When evaluating the intensity of S2, note the relative intensity of the aortic component (A2) and the pulmonic component (P2). Pathologic changes in the intensity of S1 relative to S2 may be seen in certain disease states. Normally, S1 is louder than S2 at the apex, and softer than S2 at the base of the heart. The intensity of S1 depends upon: the position of the AV valves at the onset of ventricular systole, the structure of the leaflets themselves, and the rate of pressure rise in the ventricle. When listening to the first and second heart sounds with the diaphragm of the stethoscope, note the intensity of each sound, note if each is a single or split sound, and note any respiratory variation.
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