Diastolic murmur at the apex. Diastolic murmurs

Subject: Auscultation of the heart. Noises. 1st lesson.

School time: 2 hours.

Purpose of the lesson: know: the mechanism of occurrence, classification, conditions of occurrence, places of listening and conduction of cardiac murmurs; be able to: listen to murmurs, distinguish systolic from diastolic murmurs, find the epicenter of the murmur and its points of origin; be familiar with: the importance of detecting murmurs during auscultation of the heart in order to establish the nature of the damage to the valvular apparatus of the heart.

Questions for theoretical preparation:

The mechanism of occurrence of heart murmurs. Noise classification. Conditions for the appearance of systolic murmur. Conditions for the appearance of diastolic murmur. Places for listening and carrying out noises and techniques that contribute to their amplification. Distinctive signs of damage to individual valves and orifices.

Heart murmurs are sound phenomena that occur together with or instead of tones. Unlike heart sounds, they are longer and are better heard in horizontal position, on the exhale.

Murmurs appear when the normal relationship of 3 hemodynamic parameters is disrupted:

1) the diameter of the valve opening and the lumen of the vessel;

2) blood flow velocity (linear or volumetric);

3) blood viscosity.

Murmurs can occur inside the heart itself (intracardial) and outside it (extracardiac).

Intracardiac murmurs are divided into:

1) organic, arising as a result of gross organic damage to the valves and other anatomical structures of the heart (interventricular or interatrial septum);

2) more functional noises, which are based on dysfunction of the valve apparatus, acceleration of blood movement through anatomically unchanged openings or a decrease in blood viscosity. Depending on the phase of cardiac activity, murmurs are divided into systolic and diastolic.

Mechanisms of noise generation.

All noises are stenotic in nature. With stenosis, the noise occurs with normal blood flow; with valve insufficiency, the noise occurs with reverse blood flow (regurgitation).

The noise intensity depends on:

1) the speed of blood movement, which is determined by the pressure difference between the cavities and the force of heart contractions.

2) the degree of narrowing, passage of blood flow (with very to a large extent narrowing, the noise may weaken or even disappear)

3) blood viscosity (the lower the blood viscosity, the higher the speed of blood movement, the more intense the noise).

Systolic murmur occurs when, during systole, blood moves from one part of the heart to another or from the heart to large vessels and encounters a narrowing on its way. Systolic murmur is heard with aortic stenosis or pulmonary trunk, since with these defects, during the expulsion of blood from the ventricles, an obstacle arises in the path of blood flow - narrowing of the mouth of the vessel. Systolic murmur is also heard with mitral and tricuspid valve insufficiency. Its occurrence is explained by the fact that during ventricular systole the blood will pass not only into the aorta and pulmonary trunk, but also back (regurgitation) into the atrium through the uncovered mitral or tricuspid orifice, which is the cause of the murmur.

Diastolic murmur occurs when there is a narrowing in the path of blood flow in the diastole phase.

It is heard when the left or right atrioventricular orifice is narrowed, since with these defects during diastole there is a narrowing in the path of blood flow from the atria to the ventricles. Diastolic murmur also occurs in case of insufficiency of the semilunar valves of the aorta and pulmonary trunk - due to reverse blood flow (regurgitation) from the vessels into the ventricles through the gap formed when the valve leaflets are not completely closed.

During auscultation it is necessary to determine:

1. The ratio of noise to the phase of cardiac activity (to systole or diastole);

2. Properties of noise, its nature, strength, duration;

3. Noise localization;

5. Influence physical activity on the volume of noise (with organic damage, the volume of noise increases).

Difference between systolic and diastolic murmurs.

Systolic murmurs appear together with or instead of the first sound, during a short pause of the heart; they coincide with the apical impulse and the pulse in the carotid artery.

Diastolic murmur occurs after the second sound during a long pause. There are three types of diastolic murmur:

1) protodiastolic, occurring at the very beginning of diastole, immediately after the second sound;

2) mesodiastolic, heard slightly later than the second sound, in the middle of diastole;

3) presystolic murmur, increasing, heard before the first sound, occurring at the end of diastole due to the acceleration of blood flow as a result of atrial contraction and is observed with mitral stenosis.

Places for listening to noises.

The localization of the noise corresponds to the place of best listening to the valve in the area in which the noise originated. Noises are well conducted in the direction of blood flow, along the compacted heart muscle.

Vices mitral valve.

1) Mitral valve insufficiency - a systolic murmur is heard at the apex of the heart instead of or together with the first sound, often occupies the entire systole, of a decreasing nature, resulting from regurgitation of part of the blood from the ventricle into the atrium. It is carried out in the third intercostal space on the left at the sternum with blood flow, and along the tense muscle of the left ventricle in systole to the axillary region.

2) Stenosis of the left atrioventricular orifice (mitral stenosis). Caused by obstructed blood movement from the left atrium to the left ventricle in diastole.

Diastolic murmur is heard at the apex, at the V point and is not carried anywhere. Noise has 2 options:

1) protodiastolic - occurs after the opening click of the mitral valve, has a decreasing character;

2) presystolic murmur of increasing character, best heard at the apex of the heart in a position on the left side.

Vices aortic valve.

1) Stenosis of the aortic mouth

Systolic murmur occurs during systole as a result of difficulty in expelling blood from the left ventricle into the aorta. Systolic murmur is localized in the left intercostal space to the right of the sternum, is carried out to the vessels of the neck, in the interscapular region, is not associated with the areas of the heart, occupies the entire systole, is rough and loud (ejection murmur).

2) Aortic valve insufficiency

The murmur occurs in diastole and is caused by regurgitation of blood from the aorta into the left ventricle. The maximum noise is located in the village of Botkina-Erba. The murmur occurs immediately after the P tone, diminishing in nature, and usually occupies the entire diastole.

Dependence of the sonority of noise on body position:

1) in vertical position Diastolic murmurs are better heard; blood flow is directed from top to bottom.

2) systolic murmurs are better heard in a horizontal position.

It is necessary to differentiate lesions of individual valves and orifices according to the following criteria:

1) place where the noise was heard;

2) connection with heart sounds;

3) conducting noise;

4) the nature of the noise.

Independent work plan:

Carry out auscultation of the heart in the demonstrated patients according to the sequence indicated in lesson 12. When listening to the heart, pay attention to the presence of additional sound phenomena between tones (murmurs). Determine in what phase of cardiac activity the murmur is heard (in systole or diastole). Pay attention to the timbre of the noise (gentle, blowing, sawing, scraping) and its duration. Find the epicenter of the noise and possible points of its conduction (V point, left axillary region, neck vessels, interscapular space). Check how the nature of the noise changes when the patient’s body position changes and after physical activity (if the patient’s condition allows).

1. Definition. One of the most common, in some cases very serious symptoms heart lesions are heart murmurs. At the same time, they can be listened to by practically healthy people. Cardiac murmurs are sound phenomena that arise in connection with the activity of the heart, are longer than tones, and represent irregular aperiodic oscillations of varying frequency and volume. Noises are usually longer than tones and are often formed by vibrations of a higher frequency, reaching about 400-1000 Hz.

