Miracle Cure For Aortic Stenosis

The opening snap is a very early diastolic sound usually produced by the opening of a stenotic mitral valve. It is heard best just medial to the apex and along the lower left sternal border. When it is loud, an opening snap radiates to the apex and to the pulmonic area, where it may be mistaken for the pulmonic component of a split S2. Its high pitch and snapping quality help to distinguish it from an St. It is heard better with the diaphragm.

A. physiologic third heart sound is heard frequently in children. It may persist in young adults to the age of 35 or 40. It is common during the last trimester of pregnancy. Occurring early in diastole during rapid ventricular filling, it is later than an opening snap, dull and low in pitch, and heard best at the apex in the left lateral decubitus position. The bell of the stethoscope should be used with very light pressure.

A pathologic Sj or ventricular gallop sounds just like a physiologic S3. An S3 in a person over age 40 (possibly a little older in women) is almost certainly pathologic. Causes include decreased myocardial contractility, myocardial failure, and volume overloading of a ventricle, as in mitral or tricuspid regurgitation. A left-sided S3 is heard typically at the apex in the left lateral position. A right-sided S3 is usually heard along the lower left sternal border or below the xiphoid with the patient supine. It is louder on inspiration. The term gallop comes from the cadence of three heart sounds, especially at rapid heart rates, and sounds like "Kentucky."

An S4 (atrial sound or atrial gallop) occurs just before Si. It is dull, low in pitch, and heard better with the bell. An S4 is heard occasionally in an apparently normal person, especially in trained athletes and older age groups. More commonly, it is due to increased resistance to ventricular filling following atrial contraction. This increased resistance is related to decreased compliance (increased stiffness) of the ventricular myocardium. Causes of a left-sided S4 include hypertensive heart disease, coronary artery disease, aortic stenosis, and cardiomyopathy. A left-sided S4 is heard best at the apex in the left lateral position; it may sound like "Tennessee." The less common right-sided S4 is heard along the lower left sternal border or below the xiphoid. It often gets louder with inspiration. Causes of a right-sided S4 include pulmonary hypertension and pulmonic stenosis.

An S4 may also be associated with delayed conduction between atria and ventricles. This delay separates the normally faint atrial sound from the louder Si and makes it audible. An S4 is never heard in the absence of atrial contraction, as occurs with atrial fibrillation.

Occasionally, a patient has both an S3 and an S4, producing a quadruple rhythm of four heart sounds. At rapid heart rates the S3 and S4 may merge into one loud extra heart sound, called a sn m matio n gallop.

TABLE 7-6 ■ Midsystolic Murmurs

Midsystolic ejection murmurs are the most common kind of heart murmur. They may be (1) innocent—without any detectable physiologic or structural abnormality; (2) physiologic—from physiologic changes in body metabolism; or (3) pathologic— arising from a structural abnormality in the heart or great vessels. Midsystolic mur


Innocent Murmurs

Innocent murmurs result from turbulent blood flow, probably generated by left ventricular ejection of blood into the aorta. Occasionally, turbulence from right ventricular ejection may also cause them. There is no evidence of cardiovascular disease. Innocent murmurs—very common in children and young adults—may also be heard in older people.

Physiologic Murmurs l.illllf I

Pathologic Murmurs



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