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MINISTRY OF HEALTH OF REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF TRAINING GENERAL PRACTITIONERS
WITH ENDOCRINOLOGY
LECTURE TOPIC:
«DIFFERENTIAL DIAGNOSIS OF HEART NOISE. TACTICS OF
GENERAL PRACTITIONER »
(for the students of medical-pedagogical faculty)
TASHKENT – 2013
MINISTRY OF HEALTH OF REPUBLIC OF UZBEKISTAN
TASHKENT MEDICAL ACADEMY
DEPARTMENT OF TRAINING GENERAL PRACTITIONERS
WITH ENDOCRINOLOGY
«APPROVED»
Dean of medical-pedagogical faculty,
professor Zufarov P.S.
___________________
____ _____________ 2013 y
LECTURE TOPIC:
«DIFFERENTIAL DIAGNOSIS OF HEART NOISE. TACTICS OF
GENERAL PRACTITIONER »
(for the students of medical-pedagogical faculty)
LECTURER: professor Gadaev A.G.
TASHKENT – 2013
TECHNOLOGY OF THE EDUCATION
Amount student
Time - 2 hours
Form of the scholastic
occupation
Plan to lectures
Lecture - a visualization
1. The anatomical construction valvely device a
heart.
2. The reasons, bring about appearance noise in
heart. Diseases, being accompanied noise in the
field of heart
3. Notion, determination organic and functional
noise
4. Reasons of the development innate and gained
vice heart
5. Examination sick with vice heart
6. Categorization innate vice heart
7. Clinical current, diagnostics separate type innate
vice heart
8. Principles of the treatment, preventive
maintenances and dispanserization sick with noise
in the field of heart
Purpose of the scholastic occupation acquaint the student with reasons,
mechanism of the development of the diseases, revealing noise in heart; teach to
distinguish the noises in heart under different disease; recall the categorization
innate vice heart; train the principle of the diagnostics, treatments, preventive
maintenances and dispanserization of the diseases, being accompanied noise in
heart, acquaint the particularity of the current, tactician squall under some innate
vice in heart
The рedagogical problems The results of the scholastic process:
the general practitioner must know:
1. Consolidate and deepen
knowledges a student about
1.
The аnatomical construction valve
disease, being accompanied
device a heart.
noise in the field of heart
2. The reasons, bring about appearance noise in
2. Teach student it is correct
heart. Diseases, being accompanied noise in the
to install diagnosis in
field of heart
accordance with modern
3. Notion, determination organic and functional
categorization
noise
3. Train student to skill to
4. Reasons of the development innate and gained
differentiate diseases, being vice heart
accompanied different noise 5. Methods of examination sick with vice heart,
in heart
clinical current vice heart
4. Acquaint student with
particularity of the current
some innate vice heart,
tactician squall
5. education of student to
conduct sick with noise in
the field of heart, treatment
and stage of the preventive
maintenance
Methods of teaching
Form of the education
6. Categorization innate vice heart
7. Principles of the treatment, preventive
maintenances and dispanserization of sick with
noise in the field of heart
8. Differential-diagnostic signs of the different
diseases, being accompanied noise in heart
Text to lectures, video film, questions, technology
"yes-no"
Lazer projector, visual material, special technical
equipment, show thematic sick, disks with record
different noise heart
Facilities of the education
Group
Conditions of the
undertaking the scholastic
process
Auditorium
PRODUCTION CHART TO LECTURES
Stages, time
Activity
Teacher
1. Tells about subject of the
1 stage
Introductory part lectures, her purposes and plan
(5 mines)
2 stages
Actualization
(increasing to
value ) of the
knowledges
2.1. In purpose of increasing to
actualizations (increasing to value)
of the knowledge’s student will
assign the questions:
1. What you know the noises in
Students
1.
Listen
2.1. Answer questions
(20 mines)
3 stages
Main part
(information) (55
mines)
nature?
2. Enumerate the diseases being
accompanied noise in the field of
heart?
3. Tell differences between
functional and organic noise
4. Tell categorization innate vice
heart
Conducts questioning
2.2 Study slide 1
2.2. Showing on screen, offers to
get acquainted the student with
purpose and problem to lectures.
Slide 1, 2
2.3. Study slide 2
3.1. Introduces the student with
3.1. Together analyse
lecture material, value of the
heard lecture material,
subject and principle of the shaping will assign questions
intelegent cultural personality, in
particular squall-teacher.
In purpose of increasing to
actualizations of the knowledges
conducts quick questioning a
student:
On 1 point of the plan to lectures:
anatomical construction
клапанного device a heart.
