Listening to the heart (auscultation). Auscultation of the heart: heart sounds, their splitting, bifurcation, additional tones Accent 2 tones over the pulmonary artery

The work of the heart is accompanied by tension and periodic movements of its individual parts and the blood contained in the heart cavities. As a result of this, vibrations arise that are conducted through the surrounding tissues to the surface of the chest wall, where they can be heard as separate sounds. Auscultation of the heart allows you to evaluate the properties of sounds that occur in the process of cardiac activity, determine their nature and causes of occurrence.

First, in a certain sequence, the heart is heard at standard auscultation points. If auscultatory changes are detected or other symptoms indicating a pathology of the heart are detected, the entire area of absolute cardiac dullness is additionally listened to, above the sternum, in the left axillary fossa, interscapular space and on the arteries of the neck (carotid and subclavian).

Auscultation of the heart is first performed in the patient's standing (or sitting) position, and then in the supine position. In order for the auscultation of the heart not to interfere with respiratory noises, the patient is asked to periodically hold his breath for 3-5 seconds while exhaling (after a preliminary deep breath). If necessary, some special auscultation techniques are used: in the position of the patient lying on the right or left side, with a deep breath, including with straining (Valsalva test), after 10-15 squats.

If there is abundant hair on the anterior surface of the chest, it must be moistened, greased or, in extreme cases, shaved in places where the heart is heard before auscultation.

Usually the following standard auscultation points are used, the numbering of which corresponds to the sequence of their listening (Fig. 32):

the first point is the apex of the heart, i.e. the area of the apex beat or, if it is not defined, then the left border of the heart at the level of the V intercostal space (the point of listening to the mitral valve and the left atrioventricular orifice); when conducting auscultation over the top of a woman, if necessary, she is first asked to raise the left mammary gland;
the second point is the II intercostal space directly at the right edge of the sternum (the point of auscultation of the aortic valve and the aortic orifice);
the third point is the II intercostal space directly at the left edge of the sternum (the point of listening to the valve of the pulmonary artery and its mouth);
it is customary to combine the second and third points with the concept of "the base of the heart";
the fourth point is the base of the xiphoid process (the point of listening to the tricuspid valve and the right atrioventricular orifice).

It should be borne in mind that the indicated auscultation points do not coincide with the projection of the corresponding heart valves, but are chosen taking into account the propagation of sound phenomena along the blood flow in the heart. This is due to the fact that the points corresponding to the true projection of the valves on the anterior chest wall are located very close to each other, which makes it difficult to use them for auscultatory diagnosis. However, some of these points are still sometimes used to identify pathological auscultatory phenomena.

the fifth point is the place of attachment of the IV rib to the left edge of the sternum (an additional point of auscultation of the mitral valve, corresponding to its anatomical projection);
the sixth point is the Botkin-Erb point - the III intercostal space at the left edge of the sternum (additional auscultation point of the aortic valve, corresponding to its anatomical projection).

Normally, a melody is heard over the heart at all points of auscultation, consisting of two short jerky sounds quickly following one after another, the so-called basic tones, followed by a longer pause (diastole), again two tones, again a pause, etc.

According to its acoustic properties, I tone is longer than II, and lower in tone. The appearance of the I tone coincides in time with the apex beat and pulsation of the carotid arteries. The interval between I and II tones corresponds to systole and is normally two times shorter than diastole.

It is generally accepted that the formation of heart tones occurs as a result of simultaneous fluctuations of the cardiohememic system, including the myocardium, valves, blood in the cavities of the heart, as well as the initial segments of the aorta and pulmonary trunk. Two components play the main role in the origin of the I tone:

valvular - fluctuations in the leaflets of the mitral and tricuspid valves, caused by their tension when closing at the very beginning of the ventricular systole (stress phase);
muscular - the tension of the myocardium of the ventricles at the beginning of the period of expulsion of blood from them.

The occurrence of tone II is explained mainly by fluctuations in the cusps of the semilunar valves of the aorta and pulmonary artery, due to the tension of these valves when they close at the end of ventricular systole. In addition, in the origin of both I and II tones, the so-called vascular component - vibrations of the walls of the initial part of the aorta and pulmonary artery - has a certain significance.

Due to the synchronism of the occurrence of sound phenomena of various origins that underlie the formation of heart tones, they are normally perceived as whole sounds, and no additional auscultatory phenomena are heard in the intervals between tones. In pathological conditions, splitting of the main tones sometimes occurs. In addition, both in systole and diastole, sounds similar in sound to the main tones (additional tones) and more prolonged, complex sounding auscultatory phenomena (heart murmurs) can be detected.

When listening to the heart, at first in each of the auscultatory points it is necessary to determine the heart tones (basic and additional) and the heart melody (heart rate), which consists of rhythmically repeating cardiac cycles. Then, if in the process of listening to tones, heart murmurs are detected, auscultation is repeated at the points of their localization and these sound phenomena are characterized in detail.

Heart sounds

Listening to heart sounds, determine the correctness of the rhythm, the number of basic tones, their timbre and sound integrity, as well as the ratio of the volume of I and II tones. When additional tones are detected, their auscultatory features are noted: relation to the phases of the cardiac cycle, loudness and timbre. To determine the melody of the heart, one should mentally reproduce it using syllabic phonation.

During auscultation over the apex of the heart, at first, the rhythmicity of heart tones (rhythm regularity) is determined by the uniformity of diastolic pauses. Thus, a noticeable lengthening of individual diastolic pauses is characteristic of extrasystole, especially ventricular, and some types of heart blockade. Random alternation of diastolic pauses of different duration is typical for atrial fibrillation.

Having determined the correctness of the rhythm, they pay attention to the ratio of the volume of I and II tones above the top, as well as to the nature of the sound (integrity, timbre) of the I tone. Normally, over the apex of the heart, I tone is louder than II. This is explained by the fact that in the formation of the first tone, sound phenomena caused by the mitral valve and the myocardium of the left ventricle are of primary importance, and the place of their best listening is located in the region of the apex of the heart.

At the same time, the II tone in this auscultatory point is wired from the base of the heart, and therefore is heard above the apex as a relatively quieter sound. Thus, the normal melody of the heart above the apex can be represented as a syllable phonation tam-ta tam-ta tam-ta ... Such a melody is heard especially clearly in conditions accompanied by tachycardia and an increase in the rate of contraction of the ventricular myocardium, for example, during physical and emotional stress, fever, thyrotoxicosis, anemia, etc. With a vertical position of the body and on exhalation, the I tone is louder than in the prone position and with a deep breath.

With stenosis of the left atrioventricular orifice, there is a decrease in diastolic filling of the left ventricle and an increase in the amplitude of movement of the mitral valve cusps. As a result, in patients with this heart disease, the volume of the first tone above the apex increases sharply and changes its timbre, acquiring the character of a clapping tone. In patients with complete atrioventricular block, during auscultation over the apex of the heart, a sudden significant increase in the first tone ("cannon tone" Strazhesko) is sometimes heard against the background of pronounced bradycardia. This phenomenon is explained by a random coincidence of atrial and ventricular contractions.

A uniform decrease in the sound volume (mutedness) of both tones above the apex of the heart while maintaining the predominance of the first tone is usually associated with non-cardiac causes: accumulation of air or fluid in the left pleural cavity, emphysema, effusion into the pericardial cavity, obesity, etc.

In the event that the I tone above the apex of the heart is equal in volume to II or even quieter in sound, they speak of a weakening of the I tone. Accordingly, the melody of the heart also changes: ta-tam ta-tam ta-tam ... The main reasons for the weakening of the first tone above the top are:

mitral valve insufficiency (deformation of the valve leaflets, a decrease in the amplitude of their movement, the absence of a period of closed valves);
damage to the heart muscle with a weakening of the contractility of the left ventricle;
increased diastolic filling of the left ventricle;
slowing down the contraction of the left ventricle with its pronounced hypertrophy.

When the heart rate changes (acceleration or slowdown), the duration of the diastolic pause mainly changes (respectively, shortens or lengthens), while the duration of the systolic pause does not change significantly. With severe tachycardia and equal duration of systolic and diastolic pauses, a heart melody occurs, similar to the rhythm of a pendulum - a pendulum-like rhythm (with equal volume of I and II tones) or resembling the intrauterine heart rhythm of the fetus - embryocardia (I tone is louder than II). Such pathological heart rhythms can be detected during an attack of paroxysmal tachycardia, myocardial infarction, acute vascular insufficiency, high fever, etc.

Splitting of the I tone above the apex of the heart (tra-ta) occurs when the systole of the left and right ventricles does not begin simultaneously, most often due to blockade of the right leg of the His bundle or severe left ventricular hypertrophy. Sometimes unstable splitting of the I tone can also be noted in healthy people in connection with the phases of respiration or a change in body position.

In some pathological conditions, along with the main tones, additional or extratones can be detected above the apex of the heart. Such extratones most often occur during the diastolic pause and, less often, during systole (following the I tone). Among the diastolic extratons are the III and IV tones, as well as the tone of the opening of the mitral valve and the pericardial tone.

Additional III and IV tones appear with myocardial damage. Their formation is caused by a reduced resistance of the walls of the ventricles, which leads to their abnormal vibration during the rapid filling of the ventricles with blood at the beginning of diastole (III tone) and during atrial systole (IV tone).

Thus, the III tone follows the II, and the IV tone is detected at the end of diastole immediately before the I. These extratones are usually quiet, short, low in tone, sometimes inconsistent and can only be determined at the fifth auscultatory point. They are better detected by auscultation with a solid stethoscope or directly by the ear, with the patient lying on his left side, and also on exhalation. When listening to III and IV tones, the stethoscope should not put pressure on the area of the apex beat. While the IV tone is always pathological.

III can be intermittently heard in healthy people, mainly in children and young men. The emergence of such a "physiological III tone" is explained by the active expansion of the left ventricle with its rapid filling with blood at the beginning of diastole.

In patients with damage to the heart muscle, III and IV tones are often combined with a weakening of the I tone above the apex and tachycardia, which creates a kind of three-part melody that resembles the clatter of a galloping horse (gallop rhythm). Such a rhythm is perceived by the ear as three separate tones following each other at almost identical intervals, and the triad of tones is repeated regularly without the usual, longer pause.

In the presence of tone III, the so-called proto-diastolic gallop rhythm occurs, which can be reproduced by rapidly repeating three syllables, with an emphasis on the middle: ta-ta-tata-ta-ta ta-ta-ta...

In the event that an IV tone is observed, a presystolic gallop rhythm occurs: ta-ta-ta ta-ta-ta ta-ta-ta ...

The presence of both III and IV tones is usually combined with a pronounced tachycardia, so both additional tones merge into a single sound in the middle of diastole and at the same time a three-term rhythm is also heard (summation gallop rhythm).

The opening tone of the mitral valve ("mitral click") is a characteristic sign of stenosis of the left atrioventricular orifice. This extratone occurs shortly after tone II, is better heard on the left side, as well as on exhalation, and is perceived as a short, abrupt sound, approaching tone II in volume, and resembling a click in timbre. Usually the "mitral click" is combined with a clapping I tone, which creates a characteristic three-part melody, which is compared to the cry of a quail ("quail rhythm"). Such a rhythm can be reproduced using the syllabic phonation ta-t-ra ta-t-ra ta-t-ra ... with a strong accent on the first syllable, or by repeating the phrase "time to sleep" with an emphasis on the first word. The occurrence of a "mitral click" is explained by the tension of the cusps of the mitral valve fused along the commissures when they protrude into the cavity of the left ventricle during the opening of the valve at the beginning of diastole.

Another type of protodiastolic extratone above the apex of the heart can be heard in patients with constrictive pericarditis. This so-called pericardial tone, like the "mitral click", is quite loud and follows immediately after the second tone. At the same time, the pericardial tone is not combined with the clapping I tone, so the heart melody, reminiscent of the "quail rhythm", does not arise.

The main reason for the occurrence of systolic extratone over the apex of the heart is the prolapse (eversion) of the mitral valve cusps into the cavity of the left atrium during systole (mitral valve prolapse). This extratone is sometimes called a systolic click, or click, because it is a relatively loud, sharp and short sound, sometimes compared to the sound of a snapping whip.

When conducting auscultation over the base of the heart, the second and third auscultatory points are listened to sequentially. The technique for assessing tones is the same as for auscultation over the apex. At the points of auscultation of the valves of the aorta and pulmonary artery, the II tone is normally louder than the I, since it is these valves that are involved in the formation of the II tone, while the I tone is wired at the base. Thus, the normal melody of the heart over the base of the heart at the second and third auscultatory points can be represented as follows: ta-tam ta-tam ta-tam ...

In a number of pathological conditions, the II tone over the aorta or pulmonary artery can be weakened, accentuated and split. The weakening of the II tone in the second or third points is said to be in the event that at a given point of auscultation the II tone is equal in volume to I or quieter than it. The weakening of the II tone over the aorta and pulmonary artery occurs with stenosis of their mouth or insufficiency of the corresponding valve. An exception to the rule is stenosis of the aortic mouth of atherosclerotic origin: with this defect, the II tone, on the contrary, is usually loud.

After evaluating the ratio of the volume of I and II tones in each of these two points above the base of the heart, the volume of the II tone is compared in them. To do this, listen in turn at the second and third points, paying attention only to the volume of the second tone. If the II tone in one of these auscultatory points is louder than in the other, they speak of an accent of the II tone at this point. Accent II tone over the aorta occurs with an increase in blood pressure or with atherosclerotic thickening of the aortic wall. Emphasis of the II tone over the pulmonary artery can normally be observed in healthy young people, however, its detection at an older age, especially in combination with splitting of the II tone (ta-tra) at this point, usually indicates an increase in pressure in the pulmonary circulation, for example, with mitral heart disease or chronic obstructive bronchitis.

In some cases, auscultation over the base of the heart can reveal additional tones. For example, in patients with congenital aortic stenosis, a systolic extratone, resembling a click, is sometimes heard at the second auscultatory point.

In the fourth auscultatory point in the norm, as well as above the apex, the I tone is louder than P. This is due to the participation of the tricuspid valve in the formation of the I tone and the conductive nature of the II tone at this point. Possible changes in the volume of the I tone at the fourth point are generally similar to those above the top. Thus, a weakening of the first tone above the base of the xiphoid process is detected with insufficiency of the tricuspid valve, and an increase in the first tone in combination with the opening tone of the tricuspid valve ("tricuspid click") - with an extremely rare stenosis of the right atrioventricular orifice.

As already mentioned, during auscultation of the heart in the pauses between tones, sound phenomena that differ from them can sometimes be heard - heart murmurs, which are more drawn-out and complex sounds saturated with overtones. According to their acoustic properties, heart murmurs can be quiet or loud, short or long, decreasing or increasing, and in terms of timbre - blowing, sawing, scraping, roaring, whistling, etc.

Heart murmurs detected in the interval between the I and II tones are called systolic, and the murmurs heard after the II tone are called diastolic. Less commonly, in particular in dry (fibrinous) pericarditis, continuous heart murmur is not always clearly associated with any phase of the cardiac cycle.

