X-ray anatomy of the heart and large vessels. What does a heart x-ray show?

Cardiovascular Shadow- different sections of the cardiovascular bundle, which are edge-forming in the x-ray image, are called arcs, which normally smoothly transition into each other. Their location and length in different projections are not the same (Fig.).

Edge-forming arcs of the cardiovascular shadow are normal: I - straight line; II - right oblique; III-left oblique; IV-left lateral projection: I - superior vena cava; 2- right atrium; 3 - aorta; 4 - pulmonary trunk; 5 - left atrium; 6 - left ventricle; 7 - pericardium; 8 - right ventricle; 9 - inferior vena cava.

In a direct projection S. - page. t. is located asymmetrically with respect to the median plane in such a way that approximately two-thirds of the cardiac silhouette are to the left, and one third to the right of it. On the right, as a rule, two arcs are distinguished: the upper, formed by the superior vena cava, and the lower, by the right atrium. The superior vena cava protrudes to the right of the spinal column by 0.5-1 cm. Its clear and even contour below the projection of the sternoclavicular joint smoothly turns to the right, forming a concavity at the point of transition to the right brachiocephalic trunk.
At the level of the sternal border of the 1st rib, the image of the trunk is no longer differentiated.
With age, as a result of the reversal of the aorta, the ascending aorta, which has a greater intensity and a convex contour, becomes edge-forming on the right throughout its entire length.
The arch of the right atrium is convex, its most protruding point is 2.5-3 cm away from the right contour of the spinal column. At the junction of both arches, an atriovascular angle is formed, open outwards.
At the level of the cardio-diaphragmatic angle in persons with an asthenic constitution, with a deep breath, a third arc formed by the inferior vena cava can sometimes be seen. Its contour is clear, rectilinear or somewhat concave.
According to the left contour, four edge-forming arcs are usually determined. They are successively dug in from above by an arch and a partially descending aorta, a pulmonary trunk, an auricle of the left atrium and a left ventricle. The most protruding point of the left ventricle is located at the level of the mid-clavicular line or 1-1.5 cm medially from it. The degree of convexity and length of each of these arcs are different and depend on the age and constitution of the subject. On both sides, at the level of the attachment of the heart to the diaphragm, cardio-diaphragmatic angles are formed, which are normally sharp, as a rule.
In approximately 11% of the examined, the fibrous pericardial sac does not follow the arcs of the heart in its lower section, but is located somewhat outward, forming volumetric cardio-diaphragmatic sinuses with the diaphragm. In this regard, the pericardium in the supraphrenic zones, immediately before attaching it to the diaphragm, in the region of the lateral pericardial-phrenic sinuses receives a differentiated image. The rest of the pericardium merges with the edge-forming contours of the heart.
The pericardium, together with a small amount of fluid in its cavity, forms at the level of the cardio-diaphragmatic angles, more often on the left, triangular-shaped uniform darkening with a clearly defined rectilinear or somewhat concave outer contour.
In the right anterior oblique projection, the cardiovascular shadow takes the form of an obliquely lying oval with the following arrangement of its departments. The anterior contour of the cardiovascular shadow in the upper section is formed by the ascending aorta and partly by its arch. The middle arc corresponds to the output section of the right ventricle, the arterial cone; in its upper part, for a short distance, the pulmonary trunk is the edge-forming one. The lower arc of the anterior contour is formed by the left ventricle. The transition from one arc to another is smooth. The length of each of these arcs is normally approximately the same.
The posterior contour, facing the spinal column, is formed at the top by the superior vena cava, which is crossed in the lower section by the right branch of the pulmonary artery. Below are the left and right atria, which form an almost rectilinear contour and have an equal length of the arcs. In the posterior cardio-diaphragmatic angle between the diaphragm and the right atrium, the inferior vena cava is often visible, forming a triangular shadow of less intensity than the heart, with a clear, somewhat concave, oblique contour. Between the posterior contour of the heart and the spinal column, a light field 2-3 cm wide is determined, the so-called retrocardial space. The esophagus is adjacent to the posterior surface of the left atrium, normally located at this level in a straight line.
Thus, in the right anterior oblique projection, both atria are located along the posterior contour, and both ventricles are located along the anterior contour. The study in this projection is most appropriate to clarify the size of the left atrium and the outflow tract from the right ventricle.
In the left anterior oblique projection, the cardiovascular shadow acquires an irregularly spherical shape, with a greater bulge posteriorly. The anterior contour of the cardiovascular shadow from top to bottom is formed by the ascending aorta, the right atrium with its auricle, and the right ventricle. The ascending aorta projection completely covers the shadow of the upper full vein. The anterior contour of the ascending aorta is convex and posteriorly gradually and smoothly passes into the arch and descending aorta, the shadow of which in young and middle-aged people is lost against the background of the thoracic vertebrae.
On the posterior surface of the shadow of the heart, the left atrium is the edge-forming at the top, and the left ventricle is below. Thus, in this projection, each atrium is located above the corresponding ventricle. The atria and ventricles partially projectively overlap each other, so the length of the edge-forming arches of the atria and ventricles is almost the same. The contour of the left ventricle is normally located at a distance of 1-2 cm from the thoracic vertebrae.
Under the aortic arch, a light round or oval area is visible, the transparency of which is enhanced by the projection of the trachea and main bronchi - the so-called aortic window. At the level of the aortic window, the trunk and the left pulmonary artery are projected, forming an arcuate shadow, almost repeating the bend of the aorta.
It is advisable to use the left anterior oblique projection to study the size of the left ventricle, left atrium, and, to a lesser extent, the right half of the heart. In this projection, the ascending aorta is clearly visible, partially the arch and the descending aorta.
In the left lateral projection, the anterior contour of the cardiovascular shadow is formed at the top by the ascending aorta, which smoothly passes upwards and backwards into the arch and descending aorta. Below the ascending aorta lies an arterial cone, continuing caudally into the anterior wall of the right ventricle. The greatest length along the length is occupied by the right ventricle, which in the supraphrenic zone is closely adjacent to the sternum. The space between the sternum and the anterior surface of the cardiovascular shadow is called the retrosternal space. Its lower angle is pointed and normally located 5-6 cm above the diaphragm.
The posterior contour of the heart is formed at the top by the left atrium, at the bottom by the left ventricle, the length of the left ventricle is approximately twice that of the atrium. In the posterior cardio-diaphragmatic angle, the inferior vena cava is visible, which, as in the right anterior oblique projection, forms a triangular shadow of lesser intensity than the heart. The posterior contour of the inferior vena cava is clear, somewhat concave, sometimes differentiated against the background of the dome of the diaphragm (“triangle of the inferior vena cava”). Normally, the degree of adherence of the left ventricle to the diaphragm and the right ventricle to the chest wall is approximately the same (their ratio is 1: 1). The esophagus is located along the posterior surface of the left atrium almost rectilinearly. Lateral projection is used to clarify the size of the right ventricle, left ventricle, left atrium, aorta.
Edge-forming arcs of the cardiovascular shadow are studied with fluoroscopy, radiography, X-ray kymography, electroroentgen kymography in a straight line, both anterior oblique and lateral projections with simultaneous contrasting of the esophagus.