2. Noise analysis.

· onset phase: systole, diastole, systole-diastolic interval.

epicenter of noise

nature of the noise (expulsion, regurgitation)

· intensity and timbre

· carrying out

· state of heart sounds (strengthening, weakening, accents, splitting of 3 and 4 tones).

additional sounds: the sound of the mitral valve opening, a systolic click inside

Rhythm assessment

3. Additional Methods diagnostics for heart murmurs.

· ECG, FCG, sphygmography

· EchoCG with Dopplerography

radiography chest, including with contrasting of the esophagus

angiocardiography, probing of the heart cavities

4. Basic heart murmurs

systolic ejection murmur

Organic systolic ejection murmur in aortic stenosis

inorganic systolic ejection murmur in aortic stenosis

systolic ejection murmur in coarctation of the aorta

Systolic ejection murmur in aneurysms of large vessels

systolic ejection murmur with ostial stenosis pulmonary artery

systolic ejection murmur in arterial stenosis

systolic murmur regurgitation

organic systolic murmur of regurgitation during mitral insufficiency

systolic murmur of regurgitation with relative mitral insufficiency

systolic murmur of regurgitation in mitral valve prolapse syndrome

Systolic murmur of regurgitation with tricuspid insufficiency

Diastolic ejection murmur

diastolic murmur of mitral stenosis

Diastolic murmur of “false” mitral stenosis

Diastolic murmur with tricuspid stenosis

Diastolic murmur of false tricuspid stenosis

Diastolic murmur regurgitation

diastolic murmur during aortic insufficiency

Diastolic murmur due to pulmonary valve insufficiency

Systole-diastolic murmurs

Systolic diastolic murmur with patent ductus arteriosus

Systolic diastolic murmur with arteriovenous pulmonary aneurysm

Systolic diastolic murmur with coarctation of the aorta

Heart murmurs not associated with damage to the valvular apparatus of the heart and blood vessels (extracardiac murmurs)

pericardial friction rub

cardiopulmonary murmurs

pleural-pericardial murmurs

Vascular murmurs:

arterial murmurs

· venous sounds

· Accidental noises

Functional noise

The mechanism of noise formation. Blood inside the heart and blood vessels usually moves laminarly, that is, each of its particles passes through equal and parallel paths in a certain period of time. Therefore it moves silently. Noises appear in cases where laminar blood flow is replaced by turbulent one. The resulting vortices create oscillatory movements that we perceive as noise.

Turbulent motion occurs in the following four cases:

1) when blood flows through a narrow hole;

2) when two differently directed blood flows meet;

3) when blood flow accelerates;

4) with a decrease in blood viscosity.

The first two mechanisms occur with congenital and acquired heart defects, the second two - with an unchanged heart - in connection with tachycardia after exercise, with fever, hyperthyroidism, and anemia.

Murmurs of an organic nature, i.e., associated with anatomical changes in the heart, are divided into: 1) ejection sounds, 2) filling sounds, 3) backflow sounds (regurgitation).

Ejection noises occur when blood is forcefully pushed through a narrow opening. This happens with stenosis of the aortic or pulmonary artery in systole, with stenosis of the left and right atrioventricular orifices in the last part of diastole. Ejection sounds are usually the loudest and are often not only heard, but also palpated.

Filling noises usually at low volume. They arise due to turbulence in the blood flow as it moves from a narrower area to a wider one. The forces moving the blood are small, much weaker than with ejection sounds. These noises quickly weaken, as the pressure difference during blood movement equalizes, the speed of blood movement, initially fast, approaches zero.

Reverse current noise (regurgitation) occur due to valve insufficiency. In this case, two blood flows occur - one normal, the other pathological, reverse, which would not have happened if the valve had not been damaged. The meeting of two blood streams is marked by turbulence and the appearance of sound waves. In terms of volume, these noises occupy intermediate position between ejection sounds and filling sounds. They are determined by insufficiency of the left and right atrioventricular valves and the aortic valve. They also occur with relative insufficiency of these valves.

Of great importance for diagnosis is phase, in which noise is heard. Systolic murmurs occur simultaneously or immediately after the first sound and occupy all or part of the systolic pause. If there is no “gap” between the first tone and the noise, then the noise is called non-interval. If a light gap is detected between the first tone and the noise, then such noise is called interval noise. Ejection noises are usually intervallic, while reverse flow noises on leaf valves are non-interval. Systole is mentally divided into 3 segments - protosystole, mesosystole and telesystole. Reverse flow murmurs are usually protosystolic, ejection murmurs are predominantly mesosystolic, since the ejection rate does not become maximum immediately, but after reaching its apogee it weakens again. Telesystolic murmurs are a rare phenomenon; they occur when the valve leaflets prolapse.

If the murmur occupies the entire systole, including both tones, then it is called pansystolic, but if the murmur does not include tones, it is called holosystolic. Diastole is also mentally divided into 3 parts - protodiastole, mesodiastole and presystole. If a protodiastolic murmur occurs simultaneously with the second sound, then it is called non-interval protodiastolic. Such murmurs are most often heard with insufficiency of the semilunar valves of the aorta and pulmonary artery.

If a free gap is detected between the second sound and the protodiastolic murmur, the murmur is called interval protodiastolic. Such sound phenomena are characteristic of narrowing of the atrioventricular orifices. Mesodiastolic murmurs, as well as interval protodiastolic murmurs, are observed with stenosis of the left and right atrioventricular orifices. Presystolic murmurs are usually associated with the expulsion of blood from the atria into the ventricles during active atrial contraction due to stenosis of the atrioventricular orifices.

Murmurs can be holodiastolic and pandiastolic, i.e., cover the entire diastole, including (or excluding) heart sounds. Finally, some defects are characterized by noise that covers both systole and diastole. Such murmurs are called continuous, or systole-diastolic. They occur with arteriovenous fistulas (for example, with non-union ductus arteriosus).

Epicenter called the place where the noise is loudest. Usually the epicenter of the noise coincides with the place where the valve is heard, where the noise occurs, but sometimes the epicenter shifts along the blood flow. Thus, the epicenter of noise in aortic stenosis is usually the second intercostal space to the right of the sternum, while the noise of aortic valve insufficiency is better heard at the Botkin-Erb point below and to the left of the place of noise formation.

As a rule, ejection noises are best heard at the point where they are formed, while the epicenters of return flow noises are shifted. Determination of the noise epicenter - important sign in the differential diagnosis of noise. This is also one of the characteristic features of organic noise; functional noises may have no epicenter at all, in equally listen at any point of cardiac dullness.

The most important characteristic of noise necessary for their differential diagnosis is carrying out. It was found that the noise “refers” to the direction of the movement of the blood stream, due to which it can be heard not only at the point of best auscultation of a given valve, but also at a certain distance from it, even (and this is very significant) outside cardiac dullness. Sound waves carried out especially well on dense tissues - bone tissue ribs and other parts of the skeleton. The nature of the noise is subject to certain rules:

a) noise is heard on both sides of the narrowing;

b) noise is best carried out in the direction of blood flow;

c) noise is also carried out better over a wider part of the tube.

