What does a loud heartbeat mean?

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What the Sound of Your Heart Says About Your Health

Call it the sound of your life force — that “lup dub lup dub” beat your healthy heart makes, resounding like rhythmic, repetitive pounding on a drum. When those notes stray off beat or tone, a trained ear can tell that something’s amiss with your health.

A heart murmur may be diagnosed as benign — harmless — or it may need more attention. Just ask Summer Ash, now 38, an astrophysicist who is the director of outreach for Columbia University’s Department of Astronomy in New York City. During a routine physical exam when she was in college, her physician heard a heart murmur and referred Ash for an echocardiogram. The test results indicated that her murmur was nothing to worry about.

Years passed, and Ash ignored her urge to follow up — until her mother was hospitalized for a reaction to a cold medication that affected her heart rate. That was all the motivation Ash needed. She asked her mother’s cardiologist to review her echocardiogram report, and the cardiologist ordered a new echocardiogram.

To her shock, Ash found out she had an extremely rare congenital condition called a bicuspid aortic valve. This is a defect that just 1 percent of people are born with, according to the U.S. National Library of Medicine. The malfunctioning valve exerts extra pressure on the heart’s aorta. In Ash’s case, the pressure caused the artery wall to stretch and balloon, creating an aortic aneurysm. These life-threatening weak spots on an artery’s wall can rupture, causing internal bleeding that can be fatal.

Ash’s open-heart surgery two years ago to repair her aortic valve was successful. But after surgery, her heartbeat became louder, even audible, and the pounding was so strong that it became a constant reminder of her surgery. (You can hear audio of her heartbeat on RadioLab where Summer shared her story.)

Now she’s dealing with post-traumatic stress disorder (PTSD) — the emotional fallout from having a near-death experience coupled with such traumatic surgery, she says. One way she furthers her healing process is through writing and sharing her experience on her online blog.

Where Your Heartbeat Comes From

A quick review of the heart’s anatomy reveals where its various sounds come from. This four-chambered muscle contains two upper chambers, called the atria, and two lower chambers, called the ventricles. Between each chamber, four little valves open and close with every heartbeat to keep the blood flowing in the right direction, notes the Texas Heart Institute. These are called the aortic, pulmonary, tricuspid, and mitral valves.

The sounds — normal and abnormal — that your heart makes come from:

  • Vibrations when the valves open and close
  • Blood that flows too fast or abnormally through the chambers
  • Tension in the tissues that connect the heart valves to heart muscle

“Listening to heart sounds through a stethoscope, along with a patient’s medical history and other clinical data, can help us diagnose a variety of heart conditions,” says Seth Martin, MD, assistant professor of cardiology at Johns Hopkins School of Medicine in Baltimore. Heart murmurs, for example, are common heart sounds that sometimes indicate heart-valve disease, according to the National Heart, Lung, and Blood Institute. Other heart sounds can help diagnose less common conditions.

The “friction rub” sound, for example, can help diagnose pericarditis, which is an inflammation of the pericardium, the heart’s sac-like covering.

A “gallop,” which actually mimics the sound a horse makes when running, could indicate a type of heart failure in those over 40, says Dr. Martin.

What Makes Your Heart Murmur

Heart valve problems usually cause heart murmurs, notes the American Heart Association. Murmurs can occur when a valve doesn’t close properly, allowing blood to leak backwards, a condition called “regurgitation.” A murmur may also arise when blood flows through a valve that’s narrowed or stiffened by disease, a condition known as stenosis.

“Different heart murmurs make different sounds,” says Martin. While many murmurs are benign, others can point to problems. “We can gauge whether a murmur needs immediate attention or further exploration by listening to certain features of the sound,” he explains.

The murmur’s loudness can be helpful — or misleading. Someone with a loud murmur might not have serious disease, while someone with a softer murmur could. “So we pay attention to other factors as well,” says Martin. “The timing of the peak of the murmur, along with any symptoms and other clues from the physical examination, are crucial in deciding how significant a heart murmur is, and if it’s benign or needs more attention.”

Noisy Heart Problems

In addition to heart murmurs, your doctor may also be able to detect sounds that indicate congenital heart disease and sometimes disease of the heart muscle itself. These problems can make sounds that a physician can hear if he or she has been properly trained, says Theo E. Meyer, MD, PhD, director of the Advanced Heart Failure Program and Professor of Medicine at the University of Massachusetts School of Medicine in Worcester.

RELATED: 10 Things Your Doctor Won’t Tell You About Congenital Heart Defects

However, due to the advent of sophisticated imaging tests such as echocardiograms, CT scans, MRIs, and PET scans, most doctors no longer get comprehensive training in auscultation, which is the art of listening to and interpreting the sounds the body makes. “This kind of training is a dying art form these days,” says Dr. Meyer.

