Have you found a heart murmur in your child? - no reason to panic. What do doctors mean by heart murmurs? Organic systolic murmurs

You need to listen to the child's heart with a phonendoscope or a biauricular stethoscope, checking the data obtained by listening directly to the ear. Listening is done in a horizontal and vertical position sick, in calm state and after loading. Auscultation is performed at 5 points: at the top of the heart, on the sternum below, on pulmonary artery- in the second intercostal space on the left, on the aorta - in the second intercostal space on the right, at the 5th point - at the place of attachment of the III rib to the sternum on the left. At each point, they try to listen to both tones, their frequency, weakening or amplification, heart murmurs, if they are heard, and determine whether there is a systolic or diastolic murmur, its nature and distribution. It is also determined whether the number of heartbeats corresponds to the number of pulse beats.

The pericardial friction noise is heard better at the base of the heart and lower in a sitting or forward-leaning position of the patient or with some pressure on the anterior chest wall with a phonendoscope.

Strengthening of both heart tones is observed:

1. At the onset of febrile illnesses.

2. With anemia.

3. With Graves' disease.

4. When wrinkling the edge of the left lung.

5. With compaction of the parts of the lung adjacent to the heart.

6. When the cavity is attached (cavity, pneumothorax).

Strengthening of individual heart sounds is:

1. Accent of the first tone at the apex - with narrowing of the left atrioventricular orifice;

2. Emphasis of II tone on the aorta - with elevated work left ventricle, in particular:
a) with chronic nephritis;
b) with arteriosclerosis;
c) sometimes when listening in a cold room.
d) in puberty;
e) with hypertension.

3. Emphasis of II tone on the pulmonary artery occurs with an increase blood pressure in a small circle in the presence of good performance of the right ventricle, in particular:
a) with stenosis and insufficiency bicuspid valve;
b) with an open botallous (arterial) duct;
c) with non-closure of the interventricular or interatrial septa;
d) with sclerosis of the pulmonary artery;
e) at chronic inflammation lungs.

Accent II tone always indicates a vigorous contraction of the corresponding ventricle.

The weakening of the heart tones is:

2. With heart weakness.

3. With the accumulation of fluid in the pericardial cavity.

4. With emphysema, when the heart is covered with a lung.

5. In children of the first months of life, heart sounds are heard weakened. The reason for this is still unclear.

6. Weakness of the first tone at the apex with aortic valve insufficiency.

7. Weakness of the II tone during collapse and weakening contractility myocardium. Weakness of the II tone on the aorta - with valvular stenosis of the aorta.

8. With an incorrect listening technique, with strong pressure with a stethoscope (or ear) on the chest, according to the observations of D. D. Lebedev, heart sounds are also heard weakened.

Bifurcation of tones is also observed in healthy children.

Bifurcation of tones in pathological conditions is observed when the left and right halves of the heart do not contract simultaneously due to hypertrophy of one half of the heart. This is observed:

1) with a wrinkled kidney,

2) with arteriosclerosis (hypertrophy of the left heart),

3) with emphysema, etc. (hypertrophy of the right heart),

4) in case of violation of the conduction of an impulse to contraction of the heart - complete and incomplete blockade.

The rhythm of "neurasthenic quail", as the name itself indicates, is observed in neurasthenia. The gallop rhythm happens:

1) with stenosis of the left atrioventricular orifice,

2) with myocarditis, such as diphtheria.

Embryocardia is observed:

1) with myocarditis,

2) before death,

3) in shock.

When listening to the heart in children, both tones are normally heard, and starting from about 2 years old, the second tone on the pulmonary artery is somewhat accentuated and often split. Due to the fact that in a child, the II tone on the pulmonary artery is normally louder than on the aorta, therapists often think about pathology when there is no reason for this. In a newborn child, especially in a premature baby, embryocardia is the norm, when the pause between the I and II tone does not differ from the pause between the II tone and the subsequent I, and when listening, the tones follow each other, like the beats of a pendulum or a metronome. Such embryocardia is normal only in the first days of life. At an older age, it is observed with anatomical lesions of the heart and with infections: dysentery, pneumonia, sometimes with tachycardia of various origins. In any case, in a child older than 2 weeks, embryocardia is a pathological phenomenon.

For the diagnosis of heart lesions have a large diagnostic value heart murmurs. In children of the first years of life, the presence of noise often speaks in favor of a congenital defect; later (from 3-5 years) noises are observed mainly with rheumatic heart disease. During puberty, the so-called accidental noises are especially often noted, which basically do not have organic changes in the heart.

Accidental noises can also be observed in children. younger age. These murmurs are almost always systolic and are noted to the left of the sternum, more often at the apex and on the pulmonary artery, they are unstable, gentle in nature, have weak conductivity, heart sounds do not disappear with them, the borders of the heart are often normal, "cat's purr" is not defined.

Accidental noises depend on changes in blood composition and blood flow velocity, on atony and hypertension of the heart muscle and papillary muscles, in particular on changes in the lumen of blood vessels as a result of age-related or posture-related changes.

To judge the localization of organic changes in the heart and, above all, endocarditis and heart defects, the place of the best listening, time (systole or diastole), intensity, conduction, and the nature of the noise matter.

1. Systolic murmur is better heard at the apex: a) in case of insufficiency of the bicuspid valve, at the same time there is an expansion of cardiac dullness to the left, accent of the II tone of the pulmonary artery, conduction of murmur in axillary region; b) with myocarditis, if relative insufficiency of the bicuspid valve has developed due to weak contractility of the papillary muscles.

