Heart Sounds


This website provides several types of learning resources for heart auscultation. We offer courses, reference guides and repetition training. Each of these resources is described below. If you are a new visitor, we generally recommend starting with the Heart Sounds Lessons, moving from normal cardiac sounds (mini) course through murmurs and then congenital abnormalities.

Course completion certificates are now available. Signed-in users must review all course lessons and then pass a graded quiz. Personalized achievement certificates can be printed and are automatically saved to the user's dashboard.

heart sounds auscultation image

Heart Murmur Introduction

Heart Murmur Introduction


Cardiac Auscultation Reference Guide

Our auscultation reference guide includes over one hundred heart sounds, both real and simulated. Use these buttons to view sounds by auscultation area.

Heart Sounds Reference Guide

Listen to Heart Sounds: Repetition Training

In addition to our heart and lung sounds reference guide, we provide an auscultation repetition training web app. This app allows users to learn by continuously listening to heart sounds. Use this link: Auscultation Repetition Training.

Lessons

Learn cardiac auscultation by taking our lessons. These courses cover abnormal heart sounds including heart murmurs, third (S3) and fourth (S4) heart sounds and congenital conditions. Learn these sounds by selecting a topic from the table of contents below.


Normal Heart Sounds  
This course will teach you about auscultation of normal sounds including split and unsplit second heart sounds heard at various heart rates and auscultation points.
Lesson List
1 First and Second Heart Sounds - Normal and Unsplit
2 First Heart Sound (Minimally Split)
3 Second Heart Sound - Physiologically Split #1
4 Third Heart Sound - Physiologic
5 Innocent Murmur
6 Exercise - Heart Rate 120


First Heart Sounds  
This course will teach you about first heart sound auscultation. Before you take this course you should have finished the Normal Heart Sounds course and feel comfortable with your ability to listen and recognize normal heart sounds.
Lesson List
1 First Heart Sound - Loud
2 First Heart Sound (Minimally Split)
3 First Heart Sound (Markedly Split)
4 First Heart Sound - Decreased Intensity
5 Fourth Heart Sound Plus First Heart Sound
6 First Heart Sound plus Aortic Ejection Click




Second Heart Sounds  
This course will teach you about the second heart sound. Before you take this course you should have finished the Normal Heart Sound and First Heart Sound courses. You should feel comfortable with the material presented.
Lesson List
1 Second Heart Sound - Physiologically Split #2
2 Second Heart Sound with Persistent Splitting
3 Second Heart Sound with Fixed Splitting
4 Second Heart Sound: Fixed Splitting, Increased Aortic Intensity
5 Second Heart Sound: Fixed Splitting, Decreased Aortic Intensity
6 Second Heart Sound and Late Systolic Click
7 Second Heart Sound and a Tumor Plop
8 Opening Snap and Second Heart Sound



Extra Heart Sounds (S3/S4)  
This course will teach you about auscultation of extra (S3 and S4) heart sounds. Before you take this course you should have finished the Normal, First, and Second Heart Sound courses. You should feel comfortable with the material presented.
Lesson List
1 Third Heart Sound Gallop
2 Fourth Heart Sound Gallop
3 Third and Fourth Heart Sound Gallop
4 Summation Gallop at 120 beats per minute




Systolic Murmurs
This course will teach you about Systolic Murmurs. Before you take this course you should have finished our auscultation courses titled Normal, First and Second Heart Sound, and Extra Heart Sound. You should feel comfortable with the material presented.
Lesson List
1 Innocent Murmur
2 Aortic Sclerosis (Musical Murmur)
3 Aortic Stenosis -Mild
4 Aortic Stenosis - Severe #2
5 Mitral Regurgitation
6 Mitral Valve Prolapse (Click with Late Systolic Murmur)
7 Hypertrophic Cardiomyopathy


Diastolic Murmurs
This course will teach you about auscultation of Diastolic Murmurs. Before you take this course you should have finished the Normal, First and Second Heart sound, and Extra Heart Sound courses. You should feel comfortable with the material presented.
Lesson List
1 Aortic Regurgitation - Mild
2 Pulmonic Regurgitation - Mild
3 Mitral Stenosis - Mild
4 Mitral Stenosis - Moderate
5 Mitral Stenosis - Severe
6 Tricuspid Stenosis - Moderate