AT front direct projection 2/3 of the cardiovascular shadow is located to the left of the midline, "/ 3 - to the right. The contours of the heart form arcs: 2 on the right and 4 on the left (Fig. 15).

Fig. 15. Edge-forming arcs of the heart.

a - direct anterior projection; b - right oblique projection; c - left oblique projection.

YES - aortic arch; LS - pulmonary trunk; LP - left atrium; LV - left ventricle; RV - right ventricle; PP - right atrium; VA - ascending aorta; SVC - superior vena cava; NA - descending part of the aorta.

The first (upper) arc of the right contour is formed by the edge of the shadow of the superior vena cava and the ascending aorta, the second (lower) arc of the right heart contour is formed by the edge of the shadow of the right atrium. The depression between these arches is called the right cardiovascular angle (atriovascular angle).

The first (upper) arch of the left contour is the aorta; the second arc is the pulmonary trunk; the third arc - the ear of the left atrium; the fourth (lower) arch is the left ventricle. The depression between the second and third arches is the left cardiovascular angle. At the level of the cardiovascular angles - the waist of the heart.

The shadow of the heart with the diaphragm forms the cardio-diaphragmatic angles, right and left.

On a radiograph in direct anterior projection, such dimensions of the cardiovascular shadow are measured (Fig. 16).

Fig..16. Schematic representation of the size of the heart and large vessels.

