic murmurs, and extra heart sounds – Part 2 | NCLEX-RN | Khan Academy

Systolic murmurs, diastolic murmurs, and extra heart sounds – Part 2 | NCLEX-RN | Khan Academy


– [Voiceover] So the last
systolic murmur or sound that I want to talk to you
about is mitral valve prolapse. And this is pretty much
exactly what it sounds like. The valve actually prolapses or billows into the left atrium, and
so this causes a click. And so this is a click
that’s kinda similar to the one that we talked
about in aortic stenosis, which was an ejection click, but this is a click that’s not associated with ejection of blood through a valve. And so this is really
a non-ejection click, and it’s also not right at
the beginning of systole. It’s actually a mid- or
mid-to-late systolic click. And so you’ll see I’ve
labeled that for you there. And what causes that is
as the left ventricle begins to contract– Remember this would make the
mitral valve close to cause S1, so the valve closes normally, not like what’s shown in this picture, closes and causes your S1. And then as the pressure builds, this valve will actually
accelerate into the left atrium, and when it stops abruptly
because it’s held by, or should be held by,
these corday tendonay here, then there’s this rapid
tensing of either the corday or that leaflet and that
causes this little click. Now this condition is also associated with mitral regurgitation, and so you can imagine if this valve kind of billows up here, there’s probably some problems closing, and maybe it doesn’t close
completely correctly, and so you can get blood flow in here. And if that’s the case,
then after the click, you’re gonna have the murmur
of mitral regurgitation. And so you’ll get this. And so I want to make a point here. I’ve seen some textbooks that show that this is a flat murmur, and others that say that
it’s a crescendo murmur. For our purposes here, we’re
not going to dwell too much on the shape of the murmur
following the click, but what’s important is the click itself because the click, a mid-systolic click, is virtually diagnostic
for mitral valve prolapse. So overall this is described
as a mid-systolic click with a late-systolic murmur. And this, like mitral
regurgitation, is heard best at the apex or the mitral area. So now that we’re done
with systolic murmurs, let’s move on to the diastolic murmurs. So now that we’re going to talk about diastolic murmurs, I’m gonna switch my pen
color here to green, and we’re gonna move on to
the first diastolic murmur, and that’s gonna be aortic regurgitation. And so we know that this means that blood is going to be coming back
through the aortic valve when it’s supposed to be closed. And so for aortic regurgitation, this is a little counterintuitive because you would think
maybe that aortic would go to the aortic area, but because this blood
is coming back this way, we’re actually going to listen for this kind of in this area. And so this wasn’t really
one of our defined areas but we’re basically going to say along the left sternal border, meaning on the left side of the sternum. And the reason is because the
blood’s flowing the other way so why would you listen
in the normal aortic area when the blood’s gonna be
traveling the other direction? And so this time because
we’re talking about diastolic murmurs, these
murmurs are actually gonna occur between S2 and S1. And so let’s talk about
about S2 for a second. S2 is actually gonna be caused by the closing of the aortic valve, and then soon after that, the mitral valve will actually be open. And then the heart’s in diastole, meaning it’s filling with blood. But because this is aortic regurgitation, that means there’s a closing
problem with this aortic valve. And so blood, right when
this tries to close because the pressure will actually
be greater here than here. Right at S2 blood is going
to be coming through here. But blood is also filling the
ventricle from the atrium, and so the pressure, this
little p, is actually gonna start to get a little bit bigger. And so at the beginning when
the pressure is still little a bunch of this blood is gonna
come back through the aorta. And so you get this very intense part of the murmur that I’ve drawn. And as that pressure
gets a little bit bigger in the ventricle, then this
is gonna kinda diminish. And so this is the shape
that you actually get with aortic regurgitation. And this is called an
early diastolic murmur. It’s happening in the
beginning of diastole. And its shape is decrescendo. And just to mention the
right-sided condition, a pulmonic regurgitation, would
be the same type of murmur, an early diastolic decrescendo murmur, but this time it would actually be heard along the upper left side of the sternum, whereas this one was kind of generally just along the left side of the sternum. So the last murmur that I
want to talk to you about is mitral stenosis. So now that mitral valve
is having trouble opening, and because the mitral valve
is open during diastole, this is also a diastolic murmur. So if we start at S2 again. Remember that’s the closing
of the aortic valve. And that would be here. What happens just milliseconds after that is that the mitral valve should open, and it does this to fill up
the ventricle in diastole. And so instead of a nice, big opening, we kinda get this tiny, little opening that we’re gonna show like this. And so in the beginning of diastole, you actually have the most blood coming from the left atrium through
to the left ventricle. And this is known as rapid filling. So the ventricle actually
fills up with more blood in the beginning of diastole
than it does at the end. And that’s due to a pressure difference, meaning throughout diastole
the beginning of it is where that pressure difference between the atrium up here and
the venticle down here, it’s when that pressure difference
is actually the highest, at the beginning portion of diastole. And so at the beginning portion, you’re gonna have the most
intense part of that murmur. But before that happens
we have to talk about this extra sound that we may hear. And so right after the
aortic valve closes, the mitral valve is gonna open, but because this valve is stenotic, when it’s about to open the
leaflets can only just open a little bit and they kind of snap open. And so this is an opening snap. And this kinda similar
to an ejection click in the systolic murmurs. But in diastole this is
called an opening snap. And it’s from these stenotic