2. Systolic noise on the left at the attachments of the III-IV ribs to the sternum occurs with a defect interventricular septum; the noise is rough, sharp, there is no cyanosis; there may be an accent of the II tone of the pulmonary artery; may be "cat's purr"; it is possible to expand the border of the heart to the right and to the left.

3. Systolic murmur in the second intercostal space on the left is heard with: a) narrowing of the pulmonary artery; in the same case, there is a weakening of the II tone on the pulmonary artery or its complete absence, expanding the boundaries of relative cardiac dullness to the right,

4. Systolic murmur in the second intercostal space on the right is heard with aortic stenosis in the area of the valves; noise is conducted through the vessels; there is an expansion of cardiac dullness to the left and down, pallor of the face is noted.

5. Systolic noise on the handle of the sternum and lower to the left occurs with stenosis of the isthmus of the aorta; there is also an expansion of cardiac dullness to the left and down, expansion of a., mammariae, usura of the ribs, delay and weakening of the pulse in the arteries of the feet, high blood pressure in the arms and low in the legs.

6. Diastolic murmur at the apex is heard with stenosis of the left atrioventricular orifice; there is an expansion of the border of dullness to the right, pulsation in epigastric region, accent II tone of the pulmonary artery, accent I tone at the top.

7. Diastolic murmur at the 5th point (near the third rib to the left of the sternum) is heard with insufficiency of the aortic valves; the dance of the carotid is pronounced on the neck; there is a capillary pulse, a double tone and double noise on the femoral arteries are heard; the borders of the heart are expanded to the left and down.

8. Systolo- diastolic murmur auscultated with open ductus arteriosus; while the II tone of the pulmonary artery is accentuated; the murmur is sometimes well carried out posteriorly upward on the left between the shoulder blades, the murmur is well carried out on the vessels of the neck; in children with this defect, noise is heard with both I and II tone; dullness on the left side of the sternum in the second and third intercostal space (Gerhardt's band). D. D. Lebedev points out the appearance of the same dullness in the area of attachment to the sternum of the II-III ribs in the first days after the fall in temperature. In such cases, it is transient and is accompanied by other signs of "infectious heart".

Organic heart lesions, heart defects, developmental anomalies are not always accompanied by murmurs. Suffice it to point out that such a severe congenital heart disease as transposition large vessels(the aorta emerges from the right ventricle and the pulmonary artery from the left ventricle) may not be accompanied by a murmur.

With some congenital heart defects, the murmurs may be intermittent. Sometimes with congenital heart defects at birth, the noise is not heard, and later it is detected.

It is well known that the weakening of cardiac activity can lead to a decrease and even the disappearance of noise.

The pericardial friction noise is heard better with the torso tilted forward or with pressure on the chest with a stethoscope, and not only closer to the vessels, as previously thought, but also towards the top; in rheumatic and tuberculous pericarditis, the pericardial friction rub is heard more often.

Location of the murmur in the cardiac cycle. There are systolic, diastolic and systolic-diastolic (long) noises.
Loudness (intensity) of noise. The loudness of the noise is evaluated in the place where it is greatest. A scale of gradations for the loudness of heart murmurs has been developed.
I degree: a very weak noise that can be heard even in silence not immediately, but after persistent and thorough auscultation.
Grade II: a faint but easily recognizable murmur that is heard in normal conditions.
III degree: Moderate noise without jitter chest.
Grade IV: pronounced murmur with moderate trembling of the chest.
V degree: a loud noise heard immediately after applying the stethoscope to the skin of the chest, with pronounced trembling of the chest.
Grade VI: An exceptionally loud noise that can be heard even when the stethoscope is removed from the skin of the chest, with pronounced trembling of the chest.
Noise localization. For murmur localization, it is recommended to use terminology based on the topographic relationship of the heart and chest.
Noise irradiation. The distance over which the noise is conducted depends most of all on the loudness of the noise. It is important to determine whether the murmur is conducted outside the heart area and in what directions.
The nature of the noise. The special tonality of the noise and its individual timbre can be discounted subjectively (with the human ear), and not with the help of phonocardiography. The nature of the noise is described various terms: "blowing noise", "scraping noise", "snow crunching noise", "rumbling noise", "machine noise", - "rough noise", "soft noise", "gentle noise", "musical noise", etc. It should be noted that the nature of the noise may change with distance from the point of its maximum sound.
Duration and shape (configuration) of noise. A long murmur occupies almost the entire systole or diastole, or both phases, and a short one occupies only a part cardiac cycle. The shape of the noise is determined by the changes in the loudness of the long noise along its length. It is customary to allocate various options noise.
Noise in the form of a "plateau" - - with the noise volume constant throughout.
Noise in the form of "crescendo-decrescendo" - when the volume of the noise first rises to a maximum (by the middle of the cycle), and then decreases.
Noise in the form of "decrescendo" - - decreasing noise, the volume of which decreases and gradually fades away "
Noise in the form of a "crescendo" - an increasing noise with a progressive increase in its volume.

Heart murmurs are heard in the vast majority of children. They are divided into "functional" - in the absence of significant anatomical defects (transient murmurs of the developing heart and "small" hemodynamically insignificant anomalies and dysfunctions) and "organic" - associated with congenital anomalies heart, rheumatic and non-rheumatic heart disease.

