Heart sounds with afib

Cardiac Auscultation in the Older Adult

Auscultation at the Apex (Mitral Area)

My rationale for beginning at the mitral area is to compare the auscultatory findings with those previously obtained by percussion and palpation (see Nonauscultatory Cardiac Exam: Assessing the Elderly Person). Take a moment to focus on the heart sounds and to orient yourself to the cardiac cycle. This is the best place to hear S1, mitral valve murmurs, and S3 and S4 gallops. It is also useful to compare the quality of the sounds with the point of maximal impact (PMI) you palpated.

Listen to S1

Note especially the intensity of S1 relative to S2. Normally S1 is louder than S2 at the apex. The loudness of the mitral valve closure depends upon 3 things:

  • the degree of valve opening (whether it has had time to passively swing shut because of heart block),

  • the force of ventricular contraction shutting the valve, and

  • the integrity of the valve.

Think of a slamming door. The amount of its noise will depend on how far open the door is, how hard you slam it, and the integrity of the door.

Hearing a soft S1. S1 equal to or softer than S2 in the mitral area implies the following, from which you can often determine the likely mechanism:

  • First-degree AV block. Recheck the neck veins for distinct “a” and “c” waves, which reflect the PR interval on the EKG.

  • Left ventricular failure. Will show jugular venous distension, bibasilar rales, an S3 gallop, hepatomegaly, and pedal edema (consider myocardial infarction, ischemia, or ventricular aneurysm).

  • Left ventricular hypertrophy. Usually develops from chronic hypertension and characteristically produces an enlarged, displaced PMI.

  • Left bundle branch block. Produces a paradoxically split S2.

  • Significant mitral insufficiency.

Sometimes obesity and emphysema will also reduce the intensity of S1.

Hearing a loud S1. Hearing a very loud S1 suggests mitral stenosis, a hyperdynamic state (from fever, hyperthyroidism, or anemia), or an atrial myxoma (very rare).

Hearing a variable S1. Once you have appreciated the loudness of S1 compared with S2, note any beat-to-beat variation in the intensity of S1.

  • An irregularly irregular rhythm and a variable intensity of S1 suggests atrial fibrillation.

  • Decreasing intensity of S1 until a dropped beat suggests second-degree AV block Mobitz type I (Wenckebach). You may first appreciate a sense of grouped beats.

  • Hearing a regular bradycardia with a variable S1 suggests third-degree AV block.

  • Another cause of a variable S1 is ventricular tachycardia.

Hearing a split S1. Next, pay attention to whether S1 is single or double. Hearing a single sound is normal. Reduplication of S1 suggests a split S1, hearing an S4 gallop and S1, or hearing S1 and an early ejection click. A split S1 suggests right bundle branch block, which produces delayed closure of tricuspid valve. Listen for wide split S2 as well ( Table 1 ).

There are a few tricks to tell if the reduplicated first heart sound is really an S4 gallop and S1. An S4 is heard best over the ventricular chamber producing the sound, so it is not usually heard in the aortic or pulmonic areas. With the patient in the left lateral decubitus position, listen while you push your bell so that the skin is stretched and produces a diaphragm. An S4 should disappear or be significantly muffled. It will disappear during an extra systole. Also having the patient perform 3 sit-ups may accentuate an S4, which is usually not as crisp and high-pitched as an ejection click. Also, you may have been able to palpate the S4 during your cardiac palpation of the PMI.

S1 and an early ejection click can also cause a split-sounding S1. An ejection click is usually crisp and high-pitched. It will move closer to S1 when the patient is standing. You may hear a mitral valve prolapse murmur or other clicks as well.

Listen to S2

Hearing a split S2 here suggests an S3 gallop or a wide split S2 with loud P2 or S2 and an opening snap.
An S3 gallop is caused by impaired ventricular compliance in early diastole. It suggests congestive heart failure until proven otherwise and can be accentuated with mild exercise, such as having the patient perform 2 or 3 sit-ups.

Listen to Systole (the Time Interval Coincident With the Pulse)

A murmur heard here suggests mitral regurgitation, mitral prolapse, tricuspid regurgitation, or ventricular septal defect (radiates to back, to left paravertebral area). Hearing an extra sound during systole at this location suggests an ejection click, the click of mitral valve prolapse, or a pericardial friction rub.