valve leaflets shooting open during the rapid filling
phase of diastole. And so what you get is
just milliseconds after S2, you get an opening snap OS, and then like I said, because
the pressure difference is greatest during this
rapid filling time, you actually have the highest
intensity of the murmur here. And then it starts to slow down as the pressures become
a little more equal. And then finally what happens
at the end of diastole is that the atrium actually
gives a little contraction to push any leftover blood
into the left ventricle. And so we’re gonna show that like this. And it’s gonna push any leftover
blood into the ventricle. And that’s going to give
you this little up slope, like this little extra kick at the end. And so this is called
pre-systolic, right before systole, accentuation, which is
really just a fancy word for getting bigger. Pre-systolic accentuation. And so this murmur is
heard in the mitral area or again, like some
people like to call it, the apex or apical area. And so the way people describe
this murmur is actually an opening snap followed
by a mid-diastolic rumble. And people say this sounds
like a rumbling sound, and it’s also kinda because
that murmur is a weird shape. You see how it kinda goes
down and then comes back up. And so they say an opening snap followed by a mid-diastolic rumble. And just to mention the
right-sided valve condition, tricuspid stenosis, this
would produce the same murmur, an opening snap followed
by a mid-diastolic rumble, but instead you would hear
this in the tricuspid area. And so the last thing
that I want to talk about are extra heart sounds. And so whether you’ve realized it or not, we’ve actually covered two types of extra heart sounds already. One of them being the click. And remember this can be an ejection click or a non-ejection click. The ejection one being
associated with aortic stenosis, and the non-ejection one being
a little bit later in systole and being associated with
mitral valve prolapse. The other extra heart
sound that we’ve covered is the opening snap. And remember that’s associated
with mitral stenosis. The other two really
important extra heart sounds that we’re going to talk
about are what are called S3 and S4. And so you’ll realize that
we have S1 here, S2 here, so these are the next two heart sounds. But generally when these are present, it’s not a good thing. So S3 and S4 are really not murmurs. They’re just another sound. It almost sounds like another S1 but just in a different location. Or another S2 and in a different location. And so these are actually heard best in the mitral or apex position here, but specifically if you
have the patient lie in what’s called the left lateral. We’re going to abbreviate
that lat. decubitus position. Decubitus. And all that really means is that the patient rolls
over to their left side, and the physician or the nurse, or whoever’s taking care of you, will listen with their stethoscope
in the mitral position. And the reason for this is just that it brings the heart closer in position to where the actual
stethoscope is gonna be. When you roll over, your
heart will shift a little bit, and actually come closer to the rib cage. So what causes this S3 and S4? Well, S3 is classically a
volume overload condition. And so you hear this in early
diastole, so around here. And this occurs during
the rapid filling phase during diastole that
we talked about before. And so in this rapid phase, if you have too much
blood, too much volume, this ventricle’s gonna
fill up really quickly. And what happens is you get
a tensing of these strings, or these corday tendonay here. And that tensing actually
causes the S3 sound. So quickly again, it happens
in the rapid filling phase of diastole due to the
tensing of the corday tendonay when all that volume fills
up the left ventricle. And so in kids or adolescents, and we’ll kinda just write young here, an S3 can actually be present. But that’s usually normal. And this kinda just means
that the heart is capable of taking extra volume and expanding. And you’ll still hear that sound, but it’s a normal condition. But in a middle-aged or old person, or that’s not very nice, an elderly person, this
is usually a bad thing. And it’s usually due to heart disease, something like congestive heart failure, where they have too much volume
coming into that ventricle and you get an S3. And there are many other
conditions that can cause an S3, but for our purposes let’s
just know that it’s related to volume overload. So S4 is a pressure overload problem. And what happens is when the heart has to contract against increased pressure, so let’s kinda just say
that maybe there’s increased pressure here, greater
than the normal amount. So let’s say maybe in a
case of high blood pressure. The heart is contracting
against this increased pressure, and over time the heart is
going to actually hypertrophy or increase in size. But this is actually called
concentric hypertrophy, meaning the muscle increases
in size, but inward. And so it actually makes
this ventricle really stiff. And so the S4 sound is what
you hear when the atrium, remember that the atrium at
the end of diastole contracts to get that last little bit of blood out. And so the S4 is what you
hear when the atrium contracts into a very stiff ventricle. And so this sound occurs at
the end of diastole just before the next cycle of systole
is gonna take place. And I’m not sure if we mentioned this, but S4 is also heard in the mitral area, and best heard in the left
lateral decubitus postion. And so if you’ll notice
both of these sounds are in diastole, just
different parts of diastole. And so other common names that
I should probably tell you so that when you hear
them you’re not confused are that people call S3
a ventricular gallop. Remember this is a large
volume of blood coming in and tensing those corday
in the ventricles. And people call S4 an atrial gallop. And that’s because this sound
is really caused by this atrium contracting into
the stiff ventricle. And so the S4 is always pathological, meaning it’s always bad news. And so I’m gonna run you
through that original montage of heart sounds and murmurs, and let’s see if you can figure it out. I’m gonna put up a label of
which murmur it actually is towards the end of each individual murmur. (pulsing heartbeat) (pulsing heartbeat) (pulsing heartbeat) (pulsing heartbeat) (pulsing heartbeat) (pulsing heartbeat) (pulsing heartbeat)