Functional noises(accidental, atypical, innocent, inorganic, benign) listen to children very often. They are characterized by: 1) low intensity (1-3 gradations of loudness); 2) variability with a change in the position of the child, with physical activity; 3) inconstancy; 4) localization mainly within the boundaries of the region of the heart; 5) occurrence during systole.

organic noises meet less frequently. They are characterized by: 1) high intensity (3-6th gradation of loudness); 2) constancy; 3) conduction outside the heart through vessels and tissues; 4) occurrence during both systole and diastole.

Auscultation zones of valves and parts of the heart in children the same as in adults.

The zone of the left ventricle is the apex of the heart, the fourth intercostal space 1-2 cm medially from the apex and laterally - to the anterior axillary line. This is the listening area. mitral valve, III and IV tones of the left ventricle, murmurs during mitral valve prolapse, mitral insufficiency and mitral stenosis, myocarditis, sometimes - noises with aortic defects.
The zone of the right ventricle is the lower third of the sternum, as well as the area in the fourth intercostal space 1-3 cm to the left and 1-2 cm to the right of the sternum. This is the area of auscultation of the tricuspid valve, III and IV tones of the right ventricle, murmurs in case of ventricular septal defect and in case of pulmonary valve insufficiency.
The zone of the left atrium - on the back at the level bottom corner left shoulder blade and laterally to the posterior axillary line. This is the listening area for systolic murmur in mitral insufficiency.
The zone of the right atrium is at the level of the fourth intercostal space, 1-2 cm to the right of the sternum. This is the listening area for the systolic murmur of tricuspid valve insufficiency.
The aortic zone is in the third intercostal space on the left and in the second intercostal space on the right at the edge of the sternum. This is the listening area. aortic valve and murmurs in aortic stenosis, aortic valve insufficiency.
The zone of the pulmonary artery is the second intercostal space on the left at the edge of the sternum, extending up to the left sternoclavicular joint (in the first intercostal space) and down to the third intercostal space along the left edge of the sternum. This is the listening area for pulmonic valve sounds and murmurs in pulmonary stenosis.
Downstream zone thoracic aorta- back surface of the chest over II - X thoracic vertebrae and 2-3 cm to the left of the posterior midline. This is the area for listening to noises in coarctation of the aorta, aortic stenosis.

Systolic murmurs

Systolic murmurs- occur during systole, following the first heart sound.

Functional systolic murmurs

Venous "buzzing" (continuous murmur at the base of the heart and in the clavicle region), murmur of transpulmonary acceleration of blood flow (in the region of the pulmonary valve), heart vibration murmur (at the apex and along the left edge of the sternum) are truly functional murmurs; they increase with fever, thyrotoxicosis, anemia, bradycardia, excessive sports loads.
Murmurs of heart formation (localization is different) are heard more often during periods of intensive growth and development.
Noise due to change muscle tone papillary muscles and myocardium (at the apex and along the left edge of the sternum in the third and fourth intercostal spaces), are more often caused by neurocirculatory dysfunction and autonomic disorders.
Murmurs of "small" hemodynamically insignificant anomalies (localization is different) are associated with the presence of additional chords(noise with a "musical" tone), a violation of the architectonics of the myocardium and endocardium.

By their nature, functional noises are usually “gentle”, “soft”, “musical”.

Organic systolic murmurs

♦ Regurgitation murmurs:

pansystolic (holosystolic) noise - with severe mitral and tricuspid insufficiency, ventricular septal defect (with pulmonary hypertension the form "plateau" can change to "crescendo-decrescendo"), infective endocarditis, rheumatic endocarditis;
early systolic murmur (form "decrescendo") - with a small interventricular defect in the muscular part (Tolochinov-Roger disease);
late systolic murmur - with mitral valve prolapse (often in combination with a mid-systolic click).

By nature, these noises are usually more or less "rough", "blowing", sometimes with a "musical" tint.

Noises of exile(mid-systolic, "crescendo-decrescendo" form) occur:

with a mechanical obstruction to the outflow of blood from the ventricles - aortic and pulmonary stenosis, tetralogy of Fallot, hypertrophic obstructive cardiomyopathy;
with dilatation of large vessels (less often in children) - arterial hypertension;
with hypercirculation (an increase in the speed and / or volume of blood expelled through normal valve) - aortic insufficiency; defect interatrial septum and other arteriovenous shunts (in the projection of the pulmonary valve).
By nature, these noises are usually "rough", "scraping"; in children, they can be relatively "soft", with a "musical" tint.

diastolic murmurs

♦ Diastolic murmurs occur during diastole, following the second heart sound.

Organic diastolic murmurs

Early (protodiastolic) murmur - with aortic valve insufficiency, infective endocarditis. By nature, this noise is usually “soft”, “blowing”, and therefore often missed by doctors with inattentive auscultation.
Medium (mesodiastolic) noise - with mitral valve stenosis (timbre of noise - "roar", "peal"); may also be heard with increased blood flow into the ventricles through a normal or dilated atrioventricular orifice.
Late (presystolic) noise - with stenosis of the tricuspid valve (timbre - "squeak"); may also be integral part murmur in mitral stenosis.

Systolic-diastolic murmurs

Systolo-diastolic(prolonged) noises - occur at the beginning of systole and without a pause, covering the II tone, continue during diastole. The unidirectionality of the blood flow gives the continuous noise a unique "machine" character.

