Download The ECG hypertrophy of the right atrium and the right ventricle, the

The differential diagnosis of
the noise in the heart.
Professor A.G. Gadaev
Normally, a healthy person Auscultation auscultated 2
tones:
 The first tone - the tone (systolic) beginning
ventricular systole, in its formation participate
tone closure of the mitral and tricuspid valves,
the tone of the opening of the valves of the aorta
and pulmonary artery, and participates in it a
muscular component of the ventricles;
 The second tone (diastolic) - the tone of the
closing the aortic valve and the pulmonary artery,
as well as the tone of the opening of the mitral
and tricuspid valves.
These two colors are different from each other as
follows: ?? ● The first tone is longer than the
second? ● Compared to the first tone of the second
less sonority? ● First tone coincides with the apical
impulse pulsing arteries and blood vessels of the
neck? ● The first tone is listened better in the
cardiac apex and the second tone at its base. ? ●
After the first short tones auscultated systolic and
diastolic long after the second pause.
Auscultation of the heart consists of the topographic location of
the auscultation points: 1. The point of listening to the mitral
valve to the left in the V intercostal space on 1-1.5 cm medially
from the mid-clavicular line apex of the heart.? 2. Point BotkinErba (auscultation the aortic valve) in the IV intercostal space left
parasternal over the front line.? 3. The aorta - in II intercostal
space on the right in front paraster-tional line 4?. Pulmonary
artery - in II-III intercostal space left parasternal line at the front
4?. Tricuspid valve- at the base of the xiphoid process.? 5. Status
of the heart walls -.? In the IV intercostal space in the chest
Sometimes in healthy people and adolescents on the heart and its
base verhuschke auscultated 3 intermittent tone.
DETERMINATION OF NOISE HAS HEART
important differential diagnostic value, as their presence often
confirms availability heart disease Depending on the time of
occurrence of noise, they are divided into systolic and diastolic,
the latter is divided into: systolic (appears before systole),
mezodiastolichesky (appears before diastole ) and protodiastolic
(occurs after diastole).
Depending on the type of heart disease and the presence
of certain organic noise may change the hearts of the
border. ? The ECG marked increase in wave amplitude
P (spiky P) for right ventricular hypertrophy in II-III
standard lead, with left ventricular hypertrophy increase
in P wave amplitude in the I-II standard lead, increase
wave amplitude R in III, aVF with right ventricular
hypertrophy in V1-2 increase in the amplitude of the R
wave in I, aVL, V5-6 deepening of the S-wave, while
left ventricular hypertrophy in I, aVL, V5-6 increase in
the amplitude of the R in III, aVF, V1-2 deepening wave
S.
Radiographic picture of the left and right borders of the
heart in direct projection
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Right heart border:
A top hollow Vienna; Bright atrium.
The left heart border:
A bulging of the aortic
arch;
B-pulmonary artery;
B left atrium;
T- left ventricle
addition to the above organic noise may occur
anatomical? Changes in valvular heart cavities and in
which noise can be detected parakardialnae. ?
Functional noises often systolic and well listened to the
apex of the heart, they are fickle and short on character.
They are not transmitted to the neck vessels, weaken or
disappear during exercise. They are associated with
degenerative lesions of the myocardium. Some teens
systolic murmur auscultated in the period of intensive
growth.
In the dry pericarditis usually auscultated rough
systolic murmur noise pericardial friction in
systole and well heard when pressing
stethoscope on the chest, he was not transferred
to the vessels of the neck and hair resembles the
noise of friction. Pericarditis is a clinical
symptom or complication of any disease. The
correct diagnosis in addition to the presence of
noise and basic clinical data of great importance
ECG diagnostics.
● When a systolic murmur in a patient, if there is no
history of symptoms and objective data of
rheumatism, as well as signs of left ventricular
hypertrophy on electrocardiogram and
echocardiogram, then soft and nezvuchnye timbre
noise is functional. ? ● If with systolic murmur
patient has palpitations, shortness of breath and
shortness of breath on exertion or at rest, he
complains of a dull pain in the heart, objectively
seen from apical impulse lifts, amplified, shifted to
the left, it is the signs of mitral insufficiency .
At the same heart defects systolic murmur
gradually or rapidly growing, it can be soft or rough
and is held in the armpit. ? Thus, there is a
weakening of heart apex tone 1, tone 3 times
appearance and emphasis auscultated 2 tones to the
pulmonary artery. ? The ECG: signs of left
ventricular hypertrophy and left atrial overload Xray diffraction:.? Signs of hypertrophy of the left
atrium and the left ventricle, with the progression of
the disease expansion of the right ventricle to the
stagnation in the lungs and a decrease in the aortic
arch.
The presence of diastolic heart noise on top of a sign of mitral
stenosis. ? Auscultation auscultated at the top and the diastolic
presystolic noise, clapping I tone, with the noise of opening of
the mitral valve, and forked II tone with emphasis on
pulmonary artery. ? The ECG: signs GPZH and left atrium
with symptoms of atrial fibrillation. ? X-ray diffraction is
characterized by the expansion of the left atrium and the right
ventricle, contrast esophagus deflected in an arc of small
radius. ? On echocardiography: is determined by the degree of
narrowing of the mitral orifice (normally 4-6 cm2). The
restriction to 0.5-1.5 cm2 is an indication for emergency heart
surgeon consultation.