On 2 points of the plan to lectures:
reasons, bring about appearance
noise in heart.
On 3 points of the plan to lectures:
diseases, being accompanied noise
in the field of heart.
On 4 points of the plan to lectures:
notion, determination organic and
functional noise.
On 5 points of the plan to lectures:
reasons of the development innate
and gained vice heart.
On 6 points of the plan to lectures:
examination sick with vice heart.
On 7 points of the plan to lectures:
categorization innate vice heart.
Main moments write in
copy-book
On 8 points of the plan to lectures:
clinical current, diagnostics
separate type innate vice heart.
On 9 points of the plan to lectures:
principles of the treatment,
preventive maintenances and
dispanserization sick with noise in
the field of heart.
Sopping for important moment of
the lectures offers to write main
positions in copy-book
4 stages
final (10 mines)
4.1. Will assign questions:
4.1. Answer 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
4.2. Listen, write
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
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 padrenoreceptor 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 Xray, 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.
Combining aortic heart disease clinically features with characteristis for each
of the components of its valvular lesions. In order to determine the prevalence of
vice, the clinical data and the results of all paraclinical methods must be carefully
analyzed. Determination of dominant species lesions is essential, since this
depends on the indications for surgery and the nature of the surgery. Sometimes
invasive methods are used in order to clarify the nature of the predominant lesions.
Tricuspid valve (insufficientia valvulae tricuspidalis) occurs relatively
frequently. Different organic and relative failure. The latter is more common.
Usually defect occurs in combination with mitral or aortic malformations. Relative
tricuspid regurgitation observed in a significant expansion of the right ventricle and
in increase its cavity. During systole of the right ventricle, some part of the blood
from the cavity comes back into the right atrium. Stagnation of blood in the cavity
of the right atrium is transmitted to the system of hollow veins. On examination of
patients, there are revealed acrocyanosis, swelling of the neck veins and their
systolic pulsation - positive venous pulse, a small icterus sclera and skin due to
functional failure congestive liver. There is a pulsation in the epigastrium due to
dilatation of the right ventricle. Sometimes there is a ripple of the liver.
In auscultation, there is determined systolic murmur, with its epicenter at the
base of the xiphoid process. This noise is amplified in the height of inspiration
(symptom Rivero - Korvallo), which distinguishes it from the noise mitral valve.
During inhalation, blood flow through the right half of the heart accelerates and the
amount of regurgitation increases. On the ECG signs of right ventricular
hypertrophy, the PCG at the base of the xiphoid process distinct systolic murmur,
beginning immediately after the I tone.On the top of inspiratory, noise amplitude
increases. In the diagnosis, there are held differential diagnosis of adhesive
pericarditis.
Stenosis of the right atrioventricular opening (tricuspid stenosis, stenosis ostii
atrioventricularis decxtra, stenosis tricuspidalis) in almost pure form does not
occur. Usually associated with mitral valvular disease. Clinical picture of the
disease in most cases determine combined with it evils. On examination, there are
revealed cyanosis, significantly extended and throbbing neck vein congestion in
the systemic circulation, hypertrophy of the right atrium. In auscultation, there is
reduction of the intensity of Eaton's lack of stagnation in the pulmonary
circulation. At the base of the xiphoid process, there is auscultated diastolic
murmur, recorded and PCG as presystolic diamond-shaped noise. The noise is
amplified in the height of inspiration, especially in the position of the patient on the
right side. Typically there was no significant pulmonary congestion, which is
confirmed radiographically. On the ECG, there are signs of hypertrophy of the
right atrium.
Congenital heart disease. Most patients with congenital heart defects are
detected in childhood, because this raises a distinct sound and symptoms appear
early hemodynamic instability. In some cases, due to the low intensity of vice it
takes a long time hidden. Only in adulthood can be the first signs of
decompensation, which forces the patient to see a doctor. As a result, a
comprehensive survey noise, regarded earlier as inorganic, associated with the
presence of congenital heart disease.
Classification of congenital heart and vessels.
1.Vices with discharge of blood from right to left: the triad of Fallot, Tetralogy of
Fallo, pentad of Fallo, a discharge of the aorta and the pulmonary artery from the
right ventricle, tricuspid atresia (with the usual discharge of large vessels),
malformations of the right ventricle (hypoplasia, defects in muscle), transposition
of the great vessels , atresia of the aortic arch malformations left heart syndrome
(atresia or hypoplasia of the aortic, left ventricular diverticulum), truncusarteriosus
(true and false), Common ventricle, Arteriovenous aneurysm (systemic and
pulmonary). Vices with the initial discharge of blood from left to the right. Open
ductusarteriosus, aortopulmonary fistula, primary and secondary atrial septal defect
atrium. Total LyutembasheThree auricles heart syndrome Common atrioventricular
canal defect septal sinus of Valsalva aneurysm is a breakthrough in the pulmonary
circulation.
