Lecture topic: «differential diagnosis of heart noise. Tactics of general practitioner»

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4 stages final (10 mines)

4.1. Will assign questions: 1. Enumerate most often meeting diseases, being accompanied noise in the field of heart 2. Tell modern categorization a vice heart 3. Tell the main key moments of the clinical current different type innate vice. 4.Name cardinal principles of the treatment, preventive maintenances sick with vice heart 4.2. Gives task for independent work student: diseases, being accompanied functional noise in heart

4.1. Answer questions 4.2. Listen, write

Determination of heart murmur is an important differential diagnostic value, as their presence often confirms the presence of heart disease or other organic heart disease.
Heart defects (VITIA CORDIS) are morphological changes of valvular, leading to disruption of its function and hemodynamics, as well as congenital malformations of the heart and great vessels.
Birth defects are formed during fetal development and in most cases are diagnosed in childhood. Congenital heart disease is often associated with other developmental defects.
In infective endocarditis, atherosclerosis, syphilis predominantly affects the aortic valve. Isolated aortic valve defects are more common in men. Aortic stenosis can develop in people with abnormal structure aortic valve (bicuspid valve). Such a structure of the aortic valve abnormality, according to the echo cardiography and autopsies, observed in 10-15% of people.
The basis of clinical diagnosis of heart diseases is still today remains as a common clinical examination of the patient. Differential diagnosis of congenital and acquired heart defects often help to carry out medical history information. It is especially important to ask the patient to postpone attacks of rheumatism in childhood and adolescence. Patients with congenital heart disease, in some cases, left behind in physical development, and there are frequent pneumonia, bronchitis in a history of many of them. However, a number of patients with some mild and severe congenital heart defects survive to middle age, and their physical development is not affected.
Useful information for the diagnosis of heart diseases can be obtained by visual inspection of patients. Percussion reveals an increase in the size of the heart, especially when the dilation of his cavities. This method is difficult to determine the initial hypertrophy of the heart.
An important method for diagnosis of heart diseases is auscultation. In order to get much information, it is necessary to create conditions of increased blood flow through the affected valve. This is achieved through exercise and medication slowing of heart rate. The place of the best hearing noises during Mitral Valve is the tip of the heart, for the evils of the tricuspid valve - the lower edge of the body of the sternum, with the evils of the aortic valve - the second or third intercostal space on the right to the left of the sternum. In Mitral Valve, noise is carried in the left armpit, with aortic stenosis-on vessels of the neck.
Hypertrophy of the atrial and ventricular arrhythmias can be detected by an electrocardiogram.
In X-rays of the heart in three projections, thereare more accurately determined the increase of individual cavities of the heart, a condition in the pulmonary circulation.
Valuable diagnostic information can be obtained during echocardiography. It measures not only anatomical and myocardial contractility, but also the morphology, function of the individual structures of the heart. Today, echocardiography, performed on modern machines and skilled diagnostician, is the most informative method of the study of the heart. This method of diagnosis of heart defects has made available previously inaccessible.
Invasive diagnosis of heart diseases (sounding right and left heart with pressure gauge, blood gas study of the cavities of the heart, contrast radiographic techniques) in the CIS are used only in hospitals and cardiac surgery under strict indications.
In the diagnosis of heart diseases, a clinician is required a good knowledge of semiotics, the correct analysis of subjective symptoms and objective data, logical and comprehensive evaluation of the results of clinical and para-clinical research. It is little to establish the nature valvular lesions. It is important to interpret the nature of the disease process that led to the formation of defect, to assess its activity and phase. In case of disorder inblood circulatory, the cause should be found: an overload of the myocardium due to defect, heart rhythm disturbances or exacerbation of the basic pathological process. It should be remembered that the presence of modern instrumental methods of diagnosis of heart diseases can never replace clinical thinking of the doctor.
Often, in auscultation of the heart in healthy subjects, there are noises that are not organic. However, in such situations, there may occur problems in the differential diagnosis with heart defects. Physicians need to remember the basic cause of the functional (non-organic), heart murmur, and their distinctive features from the noise of organic origin.