Most people can’t hear the sound of their own hearts beating, unless they’ve had certain kinds of valve surgery, as in Ash’s unusual case. “People who’ve had heart surgery years ago may have older style mechanical heart valves,” explains Dr. Meyer. “These may make clicking sounds that you can easily hear. Newer valves are quieter,” he says.

Children Can Have Noisy — but Healthy — Hearts

If your child’s pediatrician mentions that your son or daughter has a heart murmur, it’s not necessarily cause for alarm, says W. Reid Thompson, MD, associate professor of pediatric cardiology, at Johns Hopkins Children’s Center in Baltimore.

Children are more likely to have heart murmurs than adults,” says Dr. Thompson. “In fact, up to 70 percent of children will have an occasional heart murmur, and the vast majority of them are innocent — meaning they’re caused by blood flowing through a healthy heart. However, listening to a child’s heart can be complicated because little children rarely sit quietly and stay still during a physical exam. That makes listening for subtle abnormalities a bit of a challenge, says Thompson.

“Despite all the new technology we have, simply listening to the heart still gives us some quick, powerful information that can be crucial in letting us know who needs special imaging studies, when conditions have improved or worsened, and when things are probably fine,” says Thompson.

“I still use my stethoscope almost every day, even though my other specialty is echocardiography of the heart. We’re still learning how to use technology to improve our listening skills and how to teach this still-relevant skill to new doctors in training,” he says.

What Causes Heart Murmurs?

Your heart is made up of four chambers. The two upper chambers are called the atria, and the two lower chambers are called the ventricles.

Valves are located between these chambers. They make sure that your blood always flows in one direction.

  • The tricuspid valve goes from your right atrium to your right ventricle.
  • The mitral valve leads from your left atrium to your left ventricle.
  • The pulmonary valve goes from your right ventricle out to your pulmonary trunk.
  • The aortic valve goes from your left ventricle to your aorta.

Your pericardial sac surrounds your heart and protects it.

Problems with these parts of your heart may lead to unusual sounds that your doctor can detect by listening to your heart with a stethoscope or by performing an echocardiogram test.

Congenital malformations

Murmurs, especially in children, may be caused by congenital heart malformations.

These can be benign and never cause symptoms, or they can be severe malformations that require surgery or even a heart transplant.

Innocent murmurs include:

  • pulmonary flow murmurs
  • a Still’s murmur
  • a venous hum

One of the more serious congenital problems that causes heart murmurs is called Tetralogy of Fallot. This is a set of four defects in the heart that lead to episodes of cyanosis. Cyanosis happens when an infant or child’s skin turns blue from lack of oxygen during activity, such as crying or feeding.

Another heart problem that causes a murmur is patent ductus arteriosus, in which a connection between the aorta and the pulmonary artery fails to close correctly after birth.

Other congenital problems include:

  • atrial septal defect
  • coarctation of the aorta
  • ventricular septal defect

Heart valve defects

In adults, murmurs are usually the result of problems with heart valves. This may be caused by an infection, such as infective endocarditis.

Valve problems can also simply occur as part of the aging process, due to wear and tear on your heart.

Regurgitation, or backflow, happens when your valves don’t close properly:

  • Your aortic valve can have aortic regurgitation.
  • Your mitral valve can have acute regurgitation that’s caused by a heart attack or a sudden infection. It can also have chronic regurgitation that’s caused by high blood pressure, infection, mitral valve prolapse, or other causes.
  • Your tricuspid valve can also experience regurgitation, usually caused by the enlargement (dilation) of your right ventricle.
  • Pulmonary regurgitation is caused by the backflow of blood into your right ventricle when your pulmonary valve can’t close completely.

Stenosis is a narrowing or stiffening of your heart valves. Your heart has four valves and each valve can have stenosis in a unique way:

  • Mitral stenosis is usually caused by rheumatic fever, a complication of untreated strep throat, or scarlet fever. Mitral stenosis can cause fluid to back up into your lungs, causing pulmonary edema.
  • Aortic stenosis can also occur because of rheumatic fever, and it may cause heart failure.
  • Tricuspid stenosis can occur because of rheumatic fever or heart injury.
  • Pulmonary valve stenosis is usually a congenital problem and runs in families. Aortic and tricuspid stenosis can also be congenital.

Another cause of heart murmurs is stenosis caused by hypertrophic cardiomyopathy. In this condition, the muscle of your heart thickens, which makes it harder to pump blood through your heart. This results in a heart murmur.

This is a very serious disease that’s often passed on through families.

Causes of clicks

Heart clicks are caused by problems with your mitral valve.

Mitral valve prolapse is the most common cause. It occurs when one or both flaps of your mitral valve are too long. This can cause some regurgitation of blood into your left atrium.

