Auscultation of heart sounds and murmurs

R. Beňačka, MD, PhD


Aim: To gain basic practical experiences and theoretical knowledge in auscultation of heart sounds and murmurs in preclinical training.


Methods: 1) For training of auscultations skills the model simulator is used  (The Life / Form Auscultation Trainer and Smartscope simulator. The system is equipped with a the torso of the chest of an adult man  figurine, wireless programmable unite containing with a set of pre-programmable respiratory and cardiac sound phenomena and special stethoscope with sound generator producing sounds in a stethoscope bell.  When the bell is being moved over the particular auscultatory points, the place – specific sounds are heard. A map showing these typical auscultatory sites for both respiratory and cardiac sounds is also available with the simulator and is of beneficial use. The points are also noted by colors spots on the surface of figurine in order to help in navigation. If the stethoscope bell is placed outside the usual auscultation points no sound can be heard.  2) Students perform listening in within groups one after another. In the beginning the auscultation for one or more sounds is demonstrated by the teacher. After setting of the sound in program unite teacher uses stethoscope to hear the sounds  when mover over specific points on figurine while students can hear the sounds through the speaker. After then,  each trial being separated by sufficient disinfection of the olives in the stethoscope, students can train listening of selected phenomena themselves.


Life/Form Auscultation Trainer and Smartscope. (adult) (adult) Nasco (Fort Atkinson, Wisconsin):  Lung: 5 anterior, 10 posterior, and 2 midaxillary locations. Heart: 6 anterior sites. Remote controller selects heart and lung sounds. Smartscope plays sounds through in-stelhoscope transceiver. Placement of stethoscope on chest activates transponder playback of audio files. Dual headsets and

remote speaker playback options.


Heart auscultatory simulator

1 Normal sounds

2 Pulmonary stenosis

3 Aortic stenosis

4 Aortic regurgitation

5 Mitral stenosis

6 Mitral valve prolapse

7 Holosystolic (mitral regurgitation)

8 Midsystolic ejection

9 Midsystolic click

10 S3 Galop

11 S4 Gallop

12 Ventricular septal defect

13 Atrial septal defect pulm

14 Atrial septal defect int

15 Patent ductus arteriodus


Technology for Enhancing Chest Auscultation in Clinical Simulation |  Respiratory Care

S1 = closure of  tricuspidal and mitral valves

S2 = closure of aortic and pumonary artery valves


(A)Systolic murmus = after S1  (beween S1 and S2)

– Aortic stenosis/ Pulmonary stenosis

– Mitral regurgitation / Tricuspidal regurgitation

– Mitral valve prolaps


(B) Diastolic murmus =  after S2 (between S2 and S1)

– Aortic regurgitation/ Pulmonary regurgitation

– Mitral stenosis/ Tricuspidal stenosis


(C) Continuous murmurs


Left side problems (aortic, mitral) are much more common than right side defects.




Murmur accoridng to duration

Ø Systolic (after S1, between S1 & S2)

-       Ejection

-       Regurgitation

Ø Diastolic (za S2, medzi S2 a S1)


Phase of the heart cycle

Ø Early (protosystolic, protodiastolic)

Ø  Medium (mezo-)

Ø Late (tele-) Intensity change

Change in intensity

Ø Permanent (no change|

Ø Crescendo

Ø  Decrescendous

Ø Crescendo-descrescend

Frequency of murmurs

Ø Low frequency (murmur is called rumble)

Ø Medium frequency (murmurs rough, coarse)

Ø High frequency (blowing, vibrant|

The intensity of the murmur

 1/6 minimum (for experienced)

 2/6 quietest (hear when concentrating)

 3/6 noisy (clear)

 4/6 accompanied by palpable vortex

 5/6 can also be heard with the edge of the stethoscope

 6/6 also in the stethoscope above the surface


Where to hear ?    Auscultation sites:

Ø Aortic point = 2nd intercostal space; right to sternum

Ø Pulmonic =  2nd intercostal space on left to sternum

Ø Tricuspid =  4th intercostal space left close to sternum

Ø Mitral = 4-5th intercostal space, left  over heart apex

Ø Erb point = 3rd-intercostal space; left from sternum


Normal heartbeat sound consists of an S1 and an S2 and is heard throughout the precordium It occurs without any rubs, gallops or murmurs.

Decubital posisiton


Medical Terminology - Body position








Aortic stenosis is a harsh crescendo – decrescendo systolic ejection murmur and can be

Listen: aortic point (right sternal boarder 2nd IC space); radiates  to the carotids. Pulsus parvus et tardus (pulse weak and delayed)

Cause: calcified aortic valves









Aortic regurgitation (aortic insufficiency), is an early diastolic decrescendo murmur .It is accompanied by wide pulse pressure

Listen: aortic point (2nd IC space on left or even lower to  left parasternal border at 3rd and 4th IC space.