Pediatric Referrals
This course will teach you when to refer pediatric patients. Before taking this course you should have completed our courses concerning heart sounds and murmurs and be comfortable with the material.
Lesson List
1 4-month-old girl. Failure to thrive.
2 6-month-old boy
3 4-year-old child with fainting episode
4 10-year-old child with chest pain.
5 6-month-old child with poor appetite
6 12-year-old child with respiratory infections
7 Twelve-year-old girl with periodic dizziness
8 Eleven-year-old girl seen after bicycle accident
9 Eight-year-old girl with elevated temperature
10 Eight-year-old boy with generalized malaise
11 Fifteen-year-old boy complains of dizziness


Complex Conditions
This course will teach you about complex conditions where there are murmurs in both systole and diastole. Before taking this auscultation course you should be familiar with the previous material on systolic murmurs, diastolic murmurs, extra heart sounds, etc.
Lesson List
1 Mitral Regurgitation - Severe
2 Tricuspid Regurgitation - Severe
3 Mitral Stenosis Severe and Regurgitation Mild - Rheumatic Origin
4 Aortic Stenosis Moderate and Regurgitation Mild - Rheumatic Origin
5 Mitral Regurgitation and Aortic Regurgitation
6 Acute Pericarditis


Congenital Abnormalities
This course will teach you how to identify the auscultatory sounds associated with congenital heart conditions. Before taking this course you should have completed the courses concerning heart sounds and murmurs and be comfortable with the material.
Lesson List
1 Coarctation of the Aorta
2 Patent Ductus Arteriosus
3 Atrial Septal Defect
4 Ventricular Septal Defect
5 Tetralogy of Fallot
6 Ebstein's Anomaly


Cardiac Conditions Associated with Sudden Death
This course will teach you how to identify sounds associated with conditions leading to sudden death. Before taking this course you should have completed the courses concerning heart sounds and murmurs and be comfortable with the material.
Lesson List
1 Hypertrophic Cardiomyopathy
2 Aortic Stenosis - Severe #2
3 Arrhythmogenic RV Dysplasia
4 Mitral Valve Prolapse (Click with Late Systolic Murmur)
5 Myocarditis
6 Commotio Cordis
7 Ebstein's Anomaly


Auscultation in Primary Care
This course is a survey of normal and abnormal sounds and murmurs encountered in primary care. The course starts with normal heart sounds and continues with extra heart sounds and murmurs.
Lesson List
1 First and Second Heart Sounds - Normal and Unsplit
2 First and Second Heart Sounds - Reduced Intensity
3 Second Heart Sound - Splitting
4 Third Heart Sound Gallop
5 Fourth Heart Sound Gallop
6 Third and Fourth Heart Sound Gallop
7 Summation Gallop at 120 beats per minute
8 Second Heart Sound - Fixed Splitting
9 Mid-Systolic Click
10 Mitral Valve Leaflet Prolapse
11 Aortic Stenosis (Diamond Shaped Systolic Murmur)
12 Aortic Regurgitation (Decrescendo Diastolic Murmur)
13 Mitral Regurgitation (pansystolic Murmur)
14 Mitral Stenosis (Diastolic Murmur)


Heart Murmurs

Heart Murmur Definition

Heart murmurs are sounds produced by turbulent blood flow, particularly from the heart's valves. They can be found in infants or develop later in life. Innocent murmurs frequently resolve without treatment. However, other abnormal heart murmurs indicate a cardiac condition.

Heart Murmur Audio

Stethoscopes are used to listen to heart murmurs. A normal heartbeat sounds like "lub-DUP", which are the sounds of your heart valves closing. This "lub-DUP" sound changes, often with additional sounds being heard.

Cardiac Auscultation

On this website, we provide lessons, reference guides and quizzes for cardiac auscultation of murmurs and other heart sounds. This includes gaining an understanding of cardiac rate and rhythm, conditions of the valves and possible anatomical abnormalities such as congenital defects. Links to our lessons, guides and quizzes are found in the 'Quick Links' box to the left.