Thanks to these patterns, noises arising from insufficiency of the left atrioventricular valve are carried out in the axillary region, to the mid- or even posterior axillary line, sometimes under the scapula. Systolic murmur with insufficiency of the left atrioventricular valve can be carried up to the Naunin and Botkin-Erb points.

Murmurs arising on the tricuspid valve can be transmitted to the right half of the chest, but their distant transmission is rarely observed. They are never carried out into the axillary region, which makes it possible to distinguish sometimes very similar sound phenomena of defects of the left and right atrioventricular valves.

Systolic murmur in aortic stenosis is directed to the right subclavian region, sometimes into the jugular fossa, very often onto the vessels of the neck. A similar noise when the trunk of the pulmonary artery is narrowed is carried out into the left subclavian cavity.

The noise in case of aortic valve insufficiency, following the blood flow, is carried out to the Botkin-Erb point, where it is often louder than at the aortic point. Sometimes it can be caught at the top and even in the armpit area.

The area of systolic murmur in case of non-fusion of the interventricular septum is very large - almost the entire chest. Typically, as you move away from the place where it originates, the noise gradually fades away. If, when moving the phonendoscope capsule, the noise intensifies again, then a different noise is heard. The loudness of the murmur depends on numerous intracardiac and extracardiac causes. In addition to the true loudness of the noise, the concept of loudness depends on subjective circumstances, hearing acuity, the quality of the phonendoscope, etc. Basically, the patterns here are as follows: expulsion noises are usually louder than return current noises and filling noises. With the onset of heart failure, the murmurs weaken. Organic noises are often louder than functional noises. All factors that influence the loudness of tones and are classified as extracardiac (chest thickness, pericardial effusion, pulmonary emphysema) also affect the loudness of cardiac murmurs. For a long time, doctors have distinguished between noises that increase (crescendo) and decrease (decrescendo).

In contrast to the idea of the shape of noise, the concept timbre noise - purely auscultatory. It depends on the frequency characteristics of the sound vibrations that make up the noise and on the overtones included in it. ABOUT diagnostic value The timbre of noise can be met with opposing points of view, up to the complete denial of the value of this feature.

The criteria for describing timbre noises are purely subjective. Often there are epithets - blowing, scraping, rough, soft. An experienced doctor “recognizes” certain defects by their characteristic timbre coloring (although this sign is not self-impressive). With stenosis of the aortic mouth, a prolonged, rough, sawing systolic murmur is heard. The diastolic murmur of stenosis of the left atrioventricular orifice is low-pitched, rumbling (“with the letter s...”), significantly different from the gentle, breathing-like noise of aortic valve insufficiency. The low-timbre noise of insufficiency of the right atrioventricular valve, reminiscent of buzzing wheezing in the lungs, is very characteristic. Systole-diastolic noise often has a special “humming” timbre when the ductus arteriosus is not closed.

It is believed that if in different points If two noises of different timbre are detected, then the mechanisms of their occurrence are different.

Occasionally, noises, due to the significant proportion of regular sinusoidal oscillations in their composition, acquire a musical character, like the vibration of a string. Musical we call those heart murmurs that are formed predominantly by regular sinusoidal oscillations. Such noises can be organic, functional or accidental, occurring in systole, diastole or both phases. They can be formed by oscillations of different frequencies (low-frequency musical noises - (150-100 Hz or less and high-frequency musical noises - 300-500 Hz or more). The latter are distinguished by a whistling or squeaking character when listening. The reasons for the “musical” timbre are numerous and not are always quite clear (the cause of such noises can be either minor changes in the structure of the heart valves, the location of the chordal filaments in relation to the blood stream, or serious pathological processes in the heart - perforation of the valves, rupture of the chordal filaments, etc.). Important role play resonance phenomena at the site of sound origin and in surrounding organs.

Correct assessment of noises sometimes seems impossible with conventional auscultation. A number of techniques have been proposed that are used in unclear cases. Usually all noises are better heard in the supine position. The murmur of aortic valve insufficiency is often easy to listen to in a standing position, and mitral murmurs are sometimes detected only in the left lateral decubitus position.

The Kukoverov-Sirotinin technique is known: in a standing position, when the head is pulled back and the arms are raised up, the systolic murmur in aortic stenosis, aortitis and atherosclerosis of the aorta becomes louder, the emphasis of the second tone over the aorta intensifies. Protodiastolic murmur with aortic valve insufficiency can sometimes be heard when the body is sharply tilted forward. If the results of the Kukoverov-Sirotinin technique are unclear, the study can be supplemented with the F.A. Udintsov technique: bending the torso forward.

It is important to study the features of noise changes in different phases of breathing. Usually, auscultation is most conveniently performed during exhalation. During exhalation, blood flow to the left ventricle increases slightly and all phenomena occurring in the left half of the heart intensify. During inhalation, the blood volume in the right half increases due to the action of the suction force of the chest. Therefore, all sound phenomena during inspiration intensify over the valves of the right half of the heart and weaken over the left half of the heart.

Physical activity causes tachycardia, but at the same time it increases the speed of blood flow, and therefore listening to the heart after slight physical exertion often gives Additional information. Usually all tones and noises of various origins are amplified.

All noises in their own way clinical significance are divided into 4 groups:

1) organic noises,

2) organofunctional noises,

3) functional noises,

4) accidental noises.

Organic noises are caused by congenital or acquired deformation of the heart valves such as valve insufficiency or orifice stenosis, as well as developmental anomalies in the form of shunts between the right and left parts of the heart.

Organo-functional noises occur in the absence of pathological processes on the valves, due to the expansion of cavities due to damage to the heart muscle - inflammatory, sclerotic or dystrophic in nature. In this case, expansion of the valve ring occurs and normal valves are unable to close the hole when they are closed. In such cases, they speak of relative valve insufficiency. The capacity of the cavity, as it expands, may increase so much that the normal opening is too narrow to allow all the blood accumulated in the cavity to pass through during systole of the corresponding part of the heart. In such cases we're talking about about relative stenosis of the foramen without obvious anatomical signs of its narrowing. The sound picture of organic and relative defects is very close and it is possible to distinguish them only on the basis of the entire set of clinical signs of the disease. Sometimes organo-functional murmurs appear when the heart muscle is weakened and disappear or weaken when its function is restored.

Functional noise (FS) occur in the intact heart due to accelerated blood flow, decreased blood viscosity during anemia, changes in the tone of the papillary muscles and for a number of other reasons that have not yet been clarified. In most healthy people, and in particular in most young men, functional systolic murmurs are heard over the apex and pulmonary artery. The difference between functional noises and organic and organo-functional ones is one of most important tasks upon auscultation. Functional noises are usually quiet. In most cases, they are heard in the mesocardium and do not have a clear epicenter. They are not carried out beyond the limits of cardiac dullness. Functional systolic murmurs above the apex are most often intervallic proto- or mesosystolic.

Indirect auscultatory symptoms are also used: the absence of weakening or unusual intensification of the first tone, the absence of emphasis of the second tone over the pulmonary artery and aorta indicates the functional nature of the noise. Other non-auscultatory symptoms should not be neglected: normal palpation data, absence of displacement of the borders of the heart also indicate the functional nature of the murmur.