Causes of rubs

Heart rubs are caused by friction between layers of your pericardium, a sac around your heart. This is usually caused by an infection in your pericardium due to a virus, bacteria, or fungus.

Causes of galloping rhythms

A galloping rhythm in your heart, with a third or fourth heart sound, is very rare.

An S3 sound is likely caused by an increased amount of blood within your ventricle. This may be harmless, but it can also indicate underlying heart problems, such as congestive heart failure.

An S4 sound is caused by blood being forced into a stiff left ventricle. This is a sign of serious heart disease.

Ask the doctor: Is it worrisome to hear a pulse in my ear?

If you hear “heartbeat” thumping in your ear, it may be pulsatile tinnitus

Updated: December 13, 2019Published: November, 2009

Q. One morning last week I woke up hearing my heartbeat in my left ear. I hear it most clearly when I am in bed or sitting quietly. My health is good, and I was told after a recent cardiac workup that my heart was “perfect.” Should I be worried that I can hear the rhythmic pattern of my heart from inside my left ear?

A. What you describe sounds like pulsatile tinnitus (pronounced TIN-nih-tus or tin-NITE-us). It is a type of rhythmic thumping, pulsing, throbbing, or whooshing only you can hear that is often in time with the heartbeat. Most people with pulsatile tinnitus hear the sound in one ear, though some hear it in both. The sound is the result of turbulent flow in blood vessels in the neck or head. The most common causes of pulsatile tinnitus include the following:

Conductive hearing loss. This is usually caused by an infection or inflammation of the middle ear or the accumulation of fluid there. Sometimes it is caused by problems with the ossicles (small bones involved in hearing). This type of hearing loss intensifies internal head noises — sounds like breathing, chewing, and blood flowing through the ear. A conductive hearing loss also makes it easier to hear blood flowing through two large vessels that travel through each ear, the carotid artery and the jugular vein, which circulate blood to and from the brain.

Carotid artery disease. The accumulation of fatty plaque inside the carotid arteries can create the kind of turbulent blood flow that resounds as pulsatile tinnitus.

High blood pressure. When blood pressure is high, blood flow through the carotid artery is more likely to be turbulent and thus cause a pulsating sound.

Blood vessel disorders. A variety of malformations and disorders are occasionally the source of pulsatile tinnitus. These include a blood vessel with a weakened, bulging patch (aneurysm), an abnormal connection between an artery and vein (arteriovenous malformation), twisted arteries, or a benign blood vessel tumor (glomus tumor) behind the eardrum.

If you were my patient, I would take a careful history (a patient’s story often holds important clues), and then examine your ears. I would also use a stethoscope to listen to the blood flow through the arteries in your neck. If I did not find any obvious cause for your symptoms, I would likely recommend some additional testing, including a hearing test. If I heard a bruit (BROO-ee) — the unusual sound that blood makes when it rushes past an obstruction — in one or both carotid arteries, I would suggest you have a test to look for a narrowing in the carotid arteries or other malformations.

Most of the time, pulsatile tinnitus is nothing to worry about. If it doesn’t go away on its own after a few weeks or becomes really bothersome, talk with your doctor about it.

— David M. Vernick, M.D.
Assistant Clinical Professor of Otology and Laryngology
Harvard Medical School and Beth Israel Deaconess Medical Center

Image: Casara Guru/Getty Images

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As a service to our readers, Harvard Health Publishing provides access to our library of archived content. Please note the date of last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

Sound Of Your Heart

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About Sound Of Your Heart

“Sound of Your Heart” is a song recorded by Canadian singer-songwriter Shawn Hook for his third studio album, Analog Love (2015). It was released through Kreative Soul Entertainment under license to Universal Music Canada on February 17, 2015 as the album’s second single. Reaching the top 25 on the Canadian Hot 100 and being certified Platinum by Music Canada, it is Hook’s most successful single to date. The song was re-released internationally in early 2016 through Hollywood Records following Hook signing to the label and has since entered the Billboard Mainstream Top 40 chart and reached the top of the magazine’s Dance Club Songs chart. more “

