Physical methods for studying the heart. Causes and mechanism of formation of an accent of the 2nd tone, splitting of the 2nd tone Accent of the 2nd tone over the pulmonary artery causes

The work of the heart is accompanied by tension and periodic movements of its individual parts and the blood contained in the cardiac cavities. As a result, 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 arising during cardiac activity, determine their nature and causes of occurrence.

First, the heart is listened to in a certain sequence at standard auscultation points. If auscultatory changes are detected or other symptoms indicating cardiac pathology 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 carried out with the patient standing (or sitting), and then in a supine position. To ensure that auscultation of the heart is not interfered with by breathing 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: with the patient lying on the right or left side, with a deep breath, including straining (Valsalva maneuver), after 10-15 squats.

If there is a lot of hair on the anterior surface of the chest, before auscultation it must be moistened, greased or, as a last resort, the hair in the areas where the heart is heard should be shaved.

The following standard auscultation points are usually 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 apical impulse or, if it is not determined, 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 performing auscultation over the apex 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 listening to the aortic valve and the aortic orifice);
third point - II intercostal space directly at the left edge of the sternum (the point of listening to the pulmonary valve and its mouth);
the second and third points are usually combined with the concept “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 were 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 them difficult to use for auscultatory diagnosis. However, some of these points are still sometimes used to identify pathological auscultatory phenomena

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

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

In terms of its acoustic properties, tone I is longer than tone II and lower in tone. The appearance of the first sound coincides in time with the apical impulse and pulsation of the carotid arteries. The interval between the first and second sounds corresponds to systole and is normally two times shorter than diastole.

It is generally accepted that the formation of heart sounds occurs due to simultaneous oscillations of the cardiohemic system, including the myocardium, valves, blood in the cavities of the heart, as well as the initial segments of the aorta and pulmonary trunk. In the origin of the first tone, two components play a major role:

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

The appearance of the second tone is explained mainly by vibrations of the leaflets of the semilunar valves of the aorta and pulmonary artery, caused by the tension of these valves when they close at the end of ventricular systole. In addition, in the origin of both the first and second sounds, 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 synchronicity of the occurrence of sound phenomena of various origins that underlie the formation of heart sounds, they are normally perceived as solid sounds, and in the intervals between sounds no additional auscultatory phenomena are heard. In pathological conditions, splitting of the fundamental tones sometimes occurs. In addition, both in systole and diastole, sounds similar in sound to the main tones (additional tones) and more drawn-out, complex-sounding auscultatory phenomena (heart murmurs) can be detected.

When listening to the heart, first at each of the auscultatory points it is necessary to determine the heart sounds (main and additional) and the melody of the heart (heart rhythm), consisting of rhythmically repeating cardiac cycles. Then, if heart murmurs are detected while listening to sounds, auscultation is repeated at the points of their localization and these sound phenomena are characterized in detail.

Heart sounds

By listening to heart sounds, the correctness of the rhythm, the number of basic tones, their timbre and sound integrity, as well as the ratio of the volume of the first and second tones are determined. When additional tones are identified, their auscultatory features are noted: relation to the phases of the cardiac cycle, volume and timbre. To determine the melody of the heart, you should mentally reproduce it using syllabic phonation.

When auscultating over the apex of the heart, the rhythm of the heart sounds (the correctness of the rhythm) is first determined by the uniformity of the diastolic pauses. Thus, a noticeable prolongation of individual diastolic pauses is characteristic of extrasystole, especially ventricular, and some types of heart block. Random alternation of diastolic pauses of different durations is typical of atrial fibrillation.

Having determined the correctness of the rhythm, pay attention to the ratio of the volume of the I and II tones above the top, as well as the nature of the sound (integrity, timbre) of the I tone. Normally, above the apex of the heart, the first sound is louder than the second. 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 best place to listen to them is located in the region of the apex of the heart.

At the same time, the second sound at this auscultatory point is conductive 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 presented in the form of syllabic phonation tom-ta tom-ta tom-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 tension, fever, thyrotoxicosis, anemia, etc. When the body is in a vertical position and when exhaling, the first tone is louder than when lying down and when inhaling deeply.

With stenosis of the left atrioventricular orifice, a decrease in diastolic filling of the left ventricle and an increase in the amplitude of movement of the mitral valve leaflets occur. As a result, in patients with this heart defect, the volume of the first tone above the apex sharply increases and changes its timbre, acquiring the character of a flapping tone. In patients with complete atrioventricular block, during auscultation over the apex of the heart, a sudden significant increase in the first sound (Strazhesko’s “cannon tone”) is sometimes heard against the background of pronounced bradycardia. This phenomenon is explained by the random coincidence of contractions of the atria and ventricles.