A - the diameter of the heart; B is the width of the chest. A: B = 1:2

The transverse size of the heart is the sum of the perpendiculars drawn from the most distant points of the left and right contours of the heart to the midline (Mg + M1). The length of the heart (L) is the distance between the right cardiovascular angle and the left cardio-diaphragmatic angle. The length of the heart with a horizontal line forms the angle of inclination of the heart (a). The height of the heart (Hc) is the line that connects the right cardiovascular angle and the right cardiodiaphragmatic angle. The height of the vascular bundle (Hv) is the perpendicular lowered from the upper contour of the aortic arch to the horizontal drawn through the right cardiovascular angle.

The cardiopulmonary ratio is the percentage of the transverse dimension of the heart to the transverse dimension of the chest, drawn at the level of the right fornix of the diaphragm. Normally it is 50%.

AT right oblique projections, the anterior contour of the cardiovascular shadow is formed by three arcs: the first (upper) arc is the ascending part of the aorta, the second arc is the arterial cone and pulmonary trunk, the third (lower) arc is the left and right ventricles. The posterior contour of the cardiovascular shadow is formed by two arches: the first (upper) arch is the superior vena cava and partially ascending aorta, the second (lower) arch is the left atrium (above) and the right atrium (below). The contrasted esophagus is adjacent to the posterior surface of the left atrium.

AT left oblique In the projection, the anterior contour of the cardiovascular shadow is formed by two arcs: the first arc is the ascending part of the aorta and the aortic arch, the second arc is the auricle of the right atrium and the right ventricle. The posterior contour of the vascular shadow is formed by the aortic arch and the descending part of the aorta, and the posterior contour of the cardiac shadow is formed by the left atrium and left ventricle. Thus, in this projection, the right parts of the heart go to the anterior contour of the cardiac shadow, and the left parts go to the back.

AT left side In the projection, the anterior contour of the cardiovascular shadow is formed by two arcs: the first arc is the aorta, the second arc is the arterial cone and the right ventricle. The posterior contour of the cardiovascular shadow is formed by two arcs: the first arc is the aorta, the second arc is the left atrium (above), the third is the left ventricle (below).

Heart position determined by the angle of inclination of the axis of the heart. This position depends on the constitutional features, age, shape of the chest. The oblique position is typical for normosthenics, the angle of inclination of the heart is about 45 ° (43-48 °). The vertical position of the heart is found in asthenics, persons of high stature, thin and with a lowered diaphragm; the tilt angle is less than 43°. The horizontal position is found in hypersthenics, people with obesity and a high position of the diaphragm (in pregnant women), the angle of inclination of the heart is more than 48 ° (Fig. 17).

Fig..17. Diagram of the position of the heart.

A - vertical; B - oblique; B is horizontal.

heart shape determined by the degree of severity of edge-forming arcs of the cardiovascular shadow in direct projection.

There are ordinary, mitral, aortic, trapezoidal (triangular) and spherical heart shapes (Fig. 18). The name of the shape of the heart is the same as the name of the syndrome of cardiac pathology. The usual form in normosthenics is characterized by a smooth transition of the arcs of the left contour one into another, the severity of the aortic arch and the left ventricle. The mitral form is characterized by an increase in the second and third arcs along the left contour, smoothness (absence) of the waist of the heart, an upward displacement of the right cardiovascular angle; this heart shape is characteristic of mitral valve insufficiency.

1 2 3 4 5

Fig..18. Heart shapes: 1 - normal; 2 - mitral; 3 - aortic; 4 - trapezoidal; 5 - spherical.

Signs of the aortic heart shape: a decrease in the second and third arches along the left contour, a pronounced waist of the heart, the arch of the left ventricle protrudes significantly to the left, the ascending part of the arch and the aortic arch are pronounced, the right cardiovascular angle is shifted down; this form of the heart is characteristic of aortic heart disease, hypertension, aortic atherosclerosis.

The trapezoidal shape of the heart is characterized by the smoothness of the edge-forming arcs and their smooth transition from one to another, the wide attachment of the heart to the diaphragm; what happens in inflammatory processes of the heart and pericarditis. The spherical shape of the heart is characterized by the roundness of the arches of the right atrium and left ventricle, located symmetrically on both sides of the midline; occurs with some hereditary defects, as well as in newborns and children up to 2-3 years.

During fluoroscopy and ultrasound, the amplitude, strength, rhythm, and frequency of heart contractions are determined. The normal amplitude of the pulsation of the left ventricle is 5-6 mm, the right ventricle - 3-4 mm, the atria - 2-2.5 mm. A large pulsation is called deep, a smaller one is called superficial. By strength, there are enhanced, normal and weakened pulsations; in rhythm - rhythmic, arrhythmic; by frequency - accelerated, normal, slow.

