The so-called additional heart sounds include enhanced physiological III or IV tones, the tone or click of the opening of the mitral valve in mitral stenosis, as well as the pericardial tone.
Enhanced physiological III and IV tones indicate a significant weakening of the myocardium of the left ventricle (inflammation, degenerative changes, toxic lesions) and result from the rapid stretching of its walls under the pressure of blood flowing from the atrium. Normally, III tone occurs due to stretching of the ventricular wall under the influence of the rapid entry into their cavity of the first portion of blood from the atria at the beginning of diastole, it is better detected with graphic registration on a phonocardiogram than with auscultation.
Listening to heart sounds
Listening to heart sounds - weakening of tones
Sharply weakened, almost inaudible heart sounds are called deaf, with a moderate decrease in the sonority of the tones, they speak of muffled tones. Weakening of the I tone is possible with valvular heart disease - insufficiency of the mitral and aortic valves due to the weakening of its valvular and muscle components. The weakening of the I heart sound with damage to the heart muscle (for example, with acute myocarditis, cardiosclerosis) is explained by a decrease in the force of contraction of the heart muscle, and with hypertrophy of the heart (for example, with hypertension) - a decrease in the speed of tension of the heart muscle.
The weakening of the II heart sound on the aorta is observed when the cusps of the aortic valves are destroyed (insufficiency of the aortic valves) and the blood pressure in the aorta decreases (for example, when the aortic orifice narrows).
The weakening of the second heart sound on the pulmonary artery during auscultation occurs when its valves are insufficiency and narrowing of its mouth. The reasons for the weakening of the II tone with these defects are the same as with aortic ones.
Increased heart sounds when listening
Strengthening of both heart sounds can be observed with wrinkling (retraction) of the lung edges, with inflammatory compaction of the lung edges adjacent to the heart. It is also found in tachycardia, febrile process, hyperthyroidism. In all the latter cases, the reason for the amplification of both heart sounds during listening is an increase in heart rate, in which the blood filling of the heart cavities decreases and the amplitude of closing of the leaflets valves increases, as a result of which the I tone increases. II tone under these conditions increases as a result of a decrease in systolic blood volume and a more rapid slamming of the semilunar aortic and pulmonary valves.
The amplification of both heart sounds is of much lesser importance than the amplification of each tone separately. Strengthening of the I heart sound can be caught especially clearly at the apex with stenosis of the left atrioventricular orifice (mitral stenosis), narrowing of the right atrioventricular orifice (tricuspid stenosis), atrial fibrillation, ventricular extrasystoles, tachycardia, complete atrioventricular blockade.
Strengthening of the I tone in mitral and tricuspid stenosis, atrial fibrillation, ventricular extrasystoles, tachycardia is due to low blood filling of the ventricles during diastole of the heart. It should be pointed out, however, that tricuspid stenosis (narrowing of the right atrioventricular orifice) is very rare in practice. The I tone is especially loud with complete atrioventricular blockade of the heart, in which the simultaneous contraction of the atria and ventricles periodically occurs. This tone was first described by N.D. Strazhesko and was called "cannon tone".
Strengthening of the II tone can be observed both in the aorta and in the pulmonary artery. In healthy adults, the sound strength of the second heart sound on the aorta and pulmonary artery is the same when listening. This is explained by the fact that the pulmonary valve is located closer in the chest than the aortic valve, due to which the transmission of sound phenomena from them is equalized. But under certain conditions, the strength of sounding of the second tone on these vessels may not be the same. In such cases, they speak of an accent of the II tone on one or another vessel. The strength of the II tone depends on the strength of the push of the back flow of blood against the valves of the aorta (or pulmonary artery) during diastole and is always parallel to the height of blood pressure.
Strengthening (emphasis) of the II tone on the aorta is most often a sign of an increase in blood pressure in the systemic circulation of various origins (hypertension, symptomatic arterial hypertension, as well as a temporary increase in blood pressure during exercise and excitement). Emphasis of II tone on the aorta can also occur with low pressure in the systemic circulation, in particular with calcification of the aortic valve cusps (atherosclerosis) and syphilitic aorthritis. In the latter case, the sound acquires a sharp metallic tint.
Strengthening (emphasis) of the II tone on the pulmonary artery is heard with an increase in pressure in the pulmonary circulation system. It occurs:
- with primary heart lesions that create conditions for pulmonary hypertension (mitral heart disease and especially stenosis of the left atrioventricular orifice, non-closure of the batal duct, sclerosis of the pulmonary artery);
- with lung diseases leading to narrowing of the channel and a decrease in the pool of the pulmonary circulation (pulmonary emphysema, pneumosclerosis, chronic bronchitis, pneumonia, massive pleural exudates, sclerosis of the branches of the pulmonary artery, etc.);
- with lesions of the spine and deformities of the chest in the form of kyphosis and scoliosis, which, limiting the excursion of the lungs, lead to emphysematous swelling of the lungs from the side of the convexity of the chest and compression or even atecatasis from the side of its concavity, as well as to inflammatory processes in the bronchi and lungs.
As a result of hypertension of the pulmonary circulation, which has developed as a result of acquired or congenital heart defects, diseases of the bronchi and lungs, chest deformity, hypertrophy is formed, and then dilatation of the right ventricle. Therefore, the emphasis of the II tone on the pulmonary artery is a sign of right ventricular hypertrophy. The disappearance of the previously existing amplification (emphasis) of the II tone on the pulmonary artery indicates dilatation and secondary weakness of the right ventricle of the heart.
Pathological bifurcation and splitting of heart sounds
Pathological bifurcation and splitting of the first heart sound occurs, as a rule, with blockade of the atrioventricular node or one of the legs of the atrioventricular bundle (His bundle), and is caused by non-simultaneous contraction of the right and left ventricles of the heart. Bifurcation of the first tone may appear with atherosclerosis of the initial part of the aorta. It is heard on the basis of the heart and is explained by increased fluctuations in the sclerotic walls of the aorta during the emptying of the left ventricle.
Pathological bifurcation and splitting of the second heart sound is a sign of serious changes in the heart and its valves. It can be observed when lagging behind the slamming of the aortic valve in patients with aortic stenosis; with hypertension; delayed closure of the pulmonary valve due to increased pressure in the pulmonary circulation (with mitral stenosis, emphysema, etc.), delayed contraction of one of the ventricles in patients with bundle branch block.
Listening to heart sounds - gallop rhythm
In severe myocardial damage, the physiological III heart sound increases so much that it is detected during auscultation or listening and creates a three-part rhythm melody (I, II and additional III tones), reminiscent of the tramp of a galloping horse - a gallop rhythm is heard. It must be borne in mind that the additional III heart sound with a true gallop rhythm is very weak, it is better felt by the hand from a slight concussion of the chest than auscultated. Often, the bifurcation of the first heart sound is taken as the gallop rhythm, when it is so sharp that a three-membered rhythm is heard at the apex of the heart or in the 3-4th intercostal space on the left. At the same time, unlike the true gallop rhythm, heart sounds are well heard.
The true gallop rhythm is figuratively called the "cry of the heart for help", since it is a sign of severe heart damage. The three-term rhythm due to a significant bifurcation of the 1st heart sound, auscultatively similar to the gallop rhythm, is due to the blockade of one of the legs (the bundle of His) that is very common in patients.
The gallop rhythm is best heard directly by the ear (along with the sound, a slight push is perceived, transmitted from the heart to the chest in the diastole phase) in the region of the apex of the heart or the 3rd and 4th intercostal spaces on the left. Especially clearly it is heard when the patient is lying on the left side. Since it is extremely inconvenient to directly listen to heart sounds with the ear, a stethophonendoscope is used.
Distinctive signs of heart sounds when listening
Correct recognition of heart sounds is essential for diagnosing and listening to heart disease. To differentiate I and II heart sounds, you can use the following criteria: I tone is heard after a diastolic pause of the heart (large pause), and II - after a small pause. When listening to the heart, you can catch the following rhythm: I heart sound, a small pause, II tone, a long pause, again I tone, etc.
There are differences in the sonority of I and II tones on individual auscultatory points of the heart. So, normally, at the apex of the heart, I tone is better (louder), and at the base (i.e., above the valves of the aorta and pulmonary artery) - II. This is explained by the fact that sound phenomena are best carried out to the apex of the heart from the mitral valve, the vibrations and tensions of which are involved in the formation of the I tone, while the II tone occurs far from the apex of the heart and is weaker conducted to this area.