Listen to Early Diastole

Hearing an extra sound most commonly suggests an S3 gallop. The gallop is produced by decreased ventricular compliance and implies a low-ejection fraction. It is a key finding of congestive heart failure. Other conditions that can produce an S3 include mitral regurgitation, tricuspid regurgitation, cardiomyopathy, and right ventricular myocardial infarction.
Less common sounds in early diastole are the opening snap of mitral stenosis, a pericardial knock, an atrial myxoma tumor plop, and the beginning of a mitral stenosis murmur.

Listen to Late Diastole

An extra sound in late diastole suggests an S4 gallop. The S4 is produced by decreased ventricular compliance when ventricle is full. It is usually normal in very elderly people. If the S4 is palpable as well as audible, consider hypertension, pulmonary hypertension, and cardiac ischemia.

Technique: Heart Sounds & Murmurs

Using the Stethoscope

A modern stethoscope consists of two earpieces connected by tubing to a chest piece which usually has both diaphragm and bell attachments. Earpieces should be angled forwards to match the direction of the practitioner’s external auditory meati.

The bell is used to hear low-pitched sounds. Use for mid-diastolic murmur of mitral stenosis or S3 in heart failure.
The diaphragm, by filtering out low-pitched sounds, highlights high-pitched sounds. Use for analyzing the second heart sound, ejection and midsystolic clicks and for the soft but high-pitched early diastolic murmur of aortic regurgitation.

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Positioning the Patient

Patients can be examined while lying supine, in the left lateral decubitus position (see picture) and sitting, leaning forward.

Pericardial sounds are sometime best heard with the patient on hands and knees.

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1. Auscultate the heart at various sites
  • At the apex.
  • At the base (the part of the heart between the apex and the sternum)
  • In the aortic and pulmonary areas to the right and left of the sternum, respectively

Listen for normal heart sounds:

  • The 1st heart sound, S1 (lub), marks the beginning of systole (end of systole).
    • Related to the closure of the mitral and tricuspid valves.
    • Loudest at the apex.
  • The 2nd hear sound, S2 (dub), marks the end of systole (beginning of diastole).
    • Related to the closure of the aortic and pulmonic valves.
    • Loudest at the base.

You can relate the auscultatory findings to the cardiac cycle by simultaneously palpating the carotid artery while listening to the heart:

S1 S2
Just precedes carotid pulse Follows carotid pulse
Louder at apex Louder at base
Lower pitch and longer than S2 Higher pitch and shorter than S2
Because systole is shorter than diastole:
First of two grouped beats Second of 2 grouped beats

If anything abnormal is found, move the stethoscope around until the abnormality is heard most clearly.

2. Separate findings into six categories
  1. 1st & 2nd Heart Sounds
  2. 3rd & 4th Heart Sounds
  3. Clicks & Snaps
  4. Murmurs
  5. Rubs
  6. Maneuvers
3. Analyze each category individually and then put it together to diagnosis the problem
Category Definition Audio examples
Aortic stenosis:


  • Harsh late-peaking crescendo-decrescendo systolic murmur
  • Heard best- left 2nd ICS
  • Radiation to the carotids.

Possible associated findings:

  • Abnormal carotid pulse
  • Diminished and delayed (“pulsus parvus and tardus”)
  • Sustained Apical impulse
  • Calcified aortic valve on CXR
Mitral Regurgitation:


  • Blowing holosystolic murmur
  • Heard best at the apex
  • Radiation to the axilla and inferior edge of left scapula.