Functional (inorganic, innocent, random) noise. There are many causes and mechanisms of such noise in each case. Usually functional noises are heard over the top of the heart, at Botkin or the pulmonary artery. They are found in almost every second child and almost a third of young adults. Noise on the base of the heart in children and young adults, occurs because of the presence of contraction of pulmonary artery. In children, physiological prevalence of clearance of the right ventricular cavity on diameter of the pulmonary artery remains.
Under the guise of aortic stenosis, congenital heart disease in young people are often hidden hyperkinetic cardiac syndrome - a kind of functional (disregulatory) cardiovascular disorders. This functional impairment most often found in young male conscripts. The basis of the syndrome is increased activity of p-adrenoreceptor infarction, which leads to cardiac hypertrophy with an increase in the volume and velocity of expulsion of blood and a compensatory decrease in total peripheral resistance. In such youths, there are auscultated systolic murmur over the aorta (from low to very noticeable), which is often carried out on the carotid arteries, particularly the right. At PCG, it has an asymmetric shape of the diamond, with a peak in the first half of systole. This is high-speed noise exile. Aortic stenosis contradict the expressive features of hyperthyroidism heart: increased carotid pulse, rapid pulse, blood pressure pulse raise.
Systolic murmur on aboive of the hearts of young people may occur due to changes in the tone of papillary muscles, to which aided lability of the autonomic nervous system. In the formation of functional noise, the presence of additional (abnormal, false, "blind") tendinous chords that attach to the mitral valve and the papillary muscles can make a difference. One frequent cause of functional systolic murmur is transient systolic roller protruding into the lumen of the left ventricular outflow chamber as a result of systolic thickening or bulging subaortic ventricular septal area. In other words, a common cause of systolic murmur - deformation of the left ventricular cavity contours, especially the outflow tract.
Inorganic noise may be due to an acceleration of blood flow in anemia, thyrotoxicosis while maintaining ventricular contractile function. Systolic murmur is often auscultated with myocarditis, myocardial different origins cardiosclerosis.
Functional noise is usually little intense tone of gentle blowing; they are very variable in intensity and duration with a change in body position. They are not held in the vessels of the neck in the direction of blood flow, or in the armpit. Such noise PCG has a small amplitude and duration, often located in the middle third of the systolic interval (midsystolic murmur). Form of noise varies from one cardiac cycle to the next, depending on the position of the body and respiratory phases. The amplitude of the tone I, with the exception of cases of myocarditis or cardiosclerosis, does not change.
During the inspection of some of the patients, there can be found PMK symptoms of asthenia, high arc of the upper palate, sunken chest and scoliosis.In auscultation, there is auscultated late systolic murmur and an additional tone (click) in mid-systole. These changes are well defined on the FCG. ECG is identified in 1/3 of the patients. They mainly deal with T-wave inversion in leads II, III, and aVF. There is a possibility of prolongation of Q-T, the presence of ventricular premature beats and other arrhythmias. A key role in the diagnosis of PMC is echocardiography.
Acquired heart disease.Mitral stenosis (narrowing of the left atrioventricular opening, stenosis mltralis, stenosis ostiiatrioventricularissinistra). In humans, the area of ​​the left atrioventricular opening varies in the range of 4-6 cm2. In mitral stenosis, there occurs a narrowing of the orifice. Due to the barrier to blood flow from the left atrium into the left ventricle, the blood pressure in the left atrium increases from 5 to 20-25 mm Hg. The systole of the left atrium gets long. Retrograde increases the pressure in the pulmonary veins and capillaries. Reflex may taper and arterioles (reflex Kitaev), which leads to increased pressure in the pulmonary artery. Functional spasm, and then the anatomical changes of vessels of the pulmonary circulation are creating the so-called second barrier to blood flow. The inclusion of the second barrier increases the load on the right ventricle. Hypertrophy and subsequently decompensation to the systemic circulation gets developed. In compensation stages, patients do not have complaints. As it progresses, there are vice dyspnea on exertion and later, cough, sometimes coughing up blood, palpitations, weakness, fatigue. Rarely, thereoccur aching or stabbing pain in the heart, not associated with physical activity. There occurs Athos (symptom Ortner) due to the increased pressure of the left atrium to the recurrent nerve. During the inspection may reveal cyanosis of the lips, nose, cheeks blush with slightly cyanotic hue (fades mitralis).