In the second intercostal space on the right (aorta) and on the left at the edge of the sternum (pulmonary artery), the II heart sound, on the contrary, is heard more strongly than the I, since sound phenomena from the semilunar valves are better conducted here, when they collapse, the II tone is formed. I tone coincides with the apical impulse or pulse on the carotid artery, II tone sounds at the moment of absence of the apex impulse or pulse. It is not recommended to determine 1 tone by the pulse on the radial artery, as it is late in comparison with the beginning of the systole, which gives the 1st tone.
The weakening of both heart sounds when listening may depend on causes that are not directly related to the heart. For example, a strongly developed musculature prevents the good conduction of sound phenomena from the heart, which is observed in healthy, but extremely obese people.
Strengthening of both heart sounds may be associated with their better conductivity in the stethophonendoscope. This happens in asthenics with a thin chest, a high standing of the diaphragm, a sharp weight loss, with physical stress and nervous excitement.
Listening to additional heart sounds
Depending on the phase of diastole, during which a pathological III heart sound appears, there are protodiastolic, mesodiastolic and presystolic gallop rhythms.
Protodiastolic sound appears at the beginning of diastole immediately after the second heart sound. It is an enhanced physiological III heart sound, occurs 0.12 - 0.2 s after the II tone and indicates a significant decrease in myocardial tone.
The presystolic heart sound occurs at the end of diastole closer to the I tone, as if anticipating its appearance (presystolic gallop rhythm). It is an enhanced physiological IV tone, due to a decrease in ventricular myocardial tone and a stronger atrial contraction.
The mesodiastolic heart tone that occurs in the middle of diastole is the summed III and IV heart sounds, which, in severe heart damage (for example, myocardial infarction, cardiomyopathy, etc.), merge together into a single gallop tone. A necessary condition for the fusion of III and IV tones into a single mesodiastolic gallop tone is the presence of tachycardia.
Listening to the rhythm of the quail
The tone (click) of the opening of the mitral valve in mitral stenosis is explained by a stronger opening of its valves.
The additional tone (click) of the heart of the opening of the mitral valve, together with the flapping I tone and the II heart sound accentuated on the pulmonary artery, forms a characteristic auscultatory melody resembling a quail cry. The sound sensation of a quail's cry can be depicted as follows: “time to sleep”, “time to sleep”. Hence the name of this sound phenomenon, auscultated with mitral stenosis at the apex of the heart - quail rhythm. Its distribution area is extensive - from the top of the heart up and into the axillary region.
The rhythm of the quail is somewhat reminiscent of the auscultatory picture of a bifurcation of the second heart sound, and therefore they are often confused. The main thing that distinguishes the quail rhythm from the bifurcation of the second heart sound is its clear tripartiteness; an additional tone (click) of the opening of the mitral valve is distinguished by a high clicking timbre and is perceived as a loud echo following the II tone. With adhesions of the pericardium, there may be an additional pericardial tone. It appears during diastole 0.08 - 0.14 s after the second tone and is associated with pericardial fluctuations during the rapid expansion of the ventricles at the beginning of diastole.
An additional heart sound during pericardial adhesions can also occur during the period of systole between I and II heart sounds. It sounds loud and short. Since this extra tone occurs during systole, it is also called a systolic click. A systolic click can also appear with mitral valve prolapse, i.e. bulging or protrusion of the leaflet of the mitral valve into the cavity of the left atrium during left ventricular systole.
Embryocardia, or pendulum heart rhythm, is a heart rhythm that resembles fetal heart sounds or clockwork. It is observed in acute heart failure, an attack of paroxysmal tachycardia, high fever and other pathological conditions, when a sharp increase in heart rate leads to a shortening of the diastolic pause so that it becomes almost equal to the systolic one. At the same time, the heart sounds heard at the apex are approximately the same in sonority.
Listening to heart and pulmonary sounds
Auscultatory points of the heart when listening to tones are the places of the best detection of heart sounds. The anatomical structure of the heart is such that all valves are located closer to its base and are adjacent to each other. However, the sound phenomena that occur in the region of the valves are better heard not at the places where the valves are projected onto the chest, but at the so-called auscultatory points of the heart.
It has been established that sound phenomena when listening to tones from the bicuspid (mitral) valve are best heard at the apex of the heart where the apex beat is usually visible or palpable, i.e. in the 5th intercostal space, 1 cm medially from the left mid-clavicular line (the first auscultatory point of the heart). The sound phenomena that occur in the bicuspid valve are well conducted to the apex of the heart along the compacted muscle of the left ventricle during its systole.
The apex of the heart during systole most closely adheres to the anterior chest wall and is separated from it by the thinnest layer of the lung. Sound phenomena when listening to the heart from the aorta are best heard in the 2nd intercostal space at the right edge of the sternum (the second auscultatory point of the heart). The best listening to the tones of sound phenomena from the aortic valves in the 2nd intercostal space on the right at the edge of the sternum is due to the fact that they are better conducted to this place along the blood flow and the walls of the aorta. In addition, in this place, the aorta is closest to the anterior wall of the chest.
The pulmonary artery is auscultated in the 2nd intercostal space at the left edge of the sternum (the third auscultatory point of the heart). From the tricuspid valve, sound phenomena are better heard at the base of the xiphoid process on the right, i.e. at the place of attachment to the sternum of the V costal cartilage or at the place of articulation of the end of the body of the sternum with the xiphoid process (fourth auscultatory point of the heart).
S.P. Botkin proposed an additional fifth point for listening to heart sounds and sound phenomena from the aortic valves, in particular, in case of their insufficiency. Botkin's point is located in the 3rd intercostal space on the left at the edge of the sternum between the place of attachment to it of the III and IV costal cartilages.
The heart can be heard in any order, but it is better to follow a certain rule. The following sequence is usually recommended:
- mitral valve,
- aortic valve,
- pulmonary valves,
- tricuspid valve.
Then they additionally listen at the Botkin point (the fifth point of the heart). This sequence is due to the decreasing frequency of heart valve disease.
Listening to mitral stenosis of the heart
It should be pointed out that tricuspid stenosis (narrowing of the right atrioventricular orifice) is practically very rare. In a healthy heart, by the end of diastole, the left atrium is completely freed from blood, the left ventricle is filled, the mitral valve “pops up” and its valves are completely gently and smoothly closed. When listening to mitral stenosis due to narrowing of the atrioventricular orifice, a lot of blood remains in the atrium by the end of diastole, it continues to pour into the ventricle that is not yet completely filled, so the mitral valve leaflets are pulled apart by a stream of flowing blood.
When systole begins, these valves slam shut with a large swing, overcoming the resistance of the blood stream. In addition, the left ventricle fills with a small amount of blood during diastole, which leads to its rapid contraction. These valve and muscle components significantly increase and shorten tone I at the apex. Such a heart sound when listening to mitral stenosis is called flapping. As Academician A.L. Myasnikov said, in the diagnosis of mitral stenosis, "I tone sets the tone." Strengthening (emphasis) of the II tone over the aorta is often observed with atherosclerotic calcification (compaction) of the aortic valve cusps. In this case, the II heart sound above the aorta acquires a sharp metallic hue.
Strengthening (emphasis) of the II heart sound above the pulmonary artery occurs when the push of the back flow of blood against the valves of the pulmonary artery increases during diastole with an increase in pressure in the pulmonary circulation system. It occurs with mitral heart disease, in which conditions for pulmonary hypertension are created.
Diagnosis of listening to heart sounds
Diagnosis of chronic cor pulmonale by auscultation
Currently, diagnostic schemes have been developed for listening to heart sounds, which include the most reliable electrocardiographic signs, giving the practitioner the ability to recognize hypertrophy of the right heart with a certain certainty. The most widely used scheme is Widimsky et al., in which a large number of electrocardiographic signs of CLS are divided into direct and indirect.
According to Widimsky, in the presence of two or more direct signs of right ventricular hypertrophy, the electrocardiographic diagnosis of CHLS can be considered reliable, one direct and one or more indirect signs can be considered probable, and any one sign is doubtful. However, when assessing the ECG using the Widimsky method, there is a significant overdiagnosis of CHL, especially in individuals with a vertical and semi-vertical electrical position of the heart.