Systolic and diastolic murmurs result from a violation of laminar blood flow in the corresponding phase of the cardiac cycle. The reasons for the appearance of eddies in the bloodstream and its transformation from laminar to turbulent can be very diverse. A group of murmurs arising from congenital or acquired heart defects, as well as from myocardial damage, is called organic. Noises caused by other causes and not combined with changes in tones, expansion of the chambers of the heart and signs of heart failure are called functional or innocent. Diastolic murmurs, as a rule, are organic, and systolic murmurs can be both organic and functional.

Having found a noise during auscultation of the heart at standard points, it is necessary to determine:

the phase of the cardiac cycle in which the murmur is heard (systolic, diastolic, systolic-diastolic);
the duration of the noise (short or long) and what part of the phase of the cardiac cycle it occupies (protodiastolic, middiastolic, presystolic or pandiastolic, early systolic, late systolic or pansystolic);
the loudness of the noise in general (quiet or loud) and the change in loudness in the phase of the cardiac cycle (decreasing, increasing, decreasing-increasing, increasing-decreasing or monotonous);
timbre of noise (blowing, scraping, sawing, etc.);
the point of maximum noise sound volume (punctum maximum) and the direction of its conduction (left axillary fossa, carotid and subclavian arteries, interscapular space);
noise variability, i.e. dependence of sound volume, timbre and duration on body position, phases of breathing and physical activity.

Compliance with these rules allows in most cases to decide whether the noise is functional or organic, and also to determine the most likely cause of organic noise.

Most often, they occur with such heart defects as stenosis of the left atrioventricular orifice and aortic valve insufficiency, much less often with stenosis of the right atrioventricular orifice, insufficiency of the pulmonary valve, etc.

Diastolic murmur over the apex of the heart is heard with stenosis of the left atrioventricular orifice and in most cases is combined with the "quail rhythm". In the initial stages of mitral stenosis, it can be detected only at the beginning of diastole immediately after the "mitral click" (decreasing protodiastolic murmur) or only at the end of diastole before the clapping I tone (increasing presystolic murmur). With severe mitral stenosis, the murmur becomes pan-diastolic, acquires a peculiar low, rumbling timbre, and is sometimes determined by palpation above the apex of the heart in the form of the "cat's purr" phenomenon. The diastolic murmur of mitral stenosis is usually heard in a limited area and does not spread far. Usually it is better detected in the position of the patient lying on the left side and increases after physical exertion.

A soft, gentle diastolic (presystolic) murmur over the apex of the heart is also sometimes heard in patients with severe aortic valve insufficiency. This is the noise of the so-called functional mitral stenosis (Flint's noise). It occurs due to the fact that during diastole, the reverse flow of blood from the aorta to the left ventricle raises the anterior leaflet of the mitral valve, narrowing the atrioventricular orifice.

A diastolic murmur heard at the second auscultatory point indicates insufficiency of the aortic valve. However, in the early stage of the formation of the defect, the diastolic murmur of aortic insufficiency can be heard only in the III intercostal space to the left of the sternum, i.e. at the Botkin-Erb point corresponding to the anatomical projection of the aortic valve. It is usually "soft", blowing, decreasing, as if "pouring", it is better detected in a standing or sitting position with the torso tilted forward, as well as in the lying position on the right side. At the same time, after exercise, the noise weakens.

With severe aortic valve insufficiency, diastolic murmur usually extends to the carotid and subclavian arteries. Over the aorta, the II tone in such patients, as a rule, is sharply weakened or even completely absent. Above the apex I, the tone is also weakened, due to diastolic overflow of the left ventricle.

Diastolic murmur at the third auscultatory point is rarely detected. One of the reasons for it may be insufficiency of the pulmonary valve. In addition, a soft, blowing diastolic murmur in the II intercostal space at the left edge of the sternum is sometimes determined in patients with severe hypertension of the pulmonary circulation. This is a murmur of relative pulmonary valve insufficiency (Graham-Still murmur). Its occurrence is explained by the expansion of the infundibular part of the right ventricle and the mouth of the pulmonary artery with stretching of its valve ring. In the presence of an open ductus arteriosus connecting the aorta with the pulmonary artery, a combined systole-diastolic murmur is heard at the third auscultatory point. The diastolic (protodiastolic) component of such a noise is better heard in the supine position, does not spread far and disappears or significantly weakens when the patient strains at the height of a deep breath (Valsalva test).

Diastolic murmur at the fourth auscultatory point is also rarely detected and indicates the presence of stenosis of the right atrioventricular orifice. It is auscultated in a limited area above the base of the xiphoid process and to the left of it to the parasternal line, increases in the position of the patient on the right side and with a deep breath. Along with the diastolic murmur in this defect, a clapping I tone and a "tricuspid click" can also be detected, i.e. "quail rhythm".

They can be caused by insufficiency of atrioventricular valves (valvular or muscular origin), stenosis of the aortic and pulmonary arteries, a defect in the heart septum, and some other reasons. Distinctive features of organic systolic murmur are its loudness, duration and rough timbre. Sometimes it is heard over the entire surface of the heart, however, the maximum volume and duration of its sound are always determined at the point of auscultation of the valve or hole where this noise originated. In addition, organic systolic murmurs often have characteristic irradiation zones.

Another feature of such noises is their relative stability, since they are well heard in different positions of the patient, in both phases of breathing, and always increase after exercise.

Organic systolic murmur over the apex of the heart is heard with mitral valve insufficiency. It is of a decreasing nature and is usually combined with a weakening or even complete disappearance of the first tone. Quite often the III tone also comes to light at the same time. The noise increases in the position of the patient lying on his left side, while holding his breath on exhalation, after physical exertion. Its characteristic area of irradiation is the left axillary fossa. Sometimes it is heard better at the fifth auscultatory point. The systolic murmur of mitral valve insufficiency can be caused by structural changes in the valve itself (cicatricial rupture of the leaflets, detachment of chords) or dilatation of the left ventricular cavity with expansion of the fibrous ring of the valve (relative mitral valve insufficiency). Noise of valvular origin is generally louder, rougher and more prolonged than muscular, and has a large area of irradiation. However, in some cases, valvular and muscle murmurs have very similar acoustic features.

Organic systolic murmur in the second auscultatory point is determined by stenosis of the aortic mouth. Often it is so loud and rough that it is well heard over the entire region of the heart, and sometimes it is even felt by palpation on the handle of the sternum or to the right of it in the form of systolic trembling. Noise, as a rule, extends to the carotid and subclavian arteries, and is often also determined in the interscapular space at the level of I-III thoracic vertebrae. At the same time, in the direction of the left axillary fossa, its intensity subsides. In a standing position, the noise increases. Over the aorta, the II tone can be weakened, but with severe atherosclerosis, on the contrary, it is strengthened.

With a small degree of stenosis of the aortic orifice or unevenness of its walls caused by atherosclerotic lesions, systolic murmur over the aorta can be detected by asking the patient to raise his hands behind his head, which creates conditions for the approach of the vascular bundle to the sternum (Sirotinin-Kukoverov symptom).

Organic systolic murmur at the third auscultatory point is rarely heard. One of its causes may be stenosis of the mouth of the pulmonary artery. In patients with an atrial septal defect, systolic murmur over the pulmonary artery is also detected, but in most cases it is not very loud, short-lived, has a soft timbre and does not spread far, resembling functional murmur in its acoustic characteristics.

With an open ductus duct at the third auscultatory point, a systolic-diastolic murmur is determined, the systolic component of which is usually rough and loud, extends to the entire precordial region, neck vessels, to the left axillary fossa and interscapular space. Its peculiarity is a significant weakening during the Valsalva maneuver.

Organic systolic murmur at the fourth auscultatory point is characteristic of tricuspid valve insufficiency, which, like mitral insufficiency, can be of valvular or muscular origin. The murmur is decreasing in nature, not necessarily combined with a weakening of the I tone and additional III and IV tones, is carried out on both sides of the sternum and upwards along its left edge, and, unlike other heart murmurs, it increases on inspiration (Rivero-Corvallo symptom).

One of the loudest and coarsest systolic murmurs over the region of the heart is characteristic of a ventricular septal defect (Tolochinov-Roger disease). The epicenter of its sound is located above the sternum or at its left edge at the level of the III-IV intercostal space. Noise is better heard in the supine position and spreads to the left axillary fossa, interscapular space, brachial arteries, and occasionally to the neck. The volume of the I tone above the tip is usually preserved.

A rough systolic murmur over the region of the heart is also determined by coarctation (congenital narrowing) of the aorta. It can spread to the neck, but the epicenter of its sound is in the interscapular space to the left of the II-V thoracic vertebrae.

Most common in childhood and adolescence. Their appearance is most often due to the following reasons:

incomplete correspondence between the rates of development of various cardiac structures;
papillary muscle dysfunction;
abnormal development of chords;
an increase in the speed of blood flow;
changes in the rheological properties of blood.

Functional systolic murmurs are most often heard over the pulmonary artery, the apex of the heart and at the left edge of the sternum in the III-IV intercostal space, less often over the aorta. They have a number of features, the knowledge of which makes it possible to distinguish these murmurs from systolic murmurs of organic origin. In particular, the following features are characteristic of functional systolic murmurs:

are heard only in a limited area and do not spread anywhere;
sounding quiet, short, blowing; the exceptions are noises associated with dysfunction of chords and papillary muscles, since they sometimes have a peculiar musical timbre, which is compared with the sound of a ringing or broken string;
labile, because they can change their timbre, volume and duration, appear or, conversely, disappear under the influence of psycho-emotional and physical stress, with a change in body position, in different phases of breathing, etc .;
are not accompanied by changes in I and II tones, the appearance of additional tones, expansion of the boundaries of the heart and signs of circulatory failure; with mitral valve prolapse, systolic extratone can be determined.

Anemic systolic murmur, detected in patients with severe anemia, can be classified as functional noise only conditionally, both in terms of the mechanism of its formation and acoustic characteristics. In the origin of this noise, along with a decrease in blood viscosity and an acceleration of blood flow, myocardial dystrophy, often observed in anemia, also plays a certain role.

Anemic murmur is best heard at the left edge of the sternum or over the entire region of the heart. It can be loud, sometimes quite rough, with a musical tint, often spreads to large vessels, increases when the patient moves from a horizontal to a vertical position, and also after physical exertion.

Pericardial friction rub refers to extracardiac murmurs. Normally, smooth, moistened sheets of the pericardium glide silently during heart contractions. Pericardial friction rub most often occurs with dry (fibrinous) pericarditis and is its only objective sign. Inflamed sheets of the heart shirt become rough due to the presence of fibrin deposits on their surface.

Noise can also occur in the acute period of myocardial infarction and in some other pathological conditions that disrupt the smoothness of the sheets of the pericardium, for example, with uremia, severe dehydration, tuberculosis or tumor, including metastatic, damage to the heart shirt.

The pericardial friction rub does not have a typical localization, but most often it is detected in the area of absolute cardiac dullness at the left edge of the sternum or above the base of the heart on the sternum handle. Usually it is heard in a limited area and does not spread anywhere, it can be quiet or loud, and in timbre it resembles a rustling, scratching, scraping or crackling sound, and sometimes it is so rough that it is even felt by palpation.

Pericardial friction noise can be detected both in systole and diastole, not always exactly coinciding with them and is often perceived as a continuous noise with amplification in one of the phases. It is perceived as a sound that occurs at the very surface of the chest wall, and pressure with a stethoscope causes an increase in the volume of the noise. At the same time, other heart murmurs are perceived as coming from deep within the chest.

The pericardial friction noise is better heard in a standing or sitting position with the torso tilted forward, with a deep breath, its intensity weakens. In addition, due to its origin, it is very unstable: within a short time it can change its localization, connection with the phases of the cardiac cycle, and acoustic characteristics. When the pericardial cavity is filled with exudate, the noise disappears, and after resorption of the effusion, it reappears.

Sometimes, in the left circuit of the heart, breath sounds synchronous with its activity are heard, which can be mistaken for noises of cardiac origin. An example of such a murmur is a pleuro-pericardial murmur that occurs with local inflammation of the area of the pleura immediately adjacent to the heart, in particular, the pleura lining the left costophrenic sinus. Unlike most heart murmurs, this extracardiac murmur increases with deep inspiration, while during expiration and holding the breath, it significantly weakens or disappears altogether.

The detection of both systolic and diastolic murmurs at one of the auscultation points indicates a combined heart disease, i.e. about the presence of insufficiency of the valve heard at this point and stenosis of the opening corresponding to it. The detection of an organic systolic murmur at one point, and a diastolic murmur at another point indicates a combined heart disease, i.e. to defeat two different valves at the same time.

When listening at different points of auscultation of noise in the same phase of the cardiac cycle, it is necessary to establish which valve it belongs to, comparing the volume, timbre and duration of the noise at each point, as well as the direction of its conduction. If these characteristics differ, then the patient has a combined heart disease. If the noises are similar in acoustic characteristics and do not have conduction zones, auscultation of the heart should be performed along the line connecting the two points at which they are heard. A gradual increase (decrease) in the volume and duration of the noise from one point to another indicates its formation in the valve (hole) to which the point of maximum sound belongs, and the wired nature of the noise at another point. On the contrary, if the volume and duration of the noise first subsides, and then increases again, a combined heart disease is likely, for example, stenosis of the left atrioventricular orifice and aortic valve insufficiency.

Methodology for studying the objective status of the patient Methods for studying the objective status General examination Local examination Cardiovascular system

P tone accent. It is estimated by comparing the volume of the II tone in the II intercostal space at the edge of the sternum, respectively, on the right or left. The accent is noted where the tone is louder, and may be on the aorta or on the pulmonary trunk. Acceptance of the II tone can be physiological and pathological. The physiological emphasis is age related. On the pulmonary trunk, it is heard in children and adolescents. It is usually explained by a closer location of the pulmonary trunk to the site of auscultation. On the aorta, the accent appears by the age of 25-30 and somewhat intensifies with age due to the gradual thickening of the aortic wall. You can talk about a pathological accent in two situations:

1) when the accent does not correspond to the proper auscultation point corresponding to age (for example, a loud volume II on the aorta in a young man) and

2) when the volume of the II tone is greater at a point, although corresponding to age, but it is too large in comparison with a healthy person of this age and physique, or the II tone has a special character (ringing, metallic)

The reason for the pathological acceptance of the second tone on the aorta is an increase in blood pressure and (or) thickening of the valve leaflets and the aortic wall. The emphasis of the second tone on the pulmonary trunk is usually observed with pulmonary arterial hypertension (mitral stenosis, pulmonary heart, left ventricular failure)

The physiological bifurcation of the second tone is heard exclusively at the base of the heart during inhalation and exhalation or during physical exertion. At the end of a deep breath, with the expansion of the chest due to a decrease in pressure in it, the blood is somewhat delayed in the dilated vessels of the small circle and therefore enters the left atrium in a smaller amount, and from there into the left ventricle. The latter, due to less blood supply, finishes systole earlier than the right one, and the slamming of the aortic valve precedes the closure of the pulmonary artery valve. During exhalation, the opposite conditions are created. In the case of an increase in pressure in the chest, blood, as if squeezing out of the vessels of the small circle, enters the left heart in large quantities, and the systole of the left ventricle, and therefore the beginning of its diastole, occurs later than the right one.