Possible associated findings:

  • S2: wide physiologic splitting
  • S3
Aortic insufficiency:


  • Soft blowing early diastolic decrescendo murmur
  • Heard best at the left 2nd ICS without radiation
  • May also hear systolic flow murmur and diastolic rumble (Austin Flint)

Possible associated findings:

  • Dilated apical impulse
  • Abnormal and collapsing arterial pulses
Tricuspid regurgitation:


  • Soft holosystolic murmur
  • Heard best at the LLSB without radiation
  • Intensity increases with inspiration or pressure over liver

Possible associated findings:

  • Elevated neck veins
  • Systolic regurgitant neck vein
  • Systolic retraction of apical pulse
  • Edema, Ascites or both
Pulmonic Insufficiency


  • High frequency early diastolic decrescendo murmur
  • Heard best at 2nd-3rd ICS
  • Increases with inspiration

Associated findings:

  • Abnormal S2 splitting
  • Sustained pulmonary hypertension
Pulmonary stenosis


  • Harsh crescendo-decrescendo systolic murmur
  • Heard best sternal border bat 2nd or 3rd intercostal spaces
  • Increases with inspiration

Associated findings:

  • Ejection sounds heard at sternal edge, 2nd or 3rd intercostal space
  • Wide physiological splitting of S2
  • Prominent A wave of the jugular venous pulse
Mitral stenosis


  • Low frequency rumbling mid-diastolic murmur, with presystolic component possible
  • Heard best at apex
  • Accentuated in left lateral decubitus position

Associated findings:

  • Apical impulse absent or small
  • Irregular pulse ( atrial fibrillation)
  • Loud S1
  • Elevated neck veins with exaggerated A wave
Hypertrophic cardiomyopathy


  • Harsh quality midsystolic murmur
  • Heard best LSB
  • Increases with decreased venous return

Possible associated findings:

  • Sustained apical beat to palpation
  • S4 (50% of the time)

6 Ways Your Heart Can Get Out of Rhythm

2. Tachycardia

Tachycardia occurs when your heart suddenly starts beating very fast. If it happens as a result of exercise, excitement, or fever, it’s usually not a cause for concern and doesn’t need treatment. But one type of arrhythmia called paroxysmal supraventricular tachycardia (PSVT) is more dangerous. It creates extra heartbeats because electrical signals that move from the heart’s upper chambers to its lower chambers tend to loop back around to the upper chambers. This condition can cause sudden cardiac arrest if it affects the heart’s lower chambers, but it’s curable through ablation. Tachycardia is most common in children and young people, and is more common in women than men.

3. Ventricular Fibrillation

Ventricular fibrillation is the most deadly type of arrhythmia. It occurs when the lower chambers of the heart (the ventricles) begin to quiver instead of pumping normally. Because these chambers handle most of the heavy lifting for the circulatory system, ventricular fibrillation causes blood flow to very nearly cease. “If it’s not shocked in a timely fashion — and we’re talking minutes — then the patient will die,” says Gordon Tomaselli, MD, professor of medicine and chief of cardiology at Johns Hopkins Medicine in Baltimore.

Ventricular fibrillation usually happens in people with some sort of underlying heart condition. Those at risk can be treated with medication or an implanted defibrillator that will shock the heart if it stops beating.

4. Premature Beats

Most irregular heart rhythms involve extra or skipped beats. These types of arrhythmias are harmless and usually don’t cause symptoms. People who do feel symptoms report fluttering in the chest or a feeling that their heart has skipped. Premature beats can occur in anyone, most often happen naturally, and don’t require treatment. But they also can happen as a result of heart disease, stress, overexercising, or too much caffeine or nicotine. In those instances, you should talk with a cardiologist about your heart and any needed lifestyle changes.

5. Bradycardia

Bradycardia is a type of arrhythmia that, for many people, is no big deal. It means your heart rate is slower than normal — fewer than 60 beats a minute for adults. Young people and others who are very physically fit may experience bradycardia because they’re in good shape, and for them it isn’t dangerous and doesn’t cause symptoms. But people can also have bradycardia if they’ve had a heart attack or if an underactive thyroid gland or aging has slowed the heart. In these situations, taking medication or having a pacemaker implanted may be needed.

Bradycardia can also occur because of a nutritional imbalance. If this is the cause, your doctor may recommend a dietary supplement. In addition, the condition can be a side effect of medication, and in those cases a doctor may adjust your prescription.