Auscultation is the most informative method for diagnosing diseases of the cardiovascular system. The method is based on listening to sound phenomena associated with the activity of the cardiovascular system. Auscultation requires not only excellent hearing, but also the ability to distinguish sounds in their pitch and time. Many doctors have never mastered this research or have lost this quality due to lack of practice.This is one of the most difficult diagnostic techniques. Auscultation is listening to heart sounds and identifying diagnostic symptoms.
Auscultation rules:
1) the position of the patient during auscultation. Usually, auscultation is performed in the position of the patient standing, lying, including on the left side, after exercise, etc.;2) the position of the doctor - to the right of the patient, the phonendoscope should fit snugly to the auscultated point;
3) listening to the heart is performed with a phonendoscope, which makes it possible to isolate all sounds received by the phonendoscope at a certain point.
High-pitched heart sounds are heard with a stethoscope. Low heart sounds are heard better not with a phonendoscope, but with a stethoscope. There is auscultation with the ear. It is better to listen to low sounds without a membrane, high sounds - with a membrane;
4) listening should be carried out in different phases of breathing. This is due to the fact that during a deep breath, blood flow to the right chambers of the heart increases, which enhances some sound phenomena; during a deep exhalation, the conduction of sounds from the left half of the heart improves;
5) locations and projection of the valves on the chest:
a) at the place of attachment to the sternum of the cartilage of the IV rib, the mitral valve is projected on the left;
b) at the site of attachment of the III rib to the right of the sternum, the aortic valve is projected;
c) to the left of the sternum, in the III intercostal space, the pulmonary artery valve is projected;
d) a tricuspid valve is projected to the right of the sternum in the IV intercostal space.
Through numerous studies, it has been found that sound effects are heard better at certain points:
1) the mitral valve is better auscultated at the apex of the heart;2) aortic valve - in the II intercostal space to the right of the sternum;
3) tricuspid valve - at the edge of the sternum or in the IV intercostal space to the right of the sternum.
There are additional points, noise conduction zones, for example, axillary, subclavian regions, jugular notch.
Listening begins at the apex of the heart, then moves to the aorta, pulmonary artery and tricuspid valve. When listening to the patient, the stethoscope is transferred from one place to another, so it is more convenient to catch sound phenomena, and also to catch:
1) strength and clarity of tones;
2) frequency and rhythm;
3) timbre of tones;
4) properties of noises or their absence.
Heart sounds:
Heart sounds are the sum of various phenomena that occur during the period of heart contractions. Usually two tones are heard, but in 20% of healthy individuals III and IV tones are heard. With diseases, the characteristic of tones changes.The tone is formed from several points:
1) valvular, associated with the slamming and vibration of the leaflets of the two-leaf and three-leaf valves;2) muscular, associated with contraction of both atria and both ventricles;
3) vascular, associated with the vibration of the walls of the aorta and pulmonary artery due to the blood flowing into them from the ventricles.
In addition to sounds from atrial contractions, the above sounds occur simultaneously and are perceived as one systolic I tone. As for the sound of atrial contraction, the interval between them and contractions of the ventricles is very small, so that when listening with the ear it is almost impossible to distinguish it, therefore it is perceived as one systolic I tone.
Two components take part in the formation of the II tone:
1) slamming of the valves of the aorta and pulmonary artery;2) vibrations of the leaflets of these valves.
The slamming of the valves of these vessels occurs in the diastolic phase, so the second tone is designated as diastolic.
III tone is formed due to the rapid tension and expansion of the walls of the ventricles with a stream of blood leaving the atria during the onset of diastole.
Thus, five mechanisms of the first tone are distinguished:
1) valve component that occurs when the mitral valve closes at the beginning of systole;2) fluctuation and closing of the tricuspid valve leaflets;
3) oscillation of the walls of the ventricles in the contraction phase at the beginning of systole, when the heart pushes blood into the vessels, this is a muscle component;
4) oscillation of the walls of the aorta and pulmonary artery;
5) atrial fluctuation at the end of atrial systole.
I tone is normally heard at all points. Place of evaluation: apex, Botkin's point, II intercostal space at the left edge of the sternum.
Assessment method - comparisons with II tone: I tone is characterized by the fact that it occurs after a long pause before a short one, at the top of the heart it is more than II tone, longer and lower than II tone, coincides with the apex beat. In 20% of the healthy population, the third tone is heard, but more often it is a sign of pathology.
Physiological III tone is formed as a result of fluctuations in the walls of the ventricles during their rapid filling with blood at the beginning of diastole. It is usually observed due to the hyperkinetic type of blood flow. III tone is recorded at the beginning of diastole, not earlier than 0.12 s after tone II. Pathological III tone forms a three-membered rhythm, it occurs as a result of relaxation of the muscles of the ventricles that have lost their tone with the rapid flow of blood into them. This is the “cry of the heart” for help, or the gallop rhythm.
IV tone can be physiological, occurs before the I tone, in the diastole phase. This presystolic tone represents the vibrations of the atrial walls at the end of diastole. Normally, it occurs only in children. In adults, it is always pathological, due to contraction of the hypertrophied left atrium with a loss of ventricular muscle tone. This is the presystolic gallop rhythm.
Clicks can be heard during auscultation. A click is a high-pitched, low-intensity sound heard during systole.
The clicks are high pitched, shorter in duration, and inconsistent. The tone can be amplified or weakened.
Change in the sonority of the 1st heart sound:
It may depend on extracardiac and cardiac causes.Extracardiac causes include the following:
1) paralytic chest;2) decrease in the airiness of the lung tissue;
3) barrel chest;
4) thick chest;
5) emphysema of the chest;
6) effusion in the pericardial region.
Cardinal reasons include:
1) damage to the heart muscle;
2) myocarditis, cardiosclerosis;
3) destruction of valves;
4) decrease in the amplitude of movement of the valve flaps;
5) decrease in the rate of pressure rise in the cavity of the ventricles;
6) mitral and tricuspid insufficiency.
Strengthening of the I tone is observed with myocardial hypotrophy, increased heart rate, with complete transverse heart block.
It is characteristic of the narrowing of the left atrioventricular orifice (mitral stenosis).
With this defect, the left ventricle is not completely filled during diastole, as a result of which it contracts quickly and the valve closes just as quickly with a characteristic popping sound - “popping tone”. With heart block, a cannon tone is noted.
The weakening of the I tone at the apex of the heart is observed with insufficiency of the tricuspid valve, due to deformation of the valve, its slamming is incomplete. There is no valve closing period. Due to the latter factor, the weakening of the first tone at the apex of the heart is also noted with insufficiency of the aortic valves. Weak I tone at the apex of the heart with narrowing of the aortic orifice or aortic valves has a different origin and is associated with an increase in blood supply to the left ventricle and a slow expulsion of blood from its cavity. I tone is weakened at the apex of the heart with weakness of the heart muscle, with myocarditis and myocardial dystrophy. The reason for the weakening of the I tone on the projection of the tricuspid valve is the insufficiency of this valve.
Change in sonority 2 heart sounds:
Strengthening on the aorta is observed with an increase in blood pressure in the systemic circulation.A short-term accent can appear with emotional experiences, excessive arousal. The emphasis of the second tone on the aorta is heard in symptomatic hypertension, in particular renal, of endocrine origin.
With the development of left ventricular hypertrophy, an accent of the II tone on the aorta also appears, but this accent disappears as weakness of the hypertrophied ventricle develops.
The weakening of the II tone on the aorta is observed with insufficiency of the aortic valves. There is a direct relationship between the degree of deformation of the aortic valves and the degree of weakening of the II tone at the indicated point. The weakening of the II tone on the aorta also occurs when this vessel narrows at the point of exit from the heart, since the pressure in the aorta decreases and the force of closing of the aortic valves decreases.
Strengthening of the II tone on the pulmonary artery always appears with hypertension in the pulmonary circulation, i.e. with all heart defects of acquired and congenital origin with overflow of the pulmonary circulation. These heart defects include mitral stenosis, atrial and ventricular septal defects.
The accent of the second tone is heard in secondary pulmonary hypertension of any origin.
First tone occurs during systole after a long pauses. It is best heard at the apex of the heart, since the systolic tension of the left ventricle is more pronounced than the right one.