Organic systolic-diastolic murmurs

The first group of noises - in the presence of a shunt between the chambers of the heart (or vessels) with high and low pressure (open ductus arteriosus). End at the end of diastole.
The second group of murmurs - during blood flow (with a high pressure gradient) through a sharply narrowed place in the altered vessel (coarctation of the aorta). End in early diastole.
The third group of noises - occur over dilated collaterals with pulmonary stenosis and coarctation of the aorta.
Systolic-diastolic pericardial friction noise (tone - "crunching snow", scraping) can be heard with pericarditis.

Peculiarities of examining children with heart murmurs

When a functional heart murmur is detected in a child, it is necessary:

carefully analyze the history for the possibility of the presence of a cardiac disease;
spend initial examination, necessarily including electrocardiography;
on suspicion of cardiac disease carry out echocardiography and refer the child for a consultation with a pediatric cardiorheumatologist.

It is reasonable to divide children with functional noises into three categories:

healthy children with functional heart murmur;
children with muscle murmurs requiring immediate or planned in-depth examination;
children with noises requiring dynamic observation.

Children with organic noises(or if a child has pathological changes in the heart and large vessels) should be referred for a consultation with a pediatric cardio-rheumatologist (and/or cardiac surgeon) for the purpose of immediate or scheduled specialized examination and treatment.

Systolic murmur in the heart is an acoustic manifestation provoked by a change in the nature of blood flow in the vessels. Patients who are diagnosed with such a deviation need to remember that it is not dangerous, but may report some problems and malfunctions. of cardio-vascular system. Such sounds have a clear amplitude, which is heard in the interval 1 and 2 heart tone, namely the contraction of the ventricles. The sound developer in this situation is a failure of blood flow near the heart valves.

Types of systolic murmur

There are two types of noise:

functional;
organic.

Functional noises are in no way interdependent with heart diseases, the manifestation of physiological sounds can be triggered by other diseases in the human body. Organic noises are caused by improper functioning of the heart muscle.

Functional noises are characterized by the following parameters:

They have a rather soft timbre and intensity, it is very difficult to listen to them.
They can also be exacerbated during strenuous exercise.
A characteristic feature is that they do not produce resonance with nearby organs and tissues.
Nothing connects them with heart rhythms, they can be caused by a sharp change in body position. In most cases, they become noticeable when the patient takes horizontal position and his head is slightly raised.

Children are also susceptible to the occurrence of such a deviation. Sometimes the occurrence is associated with anatomical features structure of the pulmonary arteries in children.

This is due to the fit to the anterior plane of the chest. In these cases, the changes are called pulmonary, they can be heard over the artery.

Functional murmurs may occur due to hyalinosis of the heart muscle, in this situation, a systolic murmur at the apex of the heart will be heard. Among the causes of occurrence, anemia and squeezing of blood vessels are distinguished.

provoke organic noises may be valvular or septal insufficiency of the interatrial or interventricular septum.

Their characteristics are:

These manifestations are dominated by a sharp, pronounced and prolonged character.
Sound deviations go beyond the boundaries of the cardiac zone and are given to the interscapular or axillary zone.
At the moments of physical exertion, the noises increase, after the completion of the events they do not disappear immediately, they can retain their expressiveness for a long time.

Organic manifestations are in close connection with the sounds of the heart.

Causes of heart murmurs

Murmurs in the heart can manifest themselves for several reasons that provoke them. Systolic murmur tends to occur due to aortic stenosis. Under this term, one can understand both congenital and life-long thinning of the aortic orifices, which occurs due to fusion of the valve leaflets. This event leads to difficulty in the flow of blood inside the cavity of the heart. Similar pathology in cardiology, they are among the most common heart defects that are diagnosed in middle-aged and older patients. With this deviation, aortic insufficiency and mitral valve disease are often manifested. The disease can progress due to the fact that the aortic apparatus is prone to calcification. With this conclusion, the left ventricle is significantly loaded, then the heart muscle and brain begin to die from the insufficiency of the incoming blood.

It is aortic insufficiency that is the main cause of the formation of a heart murmur. The disease is that the valve of the heart cannot close completely.

Pathology often occurs against the background of endocarditis, which has infectious nature, which can be provoked by:

syphilis;
atherosclerosis;
rheumatism.

Mitral regurgitation is a less common but still present provocateur of systolic murmurs. In this case, the source lies in the transient movement due to the contraction of fluid and gas, which are localized in the hollow organs of the muscles. Such a phenomenon is pathological character. Such a diagnosis develops as a result of a violation of the functions of the separating partitions.

The main symptoms of systolic heart murmurs

With physiological noise, the following symptoms may appear:

increased fatigue of the body;
pallor skin faces;
weakness, depression;
tremor of the limbs;
weight loss;
increased irritability;
shortness of breath after physical exertion;
swelling of the legs;
increased heart rate;
dizziness;
loss of consciousness.

Pathological noises are characterized by:

violation of the heart rhythm;
shortness of breath that occurs not only at the time of exertion, but also at rest;
attacks of nocturnal suffocation;
swelling of the limbs;
increased irritability;
dizziness ending in loss of consciousness;
heart pain;
chest pain.

It is important to undergo examinations at the first symptoms, especially if anxiety symptoms appeared in the baby. Only a doctor can determine which pathological processes take place in the child's heart.