6. Long QT Syndrome

A number of other disorders occur because of problems with the heart’s electrical system. Long QT syndrome, a hereditary disorder that usually affects children or young adults, slows the signal that causes the ventricles to contract. Another electrical signal problem, atrial flutter, happens when a single electrical wave circulates rapidly in the atrium, causing a very fast but steady heartbeat. Heart block involves weak or improperly conducted electrical signals from the upper chambers that can’t make it to the lower chambers, causing the heart to beat too slowly. These conditions can put you at risk for cardiac arrest. Treatment might involve medication, ablation, or an implanted device to correct the misfiring, such as a pacemaker or defibrillator.

RELATED VIDEO: Dana Vollmer’s Best Advice To Someone Who Has an Arrhythmia

Your heart is wired to beat up to 100,000 times a day. Tiny, electrical signals create a constant pulse that controls the rate and rhythm of each beat. But sometimes, the heart’s electrical system gets faulty, causing it to beat abnormally. One common type of irregular heartbeat is Atrial Fibrillation — or AFib for short.
With AFib, the upper chambers of the heart — the atria — ‘fibrillate’ or quiver erratically. When this happens, blood doesn’t get pumped into the ventricles like it should, and blood pools in the atria. Clots can form that break free and travel…causing a dangerous risk of heart attack and stroke and an increased risk of heart failure.
Many people with AFib don’t have any symptoms at all, while others may have chest pain, a rapid heartbeat, or dizziness. While most AFib episodes aren’t usually life threatening, it can be part of an underlying heart condition. Your doctor may suggest treatments like medication to prevent blood clots… Or surgery to implant a pacemaker.
So talk to your doctor about AFib… And find out what you can do to stay heart healthy.

How to Know It’s Atrial Fibrillation


Atrial fibrillation can be scary and cause fear and anxiety. It’s important that it be diagnosed and treated promptly. Failure to treat your afib can be life-threatening.

What are the symptoms of atrial fibrillation? How would you know to suspect it? What does it feel like?


When you have atrial fibrillation, you might notice a skipped heartbeat, and then feel a thud or thump, followed by your heart racing for an extended amount of time. Or you might feel heart palpitations or fluttering or jumping of your heart. Or you might experience sweating or chest pain, mimicking a heart attack. Or you may find that your pulse, instead of being strong and regular, is instead erratic or weak. Or atrial fibrillation may be so subtle that you don’t feel an irregular heartbeat, but you may realize that you’re dizzy, weak, tired, or breathless.

If you have atrial fibrillation that starts and stops, you may feel drained after an episode, but if you have continuous atrial fibrillation, you may not even realize what it is and only be aware that you just don’t have as much energy as usual or that you don’t feel like yourself. One afib patient simply described it as feeling like having “diminished capacity.”

If you’ve experienced these symptoms, it’s important to tell your doctor about them and to ask about tests to find out if you have atrial fibrillation or any irregular heartbeat or cardiac arrhythmia. The sooner you are diagnosed, the less unchecked damage it will do.

Diagnosing Atrial Fibrillation

You or your doctor may suspect that you have atrial fibrillation because of hearing or experiencing an unusual heartbeat or a rapid heart rate. There are several ways to verify it.

Typically, afib is diagnosed by a simple EKG or ECG (electrocardiogram) where several electrodes are placed on your skin to measure and record your heart’s electrical activity in wavelengths. It is painless and takes only a few minutes as you lie down for the test to be administered.

You must be undergoing an episode of afib at the time of the EKG in order for it to be seen on the readout. This works best for patients in persistent or longstanding persistent atrial fibrillation.

If your afib episodes are intermittent, as with paroxysmal atrial fibrillation, then they most likely will not be recorded on the EKG and you may need to wear a small portable electrocardiogram device, called a Holter Monitor, for 24–48 hours in order for your episodes to be captured.

In some cases, episodes may be so sporadic or infrequent that it’s unlikely that they will be captured at all on an EKG or Holter monitor. In those cases, you may wear an event monitor, which you activate or that activates by itself when an episode occurs, to record abnormal heart rhythms that may confirm atrial fibrillation.

There are other tests that may be used for more in-depth diagnosis. For example, if atrial fibrillation is related to exercise, a treadmill stress test may be used to diagnose it. Or for infrequent episodes, a more detailed electrophysiologic study with catheters may be done in the lab. For electrophysiologic studies, the heart is stimulated to induce erratic beats and then certain drugs can be tested to determine their suitability for treating the atrial fibrillation.