The nature the first tone is longer and lower than the second.
Second tone formed during diastole after a short pauses. It is heard better at the base of the heart, as it occurs when the semilunar cusps of the aortic and pulmonary valves slam shut. Unlike the first tone, shorter and higher.
In pathology, when the sonority of tones can change, it helps to distinguish between the first and second tones that the first tone coincides with the apex beat(if the latter is palpable) and with the pulse of the aorta and carotid artery.
The change in heart sounds can be expressed as:
v weakening or strengthening the sonority of one or both tones,
v in changing their timbre, duration,
v in the appearance of a bifurcation or splitting of the main tones,
v occurrence of additional tones.
Heart sounds intensify when large air cavities are located near it (a large pulmonary cavity, a large gas bubble of the stomach) - due to resonance. The sonority of tones also depends on the composition of the blood flowing through the heart: with a decrease in blood viscosity, as is observed with anemia, the sonority of tones increases.
Figure 8. Locations of valve projections
on the anterior chest wall
In the diagnosis of heart disease
it is of great importance to identify changes in tones caused by damage to the heart itself, i.e. caused by cardiac causes.
Weakening both tones can be observed with a decrease in the contractility of the heart muscle in patients with myocarditis, myocardial dystrophy, cardiosclerosis, with collapse, accumulation of fluid in the pericardial cavity.
Gain both tones arise by increasing the influence of the sympathetic nervous system on the heart. This is noted during hard physical work, unrest, in persons suffering from Graves' disease.
More often than a change in both heart sounds, there is a change in one of them, which is especially important in the diagnosis of heart disease.
Weakening of the first toneat the top the heart is observed
In case of insufficiency of the mitral and aortic valves.
With mitral valve insufficiency during systole, the valve leaflets do not completely cover the left atrioventricular orifice.
Gain first tone at the top the heart is observed
with narrowing of the mitral orifice.
Weakening of the first toneat the base of the xiphoid process of the sternum
in case of insufficiency of the tricuspid valve and the valve of the pulmonary trunk.
Gain the first tone base of the xiphoid the process of the sternum is auscultated:
with stenosis of the right atrioventricular orifice.
Strengthening of the first tone is also observed with extrasystole- premature contraction of the heart - due to small diastolic filling of the ventricles.
Fine, the power of the second tone above the aorta and pulmonary trunk is the same.
Weakening of the second tone above the aorta is observed:
· at aortic insufficiency valve, or due to their cicatricial compaction;
With a large destruction of the aortic valve cusps, the second tone above it may not be heard at all;
with a significant decrease in blood pressure;
Weakening of the second toneover the lung the trunk is observed:
in case of insufficiency of its valve (which is extremely rare);
With a decrease in pressure in the pulmonary circulation.
Amplification of the second tone may be noted either above the aorta or above the pulmonary trunk.
In cases where the second tone is louder over the aorta, they talk about the accent of the second tone on the aorta, if it is louder over the pulmonary trunk, they talk about the accent of the second tone on the pulmonary artery.
Emphasis of the second tone on the aorta observed:
With an increase in pressure in it (hypertension, nephritis, hard physical work, mental arousal), because at the beginning of diastole, the blood hits the valve flaps with greater force.
Emphasis of the second tone on the pulmonary artery appears:
With an increase in pressure in the pulmonary circulation, overflow of blood vessels in the pulmonary circulation (for example, with mitral heart disease),
Difficulty in blood circulation in the lungs and narrowing of the pulmonary artery (with emphysema, pneumosclerosis, etc.)
Heart murmurs.
During auscultation of the heart, in some cases, in addition to tones, sound phenomena called heart murmurs are heard.
Noises can occur: inside the heart itself - intracardiac outside its extracardiac.
organic noises- occur with anatomical changes in the structure of the heart valves.
Functional noises- appear:
in violation of the function of unchanged valves
With an increase in blood flow velocity or a decrease in blood viscosity.
The most common cause of intracardiac murmur is heart disease.
According to the time of appearance of noise during systole or during diastole distinguish between systolic and diastolic murmurs.
Systolic murmur appears:
when, during systole, blood, moving from one part of the heart to another or from the heart to large vessels, encounters constriction on its way.
With stenosis of the mouth of the aorta or pulmonary trunk, since with these defects during the expulsion of blood from the ventricles, an obstacle arises in the path of blood flow - narrowing of the vessel.
· listened to insufficiency of the mitral and tricuspid valves.
Its occurrence is explained by the fact that during ventricular systole the blood will flow not only into the aorta and pulmonary trunk, but also back into the atrium through an incompletely covered mitral or tricuspid opening. Since this incompletely covered opening is a narrow gap, noise is produced when blood passes through it.
diastolic murmur appears when there is a narrowing in the path of blood flow to diastolic phase:
· with narrowing of the left or right atrioventricular orifice, since with these defects during diastole there is a narrowing in the path of blood flow from the atria to the ventricles.
In case of insufficiency of the aortic valve, pulmonary trunk - due to reverse blood flow from the vessels to the ventricles through the gap formed when the leaflets of the altered valve are not completely closed.
During auscultation, it is necessary to determine:
1) the ratio of noise to the phase of cardiac activity (to systole or diastole);
2) properties of noise, its nature, strength, duration;
3) noise localization, i.e. the place of the best listening;
The relation of noise to a systole or a diastole is defined by the same signs on which we distinguish the first and second tones.
II tone is heard at the base of the heart, where normally it is louder than tone I and is the same in strength in the second intercostal space on the right and left. Weakening- if the II tone is equal in volume to I or quieter. It happens at low pressure in large vessels, a decrease in their blood supply, with damage to the valves of the aorta and pulmonary artery, which leads to a violation of their slamming. Above the aorta - with the deposition of calcium salts, which leads to a decrease in mobility valve. Above the pulmonary artery - with a large thickness of the chest. Gain- Accent II tone on the aorta may occur due to its strengthening at this point, or weakening on the pulmonary artery. small circle (stenosis of the mouth of the pulmonary artery). The emphasis of the II tone on the pulmonary artery may be due to its strengthening on the pulmonary artery or weakening on the aorta. In childhood and adolescence, the II tone on the pulmonary artery is louder than on the aorta. In adulthood, their volume is the same, in the elderly, the II tone is louder on the aorta due to its thickening in atherosclerosis.
24.III and IV heart sounds. Gallop rhythm.
III tone goes after II in 0-15 seconds. It is low, deaf, heard at the top in the position of the patient lying on the left side. Normally occurs in children under 6 years old, in asthenic adults up to 35-40 years old, in pregnant women in the third trimester due to imperfections in the regulation of myocardial tone). Caused by fluctuations in the myocardium of the left ventricle during its rapid passive filling with blood at the beginning of diastole. tricuspid valve). IV tone goes before tone I at the beginning of diastole. It is low, deaf, associated with rapid filling of the left ventricle due to contractions of the left atrium. Normally, in the elderly, no changes in the heart, in trained people. In pathology, hypertension, aortic stenosis, cardiomyopathy. gallop rhythm goes before tone I, or after tone II, is associated with the appearance of tone III or IV, resembles the sound of a galloping horse's hooves. III tone forms a protodiastolic gallop rhythm, and with IY tone - presystolic.
25. Bifurcation of heart sounds. Mitral valve opening tone.
Bifurcation of the II tone - due to non-simultaneous slamming of the valves of the aorta and pulmonary artery due to the different duration of contractions of the left and right ventricles, respectively, changes in the large and small circle. With an increase in pressure, increased blood filling in the small or large circle. in the 2nd intercostal space) - in young people with a deep breath (due to increased blood flow to the right heart, the systole of the right ventricle lengthens, splitting above the pulmonary artery. Its second component is associated with the slamming of the aortic valve. In pathology, with dilatation of the right ventricle against the background of stenosis pulmonary artery, in case of violation of the conduction of excitation along the right leg of the atrioventricular bundle of His (later slamming of the pulmonary valve). In case of an atrial septal defect, an increase in the volume of the cut in the right atrium, then in the right ventricle, which leads to an overload of blood in the small circle ( splitting is strong, over the pulmonary artery does not depend on the phases of respiration). pulmonary hypertension in patients with chronic lung diseases (splitting is less pronounced and distinct, because The right ventricle is hypertrophied and its systole is not lengthened. Bifurcation of the I tone- normal along the left edge of the sternum (a tricuspid component is heard), sometimes at the apex, along with an IV tone and an early systolic click.
