Heart Sounds and Physical Findings in Right Heart Strain

Key Auscultatory Findings

Accentuated pulmonary component (P2) of the second heart sound is often audible at the apex, reflecting increased force of pulmonary valve closure due to elevated pulmonary artery pressure, as noted by the American Thoracic Society 1
Fixed splitting of S2 during inspiration and expiration may suggest atrial septal defect with right heart volume overload, according to the American Heart Association 2, 3
A soft or absent aortic component (A2) may be present in severe cases, as reported by the American Heart Association 2, 3

Right ventricular S4 gallop due to forceful right atrial contraction against a stiff right ventricle is a common finding, as noted by the American College of Chest Physicians 1
Holosystolic murmur of tricuspid regurgitation, audible at the lower left sternal border and augmented with inspiration, is a characteristic murmur, according to the American Heart Association 1
Diastolic murmur of pulmonary regurgitation (low-pitched, early ending) in cases with pulmonary hypertension is a significant finding, as reported by the European Society of Cardiology 4

Right-sided murmurs generally increase with inspiration, while left-sided murmurs are louder during expiration, as noted by the American Heart Association 2, 3
Murmurs caused by blood flow across stenotic valves (e.g., pulmonary stenosis) become louder with both isotonic and isometric exercise, according to the American Heart Association 2, 3

Prominent jugular "a" wave suggesting high right ventricular filling pressure is a common finding, as reported by the American College of Chest Physicians 1
Hepatojugular reflux and a pulsatile liver in tricuspid regurgitation are significant physical findings, according to the American Heart Association 1
Peripheral edema and ascites indicating right ventricular failure are common complications, as noted by the American College of Chest Physicians 1

Right-axis deviation is a common ECG finding, as reported by the American College of Chest Physicians 1
Right ventricular hypertrophy patterns (tall R wave and small S wave with R/S ratio >1 in lead V1) are characteristic ECG findings, according to the American Heart Association 1

The presence of right heart strain sounds should prompt further evaluation with echocardiography to assess right ventricular function, pulmonary artery pressure, and tricuspid valve function, as recommended by the European Respiratory Society 5
Careful auscultation during various hemodynamic states helps characterize murmurs and differentiate causes of right heart strain, according to the American Heart Association 6

A right ventricular S3 gallop occurs due to rapid ventricular filling in a dilated, failing right ventricle and is best heard at the lower left sternal border, according to the European Heart Journal 7
A holosystolic murmur at the lower left sternal border is the characteristic murmur of tricuspid regurgitation, which occurs in approximately 80% of significant right heart failure cases due to annular dilation and leaflet tethering, as recommended by the American College of Cardiology 8
This murmur increases in intensity with inspiration (Carvallo's sign), a key distinguishing feature from left-sided murmurs, as noted in Circulation 9
A low-pitched, early diastolic murmur of pulmonary regurgitation may be present in cases with pulmonary hypertension, reflecting incompetence of the pulmonary valve due to elevated pulmonary artery pressures, according to the European Heart Journal 7

Elevated jugular venous pressure with prominent "c-V" waves is often the most reliable clinical sign of advanced tricuspid regurgitation, as recommended by the American College of Cardiology 8
A pulsatile liver edge (hepatojugular reflux) indicates significant tricuspid regurgitation with transmission of right ventricular systolic pressure to the hepatic veins, as noted by the American College of Cardiology 8

The absence of a murmur does not exclude severe tricuspid regurgitation, as the murmur may be inaudible even with severe tricuspid regurgitation, making jugular venous pulse examination critical, as recommended by the American College of Cardiology 8