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

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

mitral valve insufficiency (deformation of the valve leaflets, decrease in the amplitude of their movement, absence of a period of closed valves);
damage to the heart muscle with 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 (faster or slower), the duration mainly of the diastolic pause changes (it shortens or lengthens, respectively), while the duration of the systolic pause does not change significantly. With pronounced tachycardia and equal duration of systolic and diastolic pauses, a cardiac melody appears, similar to the rhythm of a pendulum - a pendulum-like rhythm (with equal volumes of the first and second sounds) or reminiscent of the intrauterine heart rhythm of the fetus - embryocardia (the first tone is louder than the second). Such pathological heart rhythms can be detected during an attack of paroxysmal tachycardia, myocardial infarction, acute vascular insufficiency, high fever, etc.

Splitting of the first sound above the apex of the heart (tra-ta) occurs when the systole of the left and right ventricles begins non-simultaneously, most often due to blockade of the right bundle branch or severe hypertrophy of the left ventricle. Sometimes inconsistent splitting of the first tone can be noted in healthy people in connection with the phases of breathing or changes in body position.

In some pathological conditions, additional or extratones may be detected above the apex of the heart, along with the main tones. Such extratones most often occur during the diastolic pause and, less often, during systole (following the 1st sound). Diastolic extratones include the III and IV sounds, as well as the opening tone of the mitral valve and the pericardial tone.

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

Thus, the III tone follows after 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 detected at the fifth auscultatory point. They are better identified by auscultation with a solid stethoscope or directly with the ear, with the patient lying on his left side, as well as while exhaling. When listening to the III and IV sounds, the stethoscope should not apply pressure to the area of the apex beat. While the IV tone is always pathological.

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

In patients with damage to the heart muscle, the third and fourth sounds are often combined with a weakening of the first tone above the apex and tachycardia, which creates a unique three-part melody, reminiscent of the clatter of a galloping horse (gallop rhythm). This rhythm is perceived by the ear as three separate tones, following each other at almost equal intervals, and the triad of tones is repeated regularly without the usual, longer pause.

In the presence of the third tone, the so-called proto-diastolic gallop rhythm occurs, which can be reproduced by rapid repetition of three syllables, with emphasis on the middle one: ta-ta-tata-ta-ta ta-ta-ta...

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

The presence of simultaneous sounds III and IV is usually combined with pronounced tachycardia, so both additional tones merge into a single sound in the middle of diastole and a three-part 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 soon after the 2nd tone, is better heard on the left side, as well as on exhalation, and is perceived as a short, abrupt sound, approaching the 2nd tone in volume, and resembling a click in timbre. Typically, a "mitral click" is combined with a clapping I tone, which creates a characteristic three-part melody that has been compared to the call of a quail ("quail rhythm"). This rhythm can be reproduced by using the syllabic phonation ta-t-ra ta-t-ra ta-t-ra... with a strong emphasis on the first syllable, or by repeating the phrase “it’s time to sleep” with an emphasis on the first word. The occurrence of a “mitral click” is explained by the tension of the mitral valve leaflets 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 extraton 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 sound. At the same time, the pericardial tone is not combined with the clapping I sound, so the heart melody, reminiscent of the “quail rhythm,” does not arise.

The main cause of systolic extraton above the apex of the heart is prolapse (evering) of the mitral valve leaflets into the cavity of the left atrium during systole (mitral valve prolapse). This extratone is sometimes called the systolic click, or click, because it is a relatively loud, sharp, and short sound, sometimes compared to the sound of a whip cracking.

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

In a number of pathological conditions, the second tone above the aorta or pulmonary artery can be weakened, accentuated and split. The weakening of the second tone at the second or third points is said to be the case if at a given point of auscultation the second tone is equal in volume to the first or quieter than it. Weakening of the second 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 second tone, on the contrary, is usually loud.

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

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

At the fourth auscultatory point, normally, as well as above the apex, the first tone is louder than the P. This is explained by the participation of the tricuspid valve in the formation of the first sound and the conductive nature of the second tone at this point. Possible changes in the volume of the first tone at the fourth point are generally similar to those above the apex. Thus, a weakening of the first tone above the base of the xiphoid process is detected with tricuspid valve insufficiency, and an increase in the first tone in combination with the sound of the opening of the tricuspid valve (“tricuspid click”) is detected with extremely rare stenosis of the right atrioventricular orifice.

As already indicated, when auscultating the heart in pauses between tones, sound phenomena that differ from them can sometimes be heard - heart murmurs, which are more drawn-out and complex sounds, rich in overtones. According to their acoustic properties, heart sounds can be quiet or loud, short or long, decreasing or increasing, and according to their timbre - blowing, sawing, scraping, rumbling, whistling, etc.