However, a bifurcation of the second tone may be a sign of serious pathological changes in the heart and its valves. So, a bifurcation of the second tone at the base of the heart (II intercostal space on the left) is heard with mitral stenosis. This is due to the fact that the hypertrophied and overflowing with blood right ventricle finishes systole later than the left one. Therefore, the aortic component of the second tone occurs earlier than the pulmonary. Bifurcation or splitting of the second tone in case of insufficiency of the bicuspid valve is associated with a large blood filling of the left ventricle compared to the norm, which leads to a lengthening of its systole, and the diastole of the left ventricle begins later than the right one. As a result, the aortic valve closes later than the pulmonary valve.

The first phonendoscopes were sheets of paper folded into a tube or hollow bamboo sticks, and many doctors used only their own hearing organ. But they all wanted to hear what was happening inside the human body, especially when it comes to such an important organ as the heart.

Heart sounds are sounds that are formed during the contraction of the walls of the myocardium. Normally, a healthy person has two tones, which may be accompanied by additional sounds, depending on which pathological process develops. A doctor of any specialty must be able to listen to these sounds and interpret them.

Cardiac cycle

The heart beats at a rate of sixty to eighty beats per minute. This, of course, is an average value, but ninety percent of the people on the planet fall under it, which means that you can take it as the norm. Each beat consists of two alternating components: systole and diastole. The systolic heart sound, in turn, is divided into atrial and ventricular. In time, it takes 0.8 seconds, but the heart has time to contract and relax.

Systole

As mentioned above, there are two components involved. First, there is atrial systole: their walls contract, blood enters the ventricles under pressure, and the valve flaps slam shut. It is the sound of closing valves that is heard through the phonendoscope. This entire process takes 0.1 seconds.

Then comes the systole of the ventricles, which is a much more complex work than it happens with the atria. First, note that the process lasts three times longer - 0.33 seconds.

The first period is the tension of the ventricles. It includes phases of asynchronous and isometric contractions. It all starts with the fact that the eclectic impulse spreads through the myocardium, It excites individual muscle fibers and causes them to spontaneously contract. Because of this, the shape of the heart changes. Due to this, the atrioventricular valves close tightly, increasing the pressure. Then there is a powerful contraction of the ventricles, and the blood enters the aorta or pulmonary artery. These two phases take 0.08 seconds, and in the remaining 0.25 seconds, blood enters the great vessels.

Diastole

Here, too, everything is not as simple as it might seem at first glance. The relaxation of the ventricles lasts 0.37 seconds and occurs in three stages:

Proto-diastolic: after the blood has left the heart, the pressure in its cavities decreases, and the valves leading to the large vessels close.
Isometric relaxation: the muscles continue to relax, the pressure drops even more and equalizes with the atrial. This opens the atrioventricular valves, and blood from the atria enters the ventricles.
Filling of the ventricles: fluid fills the lower ventricles along the pressure gradient. When the pressure equalizes, the flow of blood gradually slows down, and then stops.

Then the cycle repeats again, starting with systole. Its duration is always the same, but diastole can be shortened or lengthened depending on the speed of the heartbeat.

The mechanism of formation of I tone

No matter how strange it may sound, but 1 heart sound consists of four components:

Valve - he is the leader in the formation of sound. In fact, these are fluctuations of the cusps of the atrioventricular valves at the end of ventricular systole.
Muscular - oscillatory movements of the walls of the ventricles during contraction.
Vascular - stretching of the walls at the moment when blood enters them under pressure.
Atrial - atrial systole. This is the immediate beginning of the first tone.

The mechanism of formation of II tone and additional tones

So, the 2nd heart sound includes only two components: valvular and vascular. The first is the sound that arises from the blows of blood on the valves of the artia and the pulmonary trunk at the moment when they are still closed. The second, that is, the vascular component, is the movements of the walls of large vessels when the valves finally open.

In addition to the two main ones, there are also 3 and 4 tones.

The third tone is the oscillation of the ventricular myocardium during diastole, when blood passively drains into an area of lower pressure.

The fourth tone appears at the end of systole and is associated with the end of the expulsion of blood from the atria.

Characteristics of the first tone

Heart sounds depend on many causes, both intra- and extracardiac. The sonority of 1 tone depends on the objective state of the myocardium. So, first of all, the volume is provided by the tight closure of the heart valves and the speed with which the ventricles contract. Such features as the density of the cusps of the atrioventricular valves, as well as their position in the cavity of the heart, are considered secondary.

It is best to listen to the first heart sound at its apex - in the 4th-5th intercostal space to the left of the sternum. For more accurate coordinates, it is necessary to percussion the chest in this area and clearly define the boundaries of cardiac dullness.

Characteristic II tone

To listen to him, you need to put the bell of the phonendoscope over the base of the heart. This point is located slightly to the right of the xiphoid process of the sternum.

The volume and clarity of the second tone also depends on how tightly the valves close, only now semilunar. In addition, the speed of their work, that is, the closing and oscillation of the risers, affects the reproduced sound. And additional qualities are the density of all structures involved in the formation of tone, as well as the position of the valves during the expulsion of blood from the heart.

Rules for listening to heart sounds

The sound of the heart is probably the most peaceful in the world, after white noise. Scientists have a hypothesis that it is he who hears the child in the prenatal period. But in order to identify damage to the heart, just listening to how it beats is not enough.

First of all, you need to do auscultation in a quiet and warm room. The posture of the examined person depends on which valve needs to be listened to more carefully. This can be a lying position on the left side, vertically, but with the body tilted forward, on the right side, etc.

The patient should breathe rarely and shallowly, and at the request of the doctor, hold his breath. In order to clearly understand where the systole is and where the diastole is, the doctor must, in parallel with listening, palpate the carotid artery, the pulse on which completely coincides with the systolic phase.

Order of auscultation of the heart

After a preliminary determination of absolute and relative cardiac dullness, the doctor listens to the heart sounds. It starts, as a rule, from the top of the organ. The mitral valve is clearly audible. Then they move on to the valves of the main arteries. First, to the aortic - in the second intercostal space to the right of the sternum, then to the pulmonary artery - at the same level, only on the left.

The fourth point to listen to is the base of the heart. It is located at the base but can move to the sides. So the doctor must check what is the shape of the heart, and the electrical axis to accurately listen

Auscultation is completed at the Botkin-Erb point. Here you can hear She is in the fourth intercostal space on the left side of the sternum.

Additional tones

The sound of the heart does not always resemble rhythmic clicks. Sometimes, more often than we would like, it takes bizarre forms. Doctors have learned to identify some of them only by listening. These include:

Mitral valve click. It can be heard near the apex of the heart, it is associated with organic changes in the valve leaflets and appears only with acquired heart disease.

Systolic click. Another type of mitral valve disease. In this case, its valves do not close tightly and, as it were, turn outward during systole.

Perekardton. Found in adhesive pericarditis. Associated with excessive stretching of the ventricles due to the mooring formed inside.

Rhythm quail. Occurs with mitral stenosis, manifested by an increase in the first tone, an accent of the second tone on the pulmonary artery and a click of the mitral valve.

gallop rhythm. The reason for its appearance is a decrease in myocardial tone, appears against the background of tachycardia.

Extracardiac causes of amplification and weakening of tones

The heart beats in the body throughout life, without interruption and rest. So, when it wears out, outsiders appear in the measured sounds of its work. The reasons for this can be either directly related to damage to the heart, or not depend on it.

Strengthening tones contribute to:

Cachexia, anorexia, thin chest wall;

Atelectasis of the lung or part of it;

Tumor in the posterior mediastinum, moving the lung;

Infiltration of the lower lobes of the lungs;

Bullae in the lungs.

Decreased heart sounds:

Excessive weight;

The development of the muscles of the chest wall;

subcutaneous emphysema;

The presence of fluid in the chest cavity;

Intracardiac causes of amplification and weakening of heart sounds

Heart sounds are clear and rhythmic when the person is at rest or asleep. If he began to move, for example, climbed the stairs to the doctor's office, then this can cause an increase in heart sound. Also, an acceleration of the pulse can be caused by anemia, diseases of the endocrine system, etc.

A muffled heart sound is heard with acquired heart defects, such as mitral or aortic stenosis, valve insufficiency. Aortic stenosis contributes to the divisions close to the heart: the ascending part, the arch, the descending part. Muffled heart sounds are associated with an increase in myocardial mass, as well as with inflammatory diseases of the heart muscle, leading to dystrophy or sclerosis.

Heart murmurs

In addition to tones, the doctor can hear other sounds, the so-called noises. They are formed from the turbulence of the flow of blood that passes through the cavities of the heart. Normally, they shouldn't be. All noise can be divided into organic and functional.

Organic ones appear when anatomical, irreversible changes in the valve system occur in the organ.
Functional noises are associated with impaired innervation or nutrition of the papillary muscles, an increase in heart rate and blood flow velocity, and a decrease in its viscosity.

Murmurs may accompany heart sounds or may be independent of them. Sometimes, in inflammatory diseases, it is superimposed on the heartbeat, and then you need to ask the patient to hold his breath or lean forward and auscultate again. This simple trick will help you avoid mistakes. As a rule, when listening to pathological noises, they try to determine in which phase of the cardiac cycle they occur, to find the place of the best listening and to collect the characteristics of the noise: strength, duration and direction.

Noise Properties

According to the timbre, several types of noise are distinguished:

Soft or blowing (usually not associated with pathology, often in children);

Rough, scraping or sawing;

Musical.

According to the duration, they are distinguished:

Short;

By volume:

Descending;

Increasing (especially with narrowing of the left atrioventricular orifice);

Increasing-decreasing.

The change in volume is recorded during one of the phases of cardiac activity.

Height:

High-frequency (with aortic stenosis);

Low-frequency (with mitral stenosis).

There are some general patterns in auscultation of noises. Firstly, they are well heard in the locations of the valves, due to the pathology of which they were formed. Secondly, the noise radiates in the direction of blood flow, and not against it. And thirdly, like heart sounds, pathological murmurs are best heard where the heart is not covered by the lungs and is tightly attached to the chest.

It is better to listen in the supine position, because the blood flow from the ventricles becomes easier and faster, and diastolic - sitting, because under gravity, the fluid from the atria quickly enters the ventricles.

Murmurs can be differentiated by their localization and the phase of the cardiac cycle. If the noise in the same place appears both in systole and in diastole, then this indicates a combined lesion of one valve. If, in systole, noise appears at one point, and in diastole - at another, then this is already a combined lesion of two valves.

Accent II tone on the aorta

Weakening of the II tone on the aorta

Muffled heart sounds

Task 2. Patient A., 56 years old. Was admitted to the intensive care unit with large-focal myocardial infarction in the anterolateral wall. What changes in heart sounds can be heard in this patient during auscultation?

Rhythm "quail"

Rhythm "gallop"

Atrial fibrillation

Accent II tone on the aorta

Weakening of the II tone on the aorta

Muffled heart sounds

Task 3. Patient G., 60 years old, track worker. For many years he has been suffering from chronic obstructive bronchitis and pulmonary emphysema. What changes in heart sounds can be heard in this patient during auscultation?

Rhythm "quail"

Rhythm "gallop"

Atrial fibrillation

Accent II tone on the aorta

Weakening of the II tone on the aorta

Muffled heart sounds

Weakening of the I tone at the top

Task 4. Patient D., 49 years old. For a long time suffers from arterial hypertension with high blood pressure figures. What changes in heart sounds can be heard in this patient during auscultation?

Rhythm "quail"

Rhythm "gallop"

Atrial fibrillation

Accent II tone on the pulmonary artery

Accent II tone on the aorta

Weakening of the II tone on the aorta

Muffled heart sounds

Weakening of the I tone at the top

Task 5. Patient K., 23 years old. He is in the Department of Cardiology with a diagnosis of subacute septic endocarditis, aortic valve insufficiency of the 3rd degree. What changes in heart sounds can be heard in this patient during auscultation?

Rhythm "quail"

Rhythm "gallop"

Atrial fibrillation

Accent II tone on the pulmonary artery

Accent II tone on the aorta

Weakening of the II tone on the aorta

Muffled heart sounds

Weakening of the I tone at the top

Topic 10. Auscultation of heart murmurs

Purpose of the lesson: to study the mechanism of formation of heart murmurs, using the knowledge of normal and pathological anatomy, normal and pathological physiology of the circulatory system, their classification, the method of listening.

1. Mechanism of noise generation

2. Noise classification

3. Characteristics of organic noise (in relation to the phases of cardiac activity, according to the change in sonority over time, points of listening and conduction)

4. Functional noises

5. Extracardiac murmurs (pericardial friction murmur, pleuropericardial murmur).

1. Listen for noises at the right points

2. Distinguish between systolic and diastolic murmurs; organic and functional

3. Identify pericardial friction rub and pleuropericardial murmur

4. Give a correct characterization and diagnostic assessment of heart murmurs.

Motivation: auscultation of heart sounds is one of the important diagnostic methods in cardiology. Correct diagnosis of heart defects is impossible without the correct interpretation of the noise. In order to qualitatively assess the sounds heard, sufficient theoretical knowledge and constant training are needed to acquire auscultation skills.

Initial data:

LEARNING ELEMENTS

During auscultation of the heart, in addition to tones, additional sounds of a longer duration, called heart murmurs .

All noises are divided into two groups - intracardial and extracardiac.

Intracardiac arising from anatomical changes in the structure of the heart valves (organic noises) or in violation of the function of unchanged valves (functional noise). Functional noises can be observed with an increase in blood flow velocity or a decrease in blood viscosity.

organic noises are classified:

1) According to the mechanism of formation (according to Zuckerman):

a) ejection (expulsion) noises - with stenosis of the mouth of the aorta and pulmonary artery.

b) noises of regurgitation (return) - with valve insufficiency.

c) filling (shock) noises - with mitral and tricuspid stenosis.

2) In relation to the phases of cardiac activity:

a) systolic murmurs (appear together with the first tone, coincide with the apex beat and the pulse of the carotid artery).

b) diastolic noise (appear after the second tone), which are divided into:

Ø protodiastolic,

Ø mesodiastolic,

Ø presystolic.

3) By changing the volume over time, they distinguish:

a) decreasing noise;

b) growing;

c) increasing-decreasing.

4) According to the timbre, they distinguish:

soft, rough, blowing, whistling noises.

Noises are best heard where they are formed and carried through the bloodstream.

Distinguish between systolic and diastolic murmurs:

Systolic

At mitral valve insufficiency the noise is maximally auscultated at the apex, is carried out to the left axillary region, or to the second, third intercostal space to the left of the sternum, the noise is decreasing.

At aortic stenosis - the noise is increasing-decreasing (rhomboid), auscultated in the second intercostal space to the right of the sternum, at the Botkin-Erb point, carried out on the carotid and subclavian arteries.

At tricuspid valve insufficiency Decreasing noise is heard at the xiphoid process of the sternum, is carried out in the third, fourth intercostal space to the right of the sternum, the intensity of the noise increases with holding the breath at the height of inspiration.