3. Malformations of the right half of the heart. Pulmonary stenosis (valve,
infundibulyarny, on valve) Disease Ebstein Primary pulmonary hypertension
IV. Vices of left heart anomalies of the aortic arch of the aorta Coarctation of
aortic stenosis of coronary artery anomalies of mitral valve stenosis
V. Other abnormalities
Anomalies of the heart and the provisions of its individual chambers
(dextrocardia, dekstroversiya with reverse arrangement of the internal organs, etc.)
Congenital with discharge of blood from right to left are called vices "blue
type", and the dumping of left to right - vices "pale type." Principle for syndromic
congenital heart disease can be divided into pure gateways (aortic stenosis,
coarctation of the aorta, pulmonary stenosis), net discharges (patent ductus
arteriosus, atrial septal defect and ventricular septal), a combination of discharges
and the gateway (triad and tetralogy of Fallo, transposition of the main vessels).
Tetralogy of Fallo. Classic tetralogy of Fallo consists of stenosis or atresia of
the output department of pulmonary artery, ventricular septal defect, aortic
dekstrapozitsii (right shift) and right ventricular hypertrophy. In the triad of Fallo,
dextraposition of aorta is absent. Hemodynamics in tetralogy of Fallo is primarily
dependent on the degree of narrowing of the pulmonary artery. Discharge of blood
happens from right to left. There are determined dyspnea, cyanosis, fingers in a
"clubbing". In auscultation 1 ton, as a rule, is not changed, II tone of the pulmonary
artery is weakened or does not listen.
Along the left edge of the sternum sharp, there is auscultated systolic murmur
with the greatest intensity in the second - the third intercostal space. Noise is well
performed on vessels of the neck and in the lower-interscapular region. Deflection
on the ECG electrical goes to the right. In X-rays, there is revealed the depletion
lung pattern due to insufficient blood supply. Aorta expanded and shifted to the
right.
Ductus arteriosus is more common in women. The clinical picture is
determined by the discharge of blood through the shunt. Discharge of blood from
the aorta is the pulmonary artery. At a low discharge, patients remain disabled for
many years, there often found fault with a random survey. With significant relief
sooner, there isshortness of breath, fatigue, impaired physical development.
Systolic-diastolic noise in the second intercostal space to the left of the sternum is
determined in auscultation and in PCG. The noise is associated with the movement
of blood flowing from the aorta to the pulmonary artery, both during systole and
diastole. This noise is metaphorically compared with the noise "crash a train in the
tunnel", "engine noise." He amplified on the breath, because at this time the
pressure in the pulmonary artery is reduced. On the ECG, signs of hypertrophy are
on the left heart. Radiographically, there are defined in the lungs increased lung
markings due to the overflow of the arterial bed, expansion and pulsation roots of
the lungs.
ASD is diagnosed more often in adults (10% of congenital heart defects). In
most patients, long flowing is relatively favorable. Shunt happens from left to
right. Patients complain of shortness of breath, fatigue, stabbing pain in the heart,
heart. In auscultation , there is moderate systolic murmur in the second - the third
intercostal space on the left of the sternum. In right ventricular failure, intensity of
noise is greatly weakened. There is determined intensification of Eaton on
pulmonary artery. X-ray reveals the enlargement of the heart to the left due to a
shift enlarged right ventricle and the pulmonary artery bulging, increased lung
markings. On the ECG, there are signs of partial or complete right bundle branch
block, right ventricular hypertrophy.
Lyutembashe syndrome - a combination of atrial septal defect and mitral
stenosis. The latter is more common rheumatic etiology, but may be congenital. In
syndrome of Lyutembashe, shunt left to rightamplifies, in connection with the
earlier manifested hemodynamic disturbances. Diagnosis is based on the
identification of the symptoms of atrial septal defect and mitral stenosis.
Ventricular septal defect (illness Tolochinova-Roger) can be isolated or
associated with other cardiac anomalies. More common in the upper third of the
septum, the size - 1-2 mm wall or completely absent. Shunt from left to right.