Year: 2015 3:19 235 Views

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You were my courage, my sword and shield Grace under pressure, my wall of steel I was a stone, weighing us down You were the angel I chained to the ground I miss the way you undress, I miss your head on my chest Can’t stop this bleeding, can’t stop believing I’m missing the sound of your heart beating Baby I’m in love with you Oh I’m missing the sound of your heart beating Baby you were mine to lose Oh, I’m missing the sound of your heart beating You showed me heaven, you rang up bells I played with matches, it hurt like hell Asleep and wake, you’re all I see I can’t escape you, can’t set you free I miss your full moon rising, catching a breath in silence Can’t stop this bleeding, can’t stop believing I’m missing the sound of your heart beating Baby I’m in love with you Oh, I’m missing the sound of your heart beating Baby you were mine to lose Oh, I’m missing the sound of your heart beating Missing you, missing you I’m missing the sound of your heart beating Missing you, missing you I’m missing the sound of your heart beating Baby I’m coming, baby I’m coming Tell me now, baby I’ll come running Baby I’m coming, baby I’m coming Say the words, baby I’ll come running Baby I’m in love with you Oh and I’m missing the sound of your heart beating Baby you were mine to lose Oh and I’m missing the sound of your heart beating Oh, I’m missing the sound, I’m missing the sound of your heart beating, beating I’m missing the sound of your heart beating Missing you, missing you Oh, I’m missing the sound of your heart beating Missing you missing you Oh and I’m missing the sound of your heart beating Beating, beating, oh I’m missing the sound of your heart beating

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Shawn Hook

Shawn Hlookoff (born September 5, 1984, South Slocan, British Columbia, Canada), known as Shawn Hook, is a Canadian singer, songwriter and producer. more “

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Genre: Pop

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Written by: Shawn Travis Hlookoof, Sherman Todd Clark, Noel Stephen Kozmeniuk

Lyrics © Sony/ATV Music Publishing LLC

Lyrics Licensed & Provided by LyricFind

You were my courage
My sword and shield
Grace under pressure
My wall of steel
I was a stone
Weighing us down
You were the angel I chained to the ground

I miss the way you undress
I miss your hair on my chest

Can’t stop this bleeding
Can’t stop you leaving

I’m missing the sound of your heart beating
Baby I’m in love with you
Oh, and I’m missing the sound of your heart beating
Baby you were mine to lose
Oh, and I’m missing the sound of your heart beating

You showed me heaven
You rang a bell
I played with matches
It hurt like hell
Asleep, awake
You’re all I see
I can’t escape you
Can’t set you free

I miss your full moon rising
Catching a breath in silence

Can’t stop this bleeding
Can’t stop you leaving

I’m missing the sound of your heart beating
Baby I’m in love with you
Oh, and I’m missing the sound of your heart beating
Baby you were mine to lose
Oh, and I’m missing the sound of your heart beating
(Missing you, missing you 2x)
I’m missing the sound of your heart beating
(Missing you, missing you 2x)

I’m missing the sound of your heart beating
Baby I’m comin, baby I’m comin
Tell me now baby I’ll come running
Baby I’m comin, baby I’m comin
Say the word baby I’ll come running

Baby I’m in love with you
Oh, and I’m missing the sound of your heart beating
Baby you were mine to lose
Oh, and I’m missing the sound of your heart beating

Oh, I’m missing the sound
I’m missing the sound of your beating, beating
I’m missing the sound of your heart beating
(Missing you, missing you 2x)
Oh and I’m missing the sound of your heart beating
(Missing you, missing you 2x)
Oh, and I’m missing the sound of your heart beating

Beating, beating
Oh, I’m missing the sound of your heart beating

What causes the sound of a heartbeat?

Everyone knows what makes a heart beat — cute cashiers at the grocery ­store. But what is responsible for its distinctive sound? You know the one: lub-dub, lub-dub, lub-dub. Most of us think it’s the sound of our heart beating or contracting, but it’s not. What we’re hearing is the sound of two pairs of valves closing inside the chambers of our heart. Like turnstiles, these valves allow blood to move in one direction through the heart and keep it from backing up down a one-way street.

Can’t quite picture it? Imagine you’re going to a concert and two lines snake around the arena: one for lucky people who snagged floor-seat tickets and another line for ticket-holders headed to the nosebleeds. Each line has two sets of turnstiles. The first turnstiles that each line passes through rotate at the same time, controlling the flow of concertgoers into the venue. When these turnstiles rotate, they make a noise — lub.

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Now the two people in separate lines shuffle forward a few steps to the next turnstile to pass through security. As these would-be rockers cross through this second set, the turnstiles rotate in sync and make a different noise — dub.

All night long, people in both lines simultaneously pass through these two sets of turnstiles — lub-dub, lub-dub, lub-dub. If anyone goes through one and tries to go back, no luck. They only allow forward movement.

This scenario, minus the expensive nosebleed seats and the $50 concert T-shirt, is similar to how the valves in your heart work. Regardless of whether a red blood cell is holding a ticket for the lungs or a ticket for the arteries leading to the rest of the body, it will have to pass through two different chambers and two different valves as it’s propelled out of the heart and on to its destination.

Wi­th that much activity, it’s amazing that the sound of your heart doesn’t keep you up at night. But no, when we get back from the concert, remove our earplugs and collapse in bed, all we faintly hear is the sound of those four turnstiles — the valves — moving two at time. Lub-dub. Lub-dub. Lub-dub.

In the next section, we’ll learn more about how these valves keep a mob from forming inside your heart.