It should be borne in mind that each type of noise can often be caused by certain features of the body, but heart murmurs cannot be non-pathological.

Diagnosis of systolic murmurs

The definition of heart disease in each case begins with the diagnosis of the presence or absence of murmurs. The examination is performed in the supine and standing position, as well as after light physical activities. These measures are required in order to accurately identify noise, which can manifest itself for various reasons.

When determining the nature of noises, it is worth considering that they may have different phases (systole and diastole), their duration and conductivity may change.

At the diagnostic stage, it is extremely important to determine the center of the noise. Mild manifestations rarely promise serious problems- in contrast to the noise having a hard character.

During the study, it is necessary to limit non-cardiac murmurs that are outside the boundaries of the heart muscle. These manifestations are clearly audible with pericarditis. They can only be determined during systole.

It makes it possible to detect other sound phenomena, called noises. They occur when the opening through which blood flows is narrowed, and when the speed of blood flow increases. Such phenomena may be due to an increase in heart rate or a decrease in blood viscosity.

Heart murmurs divided into:

murmurs generated within the heart itself ( intracardiac),
murmurs outside the heart extracardiac, or extracardiac).

Intracardiac murmurs most often occur as a result of damage to the heart valves, with incomplete closure of their valves during the closure of the corresponding opening, or when the lumen of the latter is narrowed. They can also be caused by damage to the heart muscle.

There are intracardiac murmurs organic and functional(inorganic). The former are the most important diagnostically. They indicate anatomical lesions of the heart valves or the openings they close.

A heart murmur that occurs during systole, that is, between the first and second tone, is called systolic, and during diastole, i.e. between the second and the next first tone, - diastolic. Consequently, the systolic murmur coincides in time with the apex beat and the pulse on the carotid artery, and the diastolic murmur coincides with a large pause of the heart.

The study listening techniques for heart sounds it is better to start with systolic (with normal heart rate). These noises can be soft, blowing, rough, scraping, musical, short and long, quiet and loud. The intensity of any of them can gradually decrease or increase. Accordingly, they are called decreasing or increasing. Systolic murmurs are usually decreasing. They can be heard during the entire systole or part of it.

listening diastolic murmur requires special skills and attention. This noise is much weaker in volume than the systolic one and has a low timbre, it is difficult to catch with tachycardia (heart rate more than 90 per minute) and atrial fibrillation(erratic contractions of the heart). In the latter case, long pauses between individual systoles should be used to listen for diastolic murmurs. Diastolic murmur, depending on the phase of diastole, is divided into three types: protodiastolic(decreasing; occurs at the very beginning of diastole, immediately after the second tone), mesodiastolic(decreasing; appears in the middle of diastole, a little later after the second tone) and presystolic(increasing; formed at the end of diastole before the first tone). Diastolic murmur may last throughout diastole.

Organic intracardiac murmur, caused by acquired heart defects, can be systolic (with insufficiency of the two- and tricuspid valves, narrowing of the aortic orifice) and diastolic (with narrowing of the left and right atrioventricular orifices, insufficiency of the aortic valve). A type of diastolic murmur is presystolic murmur. It occurs with mitral stenosis due to increased blood flow through the narrowed hole at the end of diastole with a contraction of the left atrium. If two noises (systolic and diastolic) are heard above one of the valves or holes, then this indicates a combined defect, i.e. valve insufficiency and narrowing of the hole.

Rice. 49. :
a, b, c - systolic, respectively, with insufficiency of two- and three-leaf valves, with stenosis of the aortic orifice;
d - diastolic with aortic valve insufficiency.

Localization of any noise heart corresponds to the place of the best listening to the valve, in the area of which this noise was formed. However, it can be carried out along the blood flow and along the dense muscle of the heart during its contraction.

systolic murmur bicuspid valve insufficiency(Fig. 49, a) is best heard at the apex of the heart. It is carried out towards the left atrium (II-III intercostal space on the left) and into the axillary region. This noise becomes clearer when holding the breath in the expiratory phase and in the position of the patient lying down, especially on the left side, and also after physical activity.

systolic murmur tricuspid valve insufficiency(Fig. 49, b) well audible at the base xiphoid process sternum. From here it is conducted upward and to the right, towards the right atrium. This noise is better heard in the position of the patient on the right side when holding the breath at the height of inspiration.

systolic murmur narrowing of the aortic orifice(Fig. 49, c) is best heard in the II intercostal space to the right of the sternum, as well as in the interscapular space. It, as a rule, has a sawing, scraping character and is carried along the blood flow upward to the carotid arteries. This noise is amplified in the position of the patient lying on his right side with breath holding in the phase of forced exhalation.

Early systolic murmur

Mean systolic murmur (English):

Innocent systolic ejection murmur

Late systolic murmur

Late systolic murmur due to mitral valve prolapse

diastolic murmur at mitral stenosis, which occurs at the beginning or middle of diastole, is often better heard in the area of the projection of the bicuspid valve (the place where the third rib is attached to the sternum on the left) than at the apex. Presystolic, on the contrary, is better heard in the apex. It is almost never carried out and is especially well heard in the upright position of the patient, as well as after physical exertion.

diastolic murmur at aortic valve insufficiency(Fig. 49, d) is also auscultated in the II intercostal space to the right of the sternum and is carried out along the blood flow down to the left ventricle. It is often heard better at the 5th point of Botkin-Erb and increases in the vertical position of the patient.