The apical impulse is weakened. Over the apex of the heart in patients with severe mitral stenosis, there is determined diastolic tremor ("cat purring"). Hypertrophy of the right ventricle, there appears pulsation in the epigastrium, worse on inspiration. Pulse and blood pressure do not significantly change. There is a tendency to reduce the pulse pressure. During percussion shifting boundaries, there can be determined the relative cardiac dullness up (left atrium) and right (right atrium). Over the top of the heart, there is reinforced (clapping) / ton. Immediately after / / tone, can be listened click (tone) opening of the mitral valve. Popping sound I, II tone, with the tone of mitral valve opening at the apex of the heart, creates three-term "rhythm of quail." The pulmonary artery // tone reinforced, often forked. Important diagnostic feature of mitral stenosis is a diastolic murmur at the apex of the heart, usually with presystolic gain. The timbre of sound rude, it's better auscultated after physical activity in the left lateral position with a single breath on exhalation phase. Without physical activity, noise cannotbe listened. Presystolic noise usually disappears with the development of atrial fibrillation and reduced contractility of atrial.
Lack of melody mitral stenosis may occur in patients with severe fibrosis and calcification of the mitral valve with limited mobility. Over the top of the heart, in most patients there is systolic murmur, which comes with manifestation simultaneously available mitral insufficiency due to calcification of the valves or valves. In the face of considerable pulmonary hypertension on the pulmonary artery, the diastolic murmur of Stil is auscultated - the result of the relative lack of semilunar valves.
On ECG - signs of hypertrophy of the left atrium (ancipitous P wave in leads I, aVL with a duration of more than OD) and the right ventricle, often right bundle branch block, arrhythmia and atrial fibrillation. In X-rays, there is observed smoothing waist heart by hypertrophy of the left atrium. Contrast esophagus with enlarged left atrium moves to the right and back on the arc of small radius (up to 6 cm).
Due to a significant hypertrophy and dilatation of the right ventricle, there can be observed displacement of the heart to the left. To the important radiological signs of mitral stenosis belongs venous pulmonary hypertension whichappears with the extension roots with blurred boundaries. In pulmonary arterial hypertension, shadow roots expandwith clear margins. PCG is detected on the increase of the amplitude I pitch, lengthening interval Q-I tone up to 0.08-0.12, increased tone or II on the pulmonary artery bifurcation, flip through the opening of the mitral valve 0.06-0.12 seconds after I- tone (range II-OS). With the progression of stenosis II-OS interval is shortened. At PCG, there is recorded diastolic murmur, which begins immediately after the opening of the mitral valve tone or after a certain period of time after the tone. There is often typical presystolic noise. PCG value increases with atrial fibrillation.
Mitral stenosis can lead to complications: hemoptysis, pulmonary edema, fibrilloflutter, thromboembolism in the system of the systemic circulation. There is a possibility of thromboembolism and pulmonary vessels. Source of emboli can be varicose veins of the lower extremities.
On the severity, there are few degrees of mitral stenosis.I malformation degree (slightly marked):heard the short presystolic noise, there is a slight increase in the left atrium. Area of ​​the mitral orifice, by echocardiography, exceeds 3.0 sm2.Porok II degree (moderate), heardmoderate diastolic murmur, there is a clear increase in the left atrium. Area of ​​the mitral orifice is 3,0-2,0 cm 2. Vice level III (severe), heardthe entire diastolic murmur, followed by "cat purring", there are clear signs of right ventricular hypertrophy. Mitral area is less than 2.0 cm2. If the area of ​​the mitral orifice is less than 1 cm2, then there is a sharp mitral stenosis. Pronounced and sharp mitral stenosis should be considered as an indication for surgical treatment of vice, regardless of the stage of heart failure. Pronounced and sharp mitral stenosis inevitably lead to heart failure and complications, such as atrial fibrillation, pulmonary embolism, etc. An important role is played by an objective assessment of the primary outcome of rheumatic fever. Emerging signs of mitral stenosis are detected not earlier than 2-3 months from the beginning of the disease, and the period of complete formation of mitral stenosis is 6-12 months. Clinical and instrumental signs of valvulit of mitral valve proceeding with the formation of the mitral stenosis are: progressing "smartness" with okay mitral valve in diastole with simultaneous registration for PCG intermittent tone opening of the mitral valve and middiastolic murmur, the appearance of a dome diastolicbending forward mitral valve, its marginal thickening (the most important feature!) transformation of the laminar to turbulent diastolic flow, according to Doppler echocardiography, and an increase in diastolic transmitral pressure gradient. In some patients, after the attack of rheumatism, all the signs of mitral valvulit may disappear completely. There will be left only residual changes of leaflets.