To learn more about the progressive nature of atrial fibrillation, see How Atrial Fibrillation Progresses.

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The irregular heartbeat of atrial fibrillation (or AFib) is like dancing without rhythm, moving fast without a beat and stepping on your partner’s toes. If not treated, AFib is serious. It can reduce quality of life and, most ominously, can lead to a stroke. A stroke can kill off many millions of brain cells, paralyze parts of the body, interfere with speaking, or even cause death.

However, the nearly 6 million people in the U.S. who have AFib can take steps to reduce their risk of stroke. This blog series presents information, skills and health habits needed to lead a vigorous, fulfilling life with AFib.

First, let’s meet George H., a 71-year-old retired engineer with high blood pressure. George frequently experienced episodes of a rapid, irregular heartbeat lasting up to an hour. Initially occurring monthly, over time the rapid fluttering in his chest became more frequent. Often, these episodes occurred in combination with lack of sleep, increased stress, or after drinking a few beers.

During one particularly frightening episode, George phoned his doctor who instructed him to come immediately to her office. An electrocardiogram (ECG) showed AFib with an irregular heartbeat of 150 times per minute, a potentially serious situation. His doctor sent George to the emergency room for further evaluation. He left with two new prescriptions, but was disappointed by the lack of information he received.

To better understand AFib, let’s review the mechanics of how the heart works.

An internal electrical impulse travels within the heart, which triggers the muscle cells, and the muscles to contract. Normally, the electrical signal first runs through the heart’s upper chambers (the atria) and then, moments later, through the larger, more muscular lower chambers (the ventricles). The squeezing power of the lower chambers pushes blood out of the heart.

A pulsation of blood travels like a wave through the arteries to reach everywhere in the body. This creates the usual rhythmic sound we associate with a heartbeat: lub-dub, lub-dub, lub-dub.

In AFib, abnormal, random electrical impulses in the upper chambers cause the atria to quiver (or fibrillate) rather than squeeze in a normal, coordinated way. Only some electrical signals in the upper chambers are allowed to trigger the muscles of the ventricles, thanks to the heart’s own safety system. As a result, the ventricles squeeze irregularly, usually 2-3 times a second in untreated atrial fibrillation (120-180 heartbeats per minute). In contrast, normal is 60-100 beats per minute.

What results is a dancing, irregular rhythm that is more like the fast gallop of a lame horse: dub-lu-dub-lu-lu-dub-lu-dub-lu-lu-lu-dub-lu-dub-lu-dub. With this rapid, syncopated rhythm, the heart can’t pump blood as strongly as it should. It can’t fill fully with blood and has too little time to rest between beats. As a result, people with atrial fibrillation often cannot exert themselves. Enjoyable physical activity is limited, a real problem given the health benefits of exercise.

A stroke can result when the quivering in the upper chambers allows small blood clots to form on the inside walls of the heart. These tiny clots can ultimately lodge in the brain, killing the part of the brain robbed of oxygen and nutrients.

Treatment of AFib can prolong life and promote greater well-being. Overall treatment goals include:

1) preventing blood clots and strokes through the use of blood thinners (anticoagulants)
2) slowing down the irregular beating of the heart to allow better heart function
3) and, for some patients, resetting the heart’s rhythm to a normal flow of electrical signals.

AFib, along with its underlying causes and recommended treatments, can be overwhelming. Learning to live with AFib, however, is worth the effort.

This is the first in a series of blog posts called Understanding AFib to help patients with atrial fibrillation live healthier lives. The next blog post will discuss which patients with AFib should consider taking blood thinners. George H. is an actual patient with some details altered to protect his confidentiality.

Randall Stafford, MD, PhD, is a professor of medicine at Stanford and practices primary care internal medicine. Stafford and Stanford cardiologist Paul Wang, MD, lead an American Heart Association effort to improve stroke prevention decision-making in atrial fibrillation.