Organic intracardiac murmurs, as already noted, may be the result of congenital heart defects(non-closure of interatrial - foramen ovale, ventricular septal defect - Tolochinov-Roger disease, non-closure of the arterial - ductus arteriosus, narrowing of the pulmonary artery).

At non-closure of the atrial opening systolic and dastolic murmurs are noted, the maximum audibility of which is detected in the region of attachment of the third rib to the sternum on the left.

At ventricular septal defect there is a scraping systolic murmur. It is auscultated along the left edge of the sternum, at the level of III-IV intercostal spaces and is carried out into the interscapular space.

At cleft ductus arteriosus (the aorta is connected to the pulmonary artery) a systolic murmur (sometimes with diastolic) is heard in the II intercostal space on the left. It is weaker heard over the aorta. This noise is conducted to the interscapular region closer to the spine and to the carotid arteries. Its peculiarity is that it is combined with an enhanced second tone on the pulmonary artery.

At narrowing of the pulmonary artery a rough systolic murmur is heard in the II intercostal space on the left at the edge of the sternum, little transmitted to other places; the second tone in this place is weakened or absent.

Noise may also result from expansion of the cavities of the heart without organic damage valve apparatus and corresponding openings. For example, promotion blood pressure in system great circle circulation ( hypertonic disease, symptomatic hypertension) can lead to an expansion of the cavity of the left ventricle of the heart and, as a result, to stretching of the left atrioventricular orifice. In this case, the mitral valve leaflets will not close (relative insufficiency), resulting in a systolic murmur at the apex of the heart.

Systolic murmur may occur with aortic sclerosis. It is heard on the right in the II intercostal space at the edge of the sternum and is due to the relatively narrow aortic orifice compared to its expanded ascending part. This noise increases with raised hands (symptom of Sirotinin-Kukoverov).

An increase in pressure in the pulmonary circulation, for example, with mitral stenosis, can lead to expansion of the orifice of the pulmonary artery and, consequently, to the occurrence diastolic Graham-Still murmur, which is auscultated in the II intercostal space on the left. For the same reason, with mitral stenosis, the right ventricle expands and relative tricuspid valve insufficiency occurs. At the same time, in the region of the IV intercostal space on the right, near the sternum and at the xiphoid process, a blowing systolic murmur is heard.

At acceleration of blood flow as a result of tachycardia, with a decrease in its viscosity due to anemia, with dysfunction of the papillary muscles (increase or decrease in tone), and in other cases, functional systolic murmurs may occur.

With insufficiency of the aortic valve at the apex of the heart, it is often audible functional diastolic (presystolic) murmur - Flint's murmur. It appears when the leaflets of the mitral valve are lifted by a strong stream of blood coming from the aorta during diastole into the left ventricle, and thereby cause a transient narrowing of the left atrioventricular orifice. Flint's murmur is heard at the apex of the heart. Its volume and duration are not constant.

Early diastolic murmur

Mean diastolic murmur (English):

Late diastolic murmur

Functional heart murmurs, as a rule, are heard in a limited area (best of all at the apex and more often on the pulmonary artery) and have a low volume, soft timbre. They are inconsistent, they can appear and disappear with a different position of the body, after physical exertion, in different phases breathing.

To extracardiac murmurs include pericardial friction rub and pleuropericardial murmur. Rubbing noise of the pericardium occurs during inflammatory processes in it. It is heard during both systole and diastole, it is better detected in the area of absolute dullness of the heart and is not carried out anywhere. Pleuropericardial murmur occurs when inflammatory process part of the pleura adjacent to the heart. It resembles the friction noise of the pericardium, but unlike it, it increases on inhalation and exhalation, and when holding the breath, it decreases or disappears altogether. Pleuropericardial murmur is heard on the left side

Normally, heart sounds give the acoustic impression of a single short sound. With pathology, conditions are created for repeated repeated oscillations - for the appearance of noise, which are perceived as sounds of a diverse timbre. The main mechanism for the formation of noise is the passage of blood through the narrowed opening. The increase in blood flow velocity contributes to the formation of noise, the blood flow velocity depends on the increase in excitability and increased activity of the heart. The narrower the hole through which the blood passes, the stronger the noise, but with a very strong constriction, when the blood flow decreases sharply, the noise sometimes disappears. The noise increases with increasing force of contractions and weakens with a decrease. Also, the acceleration of blood flow is associated with a decrease in blood viscosity (anemia). Types of noise Noises are divided into organic and functional. Organic noises are associated with pathological changes in the heart (the valvular apparatus changes: leaflets, tendon filaments, capillary muscles), the size of the holes changes. The reason may be a stenosis of the opening, which impedes the flow of blood to the next section; valvular insufficiency, when the valvular apparatus cannot completely close the hole to prevent backflow of blood. Organic murmurs are more common in valvular and congenital heart defects. Functional noises are observed mainly in anemia, neurosis, infectious diseases, thyrotoxicosis. The cause of the noise is the acceleration of blood flow (anemia, nervous excitement, thyrotoxicosis) or insufficient innervation, or nutrition of the muscle fibers or capillary muscles of the heart, as a result of which the valve is not able to close the corresponding hole tightly. Functional noises differ from organic ones in their localization (determined on the pulmonary artery, the apex of the heart); they are shorter in duration; depend on the psycho-emotional state and physical activity; as a rule, they are amplified in a horizontal position; when listening, they are tender, blowing, weak; they have a passing character (decrease with improvement of the condition). According to the time of appearance of noise during systole or during diastole, systolic and diastolic murmurs are distinguished. Systolic murmur is heard with the vast majority of functional murmurs; with insufficiency of the mitral and tricuspid valves; with stenosis of the aortic mouth; with stenosis of the mouth of the pulmonary artery; with atherosclerotic lesions of the walls and aortic aneurysm; with open interventricular foramen. Systolic murmur appears in the first small pause and corresponds to the systole of the ventricles, while I tone is often absent, but may persist. Diastolic murmur is heard with aortic valve insufficiency; pulmonary valve insufficiency; non-closure of the botallian duct; with stenosis of the left atrioventricular orifice. Diastolic murmur appears in the second major pause and corresponds to ventricular diastole.