At stenosis of the pulmonary artery an increasing-decreasing (diamond-shaped) murmur is heard in the second intercostal space to the left of the sternum, carried into the interscapular space in the region of the third, fourth thoracic vertebra.

diastolic

At mitral stenosis heard:

Ø mesodiastolic murmur at the apex, decreasing, is not carried out.

Ø Presystolic murmur is increasing, better heard in the area of the projection of the mitral valve, not carried out.

At aortic valve insufficiency protodiastolic decreasing noise is heard, best of all in the second intercostal space to the right of the sternum and at the Botkin-Erb point.

At tricuspid stenosis heard:

decreasing mesodiastolic murmur, auscultated at the base of the xiphoid process, not carried out,

increasing presystolic murmur, auscultated at the xiphoid process, is not carried out.

At pulmonary valve insufficiency a protodiastolic murmur is heard in the second intercostal space to the left of the sternum, decreasing, not carried out.

Functional noises not caused by valvular disease.

Causes of functional noise:

An increase in the speed of blood flow - anemia (at the same time, a decrease in blood viscosity is also noted), infectious diseases that occur with fever, nervous excitement, thyrotoxicosis.

Relative valve insufficiency occurs with dilatation of the ventricles and stretching of the fibrous ring, when unchanged valves cannot cover the enlarged hole (with myocarditis, myocardial dystrophy, dilatation of cavities with heart defects).

When the tone of the papillary muscles changes, the valves are not held in the correct position.

Differences of functional noise from organic:

Functional	organic
1. Most often systolic except for: Austin-Flint murmur. This noise is heard with severe aortic valve insufficiency at the apex of the heart, due to relative stenosis of the mitral valve in diastole - the result of displacement of the anterior cusp of the mitral valve to the posterior cusp by a stream of blood flowing back; Graham-Still murmur - with pulmonary valve insufficiency, resulting from the expansion of the fibrous ring with severe pulmonary hypertension.	1. Can be systolic and diastolic.
2. More often heard on the pulmonary artery and the apex.	2. Auscultated with the same frequency at all points
3. Labile.	3 Stable
4. Short - no more than ½ systole.	4. Any duration.
5. Not held.	5. Can be carried out.
6. Not accompanied by other signs of valve defects.	6. Accompanied by other signs of valvular damage (enlargement of the heart, changes in tones, a symptom of cat's purring).
7. They are not musical.	7. Can be musical.

Extracardiac murmurs (extracardiac) appear synchronously with the activity of the heart, but arise outside it.

Extracardiac murmurs include pericardial friction murmurs and pleuropericardial murmurs.

Rubbing noise of the pericardium occurs when the surfaces of the pericardial sheets become uneven, rough, or dry (pericarditis, dehydration, urea crystals, tuberculous tubercles, cancerous nodules).

Distinguishing pericardial friction noise from intracardiac murmurs:

does not always exactly coincide with systole or diastole;

fickle;

does not coincide with the auscultation points (it is well auscultated in the area of absolute dullness of the heart);

weakly carried out from the place of its formation;

felt closer to the examiner's ear;

aggravated by pressing the stethoscope to the chest and by tilting the torso forward.

Pleuropericardial friction rub occurs with inflammation of the pleura adjacent directly to the heart due to friction of the pleural sheets, synchronous with the activity of the heart.

The difference between pleuropericardial murmur and pericardial friction murmur:

Ø is heard along the left edge of relative cardiac dullness;

Ø is usually combined with a pleural friction noise and changes intensity in different phases of breathing: it increases with a deep breath, weakens with exhalation.

Control questions:

1. What types of heart murmurs do you know?

2. How is organic noise classified?

3. How are noises divided according to the mechanism of occurrence?

4. How are murmurs divided in relation to the phase of cardiac activity?

5. What is the difference between systolic and diastolic murmurs?

6. Describe the murmur in mitral valve insufficiency.

7. Describe the murmur in mitral stenosis.

8. Describe the murmur in aortic valve insufficiency.

9. Describe the murmur during aortic stenosis.

10. List the main causes of functional noise.

11. What is the difference between functional noise and organic noise?

12. How does pericardial friction rub differ from intracardiac murmurs?

Situational tasks:

Task 1. During auscultation in the second intercostal space to the right of the sternum, a coarse systolic murmur of an increasing-decreasing character is heard, which is carried out to the vessels of the neck and to the Botkin point. Under what pathology can such a noise be heard?

Task 2. During auscultation at the apex of the heart, a systolic murmur of a decreasing nature is heard, occupying 2/3 of the systole and conducted to the left axillary region. Under what pathology can such a noise be heard?

Task 3. During auscultation in the second intercostal space to the right of the sternum, a diastolic murmur of a decreasing nature is heard, starting immediately after the second tone and occupying 2/3 of the diastole. The noise is conducted to the Botkin point. Under what pathology can such a noise be heard?

Task 4. During auscultation at the level of the lower third of the sternum, a systolic murmur of a decreasing nature is heard, conducted to the right and up. The noise increases on inspiration. Under what pathology can such a noise be heard?

Task 5. On auscultation at the apex of the heart, a systolic murmur of a blowing nature is heard, which is not conducted anywhere. The sonority of tones, the boundaries of the heart are not changed. Blood hemoglobin level 70 g/l. What is the likely mechanism for this noise?

Task 6. During auscultation at the apex of the heart, a diastolic murmur is heard, starting a short interval after the second tone, decreasing in nature, and is not conducted anywhere. In what disease can such a noise be heard?

Task 7. During auscultation of the heart at the apex, a presystolic murmur of increasing character, a clapping first heart sound and an additional heart sound are heard.

1. What disease can you think of?

2. What is the name of such a three-term rhythm?

Task 8. During auscultation at the apex of the heart, a systolic murmur is heard, which is conducted into the axillary region, of a decreasing nature, at the Botkin point and in the second intercostal space to the right of the sternum - a protodiastolic murmur of a decreasing nature, is not carried anywhere. The first and second tones are weakened. What does the patient have?

Topic 11. Study of blood vessels. Pulse and its properties. Arterial and venous pressure

Purpose of the lesson: to study the technique of studying blood vessels, learn to evaluate the properties of the arterial and venous pulse, measure arterial and venous pressure and evaluate the data obtained.

1. Zones of arteries accessible for palpation (radial, common carotid, brachial, axillary, abdominal aorta, femoral, popliteal, tibial, temporal, dorsal foot arteries).

2. Characteristics of the properties of the arterial pulse.

3. The mechanism of occurrence of pulsation of the veins in normal and pathological conditions.

4. The method of measuring blood pressure according to N.S. Korotkov.

5. The principle of operation of the sphygmomanometer, oscilloscope, phlebrtonometer.

6. Characteristics of blood pressure (systolic, diastolic, pulse, mean).

1. Assess the similarity of the pulse on both hands, the condition of the vascular wall, the following properties of the pulse: rhythm, frequency, filling, tension, size, shape.

2. Measure blood pressure according to N.S. Korotkov on arms and legs:

a. put on the cuff correctly

b. find the place of pulsation of the brachial artery (when measuring blood pressure in the arms or popliteal artery when measuring pressure on the thigh)

c. determine the value of systolic, diastolic, pulse pressure.

3. Give a complete conclusion on the study of the pulse and the result of measuring blood pressure.

4. Assess the condition of the veins of the neck and limbs.

5. Carry out auscultation of the arteries.

Motivation: the study of blood vessels in some cases helps in the diagnosis of various pathologies. Thanks to the study of the pulse, it is possible to diagnose such rhythm disturbances as atrial fibrillation, paroxysmal tachycardia, extrasystole; to assume the presence of blockades of varying degrees, to suspect such diseases as thyrotoxicosis, aortic valve insufficiency, stenosis of the aortic orifice, adhesive pericarditis, etc. The pulse can roughly judge the magnitude of stroke volume, blood pressure measurements. Measurement of blood pressure allows diagnosing hypertension, arterial hypertension of various origins, hypotension, collapses of various etiologies.

Initial data:

LEARNING ELEMENTS

The study of blood vessels is carried out by examining and palpating arteries and veins, auscultation of large vessels and studying the vascular system using instrumental methods.

Examination of blood vessels is of great importance in assessing the state of the cardiovascular system.

Visible changes in the arteries:

In the second intercostal space to the right of the sternum, one can detect aortic pulsation , which appears either with its sharp expansion (aneurysm of the ascending part and aortic arch; insufficiency of the aortic valve) or with wrinkling of the edge of the right lung that covers it.

In the second and third intercostal spaces on the left, visible to the eye ripple called dilated pulmonary trunk . It occurs in patients with mitral stenosis, with high pulmonary hypertension, open ductus arteriosus with a large discharge of blood from the aorta into the pulmonary trunk, primary pulmonary hypertension.

With aortic valve insufficiency, a pronounced pulsation of the carotid arteries - "dance of the carotid".

Sharply protruding and tortuous temporal arteries are observed in patients with hypertension and atherosclerosis due to their lengthening and sclerotic changes.

When examining veins you can see their overflow and expansion.

General venous stasis caused by damage to the right side of the heart, as well as diseases that increase pressure in the chest and impede the outflow of venous blood through the vena cava. In this case, the cervical veins expand and become swollen.

Local venous congestion caused by squeezing the vein from the outside (tumors, scars) or blockage from the inside by a thrombus.

In the neck area you can see pulsation of the jugular veins - venous pulse. In healthy people, it is hardly noticeable to the eye and becomes more distinct when the neck veins swell due to stagnation of blood in them.

Research of capillaries.

Capillaroscopy is a method of studying the capillaries of the intact surface of the epithelial integument (skin, mucous membrane). In addition to capillaroscopy, there is a method of capillarography, which consists in photographing the capillaroscopic picture using special microphoto attachments.

To detect a capillary pulse, lightly press on the end of the nail so that a small white spot forms in the middle of it: with each pulse beat, it will expand and then narrow. In the same way, a spot of hyperemia will pulsate, caused by rubbing the skin, for example, on the forehead. Capillary pulse is observed in patients with aortic valve insufficiency, and sometimes with thyrotoxic goiter.

Auscultation of vessels is of limited value in clinical practice.

Usually they listen to vessels of medium caliber - carotid, subclavian, femoral. In healthy individuals, two tones can be heard on the carotid and subclavian arteries. The first tone is due to the tension of the arterial wall during its expansion during the passage of the pulse wave, the second tone is carried out to these arteries from the aortic semilunar valve. One systolic tone is heard on the femoral artery.

With insufficiency of the aortic valve on the femoral artery, two tones are sometimes heard ( Traube double tone ), the origin of which is explained by sharp fluctuations of the vascular wall during systole and diastole.

In case of insufficiency of the aortic valves above the femoral artery, when it is squeezed with a stethoscope, it can be heard double noise Vinogradov - Durozier . The first of them - stenotic noise - is caused by blood flow through a vessel narrowed by a stethoscope. The origin of the second noise is explained by the acceleration of reverse blood flow towards the heart during diastole.

In healthy people, over the veins, as a rule, neither tones nor noises are heard.

On auscultation of the jugular veins with anemia appears top noise (associated with the acceleration of blood flow with a decrease in blood viscosity). It is best heard on the right jugular vein and increases when the head is turned to the opposite side.

Pulse called various fluctuations of the vascular wall. Allocate arterial pulse, venous pulse and capillary.

arterial pulse called the rhythmic fluctuations of the vascular wall of the arteries, due to the contraction of the heart, the ejection of blood into the arterial system and the change in pressure in it during systole and diastole.

The main method of studying the pulse is palpation. The properties of the pulse are evaluated on the radial artery, but it is also studied on other vessels: temporal, carotid, femoral, popliteal arteries, arteries of the dorsal foot, and posterior tibial arteries.

1) The study of the pulse begins by comparing the pulse on both arteries, normally it is the same on both hands. In pathology, the pulse may be different (pulsus differens) . Causes of different pulses: abnormal location of the arteries, narrowing of the arteries, compression of the arteries by scars, enlarged lymph nodes, mediastinal tumor, retrosternal goiter, sharply enlarged left atrium. In this case, a delay of a smaller pulse wave can also be observed.

2) In a healthy person, the contraction of the heart and pulse waves follow each other at regular intervals, that is, the pulse rhythmic (pulsus regularis) . With heart rhythm disorders (atrial fibrillation, blockade, extrasystole), pulse waves follow at irregular intervals, and the pulse becomes irregular (pulsus irregularis) .

3) The pulse rate normally corresponds to the number of heartbeats and is 60 - 80 per minute. With an increase in the number of heartbeats (tachycardia), the pulse frequent (pulsus frequences) , at bradycardia - rare (pulsus rarus) .

4) With atrial fibrillation, individual systoles of the left ventricle may be weak, and the pulse wave does not reach the peripheral arteries. The difference between the number of heartbeats and pulse waves counted in one minute is called pulse deficit, and the pulse scarce (pulsus deficiens) .

5) The tension of the pulse is determined by the force that must be applied to completely compress the pulsating artery. This property depends on the magnitude of systolic blood pressure. At normal pressure, the pulse is of moderate or satisfactory tension. At high pressure, the pulse hard (pulsus durus) , at low soft (pulsus mollis) .

6) To assess the state of the vascular wall, the second and third fingers of the left hand squeeze the artery above the place of its study, after the cessation of the pulsation of the vessel, they begin to probe the vessel wall, which is not normally palpated.

7) The filling of the pulse reflects the filling of the studied artery with blood. It depends on the magnitude of the stroke volume, on the total amount of blood in the body, its distribution. Normal pulse full (pulsus plenus) , with a decrease in stroke volume, the pulse empty (pulsus vacuum) .

8) The value of the pulse is determined on the basis of a comprehensive assessment of the tension and filling of the pulse. The value is greater, the greater the amplitude of the pulse wave. With an increase in the stroke volume of the blood, a large fluctuation in pressure in the artery, as well as with a decrease in the tone of the vascular wall, the magnitude of the pulse waves increases. This pulse is called large (pulsus magnus) or high (pulsus altus) , with reverse changes, the pulse small (pulsus parvus) .

In shock, acute heart failure, massive blood loss, the pulse is barely detected - filiform (pulsus filiformis) .

9) Normally, the pulse waves are the same or almost the same - the pulse smooth (pulsus aequalis) . With heart rhythm disorders, the magnitude of the pulse waves becomes different - the pulse uneven (pulsus inaequalis) .

Alternating pulse (pulsus alternans)- rhythmic pulse, characterized by the correct alternation of weak and strong beats. The reason for the alternating pulse is the rapid depletion of the excitability and contractility of the heart muscle, which is observed in severe stages of heart failure.

Intermittent pulse (pulsus intermittens) characterized by a doubling of the duration of some intervals between fluctuations of the vascular wall, observed with AV blockade.

Paradoxical pulse (pulsus paradoxalis) characterized by a decrease in filling during inspiration; observed when the mobility of the heart is limited due to its compression (constrictive pericarditis, cardiac tamponade). Paradoxical pulse is characterized by a decrease in systolic blood pressure by more than 10 mm. rt. Art. while taking a deep breath.