Heart murmurs detected in the interval between the first and second sounds are called systolic, and those heard after the second sound are called diastolic. Less commonly, in particular, with dry (fibrinous) pericarditis, a prolonged heart murmur is not always clearly associated with any phase of the cardiac cycle.

Systolic and diastolic murmurs arise as a result of disruption of laminar blood flow in the corresponding phase of the cardiac cycle. The reasons for the appearance of turbulence in the blood flow and its transformation from laminar to turbulent can be very diverse. The group of murmurs that occur with congenital or acquired heart defects, as well as with myocardial damage, is called organic. Murmurs caused by other reasons and not combined with changes in tones, dilation of the heart chambers and signs of heart failure are called functional or innocent. Diastolic murmurs, as a rule, are organic, and systolic murmurs can be either organic or functional.

Having detected a murmur 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);
duration of the murmur (short or long) and what part of the cardiac cycle phase it occupies (protodiastolic, mesodiastolic, presystolic or pandiastolic, early systolic, late systolic or pansystolic);
the volume of the noise in general (quiet or loud) and the change in volume 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 loudness of the noise (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, breathing phases and physical activity.

Compliance with these rules allows, in most cases, to resolve the question of whether the noise is functional or organic, as well as 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, pulmonary valve insufficiency, 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 a “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 first sound (increasing presystolic murmur). With severe mitral stenosis, the murmur becomes pandiastolic, acquires a peculiar low, rumbling timbre and is sometimes detected by palpation above the apex of the heart in the form of a “cat purring” phenomenon. The diastolic murmur of mitral stenosis is usually heard in a limited area and does not spread far. Usually it is better detected with the patient lying on his left side and intensifies after physical activity.

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

Diastolic murmur heard at the second auscultation point indicates aortic valve insufficiency. However, in the early stage of formation of the defect, the diastolic murmur of aortic insufficiency can be heard only in the third 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 “flowing”, it is better detected in a standing or sitting position with the torso tilted forward, as well as in a lying position on the right side. At the same time, after physical activity the noise weakens.

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

Diastolic murmur at the third auscultation point is rarely detected. One of the causes may be pulmonary valve insufficiency. In addition, a soft, blowing diastolic murmur in the second intercostal space at the left edge of the sternum is sometimes detected in patients with severe hypertension of the pulmonary circulation. This is the 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 to the pulmonary artery, a combined systolic-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 weakens significantly when the patient strains at the height of a deep inspiration (Valsalva maneuver).

Diastolic murmur at the fourth auscultatory point is also rarely detected and indicates the presence of stenosis of the right atrioventricular orifice. It is heard in a limited area above the base of the xiphoid process and to the left of it to the parasternal line, intensifies when the patient is positioned on the right side and with a deep breath. Along with diastolic murmur, with this defect, a flapping first sound and a “tricuspid click” can also be detected, i.e. "quail rhythm"

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

Another feature of such noises is their relative stability, since they can be heard well in different positions of the patient, in both phases of breathing, and always intensify after physical activity.

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. Often the third tone is also detected at the same time. The noise intensifies when the patient is lying on his left side, when holding his breath while exhaling, or after physical activity. Its characteristic area of irradiation is the left axillary fossa. Sometimes it is better heard at the fifth auscultatory point. The systolic murmur of mitral valve insufficiency can be caused by structural changes in the valve itself (scar rupture of the leaflets, separation of chords) or dilation of the left ventricular cavity with expansion of the fibrous ring of the valve (relative mitral valve insufficiency). A murmur of valvular origin is generally louder, rougher and more prolonged than a muscle murmur, and has a larger area of irradiation. However, in some cases, valve and muscle noises have very similar acoustic signs.

Organic systolic murmur at the second auscultatory point is determined with stenosis of the aortic mouth. Often it is so loud and rough that it is clearly audible over the entire region of the heart, and sometimes it is even felt by palpation on the manubrium of the sternum or to the right of it in the form of systolic tremor. The noise, as a rule, spreads to the carotid and subclavian arteries, and is often also detected in the interscapular space at the level of the I-III thoracic vertebrae. At the same time, in the direction of the left axillary fossa its intensity subsides. The noise intensifies when standing. Above the aorta, the second tone may be weakened, but with severe atherosclerosis, on the contrary, it is enhanced.

With a slight degree of stenosis of the aortic mouth 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 vascular bundle to approach the sternum (Sirotinin-Kukoverov symptom).

Organic systolic murmur is rarely heard at the third auscultatory point. One of its causes may be stenosis of the pulmonary artery. In patients with an atrial septal defect, a 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.