Heart Murmur Sound Types

Heart sounds can include multiple sound components.

  • S1: The first heart sound, a low-pitched sound caused by the closing of the mitral and tricuspid valve.
  • S2: The secound heart sound, caused by closing of the aortic and pulmonary valve.
  • S3: An extra heart sound. S3 is a ventricular gallop, a low-pitched sound that can follow S2.
  • S4: An extra heart sound. S4 is an atrial gallop, produced by the atria forcefully pushing blood into a stiff ventricle.
  • Systole: The period between S1 and S2, when the ventricles contract.
  • Diastole: The period between S2 and the beginning of the next heart beat (S1). Ventricles are relaxing.
  • Clicks: These are short, higher-pitched sounds.
  • Rubs: A creaking, leather-like sound, typically heard during systole.

Timing and Cadence

Systolic murmurs occur between the first heart sound (S1) and the second heart sound (S2). Diastolic murmurs occur between S2 and S1. In addition, timing is used to describe when murmurs occur within systole or diastole. For example, early systolic, midsystolic or late systolic.

Heart Sounds Location

Where To Auscultate Heart Sounds

Heart sounds auscultation is performed over five locations on the anterior chest wall. Use the stethoscope's diaphragm, switching to the bell to hear lower pitched sounds.

Heart Murmur Location

The recommended heart murmur location on the chest wall is indicated by an icon and text within each of our lessons. Using these auscultation positions can help in evaluating the heart sound or murmur's source.

heart murmurs location areas
aortic valve auscultation location area Aortic Valve Area Second right intercostal space (ICS), right sternal border
pulmonic valve auscultation location area Pulmonic Valve Area Second left intercostal space (ICS), left sternal border
Erb's Point  auscultation location area Erb's Point Third left ICS, left sternal border
tricuspid valve auscultation location area Tricuspid Valve Area Fourth left ICS, left sternal border
mitral valve auscultation location area Mitral Valve Area Fifth ICS, left mid-clavicular line


Duration

Heart murmur duration refers to the portion of systole or diastole that the murmur occupies. Terms used include short and long. Murmurs lasting throughout systole are referred to as holosystolic or pansystolic.

Pitch

Evaluation of the murmur's pitch should be made by classifying the pitch (frequency) as low, medium or high. The stethoscope's bell can be helpful with low-pitched sounds while the diaphragm is used for medium or high-pitched sounds.

Shape

Some murmurs are described by the sound's shape. Common classifications include crescendo (increasing intensity), decrescendo (decreasing intensity), crescendo-decrescendo (increasing then immediate decreasing intensity). Crescendo-decrescendo is also called diamond shaped. Rectangular, also termed plateau indicates a heart murmur of constant intensity. Our lessons include waveforms that illustrate these shapes.

diamond shaped murmur decrescendo murmur

Tonal Quality

Listen for additional aspects of the murmur's sounds. Heart murmurs may have qualities that can be noted as musical, harsh, blowing, booming, sharp or dull.

Respiration and Patient Position

Respiration or patient position can influence murmur intensity as well as heart sound splitting. These factors will be described within the heart sound lessons. Generally speaking, murmurs increasing with expiration originate with left side (aortic or mitral) valves, while murmurs increasing in intensity with inspiration originate with tricuspid or pulmonary valves.

Within each lesson, the author provides a sketch of the patient's position during auscultation, such as supine, left lateral decubitus, squatting or sitting.

What Does a Heart Murmur Sound Like

Here is an example of a heart murmur sound recording. This heart murmur is aortic stenosis.

Playback

virtual auscultation of patient torso
auscultation position of patient
The patient's position is sitting.

Phonocardiogram

A waveform of the heart sound's amplitude is called a phonocardiogram.

Ultrasound Training

Certain heart sounds can also be diagnosed using sonography. Ultrasound is a great way to visualize valvular abnormalities. We recommend the website ultrasound.guide for free ultrasound training lessons and quizzes.


Fundamentals of Heart Sounds

Another great course for heart auscultation (its free) is PracticalClinicalSkills.com's Fundamentals of Heart Sounds.


Contributors

Sources




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