The noise that occurs at the very beginning of diastole is called protodiastolic(occurs with valve insufficiency; left atrioventricular stenosis; non-closure of the ductus arteriosus). A presystolic murmur is a murmur that occurs at the end of diastole (mitral stenosis). Noise that occupies only the middle of the diastole is called mesodiastolic. Diastolic murmur, auscultatory detected in the aorta, makes it possible to confidently speak of aortic valve insufficiency; presystolic murmur at the apex practically makes it possible to diagnose stenosis of the left atrioventricular orifice. Unlike diastolic noise, systolic has less important diagnostic value. So, for example, when listening to a systolic murmur at the apex, it can be explained by organic or muscle failure, as well as functional changes. Noises are heard in the classical places for determining tones, as well as at some distance from them, along the path of blood flow. The murmur of aortic valve insufficiency is conducted to the ventricle, to the left and downward, it is better heard along the left edge of the sternum at the level of the III costal cartilage (64). With stenosis of the aortic mouth, the noise passes into carotid artery, into the jugular fossa. In rheumatic endocarditis, in the initial stages of damage to the aortic valves, the noise is determined at the left edge of the sternum in the third or fourth intercostal space. With mitral valve insufficiency, the noise is carried up to the second intercostal space or to the left to the armpit. Presystolic murmur in mitral stenosis is determined at the apex of the heart, occupying a very small space. The strength of the noise depends on the speed of blood flow created by the heart itself, and on the narrowness of the hole. In some cases - with a very large or very small narrowing of the hole - the noises become very weak and inaudible. In diagnostic terms, the variability of noise intensity over time is of value. So, with endocarditis, new deposits or destruction of the valve can increase the noise, which is a bad sign. In other cases, the increase in noise depends on the increase in the strength of the heart muscle and is an indicator of improvement. Clinical and laboratory data allow us to understand the change in noise over time. By their nature, the noises are soft, blowing and rough, sawing, scraping, etc. Gross, as a rule, are organic noises. Soft, blowing - both organic and functional. The height and nature of the noise is rarely of practical importance.

Systolic murmur:

This is a noise that is heard after the 1st tone and appears due to the fact that during the contraction of the ventricles the blood is expelled from it through the narrowed opening. The noise occurs simultaneously with the 1st tone or shortly after it. With a sharp weakening of the 1st tone or in those cases when a rough, as it were, systolic murmur overlaps the 1st tone in its identification, the sign that the murmur coincides, like the 1st tone, with the apex beat \ if it is palpable \ and the pulse on the carotid arteries helps.

Most of the systolic murmurs are heard over the heart, especially over the pulmonary artery and aorta, and are the result of anemia of tachycardia \ with hypothyroidism. murmurs from pathological ones. The first ones are usually softer and are heard at the base of the heart and partly over the entire surface of the heart. Systolic murmur at the apex, conducted in the direction of the left axillary cavity and in the direction of the place where the aortic valves are auscultated - a sign of blood regurgitation through the left venous opening - the cause of insufficiency 2x leaflet valve, which can be caused by endocarditis, expansion of the left, cardiosclerosis, and aortic insufficiency. With true insufficiency of the 2nd leaflet valve, there is a weakening of the 1st tone systolic murmur, expansion of the left and right displacement of the apex beat down and outward and an increased 2nd sound over the pulmonary artery. More often, the systolic murmur is blowing loud on the begins with a weakened 1st tone and continues throughout the entire systole.

Noise heard to the left of the sternum in 3-4 intercostal spaces occurs with a heart attack and is a sign of septal perforation. Similar noise is observed with a congenital defect of the interventricular septum / erysipelas

Noise heard above the aorta and conducted in the direction of the neck shoulder of the occiput is characteristic of aortic stenosis. If significant stenosis, the 2nd tone may be absent or heard but it will be delayed. This lesion is always characterized by a pause between the end of the noise and the 2nd tone.

Coarctation of the aorta also causes a systolic/ejection murmur, but in late systole it is best heard on the back of the shoulder blades.

The systolic murmur may also be caused by pulmonary stenosis, in which case it is auscultated until the 2nd tone appears.

When the pancreas is overloaded, relative stenosis of the pulmonary artery occurs and it is auscultated in the 3rd intercostal space along the left edge of the sternum. Systolic murmur over the place of auscultation of the pulmonary artery is not a pathological sign, especially at a young age.

Systolic murmur along the right edge of the sternum may occur with insufficiency of the 3-fold valve. In case of its insufficiency, a positive venous pulse and a large pulsating liver are observed.