Additional tests - with changes in body position, with physical activity - are not significant for distinguishing organic and organo-functional noises from functional ones. Functional murmurs are heard in 85% of children and adolescents. At this age, a normal three-part melody, a soft systolic murmur over the apex, not carried into the axillary region, and often a local blowing murmur in the area of the projection of the pulmonary artery are characteristic. As they grow and mature, this noise disappears.

PS for various diseases.

These are murmurs in patients with certain diseases, including the heart, but with unchanged valves; occur in patients with relative valve insufficiency or relative stenosis of the orifices, with changes in blood flow and rheological properties blood.

Most often, relative mitral valve insufficiency develops, the cause of which is pathological conditions that occur with dilation and hypertrophy of the left ventricle, which leads to expansion of the fibrous ring of the left atrioventricular orifice and incomplete closure of the valve leaflets during systole. This happens with myocarditis, dilated cardiomyopathy, arterial hypertension of any origin, aortic defects hearts. A systolic murmur with an epicenter at the apex is heard, most often blowing, not very loud, and, as a rule, not “musical.” Differential diagnosis with organic failure is based on an analysis of the clinical picture of the disease (no signs of a rheumatic process, bacterial endocarditis), echocardiography data. Often a functional systolic murmur is heard on the aorta in atherosclerosis. This noise is weaker than with organic stenosis, sometimes it is necessary to use additional techniques to detect it (the noise appears or intensifies with raised arms - Kukoverov-Sirotinin symptom), the noise is practically not transmitted to the vessels of the neck.

The causes of systolic functional murmur may be an acceleration of blood flow velocity and a decrease in blood viscosity. This is often observed in patients with anemia, thyretoxicosis, and sometimes with fever. Systolic murmur of this origin can be heard at many points; it is usually gentle, blowing, and on FCG occupies only part of systole. As the patient's condition improves and the blood flow speed decreases, the noise weakens and may disappear completely. Diastolic functional murmurs are very rare. The Graham-Steele murmur is heard in patients with severe pulmonary hypertension with mitral stenosis and is caused by relative insufficiency of the pulmonary valves. At the apex in patients with aortic insufficiency, a diastolic functional Flint murmur is sometimes heard. It occurs as a result of relative stenosis of the mitral orifice, when one of the leaflets seems to “cover” it under the influence of a stream of regurgitant blood from the aorta. Flint's murmur is protodiastolic, very gentle, is not combined with other signs of mitral stenosis, it cannot be registered on FCG (see Table 1 “Appendices”).

“Innocent” FS in practically healthy people.

“Innocent” functional murmurs are always systolic and are heard more often at the apex and pulmonary artery. Their mechanism is completely unclear, since they are detected in practically healthy individuals; in recent years, based on echocardiography data, they have been associated with dysfunction of the chordal filaments. To classify noise as “innocent”, you need to make sure that there is an intact, healthy heart. The boundaries of the heart are not changed, the tones are clear. Instrumental studies, as a rule, do not reveal significant pathology, although there may be some hemodynamic changes (hyperkinetic type of hemodynamics). The noise is usually very short, quiet, better heard in a supine position, and disappears in an upright position. In contrast to organic and functional muscle noise, “innocent” noise may disappear after exercise and reappear after some time. In most cases, routine clinical examination allows the murmur to be classified as “innocent.” However, in situations requiring expert assessment (conscription into the army, admission to certain types of work), additional examination is necessary.

Accidental noises can only be defined negatively. This includes noises that do not fit into the first two groups. The place and mechanism of their occurrence cannot be confidently identified in each individual case. Most of the systolic accidental murmurs can be likened to the sounds of leakage from pipes (Bondi) and are attributed to the formation of turbulence, due to the variability of the conditions of blood flow from the ventricles, which is already present in the norm. However, not all accidental sound phenomena can be associated with systolic blood flow from the ventricles. The possibility of murmur occurring in the ventricles themselves should also be considered.

In diastole, inorganic murmurs are also sometimes detected, which, however, can often be associated with functional stenosis of the atrioventricular orifices or with functional insufficiency of the semilunar valves and, according to the above definition, should be classified as functional. If the mechanism of the noise remains unclear, then we should talk about an accidental diastolic murmur. Although diastolic accidental murmurs (as opposed to systolic) are relatively rare, the statement that diastolic murmur always indicates organic valve damage cannot be considered fair. This statement was emphasized in the past and has been preserved in some textbooks to this day.

With the progress of our knowledge about the mechanism of noise generation, the group of accidental noises will decrease in weight more and more. We will never discover the causes of all accidental noises, since, most likely, there is no single cause due to the fact that a large number of very different changes in blood circulation can cause the occurrence of noises. Spitzbarth, in particular, recently showed this based on studies of peripheral circulation. It turned out that accidental noise was found in all individuals with a relatively large stroke volume and a wide peripheral bed, i.e., low peripheral resistance. As indicators of this state of hemodynamics, steep anacrosis, a short plateau and a high position of the incisura of the carotid sphygmogram were considered.

In children, accidental systolic murmurs are obligatory. With proper recording techniques, a weak systolic murmur can be detected in most adults. The mechanism of occurrence of systolic murmur in both normal and diseased valves is the same; there is only a quantitative difference between these murmurs.

From the above it follows that there are no reliable auscultatory and phonocardiographic signs of accidental systolic murmurs. The place of best perception of these noises is located at the level of the second fourth intercostal space at the left edge of the sternum, but some of them are best heard at the apex. Accidental noises are usually weaker than organic ones and are poorly conducted. But, as is known, the intensity of noise itself cannot serve as a decisive sign allowing us to consider noise

accidental or organic. In approximately two cases out of three, the noise is much weaker when the patient is sitting or standing, but the opposite relationship may also occur, or the intensity of the noise does not depend on body position at all. After physical exercise or inhalation of amyl nitrite, the intensity of accidental systolic murmur in most cases increases, and during the Valsalva maneuver and during extrasystoles it decreases.

If we consider heart murmurs from the perspective of phonocardiography, we will pay attention to their following forms (Fig. 1 “Appendices”).

It should be noted that the definition of “crescendo” and “decrescendo” murmurs is simplified, since each heart murmur, strictly speaking, must have a period of intensification and a period of attenuation. In relation to the total duration of the noise, these periods can, however, be very short and are neglected when determining the nature of the noise. In some cases, heart sounds are superimposed on the beginning and end of the noise, which are indistinguishable either on the phonocardiogram or during auscultation. Moreover, these characteristics depend on various factors(see Table 2 “Appendices”).