Mitral valve opening tone comes after the II tone, at the apex of the heart (medially and along the left edge of the lower third of the sternum) in the position of the patient on the left side. therefore, the flow of blood causes these valves to oscillate (they bend towards the left ventricle under the action of high pressure in the left atrium).
Sep 3 2013
Auscultation of the heart: heart tones, their splitting, bifurcation, additional tones.
MINISTRY OF HEALTH OF UKRAINE
A. A. Bogomolets National Medical University
"Approved"
at the methodological meeting of the department
propaedeutics of internal medicine No. 1
Department head
Professor V. S. Netyazhenko
________________________
(Signature)
"______" _____________ 2011
Guidelines
FOR INDEPENDENT WORK OF STUDENTS
IN PREPARATION FOR PRACTICAL LESSON
Academic discipline Propaedeutics of internal medicine
Module No. 1 Basic methods of examination of patients in the clinic of internal diseases
The topic of the lesson is Auscultation of the heart: heart tones, their splitting, bifurcation, additional tones.
Faculties II, III medical, faculty of training doctors for the Armed Forces of Ukraine
The duration of the lesson is 3 academic hours
1. Relevance of the topic:
Listening to cardiac activity is an actual method of physical examination, which helps to determine cardiac activity, sonority of tones, and identify diagnostic criteria for diseases. This is an easy-to-perform method, it can also be carried out in out-of-hospital conditions, if necessary, directly by the ear.
2. Specific goals:
— Explain the projection of the heart valves on the chest wall
- Determine the best places to listen to the valves of the heart (anatomical landmarks - the main points for listening)
- To master the procedure for auscultation of the heart at the main and additional points.
- Analyze the sound of the first and second heart sounds
— Explain the distinguishing features of the first and second heart sounds
- Interpret auscultatory characteristics of the heart melody
— Demonstrate definitions of the anatomical zones of auscultation of the heart at additional points
- Detect the presence of splitting and bifurcation of heart sounds
— Explain the mechanism of formation of additional heart sounds
- Detect the presence of the rhythm of the quail and the rhythm of the gallop
3. Basic knowledge, skills, skills (interdisciplinary integration)
| Names of previous disciplines | Acquired Skills |
| human anatomy | - Explain the structure of the heart, the components of the mitral, tricuspid valves and the structure of the semilunar valves - Determine the projection of the main structures of the heart on the chest wall |
| Physiology | - Interpret the mechanism of formation of heart sounds, - Explain the nervous regulation of the heart |
| pathological physiology | – Analyze changes in the sonority of tones and heart melody in inflammatory and degenerative processes of the myocardium and heart valves |
| pathological anatomy | – Interpret organic changes in the endocardium, myocardium, pericardium in pathological processes |
4. Tasks for self-preparation for the lesson:
4.1. The list of basic terms, characteristics that the student must learn in preparation for the lesson:
| Term | Definition |
| Punctum auscultationis | Auscultation point, the place of the best auscultation of the heart valves |
| Sonus cardiacus | Heart tone |
| Soni cardiaci normales | Normal heart sounds |
| Sonus normalis primus | Normal first tone |
| Sonus normalis secundus | Normal second tone |
| Sonus primus mitigatus | Weakened first tone |
| Sonus primus auctus | Reinforced first tone |
| Sonus primus plausus | flapping first tone, manifestation of mitral stenosis |
| Accentus soni secundi in aorta | Emphasis of the second tone on the aorta |
| Accentus soni secundi in arteria pulmonalis | Emphasis of the second tone on the pulmonary artery |
| Clangor | Klyangor, metallic shade of the second tone on the aorta |
| Arhythmia | Arrhythmia, abnormal heart activity, heart rhythm disturbances |
| Extrasystolia | Extrasystolic arrhythmia due to premature contraction of the heart followed by a compensatory pause |
| Arhythmia absoluta, s. pertetua, s. delirium cordis, s. fibrilatio atriorum |
Absolute arrhythmia, or atrial fibrillation, or atrial fibrillation |
4.2. Theoretical questions for the lesson:
1. General rules and methods of listening to the heart.
2. Places of the projection of the valves of the heart and their best listening.
3. The mechanism of formation of heart sounds.
4. Differences of the 1st and 2nd tones, diagnostic methods.
5. Factors affecting the sonority of tones.
6. Causes of amplification of the 1st tone.
7. Reasons for the weakening of the 1st tone.
8. Causes of amplification of the 2nd tone on the aorta.
9. Causes of weakening of the 2nd tone on the aorta.
10. Causes of weakening of the 2nd tone in the pulmonary artery.
11. Age features of sonority of the 2nd tone.
12. What is tone splitting? The reasons for its occurrence.
13. What is tone warfare? The reasons for its occurrence.
14. How to distinguish splitting and bifurcation of tone?
15. What additional heart sounds do you know?
16. How is the rhythm of a quail formed? Its diagnostic value.
17. When does the gallop rhythm occur?
18. What are the forms of gallop rhythm? Their diagnostic value.
4.3. Practical tasks performed in the lesson:
1. Conduct percussion examination of the right, upper, left border of relative cardiac dullness;
2. Establish localization and study the properties of the apex beat;
3. Determine the projection of the valves on the anterior chest wall;
4. Indicate the main points of auscultation, characterize the heart sounds;
5. Analyze the volume, amplitude of the signals at various points of auscultation;
6. Conduct a diagnostic difference between the first and second tones;
7. Learn to distinguish the number of tones, characterize additional heart sounds.
5. Detailed theme content:
Auscultation of the patient's heart should be carried out after collecting an anamnesis, detailing complaints, examining the patient, examining the pulse and blood pressure, palpation of the precordial region and apex beat and percussion of the heart.
Listening to the heart is carried out with a stethoscope or phonendoscope, and in some cases - by applying the ear to the patient's heart area (direct auscultation). In this case, the sounds are not distorted and are perceived from a larger surface.
Basic rules for listening to the heart:
1. Listening should be carried out on the bare chest in a sufficiently warm and quiet room.
2. The stethoscope (phonendoscope) should tightly, but without excessive pressing, touch the patient's body.
3. Auscultation of the heart is carried out in the horizontal and vertical position of the patient, at rest and after exercise. In some cases, it is rational to use special techniques: Udintsev, Sirotinin-Kukuverova, and also listen to the heart while holding the breath.
4. The order of listening to the heart: the region of the apex, the base of the xiphoid process, the 2nd intercostal space to the right of the edge of the sternum, the 2nd intercostal space to the left 1-2 cm from the edge of the sternum, the 5th Botkin point (in the 3rd intercostal space to the left of the edge sternum)
It should be remembered that the places of auscultation of the heart valves do not coincide with their projection on the chest wall.
The exception is the valves of the pulmonary artery. The bicuspid (mitral) valve is projected at the site of attachment of the 3rd costal cartilage to the sternum on the left, and it is also auscultated at the apex of the heart. The tricuspid valve is projected on the sternum approximately in the middle of the line connecting the end of the left 3rd costal cartilage with the right costal cartilage, but it is heard along the right edge of the sternum at the level of the 5th intercostal space.
The aortic valves are projected onto the sternum at the level of 3 ribs, and are heard in the second intercostal space at the right edge of the sternum.
The valves of the pulmonary artery are projected and auscultated in the second intercostal space to the left, 1-2 cm from the edge of the sternum.
In addition to the listed 4 classical points of auscultation of the heart and the fifth additional point of Botkin-Erb, there are 5 additional points in which it is recommended to auscultate the heart.
6 point Naunina- located in the 2nd intercostal space to the left of the sternum, along the upper edge of the 3rd rib. A systolic murmur is heard in it with mitral valve insufficiency.
7 point- on the xiphoid process or under it. The 3-leaf valve is well heard in it with hypertrophy and dilatation of the right ventricle.
8 point mesocardial- it is located in the 4th intercostal space along the left parasternal line. Approximately corresponds to the place of attachment of the anterior mastoid muscle of the left ventricle to its wall and is an area of good audibility of ventricular systolic murmurs of chords.
9 point at the bottom of the jugular fossa. There, a weak systolic murmur of aortic stenosis and deformation of the semilunar valves are well defined.