Cause: bicuspid aortic valve defect ( endocarditis, rheumatic fever, aortic valve base dilation (syphilitic aortitis)







Mitral stenosis is a decrescendo-crescendo diastolic rumbling murmur with loud S I  click (caused by the rapid closing of the thickened mitral valves)  early diastolic opening snap ('snapping' pf valve leaflets  into the left ventricle)  following the opening snap low-pitched diastolic murmur. It becomes louder - after a Valsalva maneuver after exercise (increase afterload)

Listen: apex

Cause: rheumatic fever, heart valve calcification








Mitral Valve Prolapse produces a mid-systolic click 'click' made by a floppy leaflet snapping into a taut) followed  by late systolic murmur  due to backflow of blood during systole from left ventricle to atrium. Most patients are asymptomatic. Palpitations or chest pain may occur commonly. Complications of MVP include: arrhythmias heart failure endocarditis

Listen: best in 5th IS  mid-clavicular line; in patient in left letral decubitus position

Cause: Myxomatous degeneration of the mitral valve leaflets; MVP is present in 2% of population



Mitral regurgitation is a holosystolic (pansystolic) murmur. When the murmur begins after S1, it always continues to the 2nd heart sound (S2).

Listen: heard best at the apex with the diaphragm of the stethoscope when the patient is in the left lateral decubitus position.







S3 Heart Sound is a low pitch sound produced by blood coming into contact with compliant ventricle after S2 click.

Listen:  cardiac apex;  in the left lateral decubitus position

Cause: In adults or elderly persons S3 is pathological. Normally present: Young adults, children. pregnancy, athletes, severe mitral & tricuspidal regurgitation, cardiomyopathy, heart failure







S4 Heart Sound (aka "atrial gallop") is  late diastolic low-frequency heart sound occurring prior to S1m  during the atrial filling phase in diastole and coincides with P in ECG (atrial systole).

Listen:  cardiac apex;  in the left lateral decubitus position

Cause: turbulence as blood enters a stiff ventricle.







Split S1 means that separate clicks M1 and T1 are heard instead of S1  (simultaneous closure of the tricuspid and mitral values). M1 andT1 sound the same. 

Listen: tricuspidal area

Cause:  It is normal finding; can be heard in app. 40 - 70% of adults; Also it be heard in Right Bundle Branch Block (RBBB).when LV is depolarized earlier than RV. This cause that  MV and TV start differently. ! Differentiate split S 1 from  pathologic S4.(sounds in lower frequency than S1)







Split S2   means that separate clicks A2 and P2 are heard instead of S2 (simultaneous closure of the aortic and pulmonic valves). Valves close at different times. A2 occurs normally  before P2, in pathol, cases P2 occurs before A2.

Listen: pulmonic area

Cause: In a normal person, heart  alternates between single S2 & split S2 sound during inspiration; Pathology: Pulmonic stenosis (wide split S2), Right bundle branch blocks

S2 split can be exaggerated by deep inspiration, which causes an increased venous return to the right side of the heart leading to the delayed closure of the pulmonic valve. Compared to a S3, which is heard later in the cycle, the split S2 heart sounds are higher in pitch vs.the S3 which is typically lower in pitch

Fixed Split S2 (persistent split S2): Atrial septal defects, Pulmonary Hypertension, Right heart failure

Paradoxical S2 (P2 before A2): Aortic stenosis, Right Venticular pacemaker, Left bundle branch block




Pediatric murmus


An innocent murmur is the sound(s) created by the vibrations of the heart walls as the blood flows through the chambers and valves. They are harmless. These are are of systolic murmurs  of short duration low intensity, grade 1-2 / 6, They often occur in children (80%) and disappear in adulthood. They do not require any treatment.




Still's murmur is a long-lasting but pronounced low-frequency vibrational murmur (similar to string vortexing) that occurs during auscultation at the lower edge of the sternum, most common in preschool children and toddlers. It changes with position and it is best to hear the recliners. Its intensity increases after exertion and weakens during the Valsava maneuver.




The physiological ejection murmur above the pulmonary artery is the systolic mumur that is most heard in the 2nd intercostal space on left ti the sternum (P point). It is more common in schoolchildren and adolescents. It can be confused with ausculatory findings in mild pulmonary stenosis or a defect of the atrial septum. Here, normal finding of S2 above the lungs (without split or clicks) is important


Recommended audiovisual internet resources


A) Heart auscultation MEDZCOLL collection

·      Normal Heart Sounds:

·      Aortic Stenosis:

·      Aortic Regurgitation:

·      Mitral Valve Prolapse:

·      Mitral Stenosis:




·      Split S1 Heart Sounds:

·      Split S2 Heart Sound:

·      S3 Heart Sound:

·      S4 Heart Sound:

·      S3 and S4 Gallop:

·      Innocent Murmur -



B) Other collection




Heart Sounds and Heart Murmurs, Animation:







Heart Murmurs and Heart Sounds: Visual Explanation for Students









Acute Coronary Syndrome: Unstable Angina, NSTEMI and STEMI






Systolic murmurs, diastolic murmurs, and extra heart sounds - Part 1 | NCLEX-RN | Khan Academy

Systolic murmurs, diastolic murmurs, and extra heart sounds - Part 1 | NCLEX-RN | Khan Academy