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The heart and great vessels are well reflected when using X-ray research methods, as they clearly stand out against the background of radiolucent lung fields. For radiography, anterior direct and left lateral projections are used (Fig. 7.1). Oblique (right and left) projections are currently used much less often (as uninformative) to reduce radiation exposure to the patient. On a direct anterior radiograph, the heart looks like a homogeneous darkening in the center of the chest cavity, having the shape of an obliquely located oval (oval-ovoid, ellipsoid), the lower pole of which (the apex of the heart) is displaced to the left. At the top, the image of the heart merges with the shadow of the mediastinum, formed mainly by the trunk

Rice. 7.1. Direct (left) and left lateral (right) chest radiographs. In the diagrams below: 1 - left atrium; 2 - eye of the left atrium; 3 - left ventricle; 4 - right ventricle; 5 - right atrium; 6 - aorta; 7 - pulmonary artery; 8 - root of the lung; 9 - trachea

vessels. Between the heart and the vascular bundle, on both sides, notches are clearly visible, called the waist of the heart. The heart is, as it were, suspended in the chest to the vascular bundle, located with the apex and lower pole of the pancreas on the diaphragm, closer to the anterior wall of the chest. The lower the diaphragm is located, the closer to the vertical position the heart is and the less pronounced its waist. Below the shadow of the heart, as a rule, is not visible. It merges with the shadow of the diaphragm, forming the cardio-diaphragmatic angles. The median shadow of the heart is located asymmetrically: to the right of the midline 1/3 of the array, to the left - 2/3.

When radiography in the anterior direct projection of the chamber of the heart and blood vessels, leaving the contour, form an arc. Normally, along the contour of the median shadow, two arcs are distinguished on the right, and four on the left. The normal ratio between the arcs of the heart is maintained regardless of the physique of a person and the depth of his breathing.

The right atriovasal angle, forming the waist of the heart on the right, divides the right contour of the heart into two arcs: the upper, or first, and the lower, or second. The first arch (in the study in the vertical position of the patient) is formed mainly by the ascending aorta, as well as the superior vena cava. The second lower arch on the right is represented by the edge of the right atrium. The length of the first and second arcs on the right is approximately the same. The most distant point of the right heart contour from the midline on the convexity of the second arch is 1-2 cm away from the right edge of the spine. On the left, the first upper arch of the cardiac shadow contour is formed by the arch and the descending part of the aorta, the second arch by the left LA branch, the third by the left atrial appendage , fourth - LV. The third arc is not always defined. The first arch on the right and the first arch on the left are 3-4 cm from the midline. The aortic arch is located 1.5-2.0 cm below the level of the sternoclavicular joints. The length and convexity of the second and third arcs of the left contour of the heart, forming the waist of the heart on the left, are approximately the same and each have a length of about 2 cm. The outer edge of the left ventricle of the heart (the fourth arc of the left contour) is located 1.5–2.0 cm medially to the left midclavicular line. .7.2).

In the left lateral projection, two arcs are formed along the anterior contour of the heart. The first arch is the shadow of the ascending aorta. The second arch is formed by the pancreas and the pulmonary cone. The posterior arc of the heart is formed by the left atrium (LA).

The structural features of the heart chambers are best visualized with CT (Fig. 7.3) and MRI (Fig. 7.4). Studying these images facilitates the recognition of anatomical structures seen on plain radiographs.

The right atrium (RA) has a spherical shape with an eye extending upwards forward and to the right. The vena cava flows into the atrium in the projection of its posterior wall. The tricuspid valve is located on the anteromedial surface. The total thickness of the myocardium of the PP and the pericardium adjacent to it does not exceed 2-3 cm. On a direct roentgenogram, the PP forms the right lower arc of the heart contour.