10 point- in the 5th intercostal space along the left anterior axillary line. In this place, mitral stenosis is most clearly and typically heard.
For a doctor who listens to the heart, it is important to recognize 1 and 2 tones. The difference in tones is based on the following features:
- 1 tone is longer (0.11-0.14 s) than 2 tone (0.04-0.08 s);
- 1 tone corresponds to the systole (beat) of the heart and the pulse on the carotid artery, and 2 tone comes after the "beat";
- 1 tone is heard after a long pause, it is somewhat longer and lower than the 2nd;
- 2nd tone is heard after a short pause, it is somewhat shorter and higher than the first;
- The place of listening to 1 ton sounds louder at the top of the heart, and the second - louder at the base of the heart.
In a healthy person, two tones are heard. At the top and at the lower edge of the sternum, the most sonorous first tone, on the aorta and pulmonary artery - the 2nd tone. At a frequency of 74 beats per minute, the duration of tones and pauses between them is as follows: 1st tone - 0.11 s, systolic pause 0.2 s, 2nd tone - 0.07 s, diastolic pause 0.4 s.
To recognize the 1st tone from the 2nd, one should focus on a short pause, after which the second tone is heard. To find the 1st tone, you can also be guided by the second technique: attach your fingers to the site of the apex beat or carotid artery. The sensation of impact corresponds to the first tone.
With direct auscultation of the heart, a third normal tone is sometimes heard. It does not have a permanent character, it is perceived as a weak, low and muffled sound at the beginning of diastole 0.1-0.2 s after the 2nd tone.
Heart sounds can vary in physiological and pathological conditions, both in the direction of strengthening and weakening.
Strengthening of both heart sounds can be for various reasons:
1. Non-cardiac factors:
- thin chest
- The approach of the heart to the chest wall with a high standing of the diaphragm, with wrinkling of the anterior edge of the lungs;
- Resonant amplification, when a large, air-filled space is located next to the heart (pneumothorax, pneumopericardium, accumulation of gases in the stomach and intestines);
- Severe infiltration of areas of the lungs adjacent to the heart.
2. Cardiac factors:
- Tachycardia with physical and emotional stress;
- Tachycardia with fever, anemia, thyrotoxicosis;
Weakening of both heart sounds can occur:
- Under the influence of non-cardiac factors that interfere with the conduction of tones: obesity, swelling of the chest; emphysema of the lungs, the presence of fluid in the pericardium, in the left pleural cavity;
- In acute and chronic heart failure;
- In acute and chronic vascular insufficiency;
The intensity of heart sounds decreases with deep inspiration and increases with exhalation. Of great importance is the change in the rate of contraction of various parts of the heart, as well as the absence of a period of closed valves in some heart defects.
From a diagnostic point of view, a change in the sonority of one of the heart sounds is of great importance, since the cause of these changes is often located in the heart itself. Drawing conclusions about the state of the heart based on the assessment of the 1st tone, it is necessary to take into account many different factors that affect its intensity.
The intensity of the 1st tone is determined by the following factors:
- Anatomical structure of the AV valves
- The position of the cusps of the AV valves before ventricular systole
- The rate of contraction of the ventricles, or the energy with which the AV valves close
- The ratio of atrial contraction to the time of ventricular contraction (with a short interval - strengthening, with a longer interval - weakening)
Pathological conditions in which there is a change in the intensity of the 1st tone:
| Amplification of the 1st tone | Weakening of the 2nd tone |
| Stenosis of the left AV foramen | With mitral valve insufficiency |
| With a reduction in AV conduction | With tricuspid valve insufficiency |
| With a decrease in blood filling of the left ventricle (extrasystoles, bleeding, etc.). | In case of aortic valve insufficiency |
| With a decrease in the contractile function of the myocardium - myocarditis, cardiosclerosis, myocardial infarction, dystrophy | |
| High hypertension in the pulmonary circulation | |
| Thrombosis of the left atrium | |
| With an increase in AV conduction |
The intensity of the second tone is determined by the pressure in the systemic and pulmonary circulation, the state of the semilunar valves and the connective tissue rings of the large vessels of the heart.
In adults, the strength of the second tone over the aorta and pulmonary artery is approximately the same. Increase in age (after 50-55 years) The second tone becomes stronger over the aorta. In children, it is stronger over the pulmonary artery (accent of the II tone).
The mechanism of splitting, bifurcation and the formation of additional tones:
In some cases, along with the normal heart melody, you can listen to additional tones - sounds of different heights. This is due to splitting or bifurcation of tones or the appearance of additional ones.
Bifurcation and splitting of tones:
Often, instead of a single 1 or 2 tones, two sounds of the same strength are heard with a slight gap between them. Depending on the size of this gap, splitting and bifurcation of 1 or 2 heart sounds are distinguished. Instead of the sound "ta" we hear the sound "t-ra". The difference between splitting and bifurcation is only quantitative, and the differentiation of these two phenomena to a certain extent is due to the experience and subjective feeling of the doctor.
Bifurcation of 1 and 2 tones can be both physiological and pathological. Physiological bifurcation of tones most often occurs in young people, it is associated with the act of breathing or physical activity and is unstable.
Bifurcation of 1 tone depends on the simultaneous closing of two- and three-leaf valves. Under physiological conditions, this phenomenon can sometimes occur during exhalation, when, due to an increase in pressure in the chest cavity, blood enters the left atrium with great force and thereby slows down the closing of the mitral valve. This leads to the fact that the sound phenomena from the atrioventricular valves are perceived as a separate tone. Bifurcation of 1 tone in pathological cases can occur when one of the legs of the bundle of His is blocked, when there is a non-simultaneous contraction of the right and left ventricles of the heart.
Bifurcation of the 2nd tone occurs due to non-simultaneous closure of the leaflets of the aortic valve and the pulmonary valve. In healthy young people, at the height of inhalation, a bifurcation of 2 tones is shown, which disappears during exhalation. This is explained by the fact that during inspiration, due to the force of the chest, the filling of the right ventricle increases. Due to this, the closure of the pulmonary artery valve is delayed even more and the pulmonary component of the 2nd tone is distinguished from the usual complex of sounds. During exhalation, when the filling of the right ventricle decreases, tone 2 is perceived by the ear as a whole. This splitting is heard only at the point of the pulmonary artery. Unlike physiological splitting, pathological splitting of the 2nd tone is most often associated with an increase in pressure in the pulmonary circulation due to non-simultaneous closure of the pulmonary artery valves and the aortic valve. With significant hypervolemia of the small circle, for example, with non-closure of the interatrial septum, the interval between the bifurcation components is called fixed. The greatest distance between the components of the bifurcated 2nd tone is observed with stenosis of the pulmonary artery orifice. Bifurcation of 2 tones can be associated not only with changes in the small circle, but also with disorders in the left half of the heart. For example, contraction of the left ventricle leads to an early appearance of the aortic component of the 2nd tone, which occurs much earlier than the pulmonary component, so it is heard separately. This is observed with insufficiency of the bicuspid valve, because with this defect, as a result of the return of part of the blood to the left atrium, the period of expulsion of the left ventricle is reduced.
Additional (abnormal) heart sounds are of great importance for assessing the condition of the heart, as well as for prognosis.
Additional tone may occur in systole. It seems that it occurs at the very ear, and is called "systolic clapping" - systolic click. When listening to it at the top, it is explained by two main mechanisms:
- Tension of pericardial adhesions in constructive pericarditis;
- Prolapse (deflection) of the leaflet of the bicuspid valve.
Additional tones in diastole are more common than in systole. By origin, they can be muscular, valvular and pericardial. Muscle tones include: pathological 3 tone; gallop rhythm (protodiastolic, presystolic, mesodiastolic, total). To valvular additional tones (diastolic) belong to the opening tones of the bicuspid and tricuspid valves. Pericardial diastolic tones are similar in mechanism of their occurrence to systolic pericardial tones.