When the ductus botallus is open, a systolic diastolic murmur is detected at the third auscultatory point, the systolic component of which is usually rough and loud, spreading to the entire precordial region, neck vessels, the left axillary fossa and the 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 of a decreasing nature, not necessarily combined with a weakening of the first tone and additional third and fourth sounds, carried out on both sides of the sternum and upward along its left edge, and, unlike other cardiac murmurs, intensifies with inspiration (Rivero-Corvallo symptom).

One of the loudest and roughest systolic murmurs over the heart region 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 spaces. The 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 first tone above the apex is usually preserved.

A rough systolic murmur over the heart area is also detected with 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 typical for childhood and adolescence. Their appearance is most often due to the following reasons:

incomplete correspondence of the rates of development of various cardiac structures;
dysfunction of the papillary muscles;
abnormal development of chords;
increasing blood flow speed;
changes in the rheological properties of blood.

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

are heard only in a limited area and do not spread anywhere;
the sound is quiet, short, blowing; the exception is noise associated with dysfunction of the chordae and papillary muscles, since they sometimes have a peculiar musical timbre, which is compared to the sound of a ringing or bursting string;
labile, because they can change their timbre, volume and duration, arise or, conversely, disappear under the influence of psycho-emotional and physical stress, when changing body position, in different phases of breathing, etc.;
are not accompanied by changes in the first and second 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 detected.

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

Anemic murmur is better heard at the left edge of the sternum or over the entire heart area. It can be loud, sometimes quite rude, with a musical tint, often spreads to large vessels, and intensifies when the patient moves from a horizontal to a vertical position, as well as after physical activity.

Pericardial friction rub is an extracardiac murmur. Normally, the smooth, moistened layers of the pericardium glide silently during heart contractions. A pericardial friction rub most often occurs with dry (fibrinous) pericarditis and is its only objective sign. The inflamed layers of the cardiac membrane become rough due to the presence of fibrin deposits on their surface.

The noise can also occur in the acute period of myocardial infarction and in some other pathological conditions that disrupt the smoothness of the pericardial layers, for example, with uremia, severe dehydration, tuberculosis or tumor, including metastatic, damage to the cardiac membrane.

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 manubrium of the sternum. Usually it is heard in a limited area and does not spread anywhere, it can be quiet or loud, and its timbre resembles a rustling, scratching, scraping or crunching sound, and sometimes it is so rough that it can even be 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 arising 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 sounds are perceived as coming from deep in the chest.

The pericardial friction noise is better heard in a standing position or sitting 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 the effusion resolves, it appears again.

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

The detection of simultaneous systolic and diastolic murmurs at one of the auscultation points indicates a combined heart defect, i.e. about the presence of insufficiency of the valve auscultated at a given point and stenosis of the corresponding opening. The detection of organic systolic murmur at one point and diastolic murmur at another indicates a combined heart defect, i.e. to damage two different valves simultaneously.

When listening to noise at different points of auscultation in the same phase of the cardiac cycle, it is necessary to establish which valve it belongs to by 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 defect. If the murmurs 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 noise from one point to another indicates its formation in the valve (hole) to which the point of maximum sound belongs, and about the conductive 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 defect 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 objective status General examination Local examination Cardiovascular system 2

At auscultation First of all, individual heart valves are listened to: the mitral valve - at the apex of the heart, the aortic valve - in the 2nd intercostal space to the right of the sternum, the pulmonary valve - in the 2nd intercostal space to the left of the sternum and the tricuspid valve - at the base of the xiphoid process of the sternum (Fig. 2). The heart is also listened to at the Botkin-Erb point (the place of attachment of the III-IV ribs to the sternum on the left), where murmurs associated with damage to the aortic valve are often detected. If auscultation reveals abnormalities at these five points, you need to carefully listen to the entire area of the heart.

Normally, two sounds are heard during auscultation of the heart. The first sound is formed during cardiac systole when the heart muscle contracts and the atrioventricular valves close; the second sound occurs during diastole when the valves of the aorta and pulmonary trunk close. The tones are separated from each other by pauses; the pause between the first and second tones is shorter than between the second and first. Sometimes during diastole it is possible to listen to additional third and fourth heart sounds, which are formed when the ventricles are filled with blood. In young, thin subjects, the third and fourth sounds can be heard even in healthy conditions; in older people, they usually indicate myocardial damage (see).

The sonority of heart sounds depends both on the state of the heart itself and on the state of the organs and tissues surrounding the heart. The sonority of heart sounds decreases with weakening of the myocardium, with the accumulation of fluid in the pericardial cavity, etc. The sounds become louder with increased work of the heart (physical and nervous tension, etc.). Sometimes the sonority of only one tone changes. Thus, the first sound at the apex weakens with insufficiency of the mitral valve, aortic valve, and intensifies with mitral stenosis. The second sound over the aorta and pulmonary trunk intensifies in cases where the pressure in these vessels increases. With increasing pressure in the aorta, the second sound intensifies above the aortic valve (emphasis of the second tone above the aorta). With an increase in pressure in the pulmonary artery, the accent of the second tone is determined above the pulmonary valve. Sometimes bifurcation or splitting of tones appears, most often associated with non-simultaneous systole of the right and left ventricles or with non-simultaneous slamming of the aortic valve leaflets and pulmonary trunk.