Illustration by Vinita Bharat/Fuzzy Synapse

Atrial fibrillation or flutter

A lot of things can make your heart beat faster, like kissing the person you love or watching a scary movie. But sometimes, your heart beats not only faster but also out of rhythm. That can be a problem if this continues over a long period of time and isn’t treated. Let’s talk about a condition called atrial fibrillation. If you can listen to your heart through a stethoscope, your heart beat should sound something like this, or lub dub, lub dub, lub dub. If you have atrial fibrillation, the top two chambers of your heart contract too quickly, and in an irregular pattern. So what you’d hear if you listened through a stethoscope would be more like this. Atrial fibrillation doesn’t just sound funny, this irregular beat can prevent your heart from pumping enough blood out to the rest of your body. Age may cause atrial fibrillation. As you get older, it’s more common to have an irregular heartbeat. You’re also more likely to have atrial fibrillation if you’ve had another heart problem, like valve disease, coronary artery disease, or heart failure. Some people get atrial fibrillation because they drink too much alcohol or take certain medicines. To find out you may have atrial fibrillation. You’ll feel your heart race and flutter-and not just once in a while, but often. You may also have trouble breathing and feel tired and dizzy. Your doctor can listen for fluttering while listening to your heart with a stethoscope. You may also need a test that records your heart’s rhythms, like an ECG, which you have in your doctor’s office, or a Holter monitor that you wear around for a day. Your doctor may also prescribe imaging tests to look at your heart and check whether its electrical system is working properly. If you do have atrial fibrillation, your doctor can give you medicine to slow your racing heart. Often, the next step is to restore the normal heart rhythm with an electric shock, a process called Cardioversion. However, if the atria haven’t been contracting well for 48 hours or more, blood clots may have formed there. These patients are usually given anti-coagulant medicines before Cardioversion to prevent the clots from moving to the brain and causing a stroke when normal rhythm is restored. If Cardioversion doesn’t solve the problem, a procedure called Cardiac ablation can be done to destroy the bad areas of your heart that are causing your heart to beat abnormally. Usually doctors can treat atrial fibrillation so that it becomes a minor nuisance, instead of a big problem. But, the condition can come back, even after it’s been treated. If it continues, atrial fibrillation can lead to heart failure. To avoid complications from atrial fibrillation, call your doctor if you’re feeling flutters in your chest, and they don’t go away.

Atrial fibrillation (also called AFib or AF) is a quivering or irregular heartbeat (arrhythmia) that can lead to blood clots, stroke, heart failure and other heart-related complications. At least 2.7 million Americans are living with AFib.

Here’s how patients have described their experience:

“My heart flip-flops, skips beats, and feels like it’s banging against my chest wall, especially if I’m carrying stuff up my stairs or bending down.” “I was nauseated, light-headed, and weak. I had a really fast heartbeat and felt like I was gasping for air.” “I had no symptoms at all. I discovered my AF at a regular check-up. I’m glad we found it early.”

What happens during AFib?

Normally, your heart contracts and relaxes to a regular beat. In atrial fibrillation, the upper chambers of the heart (the atria) beat irregularly (quiver) instead of beating effectively to move blood into the ventricles.

If a clot breaks off, enters the bloodstream and lodges in an artery leading to the brain, a stroke results. About 15–20 percent of people who have strokes have this heart arrhythmia. This clot risk is why patients with this condition are put on *blood thinners.

Even though untreated atrial fibrillation doubles the risk of heart-related deaths and is associated with a 5-fold increased risk for stroke, many patients are unaware that AFib is a serious condition.

Watch an animation of atrial fibrillation.

According to the 2009 “Out of Sync” survey:

  • Only 33% of AF patients think atrial fibrillation is a serious condition
  • Less than half of AF patients believe they have an increased risk for stroke or heart-related hospitalizations or death

AFib Treatment Saves Lives & Lowers Risks

If you or someone you love has atrial fibrillation, learn more about what AFib is, why treatment can save lives, and what you can do to reach your goals, lower your risks and live a healthy life.

If you think you may have atrial fibrillation, here are your most important steps:

  1. Know the symptoms
  2. Get the right treatment
  3. Reduce risks for stroke and heart failure

We’re here to help you live your healthiest life!

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