Heart Tones

The Quick and Dirty Guide to Heart Tones

What are they, Where are they, and What are they for?

Where to Listen

The location for auscultation of each heart sound is in the diagram above.
(M) Mitral (T) Tricuspid (A) Aortic (P) Pulmonic. The blue area is the pleura, pink is lung, red outline is heart.

Why should I care about heart sounds?

You can use heart tones in combination with other clinical findings to create a differential diagnosis and begin to treat heart failure and other cardiac pathologies en route. You can also provide a better picture to the ED, so they can treat your patient faster and more accurately. Paramedics and EMTs who know and listen to heart tones are the CSI team of cardiac EMS! By knowing what’s going on (or not going on) when you hear these sounds, it will make you a better medic. Its not hard, and you want to be a rock star, so learn them and practice them all the time. You’re not going to be able to pick out bad heart tones until you’ve listened to normal heart tones hundreds of times. As with everything clinical, practice practice, practice!

The two beats you should hear on a “normal” patient are called “Sound 1” and “Sound 2.” We shorten this to S1 and S2. They are the two “Lub dub” beats you hear in a normal heartbeat.

The First Heart sound (S1) “Lub” is caused by the closing of the Mitral (Bicuspid) and Tricuspid atrioventricular valves. If you want to review, we talked more about valves in our Quick and Dirty Guide to Cardiology I. The first sound (S1, Lub) is caused by blood slamming shut these valves. They generally shut at the same time in healthy patients so you only hear one nice distinct “Lub” The mitral side is operating at a much higher pressure, so the sound will mostly be coming from it. Sometimes, when the two atrioventricular valves aren’t shutting at the same time, you can hear them both, with the tricuspid sound much quieter. When this happens, its called a Split S1, and it is normal for about 40% of patients. Split S1 is also common in RBBB because of conduction delays. The time that you hear the S1 represents the beginning of systole (when the heart flexes ventricular muscle and SQUEEZES the blood out of it. .

The Second Heart sound (S2) “Dub” is caused by blood slamming shut of the semilunar valves (Aortic and Pulmonic). They generally shut at the same time in healthy patients so you only hear one nice distinct “Dub.” The left side (Aortic valve) is the loud one here because the left side of the heart is the high pressure side. Just like S1, these sounds can be split. The S2 sound means blood has left the ventricle and is no longer being allowed back in, so it represents the end of ventricular systole

Pro Tip: In Tachycardic (fast heart rate) patients, the two sounds “LUB DUB” sound the same sometimes and its hard to distinguish them. When you can’t tell which is which, feel a pulse while you’re listening. The Pulse is felt on every S1.

1.5 minute short video summarizing 1-2 again, so you can hear it and see it.

The Third Heart Sound (S3) “Ta” is short and called “ta.” Its known as a ventricular gallop because it makes the heart tones sound like a horse galloping. S3 is the sound of blood sloshing around in a compliant left ventricle. It occurs directly after “Dub” and is a lower pitch than “Dub.” It can be an important sign of heart failure. The best place to listen for an S3 is at the cardiac apex. (M in diagram)

Take 55 seconds and listen/watch S3 in action

The Fourth Heart Sound (S4) is rare. The best way to remember it is that it sounds like a gallop where the loudest sound (s1) comes in the middle. So, it sounds like Ta-LUB-dub, ta-LUB-dub. The S4 sound is usually caused by a failing left ventricle and is best heard at the cardiac apex.

Take 55 seconds and listen/watch S4 in action

Murmurs and Rubs

Murmers

A murmur is simply the sound of turbulent blood flowing through an incompetent valve. Sometimes hardening of the valve (stenosis) causes it to be unable to fully open or close, so blood is able to backflow against it. This is called regurgitation. It sounds like a miniature version of putting your thumb over the water hose. Here is a chart to where and when you will hear the murmur and to the condition with which it is associated. For the most part, just remember that a murmur is turbulent blood flow through a failing valve. Depending on where its heard and at what stage of lub-dub, you can predict which valve it is!

Quick Reference

As an example, here is the sound of a mitral valve regurge with a picture so you can see and hear that the blood is leaking back into the left atrium!

Pericardial Friction Rub

Pericardial friction rubs are the sounds of two layers of the pericardium rubbing together. It sounds awful and is loudest during systole (between the lub and dub) It is indicative of pericarditis (inflammation of the pericardium) and your patient is usually a chest pain CC. You can also see signs of pericarditis on a 12 lead (more about that in ECG lessons.) Pericarditis is also a significant STEMI imposter, so listening for a friction rub can be an important part of your differential diagnosis!

Take 55 Seconds and listen to a Pericardial Friction Rub

Test Yourself

Practice checking for s1, s2, splits, extra sounds and murmurs with this interactive online game. Very Helpful!

Want more??