During pathological processes, heart murmurs may appear (they can rarely occur in healthy people). Pathological heart murmurs occur either when the valve opening is narrowed, or when the heart valves are deformed, which, when closed, do not completely close the opening. They are distinguished (see) and see (see) depending on the appearance of noise in systole or diastole.

Systolic murmur occurs with insufficiency of the bicuspid and tricuspid valves, with narrowing of the aortic orifice and pulmonary trunk, etc.
see Diastolic murmur - with narrowing of the atrioventricular orifices, insufficiency of the aortic valves and pulmonary trunk, etc.

With (see) you can listen to a pericardial friction rub. Murmurs not associated with heart pathology sometimes occur when blood viscosity decreases and blood flow speed increases (with anemia, diffuse toxic goiter). After auscultation of the heart, the vessels are listened to, especially the necks, over which murmurs are sometimes found (for example, systolic murmur over the carotid arteries with narrowing of the aortic mouth, murmur over the jugular veins with anemia).

Blood pressure is determined by sphygmomanometry (see). Normally, blood pressure in the brachial artery in people 20-40 years old is on average 120/70 mmHg. Art. (See Blood Pressure).

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

Purpose of the event

With its help, medical examinations of patients are carried out to identify diseases of the heart and blood vessels. The following diseases can be suspected based on changes in the auscultatory pattern:

developmental defects (congenital/acquired);
myocarditis;
pericarditis;
anemia;
ventricular dilatation or hypertrophy;
ischemia (angina pectoris, heart attack).

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

Points for listening to heart valves

Heart auscultation should not be performed in a hurry. It is started after a conversation with the patient, examination, study of his complaints and medical history. If there are 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 carried out. The chest is tapped to determine the boundaries of the heart. Palpation examination allows you to determine the presence or absence of chest trembling or cardiac hump.

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

left pre-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 to their projections is considered advisable when determining pathological heart sounds.

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

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

Techniques to help you carry out the examination correctly

Listening to heart sounds requires compliance with certain rules. If a person’s general health is satisfactory, he is standing at the time of the examination. To reduce the likelihood of missing pathology, the patient is asked to hold his breath after a deep breath (4-5 seconds). Silence must be maintained during the examination. In severe cases 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:

If there is a lot of hair, cover with cream or water, in rare cases, shave.

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

If the auscultatory picture is questionable, an exercise test is used. In this case, the patient is asked to walk for two minutes or sit down 5 times. Then they begin to listen 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 pathological heart sounds and murmurs. Their presence requires further study using standard laboratory and instrumental research methods (phonocardiogram, ECG, Echo-CG).

For humans, 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.

If there is a pathological sound, the therapist refers the patient to a cardiologist. He studies their localization, volume, timbre, noise, dynamics and duration.

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

valvular - 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 – contraction of the atria.

It is best heard at the apex of the heart. Its duration is slightly longer than the second. If there is difficulty in determining it, then you need to feel the pulse on the carotid arteries - 1 tone coincides with it.

Characterization of the second tone is carried out at the base of the heart. It is formed by 2 components - vascular (oscillation of the walls of the great vessels) and valvular (movement of the aortic and pulmonary trunk valves) 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 vibrates their walls and creates a sound effect called the third sound.

It can often be heard at a young age. The fourth sound is determined by 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 (intensification, bifurcation, weakening, splitting). The reason for increased tones may be extracardiac pathology:

diseases of the respiratory system with changes in lung size;

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

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

Changes in heart sounds 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, heart failure, myocarditis, cardiosclerosis, atrioventricular valve insufficiency.
Bifurcation - conduction disturbance (blockade), sclerotic change in the walls of the aorta.

The following pathology causes 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.
Weakening of the pulmonary artery – pulmonary valve defects.
Weakness in the aorta – abnormalities of the aortic valve.

It is quite difficult to distinguish between the bifurcation/splitting of the main heart sounds with the appearance of additional ones. If 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 stretching of the walls of the ventricles, the volume of blood entering from the atria, with weakening of the myocardium. The rhythm can be heard directly by the ear of the patient lying on his left side.

“Quail rhythm” is a pathological sound of the heart, including clapping 1st tone, 2nd and additional tones. The rhythm has a large listening area; it is conducted from the apex of the heart to its base and to the armpit area.

Principles of cardiac auscultation in children

The points for listening to heart valves in children and the procedure for performing 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 an accent of 2 tones above the pulmonary artery at primary school age;
Availability of 3, 4 tones.