Extracardiac (extracardiac) murmurs: The noises perceived above the heart are naturally associated with the hemodynamic processes occurring in it. It should, however, be taken into account that above the heart and nearby authorities extracardiac may be detected sound vibrations, synchronous to the cardiac cycle and therefore similar to true cardiac murmurs. In terms of differential diagnosis, it is very important to be able to distinguish between them. Of course, murmurs in vessels located near the heart, such as in the patent ductus arteriosus, are also, strictly speaking, extracardiac. But usually I call extracardiac only those murmurs that are not associated with blood movement. Thus, these noises arise in connection with cardiac activity, however, not in the heart itself, but in the organs surrounding it: in the adjacent pleura, in the lungs, in the pericardium. They appear with dry fibrinous pericarditis: the leaves of the pericardium, due to the application of fibrin, lose their smoothness and when they are mutually displaced, sounds of varying volume and duration appear. Usually pericardial friction rub heard within the limits of absolute cardiac dullness. The timbre of the pericardial friction noise resembles the creaking of skin or the crunch of snow. He can be very quiet and gentle. The most characteristic pericardial friction noise - its incomplete coincidence with the heart melody, it occurs in both systole and diastole, and the time it is heard varies from cycle to cycle. The friction noise occurs mainly at the beginning of systole and the beginning of diastole, sometimes at presystole. Pericardial presystolic murmur differs from the presystolic murmur of mitral stenosis in its relatively early onset and in that it often ends before the first sound, including in cases where atrioventricular conduction is not slowed down. The higher-frequency composition of friction noise has already been mentioned above. The place of best perception can be different, sometimes changing in the same patient from day to day. The transition of a pericardial friction murmur from systole to diastole or vice versa is evidence that this is not an ordinary endocardial murmur. While the pericardial friction rub represents a rare event, extracardiac systolic murmurs are very common and important, as they provide grounds for erroneous diagnosis of cardiac defects.

The friction of the pericardial sheets against each other or the friction of the pericardium against the pleura is not associated with changes in pressure inside the heart and the resulting “play” of the valves. As kymographic studies clearly show, the heart at the critical point between contraction and relaxation is not at complete rest, but continues pendulum-like and rotational movements. It also shifts due to breathing. The intensity of the pericardial friction noise mostly depends on the phases of breathing: in some cases the noise is more intense during inspiration, in others - during exhalation. A reliable sign is a sudden increase or decrease in amplitude, i.e., very pronounced variability of the noise. Moreover, in individual cycles the location of the maximum and minimum noise can be completely different. In some cases, the noise is more intense when the patient is lying down, in others, on the contrary, when he is sitting.

Residual effects of pericardial friction murmur, which sometimes persist throughout life, are manifested by a rough late systolic murmur with or without a systolic click. When recorded graphically, cardiac and vascular murmurs look like more or less regular figures (triangles, rectangles, rhombuses). Extracardiac murmurs do not fit into these patterns; it is clearly seen that they arise without connection with the movement of blood in the heart or in large vessels. These murmurs are characterized by sudden increases and decreases in amplitude and are often not associated with periods of cardiac activity. Sometimes there is no constant maximum or minimum noise for all cycles. On auscultation, extracardiac murmurs correspond to a rough, “jumping” character of the sound.

Main distinctive features pericardial friction noise:

1. It is heard superficially, as if right next to the ear, and is sometimes detected by touch.

2. The friction noise does not coincide with the phases of cardiac activity and may consist of several fragments.

3. It is not carried out beyond the limits of cardiac dullness (“dies at the place of its birth”).

4. Does not have a specific epicenter, but is determined over the entire area of absolute cardiac dullness.

5. Intensifies when the torso is tilted forward and when pressed with a stethoscope capsule.

6. Often unstable, within a short time it can disappear and appear, change its localization and volume.

Pleural-pericardial murmur occurs with the development of fibrinous pleurisy in areas adjacent to the pericardium, where it is also observed inflammatory process. In their timbre, pleuro-pericardial noises are similar to the friction noise of the pericardium and the friction noise of the pleura, i.e., they resemble the crunch of snow. However, they are always localized along the edge of relative cardiac dullness, most often the left, and can intensify during inspiration, when the edge of the lung is pressed more tightly against the pericardium. At the same time, in time they coincide with the phases of cardiac activity. It is often possible to hear a pleural friction noise in areas of the chest distant from the heart.

Cardiopulmonary murmurs occur in those parts of the lungs that are adjacent to the heart; they are caused by the movement of air in the lungs under the influence of changes in the volume of the heart. These sounds are weak, blowing, similar to the nature of vesicular breathing, but coincide with cardiac activity, and not with the phases of breathing.

Depending on inhalation or exhalation, cardiopulmonary sounds change dramatically or even disappear. Since they can occur in healthy individuals, it is important to remember that cardiopulmonary murmurs can be mistaken for intracardiac murmurs and this will lead to incorrect diagnostic conclusions.

systolic murmur heart diastolic

Early diastolic (protodiastolic) murmur

Early diastolic (protodiastolic) murmur (Fig. 227.4, B) begins shortly after the second sound, as soon as the pressure in the ventricle becomes lower than in the aorta or pulmonary artery. A high-frequency murmur is characteristic of aortic regurgitation and pulmonary valve regurgitation caused by pulmonary hypertension. This noise decreases as the pressure gradient between the aorta (or pulmonary artery) and the ventricle gradually decreases.

To catch the weak high-frequency noise of aortic insufficiency, you need to ask the patient to sit down, lean forward, exhale completely and hold his breath. The phonendoscope is pressed firmly against the chest wall at the left edge of the middle third of the sternum. The sound of aortic insufficiency increases with sharp increase BP (manual press) and weakens when it decreases (inhalation of amyl nitrite).

Diastolic murmur with congenital pulmonary valve insufficiency is low- or mid-frequency (the pressure gradient between the pulmonary artery and the ventricle is small) and does not occur at the moment of valve closure, but a little later.

Early diastolic (protodiastolic) murmur occurs with aortic valve insufficiency and pulmonary valve insufficiency. Usually the noise is high-frequency, decreasing, especially in chronic aortic insufficiency. Its duration indicates the severity of the lesion: the shorter it is, the more severe the aortic insufficiency.

The murmur of aortic insufficiency is most often, but not always, best heard in the second intercostal space at the left sternal border.

With valvular lesions (rheumatic defect, congenital bicuspid valve, infective endocarditis) the noise spreads along the left edge of the sternum to the apex, with damage to the aortic root (aortoannular ectasia, dissecting aortic aneurysm) - along the right edge of the sternum. Sometimes the noise is heard only when bending forward at the height of full exhalation, when the aortic root approaches the anterior chest wall. In severe aortic insufficiency, a low-frequency presystolic murmur at the apex (Flint murmur) is sometimes heard; it occurs due to the fact that during atrial systole, the counter jet of aortic regurgitation hits the anterior cusp of the mitral valve and causes it to vibrate. Flint's murmur must be distinguished from the murmur of mitral stenosis. In the absence of heart failure, severe chronic aortic insufficiency is accompanied by symptoms of reverse diastolic blood flow in the aorta: large pulse pressure and high rapid pulse (Corrigen's pulse).

In acute aortic insufficiency, the murmur is noticeably shorter and its frequency is lower. With tachycardia, this noise is difficult to hear. There may also be no symptoms of reverse diastolic blood flow in the aorta, since in the recalcitrant left ventricle diastolic pressure increases very quickly and the pressure gradient between the aorta and left ventricle disappears.