Blaufuss.org Heart Tones tutorial (Amazing!)

Wikipedia Page on Heart Sounds

Advanced Murmur Videos explaining a TON of information about murmurs and their diagnostic capability
Part 2: Murmur Pitch
Part 3: Putting it all together

MedicTests.com’s Quick and Dirty Guide to Heart Failure

Normal

The two major sounds heard in the normal heart sound like “lub dub”. The “ lub” is the first heart sound, commonly termed S1, and is caused by turbulence caused by the closure of mitral and tricuspid valves at the start of systole. The second sound,” dub” or S2, is caused by the closure of aortic and pulmonic valves, marking the end of systole. Thus the time period elapsing between the first heart sound and second sound defines systole (ventricular ejection) and the time between the second sound and the following first sound defines diastole (ventricular filling).

There is also a third and a fourth heart sound, S3 and S4. They can occur in normal persons or be associated with pathological processes. Because of their cadence or rhythmic timing S3 and S4 are called gallops. Gallops are low frequency sounds that are associated with diastolic filling.

S3

The gallop associated with early diastolic filling is the S3 and may be heard pathologically in such states as volume overload and left ventricular systolic dysfunction. The S4 is a late diastolic sound and may be heard in such pathologic states as uncontrolled hypertension.

A common aid in distinguishing these sounds auditorily, is to remember that S3 has the same cadence as the word “Kentucky” and S4 sounds like “Tennessee”.

The stethoscope has been around for nearly 200 years and is still draped across every physician’s neck or tucked into lab coat pockets. No other medical device can boast a longer life or more useful purpose.

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But you may wonder what doctors are actually listening for when they place that cool metal cone against your chest. Cardiologist Umesh Khot, MD, lets us “listen in” on what your heart has to say.

“The most important assessment is whether it’s normal,” he says. “If the heart sound is normal, meaning that there’s a regular beat without any murmurs, that’s a pretty good sign of heart health.”

Sounds of trouble

1. Irregular rhythm: “Sometimes you hear an extra beat, sometimes it’s a skipped beat or it can be bouncing all over,” says Dr. Khot. “We can’t tell what the problem is that’s causing it, but we can get a sense of whether it’s in rhythm.”

2. Heart “murmurs:” A murmur itself isn’t the problem; the abnormal sounds – “whooshing” noises that vary widely — indicate a potential problem. “These signify blood flow problems within the heart, usually a problem with the valves,” Dr. Khot says. “The pitch and where it is in the heart can tell us what the valve problem is. We do additional testing to find out if it’s significant or not.”

3. Signs of congestive heart failure: These sounds are picked up by listening to the heart and lungs for both abnormal heart function and fluid in the lungs.

No matter what physicians hear through a stethoscope, it’s not enough to make a diagnosis. But such exams usually prompt further testing to uncover the cause of abnormal or irregular heartbeats.

Technological tweaks

Even the tried-and-true stethoscope is evolving with technology:

  • Electronic stethoscopes now help physicians hear your heart more easily through sound amplification and noise canceling technology.
  • Telemonitoring tools allow a physician to listen to your heartbeat remotely through wireless technology or the Internet.
  • New technology combines a stethoscope and electrocardiogram (EKG) so doctors can listen and watch heart rhythm simultaneously.

Still a lifesaving tool

Despite new technologies, the traditional stethoscope, without all the bells and whistles, is an enduring part of practicing medicine, says Dr. Khot.

“There’s a lot of evidence that the findings on this exam are powerful in diagnosing how sick a patient is,” he says. “Within five or 10 minutes you can get a quick sense of whether the person is sick and in need of emergency therapy to save his or her life.”

Heart doctors are listening for clues to the future of their stethoscopes

W. Reid Thompson, a pediatric cardiologist and an associate professor of pediatrics at Johns Hopkins School of Medicine, left, is a proponent of stethoscope training. (Ricky Carioti/The Washington Post)

The stethoscope is having a crossroads moment. Perhaps more than at any time in its two-century history, this ubiquitous tool of the medical profession is at the center of debate over how medicine should be practiced.

In recent years, the sounds it transmits from the heart, lungs, blood vessels and bowels have been digitized, amplified, filtered and recorded. Four months ago, the Food and Drug Administration approved a stethoscope that can faithfully reproduce those sounds on a cellphone app thousands of miles away or send them directly to an electronic medical record.

Algorithms already exist that can analyze the clues picked up by a stethoscope and offer a possible diagnosis.

But whether all this represents the rebirth of diagnostic possibility or the death rattle of an obsolete device is a subject of spirited discussion in cardiology. The widespread use of echocardiograms and the development of pocket-size ultrasound devices are raising questions about why doctors and others continue to sling earphones and rubber tubing around their necks.