Failure of the mitral valve (mitral insufficiency, insufficient valvule mitralis) in isolation is rare (up to 5% of cases), often combined with mitral stenosis and aortic defects. It also occurs in relative mitral insufficiency. It may be due to diffuse myocardial lesion of the left ventricle and the expansion of its cavity or papillary muscle tone changes. Anatomical lesions of the mitral valve with a mitral regurgitation are not observed. Due to incomplete mitral valve closure, during systole, some part of blood is thrown back into the left atrium. The increased amount of blood flows into the left ventricle and that causes to gradually moderate hypertrophy and more distinct dilatation. Long time, defectis compensated with powerful left ventricle. The weakening of the contractile function of the left ventricle leads to stagnation in the lungs, right ventricular hypertrophy, and subsequently to the appearance of signs of decompensation in the systemic circulation. Clinical symptoms of mitral insufficiency occur only when mitral regurgitation is more than 15-20% of the stroke volume. In the state of compensation defect, patients feel themselves satisfactorily. In the future, there may occurdyspnea on exertion and palpitation. Rarely, cough may bother, also hemoptysis is rarely observed. There is a possibility of stabbing or aching pain in the heart. On physical examination, notable changes are not observed.
An important feature of the acoustic attenuation of mitral insufficiencyis weakening of tone at the top. Second tone of the pulmonary artery is enhanced or split. Often on the apex of the heart, there is III tone. The most characteristic feature of the defect is a systolic murmur, the intensity of which depends on the severity of valvular defect. Timbre noise is soft blowing. Noise is best auscultated at the apex of the heart with the patient on his left side. The more and longer systolic murmur, the severe mitral insufficiency is. On the ECG, there may be detected signs of hypertrophy of the left atrium and left ventricle. During the X-ray, there is determinedincrease of the left ventricle and left atrium. Contrast esophagus is deflected in an arc of large radius (more than 6 cm). In the lungs, there are expanding roots with indistinct outlines. On PCGamplitude / tone usually reduced, can be with extended interval QI tone, 0.12-0.18 seconds after Eaton there is recorded III ton. Systolic murmur begins immediately after the / tone, occupies most of the systole and it often gets decreasing character. In mitral insufficiency, there may also develop atrial fibrillation due to overload of the left atrium. There are three degrees of severity of mitral regurgitation: Flaw I degree: low intensity systolic murmur, unsharp increase in the left ventricle, a slight increase in the left atrium. Vice level II: systolic murmur of medium intensity, moderate tone III, a distinct increase in the left ventricle and the left atrium. Porok III degree: intense systolic murmur, merging with III tones, splitting II tone with increased pulmonary component, high amplitude tone III , a marked increase in the left heart. The signs of an emerging mitral valve after undergoing rheumatic fever include: the emergence of an intense systolic murmur at the apex of the heart, thickening of the anterior edge of mitral valve (with its dome-shaped curve in diastole in some patients), registration of gradually increasing turbulent systolic flow in the left atrium according to Doppler echocardiography.
Combined mitral heart disease manifests a combination of sound symptoms of stenosis and insufficiency. For the prevalence of mitral stenosis are most common: presystolic murmur at the apex of the heart, the increase of the left atrium and right ventricle, and less distinct systolic murmur. For vice dominated mitral regurgitation are the most typical: a systolic murmur at the apex, which takes place in the left armpit, increased left ventricular diastolic noise less pronounced. Atrial fibrillation is more common in the combination of mitral stenosis and significant mitral insufficiency. Elucidation of the dominant defect type is of particular importance in deciding on surgical treatment (mitral commissurotomy or mitral valve).