The pancreas has a triangular shape with the apex pointing to the left and down. The LA valve is located above and medially to the tricuspid valve and is separated from the latter by a muscular ridge. Day off

Rice. 7.2. Parameters of the cardiac shadow on a direct radiograph:

AL - median line of the body; VC - left mid-clavicular line;

GD - 1 arc of the left contour; DE - 2 arc of the left contour; Hedgehog - 3 arc of the left

contour; ZhZ - 4 arc of the left contour; RK - 1 arc of the right contour; ETC -

2 arc of the right contour; ST = 2 cm; UA = AB = 4 cm, DE = EJ = 2 cm, CL

2 cm, LM = 2 cm, PR = RS, RI = 2 cm

Rice. 7.3. Computed tomography of the heart. Three-dimensional reconstruction based on the results of spiral multi-row tomography with ECG synchronization

Rice. 7.4. Magnetic resonance imaging of the cardiovascular system. Heart, small and large circle of blood circulation. Aneurysm of the abdominal aorta

the pancreas is located in front and to the left of the aortic bulb. The prostate is characterized by pronounced trabecularity, and therefore it is rather difficult to calculate the thickness of the myocardium (approximately 3-6 mm). On a direct radiograph, the pancreas does not participate in the formation of the contours of the heart, and on the lateral one, it forms the anterior contour of the heart.

The LA has an ovoid shape with a short diameter in the anteroposterior direction. In the projection of the posterior wall, 4 pulmonary veins flow into it (upper and lower on both sides). The mitral valve is located along the inferior anterolateral wall. The LA also has an eye located on the upper lateral surface, which forms the second arch of the left heart contour on a direct radiograph. In the lateral projection, the LA forms the posterior contour of the heart.

The left ventricle is ovoid in shape with an apex pointing forward-left-down. The aortic and mitral valves are located at the base of the left ventricle (the aortic valve is above and to the right of the mitral valve). The aortic cone (LV outlet) lies behind the pulmonary cone of the pancreas. Heading up and to the right, the first crosses the last, which is why the aortic opening is located behind and to the right of the opening of the pulmonary trunk. The myocardium of the walls and apex of the left ventricle and the interventricular septum, anterior and posterior

papillary (papillary) muscles. Muscular trabeculae are located mainly on the diaphragmatic surface and in the region of the apex. The LV myocardium has an unequal thickness in different segments, and in the same segments it changes significantly in different phases of cardiac activity. With CT and MRI without synchronization of ECG studies, the average thickness of the myocardium is 10-12 mm and ranges from 7 to 18 mm. In systole, the thickness of the myocardium in different segments is 10-20 mm. Systolic thickening of the myocardium (the difference between the thickness of the myocardium in systole and diastole) by segments varies widely - from 2 to 12 mm, and the ratio of systolic thickening to myocardial thickness - from 10 to 56%. On direct radiographs, the LV forms the 4th arc of the left heart contour.

A small indentation on the surface of the heart between the left and right ventricles corresponds to the notch of the apex of the heart, which is the place where the anterior interventricular sulcus passes into the posterior one. The boundaries between the atria and ventricles on the surface of the heart correspond to the right and left coronal sulci, in which the coronary arteries are located. The left coronary artery (LCA) departs from the left coronary sinus of the aorta, goes to the left and back, forming the anterior interventricular, left anterior descending artery, (LAA) and circumflex artery (OA) with numerous branches. The right coronary artery (RCA) arises from the right coronary sinus and extends to the right along the coronary sulcus to the inferior surface of the heart. The type of coronary circulation is determined by the blood supply to the posterior wall of the left ventricle: the right type is characterized by the origin of the posterior descending and posterior lateral arteries from the RCA (up to 80% of patients), the left type - from OA (up to 10% of patients). 10% have a mixed type of blood supply. The most accurate information about the structural features of the coronary arteries, the nature and types of myocardial blood supply, the presence of pathological changes is obtained with coronary angiography.

The pericardium is the bilayered serosa of the heart, which is normally not visible on chest x-rays. However, it is the pericardium, together with epicardial fat, that forms the border of the shadow of the heart against the background of transparent lungs. The pericardium is clearly visible as a thin strip on CT and MR images. The fluid in the pericardial cavity (normally up to 20 ml) is practically indistinguishable, but adipose tissue is often determined.

X-ray of the heart in the anterior direct projection (Fig. 1), the left contour of the cardiovascular shadow consists of four arcs corresponding to the edge-forming cavities and vessels of the heart. The upper arch corresponds to the aortic arch, which begins to clearly contour only by the age of 3 years. In an earlier period of life, its shadow under normal conditions is of little intensity. Often at this level, the thymus gland is the edge-forming organ, which can simulate the expansion of the aorta. On overexposed radiographs, the descending aorta can be traced along the left edge of the spine against the background of the cardiac shadow.

Rice. 1. X-ray of the organs of the chest cavity in the direct projection of a child of 7 years.