In pulmonary valve insufficiency, a murmur (called a Graham Still murmur) begins simultaneously with an increased (palpable) pulmonary component of the second sound, is best heard over the pulmonary artery and is conducted along the left sternal border. Usually the noise is high-frequency decreasing. It indicates severe pulmonary hypertension with a high diastolic pressure gradient between the pulmonary artery and the right ventricle. The murmur intensifies on inspiration, which distinguishes it from the murmur of aortic insufficiency. There are often symptoms of right ventricular pressure and volume overload.

In mitral stenosis, a diminishing early diastolic murmur along the left sternal border is most often caused by concomitant aortic regurgitation rather than pulmonary valve insufficiency, although these patients do have pulmonary hypertension.

Pulmonary valve insufficiency is not necessarily caused by pulmonary hypertension: it can also be congenital, and occasionally the valve is affected by infective endocarditis. The murmur begins simultaneously with the pulmonary component of the second sound or immediately after it. In the absence of pulmonary hypertension, the murmur is low-frequency and less loud than the classic Graham Still murmur.

Heart: mesodiastolic murmur

A mesodiastolic murmur occurs during early diastolic filling (Fig. 227.4, D) due to a discrepancy between the size of the mitral or tricuspid valve orifices and the volume of blood flow through them. The duration of the murmur is a much better indicator of the severity of the stenosis than the loudness: the more severe the stenosis, the longer the murmur, whereas with normal cardiac output the murmur can be quite loud ( III degree), despite slight stenosis. Conversely, the murmur may weaken and even disappear in severe stenosis if cardiac output is significantly reduced.

The low-frequency murmur of mitral stenosis immediately follows the opening click of the mitral valve. It is best to listen to it at the apex using a stethoscope with the patient in the left lateral position; Sometimes this is the only way to hear this noise. To strengthen it, you can resort to slight physical activity while lying down or inhaling amyl nitrite.

With tricuspid insufficiency, the noise is heard in a rather limited area at the left edge of the sternum, it intensifies with inspiration.

A mesodiastolic murmur is most often caused by mitral stenosis or tricuspid stenosis or increased blood flow through the AV valves. A classic example is rheumatic mitral stenosis (Fig. 34.1, E). If there is no pronounced calcification of the leaflets, then a loud (popping) first sound and a click of the opening of the mitral valve are heard, followed by a murmur. The higher the pressure gradient between the left atrium and the ventricle, the shorter the interval between the second sound and the opening click. The noise is low-frequency and is best heard with a stethoscope at the top of the stethoscope. The murmur is aggravated in the left lateral position, and the duration of the murmur, rather than its loudness, reflects the severity of the stenosis: a prolonged murmur indicates that a pressure gradient between the left atrium and ventricle is maintained throughout most of diastole. Against the background of sinus rhythm, a presystolic increase in murmur is often detected (Fig. 34.1, A), corresponding to atrial systole.

With tricuspid stenosis, the murmur is in many ways similar to the murmur of mitral stenosis, but it is heard along the lower third of the left edge of the sternum and, like other murmurs from the right side of the heart, intensifies with inspiration. You may also find a flat Y-slope on venous pulse examination and symptoms of right ventricular failure.

Mesodiastolic murmur also occurs in other diseases; in all cases necessary differential diagnosis with mitral stenosis.

With left atrial myxoma there is no opening click of the mitral valve and no presystolic increase in murmur. A brief, low-frequency apical murmur may be caused by increased mitral valve flow in severe mitral regurgitation, intracardiac shunt, or extracardiac shunt. This noise is low-frequency, it appears after a quiet third sound (which occurs later than the click of the mitral valve opening; Fig. 34.1, G). Increased diastolic blood flow through the tricuspid valve in severe tricuspid regurgitation leads to similar sound phenomena. In severe aortic insufficiency, a Flint murmur is heard.

Mesodiastolic murmur above the mitral valve occurs not only with stenosis, but also with severe mitral regurgitation, patent ductus arteriosus and ventricular septal defect with large shunt, and above the tricuspid valve - with severe tricuspid regurgitation and atrial septal defect. This murmur is caused by very high blood flow and usually follows the third sound.

A soft mesodiastolic murmur is sometimes heard during rheumatic attacks (Coombs' murmur), probably caused by valvulitis.

In acute severe aortic regurgitation, the diastolic pressure in the left ventricle may be higher than in the left atrium, leading to the appearance of a mesodiastolic murmur called “diastolic mitral regurgitation.”

In chronic severe aortic insufficiency, a mesodiastolic or presystolic murmur (Flint murmur) often appears. The murmur occurs due to the fact that during atrial systole, the oncoming flow of aortic regurgitation hits the anterior leaflet of the mitral valve and causes it to vibrate.

Presystolic murmur

Presystolic murmur occurs during atrial systole, therefore it occurs only when sinus rhythm. The most common reason- tricuspid stenosis or, less commonly, mitral stenosis. Another cause is myxoma of the right or left atrium. The murmur resembles a mesodiastolic murmur, but in shape it is usually increasing and reaches a peak at the beginning of the loud 1st sound.

Presystolic murmur occurs against the background of moderate obstruction, in which the transmitral or trans-tricuspid pressure gradient remains small throughout diastole and increases only during atrial systole.

Heart: systolic-diastolic murmur

Systole-diastolic murmur begins in systole, reaches a maximum at the second sound and continues into diastole, sometimes occupying it all (Fig. 34.1, 3). This murmur indicates continuous communication between the chambers of the heart or continuous communication between large vessels in both phases cardiac cycle. The noise increases with increasing blood pressure and decreases with inhalation of amyl nitrite. Artificial aortopulmonary or subclavian pulmonary shunts lead to the appearance of a similar noise.

The causes of systole-diastolic murmur are listed in Table. 34.1. In two cases this is a variant of the norm.

With pulmonary hypertension, the diastolic component disappears and the murmur becomes systolic, therefore, with an aortopulmonary septal defect, which is always accompanied by severe pulmonary hypertension, systolic-diastolic murmur is rare.

A murmur over the veins of the neck is heard in children and young people in the right supraclavicular fossa and disappears when the internal jugular vein is compressed; its diastolic component is usually louder than the systolic one.

Vascular murmur over the mammary glands is caused by an increase in blood flow in them at the end of the third trimester of pregnancy and during lactation; if the phonendoscope membrane is pressed harder, the diastolic component disappears.

A classic example of a systolic-diastolic murmur is the murmur of a patent ductus arteriosus. It is heard above or to the left of the pulmonary artery and is sometimes performed on the back. With large shunts, pulmonary vascular resistance increases over time, so the diastolic component of the murmur decreases or disappears.

Systole-diastolic murmur also occurs when an aneurysm of the sinus of Valsalva ruptures (congenital or caused by infective endocarditis). A fistula forms between the aorta and one of the parts of the heart, most often the right atrium or ventricle. The pressure gradient on its different sides is high both in systole and diastole. The murmur is heard along the right or left edge of the sternum and is often accompanied by tremors. It is noteworthy that the diastolic component of the murmur is louder than the systolic component.