The narrowing of the mouth of the aorta (aortic stenosis, stenosis ostiiaortac).It is about 3 times more common in men. Because of the obstacles to blood flow, there develops severe left ventricular hypertrophy. The volume of the cavity is not increased. Severe hemodynamic disturbances occur in the mouth of the aortic narrowing by 75 percent or more. Defect for a long time can be compensated. In the lower left ventricular, there observed its dilatation. Only in severe stenosis, patients have complaints, caused by lack of adequate increase in cardiac output during exercise, fatigue, dizziness, fainting, squeezing pain in the heart and behind the sternum. The reason for the latter - reduced coronary blood flow due to the reduced volume of blood flow in the coronary arteries and myocardial hypertrophy. Dyspnea is characterized by later stages of vice. The appearance of attacks of breathlessness and wheezing indicates decreased myocardial contractility. On examination, there is pallor of the skin, which is associated with spasm of the blood vessels of the skin. This is a reaction to the low cardiac output. In cases of severe stenosis, there can be observed enhanced apical impulse. He moves into the sixth - seventh intercostal space to the anterior axillary line. On palpation on expiratory phase in the second intercostal space to the right of the sternum, there can be determined a systolic tremor. Signs of heart failure appear first in the small, and then the systemic circulation. In the compensated phase defect, there may be only a small left ventricular hypertrophy. In dilatation of the heart, its boundary substantially shifted to the left. Pulse small, slow growing. Systolic blood pressure decreased moderately. Often there is found bradycardia. First tone at the apex of the heart kept or weakened, it can be split. Second tone of the aorta often reduced or not detected due to stiffness of the aortic valve and reduces the pressure in the aorta. There is auscultated rough scraping or cutting vibrating systolic murmur. The epicenter of the noise - the second intercostal space to the right of the sternum or point Botkin. Noise is well performed on vessels of the neck, the jugular fossa and interscapularregion, it is best auscultated at expiratory phase in position on the right side, and sometimes conducted in the apex of the heart, which can serve the cause of erroneous diagnosis of mitral insufficiency. The intensity of the systolic murmur may be weak with severe emphysema, concomitant mitral stenosis, tachycardia, cardiac failure.
Radiologically, in compensation period, blemish left ventricular size changed slightly. With the development of decompensation, left ventricle extends, and then the left atrium. The heart gets a typical aortic configuration. In significant stenosis in the ECG signs of left ventricular hypertrophy, there may be registered full left bundle branch block. Atrial fibrillation is rare. In PCG, there are typical diamond holosystolic noise attenuation or extinction / / tone of the aorta, lower amplitude / tone at the top of the heart. Insubaortic (subvalvular) congenital stenosis, systolic murmur of high amplitude is recorded not only in the aorta, but also on the top. Amplitude / / tone of the aorta is preserved.
Feature of aortic stenosis - a long period of compensation. Heart failure occurs with cardiac asthma attacks. Decompensation period blemish usually lasts a relatively short time (1-2 years). Patients may also die from coronary disease, which develops as a result of inadequate blood flow in the coronary arteries due to reduced cardiac output, and discrepancies between the network of the coronary vessels and severe left ventricular hypertrophy.
There are 3 degrees of aortic stenosis:
Vice degree I: typical auscultatory pattern, combined with a slightly pronounced signs of increasing left ventricular wall thickness, increase of the left ventricle to 1.2 cm
Vice II degree, there are heard typical systolic murmur (rhomboid in shape to the PCG), which takes place on the vessels of the neck, clear cut / / tone, there are determined a distinct left ventricular hypertrophy, increased left ventricular wall thickness of 1.5 cm (by echocardiography).
Vice level III: marked subjective symptoms with left ventricular dilatation and marked changes in the ECG, left ventricular wall thickness is more than 1.5 cm.