I - aortic arch; 2 - trunk of the pulmonary artery; 3 - eye of the left atrium; 4 - left ventricle; 5 - superior vena cava; 6 - right atrium.

The second arc is formed by the trunk of the pulmonary artery and the initial part of the left pulmonary artery; the degree of its severity depends on the shape of the chest and the constitution of the child. In asthenics, the second arch is more convex, and therefore the radiologist may have an assumption about the expansion of the vessel. As a result, in order to get an idea of ​​the state of the second arch as one of the indicators of the hemodynamics of the pulmonary circulation, it is always necessary to compare this indicator with the diameter of the descending branch of the right and left pulmonary arteries, as well as the state of the pulmonary pattern. With a true expansion of the trunk, due to an increase in pressure in the pulmonary artery system or an increase in the minute volume of the pulmonary circulation (hypervolemia), along with an increase in the diameter of the root sections of the right and left pulmonary arteries, the vascular pattern of the lungs will be detected, represented by wide intrapulmonary vessels. If the bulging of the trunk of the pulmonary artery is a variant of the norm, then the roots of the lungs and the pulmonary pattern are not changed.

The third arch on the left is formed by the left atrial appendage, which is well differentiated only when the cavity is enlarged. Normally, the third arc merges with the fourth, related to the left ventricle. In young children, the lower arch along the left contour is often formed by the right ventricle.

The right contour of the cardiovascular shadow consists of two arches: the upper one, which is the contour of the superior vena cava (in its lower half in older children, the contour of the ascending aorta can be the edge-forming one), and the lower one, which serves as the contour of the right atrium. The angle between these arcs is called the right atriovasal. Sometimes a shadow of the inferior vena cava or hepatic vein is visible in the right cardio-diaphragmatic angle.

Right contour. The top and bottom points of the contour are determined.

When determining the upper point, percussion is carried out along the 3rd intercostal space in the direction from the right mid-clavicular line to the right edge of the sternum.

· The lower point of the contour coincides with the right border of the relative dullness of the heart.

Left contour. The top, middle and bottom points of the contour are determined.

When determining the upper point, percussion is carried out along the 3rd intercostal space in the direction from the left mid-clavicular line to the right edge of the sternum.

When determining the midpoint, percussion is carried out along the 4th intercostal space in the direction from the left midclavicular line to the right edge of the sternum.

· The lower point of the left contour coincides with the left border of the relative dullness of the heart.

Heart size according to Kurlov:

Diameter of the heart- the sum of perpendiculars lowered from the lower points of the right and left contours to the anterior midline of the body. Normally it is 11-13 cm.

Heart length is the distance from the top point of the right contour to the bottom point of the left contour. Normally it is 13-15 cm.

Heart configuration. Normal, mitral, aortic, mitral-aortic.

Auscultation of the heart. It is necessary to describe tones 1 and 2, their sonority, correlation (amplification, weakening), additional tones, bifurcation of tones, pathological rhythms (quail rhythm, gallop rhythm), heart murmurs (systolic, diastolic), their relationship with heart sounds (1 and 2), duration, shape (decreasing, increasing, rhomboid, fusiform, etc.), the best point of listening to the noise (punctum maximum), areas of noise conduction (axillary, left edge of the sternum, carotid arteries, etc.).

The main points of auscultation of the heart:

1. The area of ​​the apex beat or the left border of the relative dullness of the heart (the point of best listening to the mitral valve).

2. II intercostal space at the right edge of the sternum (the point of best auscultation of the aortic valve).

3. II intercostal space at the left edge of the sternum (the point of best listening to the pulmonary valve).

4. The place of attachment of the xiphoid process to the sternum (the point of best listening to the tricuspid valve).

Additional points of auscultation of the heart:

1. III intercostal space at the left edge of the sternum - the Botkin-Erb point (the point of listening to the aortic valve).

2. IV intercostal space at the left edge of the sternum - Naunin's point (listening point of the mitral valve).

3. Apex of the epigastric angle - Levina's point (auscultation point of the tricuspid valve).

Inspection of large vessels. Pulsation of the carotid (Musset symptom) and other large arteries, swelling of the jugular veins. Varicose veins.

Vascular palpation. Palpation of arteries (carotid, radial, femoral, tibial).

Pulse and its properties (frequency, rhythm, uniformity, size, tension, content, form).

Venous pulse(negative, positive).

Capillary Quincke pulse. positive or negative.

Blood pressure measurement(BP) on both arms, and in patients with arterial hypertension and on the legs.