Symptoms depend on the defect size of the defect. In the natural state of the defect,
patients usually get progressively deteriorated after 20-25 years. There are fatigue,
palpitations, shortness of breath. There can be identified heart hump, systolic
tremor in the third - fourth intercostal space on the left of the sternum. In
auscultation, there is heard loud systolic murmur ("much ado about nothing"), with
a maximum playing time in the third or fourth intercostal space on the left of the
sternum.
In X-rays, there is revealed a bulging arc pulmonary artery, the increase of the
left ventricle. On PCG, systolic murmur is in the form of an oval or diamond,
amplification and cleavage / / tone in the pulmonary artery.
Common atrioventricular canal - a large septal defect, an exciting bottom of
the atrial septum and the adjacent part of the interventricular septum, and the split
common atrioventricular valve, overhanging component ventricular septal defect.
Isolated pulmonary stenosis is relatively benign, often associated with other
defects of the heart. Emission reduction of blood right ventricle leads to a
reduction of pulmonary blood flow. Develop shortness of breath, fatigue. In
auscultation and the PCG, in the second intercostal space to the left of the sternum,
there is defined rough systolic murmur in the shape of a diamond. Second tone of
the pulmonary artery sharply weakened and bifurcated.
Ebstein's disease appears bias the tricuspid valve into the right ventricle due to
anomalous attachment of its wings. Abnormally located valve hole divides the
right ventricle to the proximal portion and a distal functional small ventricular
chamber. Hemodynamic disturbances are due to inefficient functioning of the
small right ventricle.
Coarctation of the aorta - a significant narrowing of the aorta, usually in the
area of blood flow, sometimes in the lower thoracic or abdominal aorta. Some of
the patients can be treated at the hypertensionlong time before the diagnosis.
Coarctation of the aorta leads to the development of hypertension and collateral
circulation around space narrowing. Blood pressure rises due to mechanical
obstruction to blood flow and the inclusion of an endocrine mechanism (the renin angiotensin - aldosterone). Patients complain of headache, fatigue, pain in the
ankle joints. On examination of blood pressure, there issystolic murmur. Blood
pressure on the legs is decreased or even not determined, also pulseweakened.
These patients are usually well developed upper body than the lower limbs.
Pulsation of the carotid artery is strengthened. At the base of the heart (in the
second intercostal space to the left or right, in the third intercostal space on the left)
is heard systolic murmur. It is well performed in the vessels of the neck and in the
interscapular region. On the ECG, there are signs of left ventricular hypertrophy. In
X-rays revealed an increase in the left ventricle. Characterized uzuratsiya III-VII
pairs of ribs due to a sharp increase in the diameter of the intercostal arteries and
tortuous course. Setting definite diagnosis helps aortography.
Aortic stenosis is an obstacle to blood flow from the left ventricle. More
common aortic valve stenosis - congenital deformation of the cusps or narrowing
the valve ring, at least - subvalvular (fibrous or muscular), aortic stenosis and even
more rarely - supravalv(ul)ar stenosis. Clinical symptoms of this vice basically
reminds
manifestations
of
acquired
aortic
stenosis.
Treatment of heart disease in most cases is carried out by surgery. Main operations
- valve replacement. When the surgical correction of heart disease is impossibly,
then there is conducted a treatment with the help of drugs. Treatment of
decompensated heart disease follows the same principles as in the treatment of
chronic heart failure of other origin.
Primary prevention:
 Prevention aimed at the prevention of disease, wheredevelops heart disease
 Prevention of CHD: medical and genetic counseling, and advocacy of the
contingent risk of the
disease
 Fighting inbreeding
 Careful observation and study of women who were exposed to the rubella virus or
who have comorbidities that could lead to the development of congenital heart
defects.
Secondary prevention
 Prevention of adverse development of heart disease: the timely establishment of
vice, ensure proper care and determine the best method of defect correction
(surgical at UPU)
Tertiary prevention
 Surgery (acquired heart disease)
Prevention of complications of congenital heart disease (bacterial endocarditis)
List of the literature
1. Jeffrey Bender, Kerry Russell, Lynda Rosenfeld, Sabeen Chaudry-Oxford
American Handbook of Cardiology, 2011
2. A.Zaza An introduction to cardiac electrophysiology
3.ABC of Interventional Cardiology - Ever D. Grech, 2004
4. Cardiovascular Disease in the Elderly - Wilbert S.Aronow, Jerome L.Fleg,
5.www.vidal.ru /кардиология
6.medlistok.com./infarct.asp
7.health. mail.ru /disease/infarct/
8.мedportal.ru>…>кардиолоия
9.www.it-med.ru/library/p/heart1.htm
10.ru.wikipedia.org/wiki/пороки сердца
11.www.gutaclinik.ru>cтатьи