If the patient is auscultated systolic and diastolic
murmur at the same time, it indicates the
presence of him as mitral regurgitation or
stenosis. ? If a child is listened to the apex of the
heart and diastolic murmur in II-III intercostal
space left from sternum systolic murmur, then
this indicates the presence of congenital (CHD),
mitral stenosis and atrial defect dammed
(Lyutenbashe syndrome).
If at the point Botkin-Erba auscultated rough and enhanced
systolic murmur, you can think about the presence of CHD,
mainly of ventricular septal defect, tetralogy of Fallot, or
pentad. ? If there is a sonorous and rough pansystolic noise
emphasis II tone of the aorta, shortness of breath on
exertion, shortness of breath, fatigue, pain in the heart and
history of recurrent pneumonia, and when viewed from the
detection of expansion right heart border with systolic
trembling and heart hump can think of ventricular septal
defect.? The ECG and X-ray determined by the signs of
hypertrophy of the left and right ventricle, and
atroventrikulyarnaya blockade.
Depending on the location of the defect defects are
divided into several types: defect in the bottom of the
IVS; upper and lower defect (Tolochinova disease Roger); defect in the top of the right-hand position
of the aorta (Eisenmenger complex). After the GP
echocardiography can detect the presence of evil.
Such patients are sent for consultation to the heart
surgeon and indications are assigned to cardiac
catheterization and other studies in the specialized
agencies. Treatment - surgery
Signs notebook or pentad Fallot is the presence of:
systolic murmur at Botkin-Erb and in II - III intercostal
space left of the sternum, I gain tone at the top, the
weakening II tone on the pulmonary artery, diffuse
cyanosis, and asthma attacks. Tetralogy of Fallot is
characterized by pulmonary artery stenosis, VSD, righthand position of the aortic arch, a sharp right ventricular
hypertrophy, when pentad Fallot + ASD.
Most often they are in a position embracing his knees
(on the "squatting"), they have a shortness of breath at
the slightest exertion, attacks of breathlessness and
cyanosis .. Objective: the lag in physical development,
diffuse cyanosis, fingers as drumsticks, and having a
heart hump offset borders of the heart to the right. ? The
ECG hypertrophy of the right atrium and right ventricle,
signs of overload of the right atrium, the configuration
of X-ray aortalnayaya heart, increase the right ventricle
and the pulmonary pattern impoverishment. The
diagnosis is confirmed by echocardiography.
The main symptoms of aortic insufficiency diastolic murmur at the point Botkin -Erba and in II
intercostal space to the right of the sternum
(sometimes presystolic noise Flint), here at the aorta
due to the relative aortic stenosis extra systolic
murmur at the apex as a result of the relative failure
of the mitral valve decreasing systolic noise
attenuation I tone at the top, II of tone of the aorta
and the presence of dual tone Duroziez on large
vessels.
Ripple large vessels, capillary pulse, raises the apical
impulse, shifting borders of the heart down and left.
Systolic blood pressure is normal, while the diastolic
low, there is a correspondingly high pulse pressure. The
ECG left ventricular hypertrophy and overload, aortic
configuration of the X-ray of the heart, increased left
heart, increasing the ascending aorta. Fluoroscopically
visible deep and rapid pulsation of the left ventricle and
the aorta. The diagnosis is confirmed by
echocardiography.
If along with the systolic and diastolic noise
at Botkin-Erb, wired rough systolic murmur
in the aorta, carotid arteries, in the
interscapular region, neck cavities, it is
possible to think about the insufficiency of
aortic valve with a narrowing of the aorta.
In the presence of the patient's pulmonary artery stenosis in
II intercostal space left of the sternum is listened rough
systolic murmur. ? The ECG will be signs of right
ventricular hypertrophy and blockade of CBH. ? X-ray
diffraction spot observed changes in arterial narrowing. If
the constriction is located near the pulmonary valve, there is
a sharp increase in the right ventricle, pulmonary artery
trunk extension, and its bulging with a sharp narrowing of
the smaller of its branches, as well as the depletion of the
lung pattern. If the constriction is located under the valves of
the pulmonary artery, observed lengthening of the left
pulmonary artery, at the location of the narrowing of the
entire length of the pulmonary trunk - increased pulmonary
pattern, and the left on the contrary depletion pattern.
If a patient with systolic murmur marked difference in blood
pressure on the upper and lower limbs can be assumed
coarctation of the aorta. Sometimes the noise is performed
on the neck vessels, and interscapular region. II tone of the
aorta strengthened. An objective examination, palpation,
percussion there is a difference in the pulse of the upper and
lower torso, seen pulsating collaterals on the ribs, sternum
and armpit, as well as above the presence of blood pressure
on the upper limbs and lower absence. On EKGpriznaki left
ventricular hypertrophy, the increase in X-ray left heart
border expansion of the aorta. In the outpatient setting is
needed to confirm the diagnosis echo-Doppler.