Definition of “cat purring” at 12-15 years old.
Changes in the boundaries of the heart (in centile tables you can find out the norms for each age and gender).

In newborns, detection of murmurs and abnormal heart sounds indicates congenital malformations. Their early identification and assistance increases the prognosis of survival of such patients. Heart pathology is determined during the period of intrauterine development of the fetus according to ultrasound data.

Advantages and disadvantages of the method

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

But only based on the picture heard, it is impossible to give an accurate conclusion about the diagnosis. The main disadvantage of the method is the doctor’s subjective assessment of the tone sound. In this case, you cannot listen to what the doctor heard. Digital phonendoscopes have appeared in medicine, capable of recording good quality audio signals. However, their cost is very high, which prevents their implementation in practice.

Accent of the second tone on the aorta

Weakening of the second tone on the aorta

Muffled heart sounds

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

Quail rhythm

Gallop rhythm

Atrial fibrillation

Accent of the second tone on the aorta

Weakening of the second tone on the aorta

Muffled heart sounds

Weakening of the first tone at the apex

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

Quail rhythm

Gallop rhythm

Atrial fibrillation

Emphasis of the second tone on the pulmonary artery

Accent of the second tone on the aorta

Weakening of the second tone on the aorta

Muffled heart sounds

Weakening of the first tone at the apex

Task 4. Patient D., 49 years old. He has been suffering from arterial hypertension with high blood pressure numbers for a long time. What changes in heart sounds can be heard in this patient during auscultation?

Quail rhythm

Gallop rhythm

Atrial fibrillation

Emphasis of the second tone on the pulmonary artery

Accent of the second tone on the aorta

Weakening of the second tone on the aorta

Muffled heart sounds

Weakening of the first tone at the apex

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

Quail rhythm

Gallop rhythm

Atrial fibrillation

Emphasis of the second tone on the pulmonary artery

Accent of the second tone on the aorta

Weakening of the second tone on the aorta

Muffled heart sounds

Weakening of the first tone at the apex

Topic 10. Auscultation of heart murmurs

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

1. Mechanism of noise generation

2. Noise classification

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

4. Functional noise

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

1. Listen to noises at the right points

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

3. Identify pericardial friction rub and pleuropericardial murmur

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

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

Initial data:

TRAINING ELEMENTS

When auscultating the heart, in addition to tones, additional sounds of longer duration may be heard, called heart murmurs .

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

Intracardiac arising from anatomical changes in the structure of the heart valves (organic noise) or in case of dysfunction of unchanged valves (functional noise). Functional murmurs may occur when blood flow velocity increases or blood viscosity decreases.

Organic noises classified:

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

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

b) sounds of regurgitation (return) – with valve insufficiency.

c) filling (discharge) sounds – with mitral and tricuspid stenosis.

2) In relation to the phases of cardiac activity:

a) systolic murmurs (appear along with the first sound, coincide with the apical impulse and the pulse of the carotid artery).

b) diastolic murmurs (appear after the second sound), which are divided into:

Ø protodiastolic,

Ø mesodiastolic,

Ø presystolic.

3) Based on the change in volume over time, they distinguish:

a) decreasing noise;

b) increasing;

c) increasing-decreasing.

4) By timbre there are:

soft, rough, blowing, whistling noises.

Noises are better heard where they are formed and carried through the blood tissue.

There are systolic and diastolic murmurs:

Systolic

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

At aortic stenosis – increasing-decreasing murmur (diamond-shaped), heard in the second intercostal space to the right of the sternum, at the Botkin-Erb point, carried out to the carotid and subclavian arteries.

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

At pulmonary artery stenosis A waxing-waning (diamond-shaped) murmur is heard in the second intercostal space to the left of the sternum and is carried into the interscapular space in the area of the third and fourth thoracic vertebrae.

Diastolic

At mitral stenosis heard:

Ø mesodiastolic murmur at the apex, decreasing, is not heard.

Ø increasing presystolic murmur, better auscultated in the area of the mitral valve projection, not carried out.

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

At tricuspid stenosis heard:

decreasing mesodiastolic murmur, heard at the base of the xiphoid process, not heard,

increasing presystolic murmur, heard at the xiphoid process, not performed.

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

Functional noise are not caused by damage to the valve apparatus.

Causes of functional noise:

An increase in the speed of blood flow - anemia (at the same time there is a decrease in blood viscosity), infectious diseases occurring 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 dilated hole (with myocarditis, myocardial dystrophy, dilatation of cavities with heart defects).

When the tone of the papillary muscles changes, the valves do not remain in the correct position.

Differences between functional noise and organic noise:

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

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

Extracardiac sounds include pericardial friction murmur and pleuropericardial murmur.