“The stethoscope is dead,” said Jagat Narula, a cardiologist and associate dean for global health at the Icahn School of Medicine at Mount Sinai Hospital in New York. “The time for the stethoscope is gone.”

Not so, counters W. Reid Thompson, an associate professor of pediatrics at Johns Hopkins University School of Medicine. “We are not at the place, and probably won’t be for a very long time,” where listening to the body’s sounds is replaced by imaging. “It is valuable,” he said.

LISTEN: Audio of a normal heartbeat and two anomalies:

One thing on which both sides agree, however, is that doctors aren’t very good at using stethoscopes — and haven’t been for a long while.

In 1997, researchers examined how well 453 physicians in training and 88 medical students interpreted the information obtained via stethoscope. According to their study, “both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events.”

Nineteen years later, another team tried to determine when doctors stopped improving at “auscultation” — the art of listening to the body to detect disease. The answer: after the third year of medical school.

Worse, the researchers wrote in the Archives of Internal Medicine, that skill “may decline after years in practice, which has important implications for medical decision-making, patient safety, cost-effective care and continuing medical education.”

That can’t be what French physician René Laennec envisioned in 1816 when, reluctant to place his ear against a woman’s chest to listen to her heart, he rolled sheets of paper into a tube that amplified the sounds. He went on to invent the stethoscope and is considered the father of auscultation.

Medical students and residents listen during an auscultation training session at Johns Hopkins School of Medicine. (Ricky Carioti/The Washington Post)

In 2016, the device remains one of the last instruments that health-care providers use to infer the nature of a problem, rather than viewing it directly.

Doctors “are the most conservative people on earth,” said Sanjiv Kaul, head of the division of cardiovascular medicine at the Oregon Health and Science University. “Once they have learned something, they don’t want to learn something else.”

The stethoscope is also an icon, of course. Yet it carries more than symbolic value. It narrows the physical distance between doctor and patient. It compels human touch.

Medicine’s familiar list of woes is at least partly to blame for auscultation’s decline. Doctors, especially the overworked medical residents who staff hospitals, have much less time to spend with patients. That means less time for physical examinations, including listening with stethoscopes. The demands of electronic medical records have further eaten into time with patients, many doctors complain.

“It’s all chart rounds and computer readout rounds. It’s horrible. I cringe,” said John M. Criley, professor emeritus of medicine and radiological sciences at the David Geffen School of Medicine at UCLA.

For decades now, it has been easier to send a heart patient for an echocardiogram, and that increasingly sophisticated imaging test has proved more accurate than scope-to-chest interpretation of the lub-dubs, clicks, gallops and whooshes produced by the human heart.

Some doctors point out glumly that providers and hospitals can charge separately for echocardiograms. A chest exam with a stethoscope nets nothing extra.

Now the cycle is repeating itself: Young physicians have fewer mentors who can pass on the skill of auscultation. Thompson, Criley and a handful of others teach special classes to doctors-in-training, an effort to push back.

During a late-December session at Johns Hopkins Children’s Center in Baltimore, two young doctors and a medical student visiting from Syria listened intently to the recorded sounds of a heart coming through special stethoscopes, which receive an infrared signal from a computer. The “patient” was a teenage athlete who was suddenly having trouble keeping up on the soccer field. Was there a problem with her heart?

All three ventured that there was — perhaps a hole in the wall that separates the heart’s top two chambers. This condition, known as an atrial septal defect, was indeed the correct answer.

“Think of the power of what you did,” Thompson told the trio. “With no further assistance or technology than your stethoscope . . . you said, ‘I think she has an ASD.’ ”

Thompson has collected thousands of heart sounds and created MurmurLab.org for anyone who wants listening practice. This month he will unveil MurmurQuiz.org, a site that will allow professionals, students or anyone else to test their prowess interpreting what the sounds mean.

Some medical schools have chosen a different approach. Starting in 2012, Mount Sinai began giving its students hand-held ultrasound devices that are little bigger than a cellphone but can generate real-time images of the heart right at the bedside. Several other schools will join the experiment next fall.

Stethoscopes retain their value for listening to lungs and bowels for clues of disease, experts agree. But for the cardiovascular system, “auscultation is superfluous. We are wasting time,” Narula said. “Why should I not have an echocardiogram in my hand if it’s as small as the stethoscope?”

For now, that device is utilized most commonly in emergency rooms, where speed is critical. Its quality, said Thompson, is not yet good enough for routine use in other clinical settings.

But a 2014 study in the journal JACC Cardiovascular Imaging suggests the hand-held instruments are at least superior to physical examination. Cardiologists using them accurately identified 82 percent of patients with heart abnormalities, while cardiologists using physical examination caught 47 percent.

“It is time to discard the inaccurate, albeit iconic, stethoscope and join the rest of mankind in the technology revolution,” Kaul, one of the researchers, wrote in an editorial for the Knight Cardiovascular Institute at Oregon Health and Science University.