10) The shape of the pulse is characterized by the rate of rise and fall of pressure inside the artery, depending on the rate at which the left ventricle ejects blood into the arterial system. Allocate rapid pulse (pulsus celer) or jumping (pulsus saliens) , characterized by a rapid rise in the pulse wave and its rapid decline. Such a pulse is observed with aortic valve insufficiency. For the opposite form of the pulse - slow (pulsus tardus) - characterized by a slow rise in the pulse wave and its gradual decrease. Such a pulse is observed with stenosis of the aortic orifice.

With a decrease in the tone of the peripheral arteries, a dicrotic wave is caught on palpation - dicrotic pulse (pulsus dicroticus) . The appearance of a dicrotic wave is explained by the fact that at the beginning of diastole, part of the blood in the aorta moves in the opposite direction and hits the closed valves. This impact creates a new wave following the main one.

Sphygmography- a method for studying the arterial pulse by converting mechanical vibrations of the artery wall into electrical signals.

With direct sphygmography, vibrations of the vascular wall of any superficially located artery are recorded, for which a funnel or pelota is placed on the vessel under study.

Volumetric sphygmography records the total fluctuations of the vascular wall, converted into fluctuations in the volume of a part of the body (usually a limb). They are registered using a cuff applied to the limbs.

A normal sphygmogram has a steep ascending knee - anacrota , apex of the curve, gentler descending knee - catacrot , on which there is an additional tooth - dicrota , its origin is explained by the rejection of blood from the closed leaflets of the aortic valve at the beginning of diastole. Incizura - corresponds to the moment of closing of the aortic valve.

Venous pulse - fluctuations of the venous wall associated with a change in the blood supply of large veins located close to the heart. In the region of the heart, one can see the pulsation of the jugular veins - the venous pulse. When the heart is working during atrial systole in the jugular vein, blood flow slows down, and during ventricular systole it accelerates. Slowing the blood flow leads to some swelling of the veins of the neck, and acceleration to a decline. Consequently, during systolic dilatation of the arteries, the veins collapse. This is the so-called negative venous pulse.

Similar information.

On phlebogram there are a number of waves:

1) Wave "a" appears with a contraction of the right atrium. At this moment, the emptying of the vena cava from the venous blood flowing from the periphery is delayed; veins overflow and swell, wave (+).

2) Wave "c" associated with ventricular systole and occurs due to the transmission of the pulsation of the carotid artery, located near the jugular vein, wave (+).

3) Wave "x" - systolic collapse is explained by the fact that during the systole of the ventricles, the right atrium is filled with venous blood, the veins are emptied and collapse.

4) Wave "v" - a positive wave, appears at the end of ventricular systole with a closed tricuspid valve. It is due to the fact that the blood accumulating in the atria delays the flow of new blood from the vena cava.

5) Wave "u" diastolic collapse begins when the tricuspid valve opens and blood enters the right ventricle. This contributes to the flow of blood from the hollow veins into the right atrium and the collapse of the vein, wave (-).

The normal venous pulse is called atrial or negative ; it is called negative because during the period when the curve of the arterial pulse goes down, the curve of the venous pulse has the greatest rise.

The venous pulse can begin with a high wave v, in which case it turns into the so-called ventricular (or positive) venous pulse. It is called positive because the rise of the venous pulse curve is noted almost simultaneously with the main wave on the sphygmogram. A positive venous pulse is noted with tricuspid valve insufficiency, severe venous congestion in the systemic circulation, atrial fibrillation, and complete AV block.

Arterial pressure (BP) is the pressure exerted by the blood in an artery against its wall.

The value of blood pressure depends on the value of cardiac output and total peripheral vascular resistance to blood flow.

BP is expressed in millimeters of mercury. There are the following types of AD:

Ø Systolic (maximum) pressure depends on the stroke volume of the left ventricle.

Ø Diastolic (minimum) , depends on peripheral vascular resistance - due to the tone of arterioles. Both systolic and diastolic pressures depend on the mass of circulating blood, blood viscosity.

Ø Pulse pressure is the difference between systolic and diastolic blood pressure.

Ø Average (dynamic) pressure - this is the constant pressure that could ensure the movement of blood in the vascular system at the same speed. Its value can only be judged by the oscillogram; approximately it can be calculated by the formula:

P average \u003d P diastolic + 1/3 P pulse.

Blood pressure can be measured directly and indirectly.

At direct measurement a needle or cannula connected by a tube to a pressure gauge is inserted directly into the artery.

For indirect measurements there are three methods:

Ø auscultatory

Ø palpation

Ø oscilloscope.

In everyday practice, the most common auscultatory method proposed by N.S. Korotkov in 1905 and allowing to determine systolic and diastolic blood pressure. The measurement is carried out using a mercury or spring sphygmomanometer. N.S. Korotkov described 4 phases of sound phenomena that are heard during the measurement of blood pressure over the vessel under study.

A cuff is placed on the forearm and, pumping air into it, gradually increase the pressure until it exceeds the pressure in the brachial artery. Pulsation in the brachial artery below the cuff stops. The air is released from the cuff, gradually reducing the pressure in it, which leads to the restoration of blood flow. When the pressure in the cuff drops below systolic, tones appear

The first phase is associated with fluctuations in the vessel wall that occur when blood passes into an empty vessel during systole. The second phase is the appearance of noise that occurs when blood passes from the narrowed part of the vessel to the expanded one. The third phase - tones reappear, as portions of blood become larger. The fourth phase is the disappearance of tones (restoration of blood flow in the vessel), at this moment diastolic pressure is recorded.

Palpation method only systolic blood pressure is determined.

Oscilloscope method allows you to register systolic, mean and diastolic pressure in the form of a curve - an oscillogram, as well as to judge the tone of the arteries, the elasticity of the vascular wall, the patency of the vessels.

Blood pressure in healthy people is subject to significant fluctuations depending on physical activity, emotional stress, body position and other factors.

According to the report of the experts of the Scientific Society for the Study of Arterial Hypertension optimal blood pressure considered systolic normal blood pressure systolic

There are the following types of changes in blood pressure:

An increase in blood pressure is called hypertension .

Systolic-diastolic hypertension- a proportional increase in systolic and diastolic pressure is observed in hypertension.

Predominantly systolic hypertension, while only systolic pressure rises, while diastolic pressure remains normal or decreases occurs with aortic atherosclerosis, thyrotoxicosis, or aortic valve insufficiency.

Predominantly diastolic hypertension, while diastolic pressure rises to a greater extent than systolic is observed in renal hypertension. The so-called "headless hypertension" is distinguished, in which in patients with hypertension, due to a decrease in the contractility of the left ventricle, systolic pressure decreases, and diastolic pressure remains low.

Decreased blood pressure below 100 and 60 mm Hg. Art. called hypotension , which is observed in many acute and chronic infectious diseases. A sharp drop in blood pressure occurs with heavy blood loss, shock, collapse, myocardial infarction. Sometimes only systolic blood pressure decreases, while diastolic blood pressure remains normal or even increases (with myocarditis, exudative and adhesive pericarditis, narrowing of the aortic orifice).

Venous pressure is the pressure that the blood exerts on the wall of the vein, being in its lumen. The value of venous pressure depends on the caliber of the vein, the tone of its walls, the volumetric blood flow velocity and the value of intrathoracic pressure.

Venous pressure is measured in millimeters of water (mm H2O). Measurement of venous pressure - phlebotonometry is performed by direct and indirect methods.

Direct (blood method) research is the most accurate. It is carried out using a phlebotonometer.

The phlebotonometer is a glass tube with a lumen diameter of 1.5 mm with millimeter divisions from 0 to 350. The system of glass and rubber tubes is filled with a sterile isotonic sodium chloride solution. In healthy people, venous pressure ranges from 60 to 100 mm of water.

The magnitude of venous pressure can be roughly judged by raising the arm until the veins empty and the limb turns white. The height to which the arm is raised from the level of the right atrium, expressed in millimeters, approximately corresponds to the value of venous pressure.

Changes in venous pressure play an important role in diagnosing diseases and assessing the functional state of the cardiovascular system.

Venous pressure in healthy people increases during exercise, nervous excitement, and deep exhalation. In pathology, venous pressure increases with venous congestion in the systemic circulation, in particular with right ventricular failure.

Venous pressure in healthy people decreases during inspiration. In pathology - with blood loss, loss of fluid due to burns, vomiting, etc.

Plesh test- serves to determine the stagnation of blood in the liver with latent right ventricular failure. Venous pressure is measured, then the liver area is pressed with a hand, if there is blood stasis, then venous pressure rises, the test is considered positive. One of the manifestations with a positive test is the swelling of the jugular vein on the right side with pressure on the liver.

Control questions:

1. What changes in blood vessels can be detected during examination?

2. Define the arterial pulse.

3. List the arteries available for palpation.

4. List the main properties of the pulse.

5. What is a venous pulse?

6. Describe the venous pulse in normal and pathological conditions.

7. Define blood pressure.

8. Name the types of blood pressure, what determines their value?

9. Name the ways of measuring blood pressure.

10. How can blood pressure change in pathology?

11. Describe venous pressure.

Situational tasks

Task 1. In a patient with a slightly displaced apex beat to the left and down, a coarse systolic murmur was detected during auscultation of the heart in the second intercostal space to the right of the sternum, which is carried out to the carotid arteries. The pulse is rhythmic, 56 per minute, the amplitude of the waves is small, they slowly increase and slowly decrease. BP - 110/80 mm Hg. Art. Describe the pulse. What disease are we talking about?

Task 2. In a patient with pale skin, pronounced pulsation on the neck medially from the sternocleidomastoid muscle on both sides, the apex beat is determined in the sixth intercostal space, with an area of 5 cm, domed. BP 150/30 mmHg Art. What pulse should be expected in this patient? Disease diagnosis.

Task 3. You determined the number of heartbeats of 120 per minute with irregularity and uneven pulse waves, which you counted 100 per minute. Give a description of the pulse, in what condition does such a picture occur?

Task 4. A patient has BP 180/120 mm Hg. Art. Name this state. How does the pulse change in this patient?

Task 5. In a patient with cardiovascular pathology, venous pressure is 210 mm of water column. What is the normal venous pressure? What are the symptoms of this patient?

Topic 12. Instrumental methods for studying the cardiovascular system

Purpose of the lesson: Familiarize yourself with the instrumental methods of studying the cardiovascular system, their capabilities. Learn how to evaluate data.

1. A description of all the methods of studying the cardiovascular system indicated in the topic of the lesson. capabilities of each technique.

2. ECG recording technique, FCG, PCG, etc. ECG leads, normal ECG.

1. Evaluate the results of instrumental methods for studying the activity of the heart.

2. Record an ECG.

3. By PCG determine I, II, III, IV tones, systole, diastole, systolic and diastolic murmurs.

4. Determine the main phases of the cardiac cycle by PCG and CCG.

5. To determine the SDLA according to Burstin's nomogram.

Motivation: Diagnosing heart disease is often very difficult. Therefore, in addition to the data of an objective study of the patient, it is necessary to evaluate additional instrumental research methods.

Initial data:

Learning elements

Electrocardiography (ECG) - studies the electrical phenomena that occur during the work of the heart. Recording is carried out at a paper speed of 50 mm/s. Register 12 leads: 3 standard, 3 unipolar reinforced (aVR, aVL, aVF) and 6 chest (V1, V2, V3, V4, V5, V6).

Electrode application method: red wire to the right arm, yellow wire to the left arm, green wire to the left leg, and black wire (ground) to the right leg; V1 at the right edge of the sternum in the 4th intercostal space, V2 at the left edge of the sternum in the 4th intercostal space, V3 along the left parasternal line between the 4th and 5th intercostal spaces, V4 along the left mid-clavicular line in the 5th intercostal space, V5 along the left anterior axillary line in the 5th intercostal space, V6 along the left midaxillary line in the 5th intercostal space.

Leads across the sky- Sky leads have been widely used recently, since changes may appear earlier and be more distinct than in chest leads. Sky leads are bipolar. 3 leads are recorded: D (Dorsalis), A (Anterior) and I (Inferior). The electrodes are placed in the 2nd intercostal space to the right of the sternum (red) at the point V 7 (yellow) and V 4 (green). In lead D - changes are recorded on the posterior wall of the left ventricle, A - on the anterior wall, I - on the apex and septum.

Esophageal leads: to record them in the esophagus with the help of a probe, an electrode is inserted at different levels. Distinguish: PS33 (above the left atrium), PS38 (at the level of the left atrium), PS45-52 (posterior wall of the left ventricle). The esophageal leads are mainly used for electrophysiological examination of the heart.

Remote ECG– An ECG is recorded from a patient and transmitted over a considerable distance from the patient in the form of modulated electrical oscillations via telephone lines or radio channels to a receiving device in a cardiology center.

Holter ECG monitoring is a continuous ECG recording for a long time. It is carried out using a portable electrocardiograph or a pocket cassette recorder powered by batteries. The ECG recorded on magnetic tape is then played back on the monitor screen. If pathological changes are detected, they can be recorded on a conventional electrocardiograph.

ECG study with stress tests- is performed to detect hidden pathology. A test with a dosed physical activity can be carried out using a bicycle ergometer. Master's test - walking for 1½ minutes. on a 2 step ladder. The post-exercise ECG is compared with the resting ECG.

ECG study while taking a number of medications(nitroglycerin test, potassium test, anaprilin test, etc.). Allow to reveal hidden coronary and metabolic changes.

The size of the teeth according to the II standard lead: the height of the P wave is 1-2 mm, the duration is 0.08-0.1 sec; Q wave depth not more than ¼ R wave, duration not more than 0.03 sec: R wave height – 5-15 mm; S wave not more than 6 mm, duration QRS-0.06-0.1 sec; T wave height - 2.5 - 6 mm, duration 0.12-0.16 sec.

The duration of the PQ interval is 0.12-0.18 seconds, QT - 0.35-0.4 seconds. in women and 0.31-0.37 in men. ST offset from the isoline is not more than 1 mm.

Features of a normal electrocardiogram - teeth R W, R avf , R V 1 , P V 2 can be negative, biphasic and isoelectric.

The Q wave is absent in V 1 -V 3 , even a small Q wave in these leads indicates a pathology.

In the chest leads, the value of R increases, reaching a maximum in V 4 , then decreases. The T wave changes synchronously with it. The S wave is the largest in V 1-2, in V 5-6 it may be absent. The transition zone (R =S) is V 2 , V 3 or between them.

ECG analysis scheme.

1. Determination of the heart rhythm.

2. Determining the duration of the RR interval.

3. Calculation of heart rate in 1 min. (60/RR)

4. Assess the voltage. If R 1 + R 3 >5 mm, then the voltage is considered low

5. Determine the position of the electrical axis

7. Conclusion.

Phonocardiography (PCG) - studies the sound phenomena that occur during the mechanical work of the heart.

Phonocardiograph device. There is a sensor - a microphone, which is installed on the auscultation points of the heart; frequency filters, amplifier and recording device. ECG is recorded synchronously with FCG.

Normal FCG registers I and II heart sounds, rarely III tone (physiological), very rarely IV tone.