100 comments

  1. These videos were great. I'm a pediatric cardiologist and I'm planning on incorporating them into a murmur module for pediatrics residents. Thanks.

  2. 13:40 Holosystolic murmur MR

    13:48 Early Diastolic Murmur Decrescendo AR

    13:57 Mitral Prolapse (w/mitral regurg)

    14:07 Atrial Gallop S4

    14:12 Mitral Stenosis (with opening snap)

    14:20 Aortic Stenosis (with ejection click)

    14:27 Ventricular Gallop S3

  3. Thanks you very much for the excellent explanation. I've had a vague understanding of murmurs for a while now and this clarified everything. Great appreciated.

  4. With mitral valve prolapse, is there always a late-systolic murmur that follows the mid-systolic click? What I mean is, does the valve always let blood back through, or is it possible to just hear the click and have the valve stay closed? Is it common to assume that in most/all cases, there's a late-systolic murmur that follows a mid-systolic click?

  5. Beautifully explained. Thank you for your attention to detail. The best video on the heart i've seen! ~Cardiology Technologist student

  6. Thanks for the detailed explanation…..was very useful to me in understanding the murmurs…I was confused with them so much….now I'm pristine clear…Thanks a lot!!!!

  7. I wish you could make the heart less complex, like 4 chambers as boxes. Would have been easier. Thank you for it though. Helped a lot.

  8. LAST YEAR I LITERALLY STRUGGLED WITH THIS And i eventually didn't get it well but this year we're going through this chapter again and i was about to give up but omg thank you for doing such a great job ! you saved me !

  9. thank you thank you thank you!!!!! my teachers should not practice anymore, honestly. you managed to make me love cardiology.

  10. 0:06 MVP [1:56 a midsystolic click is virtually diagnostic for MVP… (mis-sys click w/ a later sys murmur)]
    Diastolic murmurs 2:25
    -AR 2:50
    -MS 5:12
    8:40 extra heart sounds: (besides clicks & snaps) S3 & S4 (pt in L Lat decub position)
    10:18 S3 volume overload (cordae tense w/ overfilling dilated L ventricle/CHF)
    11:46 S4 pressure overload (atrial kick into hypertrophic/stiff ventricle)

  11. awesome..thanks a lot..even i heard these words but i didn't get the answer before..thanks now i understand all..thanks a lot once again..stay blessed..make many more educational purpose video..

  12. This is the most simplest and easy form of learning murmurs …I think nobody can teach me better than this ..thank uh so much

  13. Simply excellent. Very grateful for clear, concise and well presented video. Thank you for the great channel. 8/8/2018 😊

  14. Great video! I would like to make a consideration over the S3 sound – I have heard it was generated by the slowdown of the blood from the LA on the the wall of the LV. Would this explanation be right too?

  15. Excellent..! its worth paying attention to, for final yr students who face difficulty in identifying murmurs bedside. Thank you very much khanacademymedicine…!

  16. For med students
    Click here for one of the best videos
    https://www.youtube.com/watch?v=svj2ikS3PRE&t=8s

  17. love ,love your sense stress, to the point with ease on my thought processes! i will pass this subject now not from memory but from clear understanding of which thanks to you i can explain it to any one else now too , love truely personified thank you thank you, plz continue you have a gift!

  18. Just found out about this site
    http://www.med.umich.edu/lrc/psb_open/html/menu/index.html

    it has almost everything you need to know about cardiology

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