Aortic valve (aortic insufficiency, insufficientia valvule aortae). About half cases, this defect occurs in conjunction with aortic stenosis. More common in men. Significant backflow of blood from the aorta into the left ventricle due to incomplete closure of the cusps during diastole, leads to expansion of the left ventricle. As a compensatory mechanism, systolic ejection of blood increases, which develops the left ventricular hypertrophy, not only expands. Peripheral vascular resistance in the periphery decreases. In significant expansion of the left ventricular cavity, there may be developed relative mitral insufficiency – mitralization of defect (vice). Under blemish compensation patients remain disabled for a long time and they rarely complain. It may be a feeling of enhanced pulsation of the carotid arteries, heart. Aortic stenosis also characterized by chest pain stenocardial type, worse on exertion, dizziness, and a tendency to faint at a quick change of position. Consciousness may be lostin the case of sudden movements. Shortness of breath occurs when the contractile function of the left ventricle reduces.
On examination, the patient is drawn with pale skin, throbbing large vessels, especially with the carotid arteries (the "carotid dance"). There can be detected rhythmic rocking of the head (symptom Musset), ripple precordial area. Sometimes"capillary pulse" is found on the nail bed - synchronized with the pulse intensity change color nail bed. Clearly, lift the apex beat, shifted to the left and down is visible. Configuration of aortic heart is peculiar.
For aortic insufficiency, rise in systolic and diastolic pressure (the amplitude of the pulse pressure increases) is typical. In some patients, the diastolic blood pressure is reduced to zero. Pulse gets high and fast, due to the rapid increase and decrease in blood pressure. Above the large vessels, there can be determined Duroziez double noise, less dual tone Traube. In auscultation of the heart, lower intensity of I tones, weakening or absence tone on aorte is revealed.Stage of easing last proportionally valve defect. There is a diastolic murmur, with its epicenter in the second intercostal space to the right of the sternum and the third - the fourth intercostal space on the left of the sternum. The noise of soft, blowing, varying duration occurs immediately after Eton, better auscultated on expiratory phase with the patient sitting with the trunk bent forward, usually decreases with tachycardia, heart failure, atrial precordial. In aortic insufficiency, there may be heard systolic murmur (accompanying noise) based on twist of blood flow due to deformation of the aortic valve. At the apex of the heart, there may occur systolic murmur associated with the development of relative mitral insufficiency, as well as meso-or presystolic noise (Flint) as a result of the relative mitral stenosis. In radiography, increased left ventricular enlargement of the ascending aorta is revealed. Talia heart pronounced. Even with "mitralization" of aortic defect, there is no significant hypertrophy of the left atrium. On the ECG, there are signs of left ventricular hypertrophy. Unlike aortic stenosis with aortic insufficiency with V.-V6, there may appear high pointy teeth T. On PCG, there determined attenuation / tone at the top, with the express vice can be tone. Second tone on the basis of the heart is weakened. There is recorded the diastolic murmur, which begins immediately after Eton and has a downward pattern. High-frequency noise, and therefore it is sometimes better heard with ear than recorded at PCG. In the second intercostal space to the right of the sternum, there can be detected accompanying systolic murmur. It usually does nothave a definite shape and does not take more than half of systole. In aortic insufficiency patients, long time stay on compensated state. However, in the case of signs of heart failure, their condition rapidly and progressively worsens. Heart failure occurs while on left ventricular type with attacks of cardiac asthma. In the future, congestion in the systemic circulation may develop. Aortic insufficiency may be in three degrees of severity: I Defect extent, heard short protodiastolic noise (usually at Botkin) is not normally detected in the PCG, a slight increase of the left ventricle. Vice II degree: diastolic noise is more intense, II tone on the basis of the heart is weakened, clearly marked signs of peripheral vascular, clearly reveals an increase in the left ventricle. Vice level III: continuous diastolic murmur in conjunction with the absence or sharp weakening tone, a significant increase in left ventricular pronounced peripheral vascular symptoms.
Valvulita signs of aortic valve are: appearance of bright echoes from the semilunar valves through their closure, registration of turbulent diastolic flow in the left ventricular outflow tract at Doppler echocardiography and simultaneous detection of protodiasto-crystal noise.

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