I tone coincides with the descending knee of the R wave, is recorded in several oscillations, takes 0.12 - 0.20 seconds, height 10-25 mm.

II tone occurs after 0.02 - 0.04 sec. After the end of the T wave, its duration is 0.06 - 0.12 seconds, height 6-15 mm.

III tone - diagnostic, occurs after 0.12 - 0.18 seconds. After tone II, it is usually recorded with 1-2 oscillations.

IV tone is recorded in the norm very rarely, before I tone.

FCG in pathology. It is possible to assess their strengthening or weakening by the height of I and II tones, you can see splitting or bifurcation of tones, record additional pathological tones (III, IV tones) or a click of the opening of the mitral valve. According to FCG, it is easy to distinguish the III tone from the click of the opening of the mitral valve, tk. the click occurs earlier, after 0.03-0.11 sec. Noises are recorded on PCG: systolic (between I and II tone) and diastolic (between II and I tone). Diastolic murmurs on FCG are clearly characterized as protodiastolic, mesodiastolic, presystolic. You can see the shape of the noise (decreasing, increasing, diamond-shaped, etc.), its intensity. Record the conduct of the noise. According to FCG, organic noises can be distinguished from functional ones. The latter will be short, low-amplitude, not merging with the I tone, without conduction.

Polycardiography (PCG) - this is a synchronous ECG recording (standard lead II), FCG, carotid sphygmogram. You can additionally record a phlebogram of the jugular vein, a kinetocardiogram of the left and right ventricles in the PCG. Based on PCG, a phase analysis of the cardiac cycle is performed.

Phases of the cardiac cycle. In systole, 2 periods are distinguished: tension and expulsion. In the voltage period - phases of asynchronous and isometric voltage. In diastole, there are 2 periods: relaxation and filling. In the relaxation period, there are 2 phases: the protodiastole phase (the closing time of the semilunar valves) and the isometric relaxation phase. In the filling period - 3 phases (fast filling, slow filling and atrial contraction phase). In pathology, the duration of the phases of the cardiac cycle changes so that in case of heart failure, the syndrome of myocardial hypodynamia develops, when the period of exile is shortened, and the period of tension is lengthened.

Kinetocardiography (KCG) registers mechanical movements in the precordial region that occur during the work of the heart. To record the work of the left ventricle, the sensor is installed in the area of the apex beat, and the right ventricle - in the zone of absolute dullness in the IV intercostal space on the left at the edge of the sternum. According to CCG, all phases of the cardiac cycle can be calculated separately for the right and left ventricles.

echocardiography - a method of visualization of cavities, heart valves, intracardiac structures using reflected ultrasound. The resulting echo signal is fed to an electronic amplifier, a recording device, and to a screen. Echocardiography studies the anatomy of the heart, the flow of blood inside the heart. Allows you to diagnose heart defects, hypertrophy of various departments, the state of the myocardium, dilatation of the cavities of the heart, to make an indirect measurement of SAP.

EchoCG is a bloodless method for studying the cardiovascular system using ultrasound with a frequency of 2-10 MHz. The propagation velocity of ultrasound in soft human tissues is 1540 m/s, and in denser bone tissue - 3370 m/s. An ultrasonic beam is capable of being reflected from objects, provided that their magnitude is at least ¼ of the wavelength. For ultrasound examination of the heart, an echocardiograph is used, an integral part of which is a sensor (piezoelectric element) that emits and perceives ultrasonic vibrations.

One- and two-dimensional EchoCG is used to study central hemodynamic parameters (stroke volume (SV), minute volume (MO), ejection fraction (EF), cardiac index (CI), degree of shortening of the anteroposterior size of the left ventricle in systole (% S), myocardial mass) and assess the state of the valvular apparatus and myocardium.

Dopplerography - a study of the volumetric blood flow velocity, the degree of regurgitation and the pressure gradient across the valves.

Transesophageal echocardiography - detailing the state of the valvular apparatus and myocardium.

Control questions:

1. What phenomena does the ECG study?

2. What is a "remote ECG"?

3. What is Holter ECG monitoring used for?

4. What are the stress tests in the study of ECG? What is their purpose?

5. What is studied in FCG?

6. Why is PCG recorded synchronously with ECG?

7. What parameters do the heart sounds recorded on FCG have in the norm?

8. How to distinguish the III tone from the click of the mitral valve opening on FCG?

9. What are the differences between organic and functional murmurs on FCG?

10. What is "polycardiography"?

11. What is studied in PCG?

12. What are the phases of the cardiac cycle?

13. What is the syndrome of myocardial hypodynamia characterized by?

14. What does the KCG register?

15. What is the method of indirect determination of SDLA according to Burstin?

16. What is echocardiography?

17. What is studied by echocardiography?

18. What does rheography study?

Situational tasks

Task 1. Patient N., 25 years old, is being treated in a hospital for rheumatism, mitral stenosis. The FCG was recorded.

What pathological changes will be revealed on PCG? What kind of noise will be registered? On what auscultatory points will it be detected?

Task 2. Patient H., 40 years old, complains of weakness, dizziness. Pale. The borders of the heart are normal. On auscultation, the heart sounds are rhythmic, in the II intercostal space on the left, a gentle short systolic murmur is heard. In the blood test, the level of hemoglobin and erythrocytes is reduced.

What is the nature of systolic murmur? Note its characteristic features on the presented FCG.

Task 3. During auscultation of the heart, the patient listens to a 3-membered rhythm. On the FCG, an enhanced I tone is recorded, the third sound lags behind the II tone by 0.08 seconds.

What rhythm is heard in the patient? Name the third sound in the auscultated rhythm of the patient.

Task 4. Determine according to Burstin's nomogram of SDLA, if according to the CCG of the right ventricle: 1) FIR = 0.11 sec., the number of heartbeats is 85 beats per minute; 2) FIR=0.09 sec., heart rate - 90 beats per minute.

Topic 13. Cardiac arrhythmias. Clinical and ECG diagnostics.

Purpose of the lesson: To teach clinical and ECG diagnostics of the main types of cardiac arrhythmias.

Before the lesson, the student should know:

1. Classification of arrhythmias.

2. Arrhythmias associated with dysfunction of automatism.

3. Arrhythmias associated with dysfunction of excitability.

4. Arrhythmias associated with impaired conduction function.

5. Complex types of cardiac arrhythmias.

At the end of the course, the student should be able to:

1. Correctly recognize various types of arrhythmias by clinical signs.

2. Correctly recognize various types of arrhythmias by ECG.

Motivation. Arrhythmias are a common complication of heart disease. They aggravate the course of the disease. Therefore, timely accurate diagnosis of arrhythmias is important for the treatment of patients.

Initial data.

Educational elements.

Basic functions of the heart . The work of the heart is carried out thanks to 4 main functions: automatism, excitability, conductivity, contractility.

Classification of cardiac arrhythmias . Arrhythmias are divided into groups depending on the violation of a particular function of the heart: automatism, excitability, conduction and contractility.

1) Violations of the function of automatism. The most common are sinus tachycardia, sinus bradycardia, and sinus arrhythmia. On the ECG, a sign of sinus rhythm is the presence of a positive P wave in front of the QRS complex.

Ø Sinus tachycardia . It is caused by increased activity of the sinus node as a result of physical or nervous stress, fever, when taking stimulants, thyrotoxicosis, heart failure. Patients complain of palpitations, the pulse is frequent and rhythmic. On the ECG, the RR and TP intervals are shortened.

Ø Sinus bradycardia . It is due to the rare production of impulses from the sinus node. It is observed with hypothyroidism, the action of a number of medications, with an increase in the tone of the vagus nerve, with a decrease in the tone of the sympathetic nervous system, in patients with diseases of the liver and gastrointestinal tract, and in athletes. The pulse is rhythmic and rare. On the ECG, the RR and TP intervals are lengthened.

Ø sinus arrhythmia . It is caused by non-rhythmic generation of impulses from the sinus node. There are 2 forms: respiratory (youthful) and non-respiratory (with myocardial diseases). On the ECG - different duration of RR intervals in sinus rhythm.

2) Violation of the function of excitability. Manifested by extrasystole and paroxysmal tachycardia. It is caused by the appearance in some parts of the myocardium of ectopic foci of excitation, which can generate an impulse leading to an extraordinary contraction of the heart. Such heterotopic foci occur with myocardial diseases, with an overdose of a number of medications, with increased nervous excitability, etc.

Diagnostic signs of extrasystole:

Extraordinary reduction;

Complete or incomplete compensatory pause;

Drawing of an extrasystolic complex on an ECG.

In addition to single ones, there are group extrasystoles, and sometimes there is a pattern of extrasystoles, which is called allorhythmia. The types of allorhythms are as follows:

Bigeminia (extrasystoles are repeated after each normal sinus complex);

Trigeminia (every two sinus complexes are followed by an extrasystole);

Quadrigeminia (every three normal cycles are followed by an extrasystole).

Ø Atrial extrasystole . The ectopic focus of excitation is located in the atrium. In this case, excitation spreads to the ventricles in the usual way, so the ventricular QRS-T complex will not be changed, some changes in the P wave may be observed. The compensatory pause is incomplete, since at the moment the ectopic impulse is generated, the sinus node is discharged, and after the extrasystole, the next normal complex goes through the usual period of time.

Ø Atrioventricular extrasystole . In this case, an extraordinary impulse leaves the atrioventricular node. Excitation covers the ventricles in the usual way, so the QRS complex is not changed. Excitation goes to the atria from the bottom up, one hundred leads to a negative P wave. Depending on the conditions of impulse conduction in the affected myocardium, excitation may reach the atria earlier and negative P will then be recorded before the normal QRS complex (“upper nodal” extrasystole). Or the excitation will reach the ventricles earlier, and the atria will be excited later, then the negative P will move after the QRS complex (“lower nodal” extrasystole). In cases of simultaneous excitation of the atria and ventricles, negative P is layered on the QRS, which deforms the ventricular complex (“mid-nodal” extrasystole).

Ø Ventricular extrasystole due to the release of excitation from the ectopic focus in one of the ventricles. In this case, the ventricle in which the ectopic focus is located is first excited, the other excitation reaches later along the Purkinje fibers through the interventricular septum. The impulse does not reach the atria in the opposite direction, so the extrasystolic complex does not have a P wave, and the QRS complex is expanded and deformed.

Similar information.

The so-called additional heart sounds include enhanced physiological III or IV tones, the tone or click of the opening of the mitral valve in mitral stenosis, as well as the pericardial tone.

Enhanced physiological III and IV tones indicate a significant weakening of the myocardium of the left ventricle (inflammation, degenerative changes, toxic lesions) and result from the rapid stretching of its walls under the pressure of blood flowing from the atrium. Normally, III tone occurs due to stretching of the ventricular wall under the influence of the rapid entry into their cavity of the first portion of blood from the atria at the beginning of diastole, it is better detected with graphic registration on a phonocardiogram than with auscultation.

Listening to heart sounds

Listening to heart sounds - weakening of tones

Sharply weakened, almost inaudible heart sounds are called deaf, with a moderate decrease in the sonority of the tones, they speak of muffled tones. Weakening of the I tone is possible with valvular heart disease - insufficiency of the mitral and aortic valves due to the weakening of its valvular and muscle components. The weakening of the I heart sound with damage to the heart muscle (for example, with acute myocarditis, cardiosclerosis) is explained by a decrease in the force of contraction of the heart muscle, and with hypertrophy of the heart (for example, with hypertension) - a decrease in the speed of tension of the heart muscle.

The weakening of the II heart sound on the aorta is observed when the cusps of the aortic valves are destroyed (insufficiency of the aortic valves) and the blood pressure in the aorta decreases (for example, when the aortic orifice narrows).

The weakening of the second heart sound on the pulmonary artery during auscultation occurs when its valves are insufficiency and narrowing of its mouth. The reasons for the weakening of the II tone with these defects are the same as with aortic ones.

Increased heart sounds when listening

Strengthening of both heart sounds can be observed with wrinkling (retraction) of the lung edges, with inflammatory compaction of the lung edges adjacent to the heart. It is also found in tachycardia, febrile process, hyperthyroidism. In all the latter cases, the reason for the amplification of both heart sounds during listening is the increase in heart rate, in which the blood filling of the heart cavities decreases and the amplitude of closing of the leaflets valves increases, as a result of which the I tone increases. II tone under these conditions increases as a result of a decrease in systolic blood volume and a more rapid slamming of the semilunar aortic and pulmonary valves.

The amplification of both heart sounds is of much lesser importance than the amplification of each tone separately. Strengthening of the I heart sound can be caught especially clearly at the apex with stenosis of the left atrioventricular orifice (mitral stenosis), narrowing of the right atrioventricular orifice (tricuspid stenosis), atrial fibrillation, ventricular extrasystoles, tachycardia, complete atrioventricular blockade.

Strengthening of the I tone in mitral and tricuspid stenosis, atrial fibrillation, ventricular extrasystoles, tachycardia is due to low blood filling of the ventricles during diastole of the heart. It should be pointed out, however, that tricuspid stenosis (narrowing of the right atrioventricular orifice) is very rare in practice. The first tone is especially loud with complete atrioventricular blockade of the heart, in which the simultaneous contraction of the atria and ventricles periodically occurs. This tone was first described by N.D. Strazhesko and was called "cannon tone".

Strengthening of the II tone can be observed both in the aorta and in the pulmonary artery. In healthy adults, the sounding strength of the second heart sound on the aorta and pulmonary artery is the same when listening. This is explained by the fact that the pulmonary valve is located closer in the chest than the aortic valve, due to which the transmission of sound phenomena from them is equalized. But under certain conditions, the strength of sounding of the second tone on these vessels may not be the same. In such cases, they speak of an accent of the II tone on one or another vessel. The strength of the II tone depends on the strength of the push of the back flow of blood against the valves of the aorta (or pulmonary artery) during diastole and is always parallel to the height of blood pressure.

Strengthening (emphasis) of the II tone on the aorta is most often a sign of an increase in blood pressure in the systemic circulation of various origins (hypertension, symptomatic arterial hypertension, as well as a temporary increase in blood pressure during exercise and excitement). Emphasis of II tone on the aorta can also occur with low pressure in the systemic circulation, in particular with calcification of the aortic valve cusps (atherosclerosis) and syphilitic aorthritis. In the latter case, the sound acquires a sharp metallic tint.

Strengthening (emphasis) of the II tone on the pulmonary artery is heard with an increase in pressure in the pulmonary circulation system. It occurs:

with primary heart lesions that create conditions for pulmonary hypertension (mitral heart disease and especially stenosis of the left atrioventricular orifice, non-closure of the batal duct, sclerosis of the pulmonary artery);
with lung diseases leading to narrowing of the channel and a decrease in the pool of the pulmonary circulation (pulmonary emphysema, pneumosclerosis, chronic bronchitis, pneumonia, massive pleural exudates, sclerosis of the branches of the pulmonary artery, etc.);
with lesions of the spine and deformities of the chest in the form of kyphosis and scoliosis, which, limiting the excursion of the lungs, lead to emphysematous swelling of the lungs from the side of the convexity of the chest and compression or even atecatasis from the side of its concavity, as well as to inflammatory processes in the bronchi and lungs.