Pathological 3 tone. The mechanism of its formation is the same as normal 3 tones. This tone occurs as a result of a blow to the wall of the ventricle of the first portion of blood entering it from the atrium. However, unlike the normal 3rd tone, the formation of a pathological one is due to a decrease in the tone of the hypertrophied myocardium, and the presence of an increased blood volume in the ventricles. A sharply reduced tone of the left ventricle can develop with myocardial infarction. Unlike the normal 3rd tone, which is heard only in people under 25 years of age, the pathological 3rd tone is heard in people of any age. It is best heard with the ear at the top of the heart, both in the supine position and on the left side. Unlike the physiological 3 tones, the gallop rhythm is constant and does not depend on the phases of respiration.
gallop rhythm- a three-membered rhythm, is heard with a significant decrease in the tone of the heart muscle, which occurs as a result of inflammatory, degenerative and sclerotic changes (myocarditis, myocardial infarction, aneurysm of the heart, chronic nephritis in the terminal stage, heart failure and other severe myocardial damage). There are atrial (presystolic) gallop rhythm, and protodiastolic. The presystolic gallop rhythm becomes audible when the ventricular tone is weakened and the atrioventricular interval increases. The proto-diastolic (ventricular) gallop rhythm occurs when a blood wave hits the ventricular wall (flabby) at the beginning of diastole. It is caused not so much by the high rate of blood from the atria to the ventricles as by a significant decrease in the tone of the ventricular wall, it often occurs against the background of tachycardia. It is best auscultated by the ear above the apex of the heart.
The gallop rhythm indicates severe damage to the heart muscle. V.P. Obraztsov characterized this rhythm as “the cry of the heart for help”. The most serious prognostic value is the protodiastolic and total gallop rhythm, because they indicate damage to the ventricles, more often the left one.
quail rhythm- this is a three-membered, pathological rhythm, heard at the apex of the heart and is a pathognomonic sign of mitral stenosis, when the leaflets of the mitral valve are fused and represent a dense elastic membrane, which during ventricular systole bends towards the atria, and during diastole in the presence of an atrioventricular gradient pressure towards the ventricles. In Anglo-American literature, it is called "opening snap", in Russian - "click of the opening of the mitral valve". The mitral valve opening click appears in diastole 0.07-0.13 s after tone 2. It is heard better at the top of the heart, is characterized by constancy, has a high, sonorous timbre, a fragmentary character, and can be equal in volume to 2 tones.
The components of the gallop rhythm are the following sound phenomena: tone 1 is enhanced, clapping, tone 2 is enhanced by a. pulmonalis, a mitral valve click, and the presence of a diastolic murmur.
Materials for self-control:
A. Tasks for self-control.
Provide written answers to the following questions:
1. Indicate and identify the main points of auscultation of the heart.
2. Write down the algorithm for characterizing heart sounds.
3. What is tone splitting?
4. What is a bifurcation of heart sounds?
5. Under what conditions is the gallop rhythm heard?
6. Under what pathological conditions is the quail rhythm auscultated?
B. Test questions:
1. In what disease are there weakening of both heart sounds:
1. Graves' disease
2. dilatation of the heart cavity in heart failure
3. extrasystoles
4.abuse of coffee
5. inflammatory infiltrates of the anterior edges of the left lung
2. Strengthening of 1 heart sound occurs when:
1.myocardial infarction
2. synchronous atrial and ventricular systole with complete atrioventricular block
3.myocarditis
4.myocardiosclerosis
5. severe chronic anemia
3. weakening of 1 tone at the apex of the heart occurs when:
1. mitral stenosis
2.mitral insufficiency
3. extrasystoles
4. synchronous atrial and ventricular systole with complete atrioventricular block
5. With thyrotoxicosis
4. In what diseases is the weakening of the 1st heart sound observed:
1. extrasystoles
2. synchronous atrial and ventricular systole with complete atrioventricular blockade
3.myocardiosclerosis
4. mitral stenosis
5.coffee poisoning
5. In what diseases is there a weakening of 1 tone at the apex of the heart:
1.myocarditis
2. mitral stenosis
3. extrasystole
4. thyrotoxicosis
5.excitement
6. Why is there a weakening of the 2nd heart sound in case of mitral valve insufficiency?
1. Due to the protrusion of the bicuspid valve into the cavity of the left atrium and the impact of its valves on the blood that is in it
2. Since in the diastolic period, less than normal amount of blood enters the left ventricle
3.due to the absence of a period of closed valves
4. Due to cicatricial narrowing of the mitral valve
5.As a result of the destruction of the chord strings and the weakening of the papillary muscles
7. If the patient has mitral valve insufficiency, there is a further weakening of tone 1 (for example, after observing him for 5 years), then you can think about:
1. Suspension of rheumatic damage to the mitral valve;
2. Further destruction of the mitral valve and increased blood regurgitation into the left atrium;
3. About improving the contractile activity of the left ventricle;
4. When joining stenosis of the mitral orifice;
5. About the manifestation of a complete blockade of the left leg of the bundle of His;
8. If the patient has mitral valve insufficiency, there is a further weakening of 1 tone at the apex of the heart (for example, when observing the patient for 5 years), then you can think about:
1. an increase in the contractility of the left ventricle, an increase in the dilatation of its cavity;
2. About the appearance of a complete blockade of the left leg of the bundle of His;
3.About joining the stenosis of the mitral orifice;
4. When improving the contractility of the left ventricle;
5. Suspension of rheumatic damage to the mitral valve.
9. In what cases can weakening of the 1st sound at the apex of the heart increase in a patient with mitral valve insufficiency?
1. When the mitral valve is destroyed;
2. With the improvement of the contractile activity of the left ventricle under the action of cardiac glycosides;
3. With an increase in cardiac weakness;
4. With an increase in blood regurgitation into the left atrium;
5. When chondral filaments are sclerosed.
10. In what case can a weakened 1st sound at the apex of the heart increase in a patient with mitral valve insufficiency?
1. When mitral valve stenosis is attached;
2.When sclerosing chondral filaments;
3. With perforation of the walls of the mitral valve;
4. When calcium salts are deposited in the walls of the mitral valve;
5. With an increase in the degree of left ventricular hypertrophy and dilatation of its cavity;
11. Why is there a weakening of the 1st tone at the apex of the heart in aortic defects?
1. as a result of an increase in the contractility of the left ventricle;
2. as a result of hypertrophy and dilatation of the left ventricle;
3. as a result of damage to the semilunar valves of the aorta;
4. As a result, sclerosis of the aortic valve.
5.as a result of increased systolic pressure in the aorta.
12. Strengthening of 1 tone at the top of the heart occurs when:
1. insufficiency of the mitral valve;
2. mitral stenosis;
3. Insufficiency of the aortic valve;
4. stenosis of the aortic mouth;
5. Insufficiency of the tricuspid valve.
13. Amplification of 1 tone at the apex of the heart occurs when:
1. Graves' disease
2.myocarditis
3.myodystrophy
4.myocardiosclerosis
5.myocardial infarction
14. Amplification of 2 tones on the aorta occurs when:
1. Insufficiency of the aortic valves
2. Stenosis of the aortic mouth
3.symptomatic arterial hypertension
4. Increased pressure in the pulmonary circulation
5.arterial hypotension
15. At the heart of the appearance of accent 2 tones on the aorta lies:
1. Increased pressure in the systemic circulation
2. increased pressure in the pulmonary circulation
3. Increased end-diastolic pressure in the left ventricle
4. Increased end-diastolic pressure in the right ventricle
5. Increased end-systolic pressure in the left atrium
16. At the heart of the appearance of accent 2 tones on the pulmonary artery lies:
1. Increased end-diastolic pressure in the right ventricle
2. Emphysema
3. Insufficiency of 3-leaf valves
4.Pneumosclerosis
5. Increased pressure in the pulmonary circulation
17. Accent 2 tones on the pulmonary artery occurs when:
1. Stenosis of the aortic mouth
2.Stenosis of the mitral orifice
3. Tricuspid valve insufficiency
4. Stenosis of the aortic valve
5. Acute catarrhal bronchitis
18. "Clapping" 1 tone at the top of the heart occurs when:
1.Mitral valve insufficiency
2. Stenosis of the aortic mouth
3. Insufficiency of the aortic valves
4. Stenosis of the mitral orifice
5.pneumosclerosis
19. “Clapping” timbre of the 1st tone in mitral stenosis is due to:
1. left ventricular hypertrophy
2. Stretching of the chondral filaments
3. Increased pressure in the pulmonary circulation
4. Accelerated blood flow
5. Sclerosis of the mitral valve and hitting it against a large amount of blood that is in the left atrium
20. "Metallic" shade 2 tones on the aorta occurs when:
1. insufficiency of aortic valves
2.stenosis of the mouth of the aorta of rheumatic origin
3. sclerosis of the aortic valves with its atherosclerotic lesion
4.left ventricular hypertrophy
5.Hypertension
21. It is necessary to speak about the splitting of heart tones when the pause between the components (or pairs of components) is:
3. 0.035-0.050 s
5.0.015-0.02s
22. It is necessary to speak about the bifurcation of heart tones when the pause between the components (or pairs of components) is:
3.0.035-0.05s
5.0.015-0.02s
23. Splitting (separation) within one pair of components 1 ton occurs when:
1. Complete transverse heart block
2.atrioventricular blockade 2 tbsp.