If at the same blood pressure in the arms and legs, lower
systolic noise on the ECG, there are signs of right
ventricular hypertrophy and CBH blockade, it is
possible to suspect an atrial septal defect or anomalous
pulmonary veins. In atrial septal defect blood from the
left side to the right and enters the cause of right
ventricular hypertrophy, and stagnation in the
pulmonary circulation. In the anomalous pulmonary
venous drainage also auscultated systolic murmur over
the pulmonary artery. This defect is usually
accompanied by an atrial septal defect.
At insufficiency of the valves of the pulmonary artery
diastolic murmur auscultated in II -III intercostal space
at the left sternal border. Auscultation diastolic murmur
is heard along with the emphasis II tone on the
pulmonary artery. An objective examination noteworthy
pronounced cyanosis, in the presence of II -III
intercostal space on the left and behind the xiphoid
systolic pulsation. The ECG signs of right ventricular
hypertrophy and overload, increase in X-ray of the right
ventricle, pulmonary artery trunk extension, its bulging
and strong pulsation.
When listening to the left in the II -III intercostal
systolic Malvinas diastolic noise is determined by the
signs of the UPU - patent ductus arteriosus (defect
aorto-pulmonary artery). The ECG signs of left
ventricular hypertrophy, mitral configuration of Xray of the heart, an increase of the left and right
ventricle, left atrial enlargement, aortic widening,
lengthening of the left pulmonary artery, its bulging
and strong pulsation. Confirm the diagnosis of
echocardiography (Doppler). Surgical treatment
after aoartografii.
Availability epicenter systolic and diastolic noise at the
base of the xiphoid process, or a combination thereof
directs the presence of openings between the right
atrium and right ventricle. If this projection auscultated
systolic murmur, then we can think about the tricuspid
valve. This defect in itself is rare, and flows by type of
complicated mitral insufficiency. Sometimes the noise is
listened epicenter of the right or left in the IV-V
intercostal space.
The ECG hypertrophy of the right atrium and
the right ventricle, the blockade right bundle
Hiss beam, X-ray mitral heart configuration
(often it happens as a result of mitral
stenosis), an increase in the right atrium and
right ventricle, swelling of the jugular veins.
Using echocardiography revealed
hemodynamic changes, and with the heart the
size of the degree of NK.
Diastolic murmur at the base of the xiphoid process
is listened when the tricuspid valve stenosis. This
creates an obstacle the flow of blood through the
narrowed opening between the right atrium and
right ventricle, resulting in increased pressure in the
right atrium and develop signs of venous stasis in the
systemic circulation. Objectively, there is swelling of
the neck veins pulsing them during diastole
(shishinқirashi), enlargement of the liver, shifting
borders of the heart to the right, ascites, edema of
the body, the diastolic tremor at the xiphoid process.
Sometimes auscultated weakening II tone on the
pulmonary artery. The ECG marked hypertrophy
of the right atrium (P-pulmonale), confirmed by
X-ray diffraction. Keep in mind that
malformations of the mitral and aortic valves are
found not only in stenosis of the tricuspid valve,
and other vices. Using echocardiography can
detect the prevalence of this or any other
blemish, and establish the degree of narrowing of
the tricuspid orifice.
Askultativno in the presence of systolic and
diastolic noise at the base of the xiphoid
process and the narrowing of the opening
between the right atrium and ventricle can be
thought of failure 3 flapper valve. There is
also an objective examination, the ECG,
echocardiography and radiological signs are
determined by the two vices
If there is noise in the heart and conduct physical examination
continue to assign the patient:? ♦ ECG, chest radiography and
echocardiography? ♦ If there is acquired heart disease indications for
treatment in a hospital. ? ♦ If there are signs of an active process or
NC assignment of measures to etiological, pathogenetic Islands
symptomatic treatment ;? ♦ Regardless of the type of heart disease
treatment of such patients is carried out in specialized surgical wards
and hospitals. ? ♦ Remember that timely surgical interventions can
save the patient's life.
Examples diagnosis of congenital and acquired heart diseases :? ♦
Acute rheumatic fever, carditis primary, active phase, activity II.
Insufficiency of the mitral valve.? ♦ Acute rheumatic fever,
carditis primary, active phase, activity II. Insufficiency of the
mitral valve and narrowing aortic NC II FC B. III.? ♦ UPU: the
triad of Fallot - atrial septal defect, pulmonary stenosis, right
ventricular hypertrophy.? ♦ UPU: patent ductus arteriosus.
♦ Rheumatism active stage. Activity I. Recurrent
rheumatic heart disease. Insufficiency of the mitral
valve. Revmokardioskleroz with arrhythmia. GEN I
class on lawn.? ♦ Chron. rheumatic fever. Return
rheumatic heart disease. Insufficiency of the mitral
valve. Revmokardioskleroz with arrhythmia. GEN I
class on lawn.