As a result of hypertension of the pulmonary circulation, which has developed as a result of acquired or congenital heart defects, bronchial and lung diseases, chest deformities, hypertrophy is formed, and then dilatation of the right ventricle. Therefore, the emphasis of the II tone on the pulmonary artery is a sign of right ventricular hypertrophy. The disappearance of the previously existing amplification (emphasis) of the II tone on the pulmonary artery indicates dilatation and secondary weakness of the right ventricle of the heart.

Pathological bifurcation and splitting of heart sounds

Pathological bifurcation and splitting of the first heart sound occurs, as a rule, with blockade of the atrioventricular node or one of the legs of the atrioventricular bundle (His bundle), and is caused by non-simultaneous contraction of the right and left ventricles of the heart. Bifurcation of the first tone may appear with atherosclerosis of the initial part of the aorta. It is heard on the basis of the heart and is explained by increased fluctuations in the sclerotic walls of the aorta during the emptying of the left ventricle.

Pathological bifurcation and splitting of the second heart sound is a sign of serious changes in the heart and its valves. It can be observed when lagging behind the slamming of the aortic valve in patients with aortic stenosis; with hypertension; delayed closure of the pulmonary valve due to increased pressure in the pulmonary circulation (with mitral stenosis, emphysema, etc.), delayed contraction of one of the ventricles in patients with bundle branch block.

Listening to heart sounds - gallop rhythm

In severe myocardial damage, the physiological III heart sound increases so much that it is detected during auscultation or listening and creates a three-part rhythm melody (I, II and additional III tones), reminiscent of the tramp of a galloping horse - a gallop rhythm is heard. It must be borne in mind that the additional III heart sound with a true gallop rhythm is very weak, it is better felt by the hand from a slight concussion of the chest than auscultated. Often, a bifurcation of the 1st heart sound is taken for the gallop rhythm, when it is so sharp that a three-membered rhythm is heard at the apex of the heart or in the 3rd - 4th intercostal space on the left. At the same time, unlike the true gallop rhythm, heart sounds are well heard.

The true gallop rhythm is figuratively called the "cry of the heart for help", since it is a sign of severe heart damage. The three-term rhythm due to a significant bifurcation of the first heart sound, auscultatively similar to the gallop rhythm, is due to the blockade of one of the legs (the bundle of His) that is very common in patients.

The gallop rhythm is best heard directly by the ear (along with the sound, a slight push is perceived, transmitted from the heart to the chest in the diastole phase) in the region of the apex of the heart or the 3rd and 4th intercostal spaces on the left. Especially clearly it is heard when the patient is lying on the left side. Since it is extremely inconvenient to directly listen to heart sounds with the ear, a stethophonendoscope is used.

Distinctive signs of heart sounds when listening

Correct recognition of heart sounds is essential for diagnosing and listening to heart disease. To differentiate I and II heart sounds, you can use the following criteria: I tone is heard after a diastolic pause of the heart (large pause), and II - after a small pause. When listening to the heart, you can catch the following rhythm: I heart sound, a small pause, II tone, a long pause, again I tone, etc.

There are differences in the sonority of I and II tones on individual auscultatory points of the heart. So, normally, at the apex of the heart, I tone is better (louder), and at the base (i.e., above the valves of the aorta and pulmonary artery) - II. This is explained by the fact that sound phenomena are best carried out to the apex of the heart from the mitral valve, the vibrations and tensions of which are involved in the formation of the I tone, while the II tone occurs far from the apex of the heart and is weaker conducted to this area.

In the second intercostal space on the right (aorta) and on the left at the edge of the sternum (pulmonary artery), the II heart sound, on the contrary, is heard more strongly than the I, since sound phenomena from the semilunar valves are better conducted here, when they collapse, the II tone is formed. I tone coincides with the apical impulse or pulse on the carotid artery, II tone sounds at the moment of absence of the apical impulse or pulse. It is not recommended to determine 1 tone by the pulse on the radial artery, as it is late in comparison with the beginning of the systole, which gives the 1st tone.

The weakening of both heart sounds when listening may depend on causes that are not directly related to the heart. For example, a strongly developed musculature prevents the good conduction of sound phenomena from the heart, which is observed in healthy, but extremely obese people.

Strengthening of both heart sounds may be associated with their better conductivity in the stethophonendoscope. This happens in asthenics with a thin chest, a high standing of the diaphragm, a sharp weight loss, with physical stress and nervous excitement.

Listening to additional heart sounds

Depending on the phase of diastole, during which a pathological III heart sound appears, there are protodiastolic, mesodiastolic and presystolic gallop rhythms.

Protodiastolic sound appears at the beginning of diastole immediately after the second heart sound. It is an enhanced physiological III heart sound, occurs 0.12 - 0.2 s after the II tone and indicates a significant decrease in myocardial tone.

The presystolic heart sound occurs at the end of diastole closer to the I tone, as if anticipating its appearance (presystolic gallop rhythm). It is an enhanced physiological IV tone, due to a decrease in ventricular myocardial tone and a stronger atrial contraction.

The mesodiastolic heart tone that occurs in the middle of diastole is the summed III and IV heart sounds, which, in severe heart damage (for example, myocardial infarction, cardiomyopathy, etc.), merge together into a single gallop tone. A necessary condition for the fusion of III and IV tones into a single mesodiastolic gallop tone is the presence of tachycardia.

Listening to the rhythm of the quail

The tone (click) of the opening of the mitral valve in mitral stenosis is explained by a stronger opening of its valves.

The additional tone (click) of the heart of the opening of the mitral valve, together with the flapping I tone and the II heart sound accentuated on the pulmonary artery, forms a characteristic auscultatory melody resembling a quail cry. The sound sensation of a quail's cry can be depicted as follows: “time to sleep”, “time to sleep”. Hence the name of this sound phenomenon, auscultated with mitral stenosis at the apex of the heart - quail rhythm. Its distribution area is extensive - from the top of the heart up and into the axillary region.

The rhythm of the quail is somewhat reminiscent of the auscultatory picture of a bifurcation of the second heart sound, and therefore they are often confused. The main thing that distinguishes the quail rhythm from the bifurcation of the second heart sound is its clear tripartiteness; an additional tone (click) of the opening of the mitral valve is distinguished by a high clicking timbre and is perceived as a loud echo following the II tone. With adhesions of the pericardium, there may be an additional pericardial tone. It appears during diastole 0.08 - 0.14 s after the second tone and is associated with pericardial fluctuations during the rapid expansion of the ventricles at the beginning of diastole.

An additional heart sound during pericardial adhesions can also occur during the period of systole between I and II heart sounds. It sounds loud and short. Since this extra tone occurs during systole, it is also called a systolic click. A systolic click can also appear with mitral valve prolapse, i.e. bulging or protrusion of the leaflet of the mitral valve into the cavity of the left atrium during left ventricular systole.

Embryocardia, or pendulum heart rhythm, is a heart rhythm that resembles fetal heart sounds or clockwork. It is observed in acute heart failure, an attack of paroxysmal tachycardia, high fever and other pathological conditions, when a sharp increase in heart rate leads to a shortening of the diastolic pause so that it becomes almost equal to the systolic one. At the same time, the heart sounds heard at the apex are approximately the same in sonority.

Listening to heart and pulmonary sounds

Auscultatory points of the heart when listening to tones are the places of the best detection of heart sounds. The anatomical structure of the heart is such that all valves are located closer to its base and are adjacent to each other. However, the sound phenomena that occur in the region of the valves are better heard not at the places where the valves are projected onto the chest, but at the so-called auscultatory points of the heart.

It has been established that sound phenomena when listening to tones from the bicuspid (mitral) valve are best heard at the apex of the heart where the apex beat is usually visible or palpable, i.e. in the 5th intercostal space, 1 cm medially from the left mid-clavicular line (the first auscultatory point of the heart). The sound phenomena that occur in the bicuspid valve are well conducted to the apex of the heart along the compacted muscle of the left ventricle during its systole.

The apex of the heart during systole most closely adheres to the anterior chest wall and is separated from it by the thinnest layer of the lung. Sound phenomena when listening to the heart from the aorta are best heard in the 2nd intercostal space at the right edge of the sternum (the second auscultatory point of the heart). The best listening to the tones of sound phenomena from the aortic valves in the 2nd intercostal space on the right at the edge of the sternum is due to the fact that they are better conducted to this place along the blood flow and the walls of the aorta. In addition, in this place, the aorta is closest to the anterior wall of the chest.

The pulmonary artery is auscultated in the 2nd intercostal space at the left edge of the sternum (the third auscultatory point of the heart). From the tricuspid valve, sound phenomena are better heard at the base of the xiphoid process on the right, i.e. at the place of attachment to the sternum of the V costal cartilage or at the place of articulation of the end of the body of the sternum with the xiphoid process (fourth auscultatory point of the heart).

S.P. Botkin proposed an additional fifth point for listening to heart sounds and sound phenomena from the aortic valves, in particular, in case of their insufficiency. Botkin's point is located in the 3rd intercostal space on the left at the edge of the sternum between the place of attachment to it of the III and IV costal cartilages.

The heart can be heard in any order, but it is better to follow a certain rule. The following sequence is usually recommended:

mitral valve,
aortic valve,
pulmonary valves,
tricuspid valve.

Then they additionally listen at the Botkin point (the fifth point of the heart). This sequence is due to the decreasing frequency of heart valve disease.

Listening to mitral stenosis of the heart

It should be pointed out that tricuspid stenosis (narrowing of the right atrioventricular orifice) is practically very rare. In a healthy heart, by the end of diastole, the left atrium is completely freed from blood, the left ventricle is filled, the mitral valve “pops up” and its valves are completely gently and smoothly closed. When listening to mitral stenosis due to narrowing of the atrioventricular orifice, a lot of blood remains in the atrium by the end of diastole, it continues to pour into the ventricle that is not yet completely filled, so the mitral valve leaflets are pulled apart by a stream of flowing blood.

When systole begins, these valves slam shut with a large swing, overcoming the resistance of the blood stream. In addition, the left ventricle fills with a small amount of blood during diastole, which leads to its rapid contraction. These valve and muscle components significantly increase and shorten tone I at the apex. Such a heart sound when listening to mitral stenosis is called flapping. As Academician A.L. Myasnikov said, in the diagnosis of mitral stenosis, "I tone sets the tone." Strengthening (emphasis) of the II tone over the aorta is often observed with atherosclerotic calcification (compaction) of the aortic valve cusps. In this case, the II heart sound above the aorta acquires a sharp metallic hue.

Strengthening (emphasis) of the II heart sound above the pulmonary artery occurs when the push of the back flow of blood against the valves of the pulmonary artery increases during diastole with an increase in pressure in the pulmonary circulation system. It occurs with mitral heart disease, in which conditions for pulmonary hypertension are created.

Diagnosis of listening to heart sounds

Diagnosis of chronic cor pulmonale by auscultation

Currently, diagnostic schemes have been developed for listening to heart sounds, which include the most reliable electrocardiographic signs, giving the practitioner the ability to recognize hypertrophy of the right heart with a certain certainty. The most widely used scheme is Widimsky et al., in which a large number of electrocardiographic signs of CLS are divided into direct and indirect.

According to Widimsky, in the presence of two or more direct signs of right ventricular hypertrophy, the electrocardiographic diagnosis of CHLS can be considered reliable, one direct and one or more indirect signs can be considered probable, and any one sign is doubtful. However, when assessing the ECG using the Widimsky method, there is a significant overdiagnosis of CHL, especially in individuals with a vertical and semi-vertical electrical position of the heart.

One of the main methods used in everyday medical practice is auscultation of the heart. The method allows you to listen to the sounds that form during myocardial contraction with a special device - a stethoscope or a phonendoscope.

The purpose of the

With its help, patients are screened for the detection of diseases of the heart and blood vessels. The following diseases can be suspected by changes in the auscultatory picture:

malformations (congenital/acquired);
myocarditis;
pericarditis;
anemia;
dilatation or hypertrophy of the ventricles;
ischemia (angina pectoris, heart attack).

The phonendoscope registers sound impulses during myocardial contractions, called heart sounds. A description of their strength, dynamism, duration, degree of sound, place of formation is an important aspect, since each disease has a specific picture. This helps the doctor to suspect the disease and refer the patient to a specialized hospital.

Points for listening to the valves of the heart

In a hurry, you can not auscultate the heart. It is started after a conversation with the patient, examination, study of his complaints and the history of the disease. In the presence of symptoms of myocardial damage (pain behind the sternum, shortness of breath, chest compression, acrocyanosis, fingers in the form of "drumsticks"), a thorough examination of the cardiac region is performed. The chest is tapped to determine the boundaries of the heart. Palpation examination allows you to establish the presence or absence of trembling of the chest or heart hump.

Auscultation points during auscultation of the heart coincide with the anatomical projection of the valves on the chest. There is a certain algorithm of how to listen to the heart. It has the following order:

left atrial ventricular valve (1);
aortic valve (2);
pulmonary valve (3);
right atrioventricular valve (4);
additional point for the aortic valve (5).

There are 5 additional auscultation points. Listening in their projections is considered appropriate in determining pathological heart sounds.

Auscultation of the mitral valve is carried out in the area of the apex beat, which is palpated earlier. Normally, it is located in the 5th intercostal space outward from the nipple line by 1.5 centimeters. Heart valve sounds between the left ventricle and aorta are heard in the second intercostal space along the right edge of the sternum, and the pulmonary valve is in the same projection, but on the left. The study of the tricuspid valve is carried out in the region of the xiphoid process of the sternum. The additional Botkin-Erb point allows you to fully appreciate the sound of the aortic valve. To listen to it, a phonendoscope is placed in the third intercostal space from the left edge of the sternum.

Students of medical institutes study the method of auscultation of the heart in normal and pathological conditions during the cycle of therapy. To begin with, training is carried out on a mannequin, and then directly on patients.

Techniques to help you conduct the survey correctly

Listening to heart sounds requires compliance with certain rules. If the general well-being of a person is satisfactory, at the time of the examination, he is standing. To reduce the likelihood of missing pathology, the patient is asked to hold his breath after a deep breath (for 4-5 seconds). Silence must be observed during the examination. In case of severe severity of the disease, auscultation is performed while sitting or lying on the left side.

It is not always possible to hear heart sounds. Therefore, doctors use the following techniques:

In the presence of abundant hairline - cover with cream or water, in rare cases, shave off.

With an increased subcutaneous fat layer - stronger pressure on the chest of the head of the phonendoscope in places of listening to the heart valves.
If mitral stenosis is suspected, listen to the tones in the lateral position with a stethoscope (a device without a membrane).
If you suspect the presence of pathology of the aortic valve - listening to the patient while exhaling while standing with the torso leaning forward.

With a dubious auscultatory picture, a test with physical activity is used. In this case, the patient is asked to walk for two minutes or sit down 5 times. Then proceed to listening to tones. Increased blood flow due to increased myocardial load is reflected in the sound of the heart.

Interpretation of results

Auscultation reveals normal or abnormal heart sounds and murmurs. Their presence requires further study using standard laboratory and instrumental research methods (phonocardiogram, ECG, Echo-KG).