Others wonder what might be lost when doctors stop placing that round, often cold disc against a patient’s skin. In an essay last month in the New England Journal of Medicine, Elazer Edelman pointed out that a stethoscope exam is an opportunity to create a bond between doctor and patient.

“The link between patient and physician . . . is unlike any other relationship between two non-related people,” Edelman, a doctor who teaches at both Harvard Medical School and the Massachusetts Institute of Technology, stressed in an interview. “When one physically moves oneself farther and farther away, that link is either frayed or is torn.

“You can’t trust someone who won’t touch you.”

An earlier version of this story gave an incorrect name for the journal that published the 2014 study on stethoscopes. It is JACC Cardiovascular Imaging, not the Journal of American Cardiological Imaging. The story has been updated.

Normal heart sounds come in pairs. The sounds are often described as a constant “lub-dub, lub-dub.” The first “lub-dub” is the sound of the mitral and tricuspid valves closing. The second “lub-dub” is the sound of the aortic and pulmonary valves closing soon after. But if there is a problem, a murmur may be added to this normal “lub-dub.” By using a stethoscope to listen to your heart, your doctor’s trained ear can tell if the abnormal sound indicates turbulence. This is called a heart murmur.

Some heart murmurs are a harmless type called innocent heart murmurs. They are common in children and do not require treatment or lifestyle changes. In most cases, innocent murmurs disappear when children reach adulthood.

While some heart murmurs are innocent, others are a sign of a more serious heart problem. In these cases, the sound may indicate that blood is flowing through a damaged or overworked heart valve, that there may be a hole in one of the heart’s walls, or that there is a narrowing in one of the heart’s vessels.

What causes a heart murmur?

Murmurs can occur when blood is forced to flow through a narrowed valve (called stenosis), or when it leaks back through a defective valve (called regurgitation). These valve problems may be present at birth (congenital) or develop later in life because of rheumatic fever, coronary artery disease, infective endocarditis, or aging.

In other cases, a heart defect, such as a hole in one of the heart’s walls, can cause a murmur. Conditions such as pregnancy, anemia, high blood pressure, fever, or an overactive thyroid gland may also cause a heart murmur that comes and goes.

What are the symptoms?

Most people with a heart murmur do not have symptoms. Usually the murmur is found during a physical exam for other symptoms, such as chest pain, shortness of breath, fatigue, or the presence of a blue coloring to the skin or fingertips (called cyanosis).

How are heart murmurs diagnosed?

In most cases, your doctor will be able to hear your heart murmur by using a stethoscope to listen to your heart (a technique called cardiac auscultation). Heart murmurs change as your body position or breathing changes, so you may be asked to stand up, squat, lie down, breathe deeply, or hold your breath while the doctor listens to your heart.

To find out if your heart murmur is innocent or if it is caused by another heart problem, your doctor may also order these tests:

  • A chest x-ray to see if your heart is enlarged.
  • Electrocardiography (ECG or EKG) to check for an irregular heartbeat (arrhythmia) or an enlarged heart.
  • Echocardiography to see valve function, heart wall motion, and overall heart size.
  • A special medicine called amyl nitrate that is used to define certain heart murmurs. Your doctor will have you breathe in the medicine, which briefly changes your blood pressure and heart rate.

How are heart murmurs treated?

The treatment for a heart murmur depends on the cause. Innocent heart murmurs usually do not need to be treated. If your heart murmur is caused by an underlying condition, such as high blood pressure, your doctor will treat that condition. If your heart murmur is caused by disease of the valve itself (intrinsic valve disease) or other heart defects, medicines or surgery may be needed.

Lifestyle Changes

Doctors used to give anyone with a heart murmur antibiotic medicines before a dental or surgical procedure to prevent infection in your heart valves. (Some of these procedures may cause bacteria to enter the bloodstream, which can lead to infection.) Today, most doctors do not recommend routine antibiotics unless the murmur is caused by intrinsic valve disease. Talk to your doctor or dentist for current guidelines.

Medicines

Your doctor may prescribe certain medicines, depending on the underlying cause of your heart murmur.

  • Blood thinners (anticoagulants), which can prevent blood clots from forming and blocking blood vessels.
  • Beta-blockers, which help to slow a rapid heart beat or fluttering.
  • Medicines that lower blood pressure (antihypertensives), which ease the workload on the heart.
  • Antiarrhythmics, which control an irregular heartbeat (arrhythmia) and relieve the symptoms of heart palpitations.
  • Diuretics, which lower your blood pressure by ridding your body of extra fluid and salt.
  • Digoxin, which strengthens the force of the heartbeat.

Surgical Procedures

In some patients, surgery may be needed to repair a heart defect or repair or replace a damaged heart valve.

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