3.Hypertension
4.acute bronchitis
5. hypertrophy of one of the ventricles of the heart
24. The splitting (bifurcation) of 1 ton of the heart inside one of the pair of components is based on:
1. transverse asynchrony of the activity of the heart (due to the asynchronous activity of unilateral atria and ventricles)
2. asynchronous activity of the left and right parts of the heart of the same name
3. hypertrophy of one of the atria or ventricles
4.increased pressure in the systemic or pulmonary circulation
5.complete blockade
25. Physiological splitting (bifurcation) of heart sounds differs from pathological:
1.its stability
2. Lack of connection with the phase of respiration
3. the fact that it is more common in elderly and senile people
4. those that are not associated with muscle tension and changes in body position
26. Splitting (bifurcation) of 2 heart sounds occurs when:
1. AV blockade 1 tbsp.
2. AV blockade 2 tbsp.
3.Complete AV block
4. Blockade of one of the legs of the bundle of His
5.Hypertension of the systemic circulation
27. Splitting (bifurcation) of 2 heart sounds occurs when:
1.Extrasystolic arrhythmia
2.Respiratory arrhythmia
3.Hypertension of the pulmonary circulation
4.Complete AV block
5. Anemia
28. Splitting 2 tones can occur when:
1.acute diffuse bronchitis
2.Respiratory arrhythmia
3.left ventricular hypertrophy
4. right ventricular hypertrophy
5.Hypertension
29. Splitting of 2 tones can occur when:
1.Complete AV block
2. Blockade of the right leg of the bundle of His
3. Acute bronchitis
4. Emphysema
5. Dry pleurisy
30. The mitral valve opening tone is heard when:
1.Mitral valve insufficiency
2.mitral stenosis
3. mitralization of aortic defects
4. Damage to the mitral valve in septic endocarditis
5. Deposition of calcium salts on the mitral valves
31. A click of the mitral valve opening occurs after ... seconds after 2 tones:
32. With the same heart rate, the distance from tone 2 to the mitral valve opening tone will depend on:
1. Conditions of myocardial tone of the left ventricle
2. States of the conduction system of the ventricles
3. The severity of mitral stenosis and the level of pressure in the left atrium
4. Degrees of hypertrophy and dilatation of the left atrium
5. The level of pressure in the pulmonary artery
33. The mechanism of formation of presystolic gallop rhythm is based on:
1.blood blow during the release of the left ventricle on the sclerotic wall of the aorta
2.strong contraction of the hypertrophied left atrium
3. Weakening of the contractility of the left ventricle
4. Development of 2nd degree AV block
5. Sclerosis of the mitral valve leaflets
34. In what disease can gallop rhythm occur?
1. dry pleurisy
2. dry pericarditis
3.atherosclerosis of the aorta
4. In the final stage of chronic glomerulonephritis
5. Chronic bronchitis
35. On the phonocardiogram, the presystolic gallop rhythm is located:
1. To the beginning 1 ton, coincides in time with the P wave on the ECG
2. Coincides with 1 heart sound
3. Located between 1 and 2 heart sounds
4.Located at a distance of 0.07-0.11s after 2 tones
5. is at a distance of 0.12-0.18 s after 2 tones
36. Can proto-diastolic gallop rhythm occur in any disease?
1.Complete AV block
2. blockade of one of the legs of the bundle of His
3.Severe myocardial infarction
4. mitral stenosis
5.compensated aortic defects
37. Proto-diastolic gallop rhythm occurs in ... seconds after tone 2:
38. When can the proto-diastolic gallop rhythm disappear in a patient?
1. With a decrease in myocardial contractility
2. Termination of blood regurgitation from the left ventricle to the left atrium
4. Union of leaflets of the mitral valve in case of stenosis of the mitral orifice
5. Increased blood regurgitation from the left ventricle to the left atrium
39. When can the proto-diastolic gallop rhythm disappear in a patient?
1. With a deterioration in the contractility of the myocardium of the left ventricle
2. with an improvement in the contractility of the ventricular myocardium under the influence of cardiac glycosides
3. With the appearance of mitralization of aortic defects
4. With the disappearance of blood regurgitation from the left ventricle to the left atrium
5.When a complete AV block appears
40. When can the mitral valve opening tone disappear in a patient?
1. With an increase in pressure in the pulmonary circulation
2. With the appearance of atherosclerosis of the aorta
3. Development of atrial fibrillation
4. When the contractility of the left ventricle is weakened
5. With the development of severe sclerosis and calcification of the mitral valve
B. Situational tasks:
1. A 28-year-old patient complains of shortness of breath, palpitations, fatigue, fever up to 37.8 C. From the anamnesis it is known that a month ago he had an acute respiratory viral disease. At an objective examination, the weakening of the apex beat attracts attention, during auscultation - tachycardia, at the apex of the heart, the melody leads 2 tone. After conducting additional research methods, the patient was diagnosed with myocarditis.
— What, in your opinion, is the cause of the development of myocarditis in a patient?
- Interprets auscultation data at the apex of the heart.
— Why did such changes in the auscultatory picture occur?
2. When conducting a physical examination of the heart in a patient with acute myocardial infarction, the following data were found. On palpation: apex beat - in the 5th intercostal space 2 cm to the left of l.medioclav.sin., 3 cm in area, significantly weakened, reduced resistance and height. Percussion: the right border of relative cardiac dullness is 1 cm to the right of the right edge of the sternum, the upper border is the lower edge of the third rib, the left border is 2.5 cm to the left of l.medioclav.sin. Auscultation revealed: at the apex, the activity of the heart is rhythmic, a 3-membered rhythm is heard, all three tones are almost the same sonority, weakened, muffled. Based on the heart - a slight accent of the 2nd tone in the II intercostal space to the left of the sternum.
— What 3-membered rhythm is most likely auscultated at the apex of the patient's heart?
— What is the mechanism of formation of a 3-membered rhythm in this case?
3. A 32-year-old patient has been suffering from rheumatic heart disease since the age of 15. On palpation of the precordial region, there is a weakening of the apex beat, which is located in the 5th intercostal space 2 cm dosererdina from l. medioclav.sin. and has an area of 1-1.5 cm; in the epigastric region immediately below the xiphoid process, a pulsation is determined, which increases at the height of inspiration. Percussion borders of relative cardiac dullness are as follows: right - 2.5 cm to the right of the right edge of the sternum, upper - at the level of II intercostal space, left - 2 cm to the middle from l. medioclav.sin. During auscultation, a 3-membered melody is heard at the apex of the heart, while the I tone is enhanced, loud, and has a clapping character. On the basis of the heart, the accent of the II tone is determined in the II intercostal space to the left of the sternum.
- How are the limits of the patient's heart changed? What parts of the heart are affected by such data?
— What 3-membered rhythm is auscultated at the apex of the patient's heart? What is the mechanism of formation of a 3-membered rhythm in this case?
- Why did the second tone accent appear in the second intercostal space to the left of the sternum?
What disease are these findings of a physical examination of the heart typical for?
1. Fundamentals of internal medicine: propaedeutics of internal diseases (under the editorship of O. G. Yavorsky, Kyiv "Health" 2004)
2. Shklyar V.S. Diagnosis of internal diseases - M. "Higher School", 1972
3. Propaedeutics of internal diseases (under the editorship of Vasilenko V.Kh. and Grebenev A.A. - M .: Medic, 1989.
4. Propaedeutics of internal diseases with the care of therapeutic patients (under the editorship of Doctor of Medical Sciences Prof. A. V. Epishin. Ternopil "Ukrmedicina" 2001.
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