Tetradus of fallot is characterized by an intense systolic murmur heard over almost the entire surface of the heart, while the 2nd tone is very weakened or inaudible. This disease is congenital, its symptoms are cyanosis of the heart in the form of a wooden shoe \ clog \ erythrocytosis tympanic fingers developmental delay.

A systolic murmur of a musical nature occurs with sclerotic narrowing of the aortic orifice or with sclerotic changes in the mitral valve. Less commonly with a dissecting aortic aneurysm. The systolic murmur heard above the vessels is characteristic of an aortic aneurysm.

Acquired and birth defects hearts. Clinico-physical landmarks.

Acquired vices:

Mitral stenosis (m/u LV and LA) foramen: signs of pulmonary hypertension (up to pulmonary edema), right ventricular hypertrophy. Palpation - "cat's purr" (diastolic trembling), pulse on the left hand > pulse on the right. Auscultatory - quail rhythm (clapping 1st tone + click of the opening of the mitral valve + amplified 2nd tone), diastolic murmur at the point of the mitral valve, diastolic murmur at the point of the pulmonary artery.

Mitral valve insufficiency: signs of pulmonary hypertension, right ventricular hypertrophy. Auscultatory - weakened 1st tone, possible splitting of the 2nd, pathological 3rd tone, accent of the 2nd tone over the pulmonary trunk. Systolic murmur at apex.

Aortic stenosis: signs of hypertrophy of the left ventricle, left atrium, stagnation in the small circle (orthopnea, pulmonary edema, cardiac asthma). Auscultatory - weakened 2nd tone, splitting of the 2nd tone, "scraping" systolic murmur, click of the jet hitting the aortic wall.

Aortic valve insufficiency: physically - "dance of the carotid", St. de Mussy, capillary pulse, pulsation of the pupils and soft palate. Auscultatory - cannon tone (Traube) on the femoral artery, systolic murmur on the femoral artery, weakened or enhanced (maybe this way and that) 1st tone, diastolic murmur, mid-diastolic (presystolic) Austin-Flint murmur.

Birth defects:

VSD: 3 degrees: 4-5mm, 6-20mm, >20mm. Signs - developmental delay, stagnation in the ICC, frequent infections of the lungs, shortness of breath, enlarged liver, edema (usually of the limbs), orthopnea. Auscultatory - systolic murmur to the left of the sternum.

ASD: blood flow is always left to right. Auscultatory - splitting of the 2nd tone, systolic murmur in the pulmonary artery.

Botallov duct(m / a pulmonary artery and aorta): systole-diastolic "machine" noise.

Coartation of the aorta: hypertension, better development torso, blood pressure on the legs<АД на руках.

14. Broncho-obstructive syndrome is a collective term that includes a symptom complex of specifically outlined clinical manifestations of a violation of bronchial patency, which is based on a narrowing or occlusion of the airways.

From a practical point of view, depending on the etiological pathogenetic mechanisms, 4 variants of biofeedback are distinguished:

infectious developing as a result of viral and (or) bacterial inflammation in the bronchi and bronchioles;

allergic developing as a result of spasm and allergic inflammation of bronchial structures with a predominance of spastic phenomena over inflammatory ones;

obstructive observed during aspiration of a foreign body, with compression of the bronchi;

hemodynamic that occurs with heart failure of the left ventricular type.

In the course of biofeedback, it can be acute, protracted, recurrent and continuously recurrent (in the case of bronchopulmonary dysplasia, obliterating bronchiolitis, etc.).

According to the severity of obstruction, one can distinguish: mild obstruction (grade 1), moderate (grade 2), severe (grade 3).

In the genesis of bronchial obstruction in acute respiratory infections, mucosal edema, inflammatory infiltration, and hypersecretion are of primary importance. To a lesser extent, the mechanism of bronchospasm is expressed, which is due either to increased sensitivity of the interoreceptors of the cholinergic link of the ANS (primary or secondary hyperactivity), or blockade of B2-adrenergic receptors. Among the viruses that most often cause obstructive syndrome include the RS virus (about 50%), then the parainfluenza virus, mycoplasma pneumoniae, less often influenza viruses and adenovirus.

Most often BOS of infectious origin occurs in obstructive bronchitis and bronchiolitis.

Obstruction in allergic diseases is mainly due to spasm of small bronchi and bronchioles (tonic type) and, to a lesser extent, hypersecretion and edema. Significant difficulties are presented by the differential diagnosis between asthmatic bronchitis and obstructive bronchitis of infectious origin. In favor of asthmatic bronchitis is evidenced by heredity aggravated by allergic diseases, aggravated own allergic history (skin manifestations of allergy, “small” forms of respiratory allergy - allergic rhinitis, laryngitis, tracheitis, bronchitis, intestinal allergosis), the presence of a connection between the onset of the disease with a causally significant allergen and the absence of such a connection with the infection, a positive effect of elimination, recurrence of seizures, their uniformity. The wedge picture is characterized by the following signs: absence of intoxication phenomena, remote wheezing or “sawing” nature of breathing, expiratory dyspnea with the participation of auxiliary muscles, predominantly dry wheezing wheezing and a few wet wheezing, the number of which increases after stopping bronchospasm, is heard in the lungs. The attack occurs, as a rule, on the first day of the disease and is eliminated in a short time: within one to three days. Asthma bronchitis is also favored by a positive effect on the administration of bronchospasmolytics (adrenaline, eufillin, berotek, etc.). A cardinal symptom of bronchial asthma is an asthma attack.