Systolic-diastolic murmur is sometimes difficult to distinguish from a combination of systolic and diastolic murmurs, for example, with combined aortic valve disease or severe aortic insufficiency; What helps here is that the true systole-diastolic murmur is not interrupted by the second sound.

There are other causes of systole-diastolic murmur.

At coronary fistula Sometimes a weak systole-diastolic murmur with a louder diastolic component is heard at the left edge of the sternum or at the apex.

Systole-diastolic murmur can also occur with severe stenosis of a large artery. With stenosis of the branches of the pulmonary artery or atresia of the branches of the pulmonary artery and well-developed bronchial collaterals, a systolic-diastolic murmur is heard on the back or in the left axillary region.

A similar murmur is detected in severe coarctation of the aorta; it is characterized by a low delayed pulse in the legs and high blood pressure in the arms, the source of noise is dilated intercostal arteries.

Pericardial friction rub

A pericardial friction rub is an intermittent, grinding noise that may consist of presystolic, systolic, and early diastolic components. If it is heard only in systole, then it can be mistaken for a cardiac or vascular murmur.

The pericardial friction noise increases with full exhalation. It is best heard when the patient is sitting, leaning forward.

Detection and interpretation of heart murmurs are often difficult and require experience and knowledge of physiology and cardiology. Currently, if a murmur is present, the patient is immediately referred for echocardiography. Murmurs are audible vibrations caused by turbulent blood flow. They are described using a large number of characteristics given in table. 1. Noises vary in intensity (loudness), as described in table. 2.

Table 1.

Description of noise

Intensity (loudness)	Degrees 1-6 (or 1-4) (see table 1)
Duration	Short to long noise
Character (shape)	Crescendo, decrescendo, variable, plateau, crescendo-decrescendo
Time	In relation to the phases of the cardiac cycle, for example mid-systolic, pan-systolic, late systolic, early diastolic
Frequency	High or low frequency
Character	For example, blowing, rough, scratching, gurgling, scraping, etc.
Localization	Maximum intensity
Carrying out	Conducting noise to auscultation points (including the vessels of the neck)
Variability	Variability depending on the phases of breathing

Table 2.

Noise intensity gradations

Degrees 1-6	Degrees 1-4	Description
1	1	Very little noise. Usually only an experienced doctor can listen to him
2	2	Faint but distinct noise
3	3	Loud noise without accompanying vibration
4	4	Loud noise accompanied by subtle shaking
5	4	Loud noise accompanied by distinct shaking
6	4	Loud noise accompanied by shaking, audible when the stethoscope is removed from the surface of the chest

Functional noise

Not all noises are pathological; quite often there are functional noises that occur during hyperkinetic blood circulation, for example in healthy children, as well as during pregnancy, thyrotoxicosis, against the background of fever and anemia. Their presence may require an echocardiogram to ensure that the murmur is truly functional. Such murmurs are always systolic, usually quiet or of moderate intensity, have a “musical” tone, and are not rough or blowing.

Systolic murmurs

Blood flow through pathologically altered structures leads to the formation of noise due to the presence of a pressure gradient (on a pathologically altered valve, in the area of a septal defect, with coarctation, etc.). The louder the noise, the greater the pressure gradient and the higher the blood flow velocity. The murmur does not occur until the expulsion of blood from the left ventricle begins, and reaches a maximum at the moment of greatest blood flow through the narrowed opening. Consequently, in severe stenosis, the peak of the murmur is recorded in late systole. The murmur stops before the start of the second sound, as cardiac output stops. Therefore, the noise has a crescendo-decrescendo shape. This noise is called ejection noise. Since the murmur is dependent on blood flow, it may weaken or disappear when the degree of valve damage is very severe and leads to HF. The systolic murmur of regurgitation on the MV can occur as soon as the isovolemic contraction begins, that is, before the onset of ejection, since the reverse flow of blood occurs simultaneously with the beginning of an increase in pressure in the ventricle and continues until the appearance of the second sound or ends a little earlier. This occurs due to the pressure difference between the LV and LA during systole. Often the second tone is covered by noise. Murmurs of this type, occupying the entire systole, are called pansystolic or holosystolic. Pansystolic murmur also occurs with a ventricular septal defect (VSD). However, in many patients with mitral regurgitation, the valve failure is incomplete, and then the murmur begins in the middle or even at the end of systole and continues until the second sound. Late systolic murmurs may have a crescendo shape, which resembles an ejection murmur, but they arise much later in systole, cover the second sound, and then suddenly stop. To an experienced doctor it is not difficult to determine this, especially in the absence of pronounced tachycardia, but sometimes a systolic click in the middle or end of diastole is mistaken for the second sound, and the murmur is interpreted as diastolic.

Diastolic murmurs

Diastolic murmurs on AV valves it is very difficult to hear. These noises are usually low-frequency and may be mistaken for external noise by an inexperienced physician. Typically, diastolic murmur is a sign of mitral stenosis (sometimes TC stenosis), and these defects are becoming less common in developed countries. The diastolic murmur of mitral stenosis intensifies when the patient is positioned on the left side when listening to the apex area with a phonendoscope cone and/or after physical activity. Mid-diastolic murmurs intensify immediately before the onset of the next systole, since in presystole the blood flow through the MV increases due to atrial contraction (Table 3). This presystolic enhancement usually disappears as AF progresses, but may sometimes persist.

Table 3.

Differential diagnosis of systolic murmurs

	Cause	Localization	A comment
Systolic ejection murmur	Aortic stenosis	To the left of the sternum in the area of the upper third, also often at the apex. Held on carotid arteries	Slow pulse in the carotid arteries, but not always detected in the elderly. The apical impulse is usually elevating, but not displaced. In young people, the noise may be preceded by an ejection tone. The II tone varies, with severe valve calcification there is no splitting
	Pulmonary artery (PA) stenosis	To the left of the upper edge of the sternum	Intensifies on inspiration. Ejection tone, possibly delayed pulmonary component II tone
			Fixed splitting of the second tone. With a large discharge, you can palpate the contracting pancreas along the left edge of the sternum
	Functional	All points. "Musical"	May occur with high cardiac output
Pansystolic	Mitral regurgitation	At the apex, carried into the axillary region	It varies greatly, but with valvular regurgitation it often blows and covers the second sound. Pulsating top. In case of severe defect, mid-diastolic murmur and III tone may appear
	Tricuspid regurgitation	Along the left edge of the sternum	It intensifies on inspiration, the v-wave of the pulse is pronounced in the jugular veins, and pulsation of the liver is possible. Pulsation to the left of the sternum is also possible - a sign of pulmonary hypertension
		Along the left edge of the sternum	Usually rough, often accompanied by trembling. Single II tone with a large defect
Late systolic	Mitral regurgitation associated with damage to subvalvular structures (MVP, chord avulsion)	At the apex, carried into the axillary region, but can also carried out in the back and neck area	Often rough, the murmur may be preceded by a systolic click. Elevating apical impulse, mid-diastolic murmur and III sound with severe mitral regurgitation. Can be confused with an early diastolic murmur if it is preceded by a late click, which is mistaken for the second tone
Presystolic	Mitral stenosis (and also TC stenosis - very rare)	At the apex and left edge of the sternum	Sometimes it is difficult to recognize. The murmur is often mistaken for systolic and associated with mitral regurgitation. It is necessary to carefully compare the noise with the pulsation of the carotid arteries