Pericardial friction rub occurs when the surfaces of the pericardial layers become uneven, rough or dry (pericarditis, dehydration, urea crystals, tuberculous tubercles, cancerous nodules).

Difference between pericardial friction murmur and intracardiac murmur:

does not always coincide exactly with systole or diastole;

fickle;

does not coincide with the auscultation points (can be heard well in the area of absolute dullness of the heart);

weakly carried out from the place of its formation;

feels closer to the examiner's ear;

it intensifies when the stethoscope is pressed to the chest and when the torso is tilted forward.

Pleuropericardial friction rub occurs when the pleura adjacent directly to the heart becomes inflamed due to friction of the pleural layers, synchronous with the activity of the heart.

The difference between pleuropericardial murmur and pericardial friction murmur:

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

Ø is usually combined with pleural friction noise and changes intensity in different phases of breathing: intensifies with deep inspiration, weakens with exhalation.

Control questions:

1. What types of heart murmurs do you know?

2. How are organic noises classified?

3. How are noises divided according to the mechanism of their 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. Characterize the noise caused by mitral valve insufficiency.

7. Describe the noise in mitral stenosis.

8. Describe the murmur of aortic valve insufficiency.

9. Describe the noise in stenosis of the aortic mouth.

10. List the main causes of functional noise.

11. How do functional noises differ from organic ones?

12. How does the pericardial friction noise differ from intracardial murmurs?

Situational tasks:

Task 1. During auscultation in the second intercostal space to the right of the sternum, a rough systolic murmur of an increasing-decreasing nature is heard, conducted to the vessels of the neck and to the Botkin point. In what pathology can such a murmur be heard?

Task 2. During auscultation, a decreasing systolic murmur is heard at the apex of the heart, occupying 2/3 of systole and extending to the left axillary region. In what pathology can such a murmur 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 sound and occupying 2/3 of the diastole. The noise is conducted to the Botkin point. In 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, extending to the right and upward. The noise intensifies on inspiration. In what pathology can such a murmur be heard?

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

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

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

1. What disease can you think about?

2. What is this three-part rhythm called?

Task 8. During auscultation at the apex of the heart, a systolic murmur is heard, conducted to 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 character, not carried out anywhere. The first and second tones are weakened. What does the patient have?

Topic 11. Vascular examination. Pulse and its properties. Arterial and venous pressure

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

By the end of the lesson, the student should know:

1. Areas of arteries accessible to palpation (radial, common carotid, brachial, axillary, abdominal aorta, femoral, popliteal, tibial, temporal, arteries of the dorsum of the foot).

2. Characteristics of the properties of the arterial pulse.

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

4. Methodology for measuring blood pressure according to N.S. Korotkov.

5. The principle of operation of a sphygmomanometer, oscilloscope, phlebtonometer.

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

As a result of the lesson, the student should be able to:

1. Assess the similarity of the pulse in both arms, 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. apply the cuff correctly

b. find the place of pulsation of the brachial artery (when measuring blood pressure in the arms or the popliteal artery when measuring pressure in 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: Vascular examination in some cases helps in diagnosing various pathologies. Thanks to the study of the pulse, it is possible to diagnose such rhythm disturbances as atrial fibrillation, paroxysmal tachycardia, extrasystole; assume the presence of blockades of varying degrees, suspect diseases such as thyrotoxicosis, aortic valve insufficiency, aortic stenosis, adhesive pericarditis, etc. The pulse can be used to roughly judge the magnitude of the stroke volume and blood pressure measurements. Measuring blood pressure allows you to diagnose hypertension, arterial hypertension of various origins, hypotension, and collapse of various etiologies.

Initial data:

TRAINING ELEMENTS

Vascular examination 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 condition of the cardiovascular system.

Visible changes in 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; aortic valve insufficiency) or with wrinkling of the edge of the right lung covering it.

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

In case of aortic valve insufficiency, severe pulsation of the carotid arteries - “carotid dance”.

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

When examining veins you can see them overflowing and expanding.

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. At the same time, the neck veins dilate and become swollen.

Local venous stasis caused by compression of the vein from the outside (tumors, scars) or blockage from the inside by a blood clot.

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 pronounced when the neck veins swell due to stagnation of blood in them.

Study 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 involves photographing a capillaroscopic picture using special microphoto attachments.

To detect a capillary pulse, lightly press 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 contract. In the same way, a spot of hyperemia caused by rubbing the skin, for example on the forehead, will pulsate. Capillary pulse is observed in patients with aortic valve insufficiency, and sometimes with thyrotoxic goiter.

Auscultation of blood vessels has limited value in therapeutic practice.