For a person, the appearance of two main tones (1, 2) during auscultation is physiological. There are also additional heart sounds (3, 4) that can be heard in pathology or under certain conditions.

In the presence of pathological sound, the therapist refers the patient to a cardiologist. He studies their localization, loudness, timbre, noise, dynamics and duration.

The first tone occurs during ventricular contraction and consists of four components:

valvular - the movement of the leaflets of the atrioventricular valves (mitral, tricuspid);
muscular - contraction of the walls of the ventricles;
vascular - oscillatory movements of the walls of the pulmonary trunk and aorta;
atrial - atrial contraction.

It is best heard at the apex of the heart. Its duration is somewhat longer than the second. If there is a difficulty with its definition, then it is necessary to feel the pulse on the carotid arteries - 1 tone coincides with it.

The characteristic of the second tone is carried out at the base of the heart. It is formed by 2 components - vascular (vibration of the walls of the main vessels) and valvular (movement of the leaflets of the valves of the aorta and pulmonary trunk) at the moment of relaxation of the heart muscle. It has a high timbre compared to the first tone.

The rapid filling of the ventricles with blood shakes their walls and creates a sound effect called the third tone.

It can often be heard at a young age. The fourth tone is determined at the end of the relaxation phase of the heart and the beginning of atrial contraction due to the rapid filling of the ventricular cavities with blood.

Under certain conditions, people change the characteristics of tones (amplification, bifurcation, weakening, splitting). The reason for the amplification of tones may be non-cardiac pathology:

diseases of the respiratory system with a change in the size of the lungs;

thyroid disease (hyperthyroidism);
a large gas bubble in the stomach;
the density of the human skeleton (children and the elderly).

An increase in the work of the heart, during exercise or an increase in body temperature, causes an increase in sound due to compensatory heartbeat. The weakening of the tones indicates extracardiac pathology with a large fat layer, an increase in the airiness of the lung tissue, and the presence of exudative pleurisy.

Changes in heart tones in pathology

A change in the sound of the first tone can occur with the following diseases:

Strengthening - stenosis of both atrioventricular valves, tachycardia.
Weakening - left ventricular hypertrophy, insufficient heart, myocarditis, cardiosclerosis, atrioventricular valve insufficiency.
Bifurcation - violation of conduction (blockade), sclerotic change in the walls of the aorta.

The following pathology causes a variation in the sound of the second tone:

Strengthening on the right in the second intercostal space - hypertension, vascular atherosclerosis.
Strengthening on the left in the second intercostal space - lung damage (pneumosclerosis, emphysema, pneumonia), defects of the left artioventricular valve.
Bifurcation - stenosis of the left atrioventricular valve.
Weakness in the pulmonary artery - pulmonary valve defects.
Weakness on the aorta - anomalies of the aortic valve.

It is quite difficult to distinguish between bifurcation / splitting of the main heart sounds with the appearance of additional ones. When the myocardium is damaged, a "gallop rhythm" may occur. It is characterized by the addition of a third tone to the main ones. Its appearance is due to the stretching of the walls of the ventricles, the incoming volume of blood from the atria, with a weakening of the myocardium. The rhythm can be heard directly by the ear of the patient lying on his left side.

“Rhythm of a quail” is a pathological sound of the heart, including clapping 1 tone, 2 and additional tones. The rhythm has a large listening area; it is carried out from the top of the heart to its base and to the armpit.

Principles of auscultation of the heart in children

The points of auscultation of the heart valves in children and the procedure for conducting it do not differ from adults. But the age of the patient matters. Children are characterized by the presence of the following features of the auscultatory picture:

The presence of accent 2 tones over the pulmonary artery in primary school age;
The presence of 3, 4 tones.

The definition of "cat's purr" at 12-15 years old.
Changing the boundaries of the heart (in centile tables you can find out the norms for each age and gender).

In newborns, the definition of noise and abnormal heart sounds indicates congenital malformations. Their early detection and provision of care increases the survival prognosis of such patients. The pathology of the heart is determined even in the period of intrauterine development of the fetus according to ultrasound.

Advantages and disadvantages of the method

Since the time of Hippocrates, percussion, auscultation and palpation have been considered the main methods of examining patients. Thanks to them, one can assume the presence of any pathology of the heart. The advantage of auscultation is its simplicity and high specificity.

But only on the basis of the heard picture it is impossible to give an accurate conclusion about the diagnosis. The main disadvantage of the method is the doctor's subjective assessment of tone sound. In this case, you can not listen to what the doctor heard. In medicine, digital phonendoscopes have appeared that can record good quality audio signals. However, their cost is very high, which does not allow them to be put into practice.

Blood pressure 130/80 mm Hg. Art.

RESPIRATORY SYSTEM

Inspection

Breathing through the nose, free, rhythmic, shallow. The type of breathing is abdominal. The respiratory rate is 20 per minute. The shape of the chest is correct, symmetrical, both halves of the chest are equally involved in the act of breathing. Clavicles and shoulder blades are symmetrical. The shoulder blades are close to the back wall of the chest. The course of the ribs is oblique. Supraclavicular and subclavian fossae are well expressed. Intercostal spaces are traceable.

Palpation

The chest is rigid, painless. Voice trembling is symmetrical, not changed.

Percussion

Topographic percussion.

The lower borders of the right lung: l. parasternalis - the upper edge of the 6th rib along l. medioclavicularis - the lower edge of the 6th rib along l. axillaris anterior - 7th rib along l. axillaris media- 8 rib along l. axillaris posterior - 9th rib along l. scapuiaris - 10 rib along l. paravertebralis - at the level of the spinous process of the 11th thoracic vertebra

Inferior borders of the left lung:
by l. parasternalis--------
by l. medioclavicularis- -------
by l. axillaris anterior - 7th rib
by l. axillaris media-9 rib
by l. axillaris posterior - 9th rib
by l. scapuiaris- 10 rib
by l. paravertebralis - at the level of the spinous process of the 11th thoracic vertebra

Upper borders of the lungs: Anteriorly 3 cm above the collarbone. Behind at the level of the spinous process of the 7th cervical vertebra.

Active mobility of the lower pulmonary edge of the right lung along the middle axillary line: on inspiration 4 cm on expiration 4 cm

Active mobility of the lower pulmonary edge of the left lung along the middle axillary line: on inspiration 4 cm on expiration 4 cm

Comparative percussion:

Above the symmetrical areas of the lung tissue, a clear lung sound is determined.

Auscultation

Hard breathing is heard over all auscultatory points. Dry rales are heard on the anterior surface of the lungs.

DIGESTIVE SYSTEM

Inspection

The abdomen is enlarged in volume, flattened in the prone position, symmetrical, does not participate in the act of breathing, the navel is retracted.

Palpation

Superficial: The abdomen is soft, painless. A symptom of fluctuation is revealed. The liquid level is determined.

Deep: The sigmoid colon is palpated in the left iliac region in the form of an elastic cylinder, with a smooth surface 1.5 cm wide, movable, not rumbling, painless. The transverse colon is not palpable. The stomach is not palpated.

The lower edge of the liver is sharp, uneven, dense, painless, comes out from under the edge of the costal arch by 3 cm; The surface of the liver is bumpy. The gallbladder is not palpable. Symptoms of Murphy, Ortner, frenicus are negative. The spleen is palpable.

On phlebogram there are a number of waves:

2) Wave "c" associated with ventricular systole and occurs due to the transmission of the pulsation of the carotid artery, located near the jugular vein, wave (+).

3) Wave "x" - systolic collapse is explained by the fact that during the systole of the ventricles, the right atrium is filled with venous blood, the veins are emptied and collapse.

Arterial pressure (BP) is the pressure exerted by the blood in an artery against its wall.

The value of blood pressure depends on the value of cardiac output and total peripheral vascular resistance to blood flow.

BP is expressed in millimeters of mercury. There are the following types of AD:

Ø Systolic (maximum) pressure depends on the stroke volume of the left ventricle.

Ø Pulse pressure is the difference between systolic and diastolic blood pressure.

P average \u003d P diastolic + 1/3 P pulse.

Blood pressure can be measured directly and indirectly.

At direct measurement a needle or cannula connected by a tube to a pressure gauge is inserted directly into the artery.

For indirect measurements there are three methods:

Ø auscultatory

Ø palpation

Ø oscilloscope.

Palpation method only systolic blood pressure is determined.

Blood pressure in healthy people is subject to significant fluctuations depending on physical activity, emotional stress, body position and other factors.

According to the report of the experts of the Scientific Society for the Study of Arterial Hypertension optimal blood pressure considered systolic< 120 мм рт. ст., диастолическое < 80 мм рт. ст., normal blood pressure systolic<130 мм рт. ст., диастолическое <85 мм рт. ст.

There are the following types of changes in blood pressure:

An increase in blood pressure is called hypertension .

Systolic-diastolic hypertension- a proportional increase in systolic and diastolic pressure is observed in hypertension.

Venous pressure is measured in millimeters of water (mm H2O). Measurement of venous pressure - phlebotonometry is performed by direct and indirect methods.

Direct (blood method) research is the most accurate. It is carried out using a phlebotonometer.

Changes in venous pressure play an important role in diagnosing diseases and assessing the functional state of the cardiovascular system.

Venous pressure in healthy people decreases during inspiration. In pathology - with blood loss, loss of fluid due to burns, vomiting, etc.

Control questions:

1. What changes in blood vessels can be detected during examination?

2. Define the arterial pulse.

3. List the arteries available for palpation.

4. List the main properties of the pulse.

5. What is a venous pulse?

6. Describe the venous pulse in normal and pathological conditions.

7. Define blood pressure.

8. Name the types of blood pressure, what determines their value?

9. Name the ways of measuring blood pressure.

10. How can blood pressure change in pathology?

11. Describe venous pressure.

Situational tasks

Task 4. A patient has BP 180/120 mm Hg. Art. Name this state. How does the pulse change in this patient?

Task 5. In a patient with cardiovascular pathology, venous pressure is 210 mm of water column. What is the normal venous pressure? What are the symptoms of this patient?

Topic 12. Instrumental methods for studying the cardiovascular system

Purpose of the lesson: Familiarize yourself with the instrumental methods of studying the cardiovascular system, their capabilities. Learn how to evaluate data.

1. A description of all the methods of studying the cardiovascular system indicated in the topic of the lesson. capabilities of each technique.

2. ECG recording technique, FCG, PCG, etc. ECG leads, normal ECG.

1. Evaluate the results of instrumental methods for studying the activity of the heart.

2. Record an ECG.

3. By PCG determine I, II, III, IV tones, systole, diastole, systolic and diastolic murmurs.

4. Determine the main phases of the cardiac cycle by PCG and CCG.

5. To determine the SDLA according to Burstin's nomogram.

Initial data:

Learning elements

ECG study while taking a number of medications(nitroglycerin test, potassium test, anaprilin test, etc.). Allow to reveal hidden coronary and metabolic changes.

The duration of the PQ interval is 0.12-0.18 seconds, QT - 0.35-0.4 seconds. in women and 0.31-0.37 in men. ST offset from the isoline is not more than 1 mm.

Features of a normal electrocardiogram - teeth R W, R avf , R V 1 , P V 2 can be negative, biphasic and isoelectric.

The Q wave is absent in V 1 -V 3 , even a small Q wave in these leads indicates a pathology.

ECG analysis scheme.

1. Determination of the heart rhythm.

2. Determining the duration of the RR interval.

3. Calculation of heart rate in 1 min. (60/RR)

4. Assess the voltage. If R 1 + R 3 >5 mm, then the voltage is considered low

5. Determine the position of the electrical axis

7. Conclusion.

Phonocardiography (PCG) - studies the sound phenomena that occur during the mechanical work of the heart.

Normal FCG registers I and II heart sounds, rarely III tone (physiological), very rarely IV tone.

I tone coincides with the descending knee of the R wave, is recorded in several oscillations, takes 0.12 - 0.20 seconds, height 10-25 mm.

II tone occurs after 0.02 - 0.04 sec. After the end of the T wave, its duration is 0.06 - 0.12 seconds, height 6-15 mm.

III tone - diagnostic, occurs after 0.12 - 0.18 seconds. After tone II, it is usually recorded with 1-2 oscillations.

IV tone is recorded in the norm very rarely, before I tone.

Dopplerography - a study of the volumetric blood flow velocity, the degree of regurgitation and the pressure gradient across the valves.

Transesophageal echocardiography - detailing the state of the valvular apparatus and myocardium.

Control questions:

1. What phenomena does the ECG study?

2. What is a "remote ECG"?

3. What is Holter ECG monitoring used for?

4. What are the stress tests in the study of ECG? What is their purpose?

5. What is studied in FCG?

6. Why is PCG recorded synchronously with ECG?

7. What parameters do the heart sounds recorded on FCG have in the norm?

8. How to distinguish the III tone from the click of the mitral valve opening on FCG?

9. What are the differences between organic and functional murmurs on FCG?

10. What is "polycardiography"?

11. What is studied in PCG?

12. What are the phases of the cardiac cycle?

13. What is the syndrome of myocardial hypodynamia characterized by?

14. What does the KCG register?

15. What is the method of indirect determination of SDLA according to Burstin?

16. What is echocardiography?

17. What is studied by echocardiography?

18. What does rheography study?

Situational tasks

Task 1. Patient N., 25 years old, is being treated in a hospital for rheumatism, mitral stenosis. The FCG was recorded.

What pathological changes will be revealed on PCG? What kind of noise will be registered? On what auscultatory points will it be detected?

What is the nature of systolic murmur? Note its characteristic features on the presented FCG.

Task 3. During auscultation of the heart, the patient listens to a 3-membered rhythm. On the FCG, an enhanced I tone is recorded, the third sound lags behind the II tone by 0.08 seconds.

What rhythm is heard in the patient? Name the third sound in the auscultated rhythm of the patient.

Topic 13. Cardiac arrhythmias. Clinical and ECG diagnostics.

Purpose of the lesson: To teach clinical and ECG diagnostics of the main types of cardiac arrhythmias.

Before the lesson, the student should know:

1. Classification of arrhythmias.

2. Arrhythmias associated with dysfunction of automatism.

3. Arrhythmias associated with dysfunction of excitability.

4. Arrhythmias associated with impaired conduction function.

5. Complex types of cardiac arrhythmias.

At the end of the course, the student should be able to:

1. Correctly recognize various types of arrhythmias by clinical signs.

2. Correctly recognize various types of arrhythmias by ECG.

Initial data.

Educational elements.

Basic functions of the heart . The work of the heart is carried out thanks to 4 main functions: automatism, excitability, conductivity, contractility.

Diagnostic signs of extrasystole:

Extraordinary reduction;

Complete or incomplete compensatory pause;

Drawing of an extrasystolic complex on an ECG.

In addition to single ones, there are group extrasystoles, and sometimes there is a pattern of extrasystoles, which is called allorhythmia. The types of allorhythms are as follows:

Bigeminia (extrasystoles are repeated after each normal sinus complex);

Trigeminia (every two sinus complexes are followed by an extrasystole);

Quadrigeminia (every three normal cycles are followed by an extrasystole).

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