Early diastolic murmur

Early diastolic murmurs occur due to regurgitation of blood at the AC or PC. They have a decrescendo shape and follow directly the second tone. This results from the fact that the maximum pressure difference between the vessel and the ventricular cavity occurs at the beginning of diastole. Minor aortic regurgitation results in a short, soft early diastolic murmur that is difficult to hear, but the intensity of the murmur may increase as the patient bends forward and exhales. These actions make regurgitation better audible due to the closer location of the heart to the anterior surface of the chest. An increase in noise intensity may be associated with an increase in the degree of the defect, but sometimes paradoxical situations arise. When chronic aortic regurgitation is very severe, backflow of blood from the aorta into the ventricle occurs very quickly and the murmur becomes loud but very short. This phenomenon is even more pronounced with the development of acute aortic regurgitation due to valve damage due to endocarditis, dissecting aneurysm or trauma. Before the onset of the defect, the LV has normal size, and a sudden large volume of regurgitation instantly fills it to its maximum limit, leading to slamming of the MV. This leads to extremely low cardiac output and the appearance of a very short noise. Clinical signs include collapse, sinus tachycardia and the appearance of an auscultatory pattern resembling a gallop rhythm. An experienced cardiologist will immediately recognize severe degree acute aortic regurgitation and prescribe appropriate examination, including emergency echocardiography. Often, emergency surgery for AK can save the patient's life, but if the diagnosis is not made in a timely manner, the consequences can be fatal. Pulmonary hypertension leads to the appearance of an early diastolic murmur, which has a lower pitch than the murmur of aortic regurgitation. An early diastolic murmur is heard in the upper part of the sternum along its left edge and follows the loud pulmonary component of the second sound (a sign of pulmonary hypertension).

Systole-diastolic murmurs

Systole-diastolic murmurs are rare in adults. These are murmurs heard throughout the entire cardiac cycle. The systolic component is usually louder than the diastolic component, but there seems to be no interval between them, and they are well named "engine noises" because they are similar to the sound of a running engine. A systole-diastolic murmur may be a sign of a patent ductus arteriosus that was undiagnosed in childhood. However, most often in adults, systolic-diastolic murmur is a sign of an acutely developed fistula between the right and left chambers of the heart. In this case, blood flow occurs in both systole and diastole. The most common example is a rupture of the sinus of Valsalva, although infective endocarditis can lead to the formation of an arteriovenous and right-sided shunt.

Carotid murmurs

Systolic murmur on the carotid arteries has the following properties.

1.Can be performed from the heart valves - usually the aortic, although loud mitral murmurs may also be heard in the neck. The same noise will be heard above the surface of the chest.

2. It may occur due to damage to the carotid arteries, in this case it is heard only in the neck. It is sometimes difficult to understand whether there is a combined lesion of the valve and carotid arteries or an isolated lesion of the AV.

Noise irradiation

The irradiation of noises is complex, and in general any noise can be carried out to any point in the chest. Nevertheless there is typical areas- apical/mitral, pulmonary, aortic and tricuspid zones with irradiation to the carotid arteries, back and/or axillary region. It must be remembered that loud noises during MVP and chord rupture can be carried out anywhere, including to the vessels of the neck, and resemble the noise during aortic stenosis. Moreover, the noise of aortic stenosis in elderly patients is characterized by a louder sound at the apex than at classical auscultation points. This occurs due to emphysema in the elderly and interferes with auscultation, especially at the base of the heart. Aortic murmurs, heard only at the apex, are often carried out on the carotid arteries.

Other auscultatory phenomena

The pericardial friction noise that occurs with pericarditis is caused by the friction of the inflamed pericardial layers against each other with each contraction of the heart. It is an intermittent scraping sound with systolic and diastolic components. It is better heard when the patient is lying on his back, and may disappear when the patient sits down and bends forward - in this position, as a rule, the pain associated with pericarditis decreases. You should always think about the presence of pericarditis when you see a patient sitting on the bed, leaning forward.

Roger Hall, Iain Simpson

History taking and physical examination of patients with cardiovascular diseases

Diastolic murmur (murmur diastolicum; Greek diastolē stretching, expansion)

heart murmur heard in the interval II to I heart sound, i.e. during ventricular diastole; may occupy the entire period of diastole or be heard in its individual phases, for example at the beginning, immediately after the second heart sound (murmur), or at the end, immediately before the first heart sound (presystolic murmur). The ratio of noise to any phase of diastole is determined both by auscultation and, more accurately, by recording noise and heart sounds using phonocardiography (Phonocardiography) . Diastolic murmur is a pathological auscultation sign; most often heard with heart defects, and each defect has its own characteristics. Thus, protodiastolic murmur is characteristic of aortic or pulmonary valve insufficiency, presystolic murmur is characteristic of mitral stenosis (see acquired (Acquired heart defects)) . Auscultation points are identified at which the intensity of diastolic murmur for a given defect is greatest - see Cardiac murmurs .

1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. encyclopedic Dictionary medical terms. - M.: Soviet Encyclopedia. - 1982-1984.

See what “Diastolic murmur” is in other dictionaries:

Diastolic Sh., heard during the period of filling the ventricles of the heart with blood with narrowed atrioventricular openings ... Big medical dictionary

I a chaotic combination of sounds of different strength and frequency; may have adverse effects on the body. The source of Sh. is any process that causes local change pressure or mechanical vibrations in solid, liquid and... ... Medical encyclopedia

- (syn. Sh. double machine) rough systole-diastolic Sh., reminiscent of the noise of a steam engine, caused by the opposite direction of blood flow during systole and diastole, for example. with defects of the heart septum, with non-fusion... ... Large medical dictionary

A rough, growing murmur that occurs in mid-diastole, decreasing slightly just before the first clapping sound; sign of mitral stenosis... Large medical dictionary

Rough rumbling presystolic murmur heard above the apex of the heart and at the fifth point and merging with the clapping first heart sound; sign of mitral stenosis... Large medical dictionary

- (m. diastolicum) Sh. of the heart, heard throughout the entire diastole or one of its phases ... Large medical dictionary

DIASTOLIC murmur- DIASTOLIC murmur, pat. a sound phenomenon heard over the region of the heart during ventricular diastole. D. sh. They are organic and functional. Based on their origin, there are 4 organic D. sh.: 1) with narrowing of the left venous opening, ... ... Great Medical Encyclopedia

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- (Graham Steell, 1851 1942, English doctor; synonym: Graham Still murmur nrk, Still murmur) diastolic murmur heard in the area of the projection of the pulmonary valve with its relative insufficiency caused by significant pulmonary... ... Medical encyclopedia

GRAHAM STILLE NOISE- (named after the British doctor Graham Steell, 1851–1942) - a quiet decreasing diastolic murmur sometimes heard with mitral stenosis in the second intercostal space to the left of the sternum, starting with the second sound (a consequence of relative insufficiency... ... Encyclopedic Dictionary of Psychology and Pedagogy