Usually medium-sized vessels are listened to - carotid, subclavian, femoral. In healthy individuals, two tones can be heard on the carotid and subclavian arteries. The first tone is caused by the tension of the arterial wall as it expands during the passage of the pulse wave, the second is carried out to these arteries from the semilunar valve of the aorta. One systolic sound is heard on the femoral artery.

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

If there is insufficiency of the aortic valves above the femoral artery, when it is compressed with a stethoscope, you can hear double noise Vinogradov - Durosier . The first of them, stenotic noise, is caused by blood flow through a vessel narrowed by a stethoscope. The origin of the second murmur is explained by the acceleration of reverse blood flow towards the heart during diastole.

In healthy people, as a rule, no tones or noises are heard above the veins.

When auscultating the jugular veins with anemia, it appears spinning top noise (associated with the acceleration of blood flow with a decrease in blood viscosity). It is better heard on the right jugular vein and intensifies when turning the head in the opposite direction.

Pulse are called various vibrations of the vascular wall. There are arterial pulse, venous pulse and capillary pulse.

Arterial pulse call the rhythmic vibrations of the vascular wall of the arteries, caused by the contraction of the heart, the release 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 assessed on the radial artery, but it is also studied on other vessels: temporal, carotid, femoral, popliteal arteries, arteries of the dorsum of the foot, posterior tibial arteries.

1) The study of the pulse begins by comparing the pulse in both arteries; normally it is the same in both arms. In pathology, the pulse may be different (pulsus differens) . Reasons for 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 may also be observed.

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

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

4) With atrial fibrillation, individual left ventricular systoles 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 pulse deficient (pulsus deficiens) .

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

6) To assess the condition of the vascular wall, the second and third fingers of the left hand squeeze the artery above the place of its examination; after the pulsation of the vessel stops, they begin to palpate the vessel wall, which is not normally palpable.

7) Pulse filling reflects the filling of the examined artery with blood. Depends on the stroke volume, the total amount of blood in the body, and its distribution. Normal pulse full (pulsus plenus) , with a decrease in stroke volume, pulse empty (pulsus vacuus) .

8) The pulse value is determined based on a comprehensive assessment of tension and pulse filling. The greater the amplitude of the pulse wave, the greater the value. With an increase in stroke volume of blood, a large fluctuation in pressure in the artery, as well as 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 in pulse small (pulsus parvus) .

In case of shock, acute heart failure, massive blood loss, the pulse is barely detectable - thread-like (pulsus filiformis) .

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

Alternating pulse (pulsus alternans)– a rhythmic pulse, characterized by a regular alternation of weak and strong beats. The cause of the alternating pulse is the rapid depletion of excitability and contractility of the heart muscle, observed in severe stages of heart failure.

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

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). Pulsus paradoxus is characterized by a decrease in systolic blood pressure by more than 10 mm. rt. Art. with 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 speed with which the left ventricle pumps blood into the arterial system. Highlight 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 pulse shape - 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 mouth.

When the tone of the peripheral arteries decreases, a dicrotic wave is detected during 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 blow 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 pelot 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 body area (usually a limb). They are registered using a cuff placed on the limbs.

A normal sphygmogram has a steep upward slope - anacrotic , the top of the curve, a flatter downward bend – catacrota , on which there is an additional tooth - dikrota , its origin is explained by the rejection of blood from the closed leaflets of the aortic valve at the beginning of diastole. Incisura – corresponds to the moment of closure of the aortic valve.

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

Related information.

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

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

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

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

Physiological splitting of the second tone is heard exclusively at the base of the heart during inhalation and exhalation or during physical activity. At the end of a deep inhalation, when the chest expands due to a decrease in pressure in it, the blood is somewhat retained in the dilated vessels of the small circle and therefore enters in less quantity into the left atrium, and from there into the left ventricle. The latter, due to less blood filling, ends systole earlier than the right one, and the closure of the aortic valve precedes the closure of the pulmonary valve. During exhalation, the opposite conditions are created. In the case of increased pressure in the chest, blood, as if squeezed out of the vessels of the pulmonary circle, enters in large quantities into the left part of the heart, and the systole of the left ventricle, and therefore the beginning of its diastole, occurs later than the right.

At the same time, a split second tone may be a sign of serious pathological changes in the heart and its valves. Thus, a bifurcation of the second sound at the base of the heart (second intercostal space on the left) is heard with mitral stenosis. This is due to the fact that the hypertrophied and blood-filled right ventricle ends systole later than the left. Therefore, the aortic component of the second sound occurs earlier than the pulmonary one. Bifurcation or splitting of the second sound in bicuspid valve insufficiency is associated with greater blood filling of the left ventricle than normal, which leads to prolongation of its systole, and the diastole of the left ventricle begins later than the right. Because of this, the aortic valve closes later than the pulmonary valve.