Angina

Organic and functional heart murmurs. Causes of systolic murmur in the heart

First, you need to understand what heart murmurs are and distinguish between physiological and pathological. Normally, when the heart valves operate, or more precisely, when they slam shut during rhythmic heart contractions, sound vibrations occur that are not audible to the human ear.

When listening to the heart with a doctor's phonendoscope (auscultation tube), these vibrations are defined as the I and II heart sounds. If the valves do not close tightly enough, or vice versa, blood moves through them with difficulty, an enhanced and longer-lasting sound phenomenon occurs, called a heart murmur.

If such a sound occurs in the absence of serious heart disease, it is considered physiological; if the sound occurs due to organic damage to the muscle tissue of the heart and heart valves, then it is considered pathological.

When examining a patient, a doctor, without instrumental diagnostic methods, can already guess whether there is damage to a certain heart valve, which leads to a sound phenomenon in the heart.

This is largely due to the division of murmurs according to the time of occurrence - before or immediately after ventricular contraction (systolic or post-systolic murmur) and by localization, depending on the auscultation at the point of projection of a particular valve on the anterior chest wall.

Causes of sound phenomena in the heart

In order to more accurately determine what causes the amplified sound in a particular patient, you should undergo additional examination and identify the cause of the heart murmur.

Physiological reasons

Murmurs due to extracardiac causes occur when the neurohumoral regulation of cardiac activity is disrupted, for example, when the tone of the vagus nerve increases or decreases, accompanying a condition such as vegetative-vascular dystonia, as well as during periods of rapid growth in children and adolescents.
Murmurs caused by intracardiac causes often indicate minor anomalies in cardiac development in children and adults. These are not diseases, but structural features of the heart that arise during fetal development. These include mitral valve prolapse, additional or abnormally located chords of the left ventricle, and a patent foramen ovale between the atria. For example, in an adult, the basis for a heart murmur may be that the oval window has not healed since childhood, but this is quite rare. However, in this case, systolic murmur can accompany a person throughout his life. Often this sound phenomenon begins to manifest itself as mitral valve prolapse in a woman during pregnancy.
Also, physiological noises can be caused by the anatomical features of the large bronchi, located next to the aorta and pulmonary artery, and which can simply “squeeze” these vessels with a slight disruption of blood flow through their valves.

Metabolic disorders, for example, with anemia (decreased hemoglobin in the blood), the body seeks to compensate for the lack of oxygen carried by hemoglobin, and therefore the heart rate increases and blood flow inside the heart and blood vessels accelerates. The rapid flow of blood through normal valves is certainly combined with turbulence and turbulence in the blood flow, which causes the appearance of systolic murmur. Most often it is heard at the apex of the heart (in the fifth intercostal space on the left under the nipple, which corresponds to the point of listening to the mitral valve).
Changes in blood viscosity and increased heart rate due to thyrotoxicosis (excess thyroid hormones) or fever are also accompanied by the appearance of physiological noise.
Prolonged overstrain, both mental and physical, can contribute to a temporary change in the functioning of the ventricles and the appearance of noise.
One of the most common causes of sound phenomena is pregnancy, during which the volume of circulating blood in the mother’s body increases for optimal blood supply to the fetus. In this regard, during pregnancy, changes in intracardiac blood flow also occur with the auscultation of a systolic murmur. However, the doctor should be wary when murmurs appear in a pregnant woman, since if the patient has not been previously examined for cardiac diseases, sound phenomena in the heart may indicate the presence of some serious disease.

Pathological causes

Heart defects. This is a group of congenital and acquired diseases of the heart and large vessels, characterized by disruption of their normal anatomy and destruction of the normal structure of the heart valves. The latter include lesions of the pulmonary valve (at the site where the pulmonary trunk exits the right ventricle), aortic (at the site where the aorta exits the left ventricle), mitral (between the left atrium and ventricle) and tricuspid (or tricuspid, between the right atrium and ventricle) valves . The defeat of each of them can be in the form of stenosis, insufficiency, or a simultaneous combination of both. Stenosis is characterized by narrowing of the valve ring and difficulty passing blood through it. Insufficiency is caused by incomplete closure of the valve leaflets and the return of part of the blood back to the atrium or ventricle. The cause of the defects is most often acute rheumatic fever with damage to the endocardium as a result of a streptococcal infection, for example, tonsillitis or scarlet fever. Murmurs are characterized by rough sounds; they are called that way, for example, rough systolic murmur over the aortic valve with aortic valve stenosis.
You can often hear from a doctor that the patient has louder and longer sounds. heart murmur than before. If a doctor tells a patient that his heart murmurs have increased during treatment or a stay in a sanatorium, do not be alarmed, as this is a favorable sign - loud murmurs are an indicator of a strong heart with defects. The weakening of noise caused by the defect, on the contrary, may indicate an increase in circulatory failure and a deterioration in the contractile activity of the myocardium.
Cardiomyopathy is an expansion of the cavity of the heart chambers or hypertrophy (thickening) of the myocardium, caused by long-term toxic effects on the myocardium of thyroid or adrenal hormones, long-term arterial hypertension, or previous myocarditis (inflammation of the muscle tissue of the heart). For example, systolic murmur at the point of auscultation of the aortic valve is accompanied by hypertrophic cardiomyopathy with obstruction of the left ventricular outflow tract.
Rheumatic and bacterial endocarditis is inflammation of the inner lining of the heart (endocardium) and the proliferation of bacterial vegetations on the heart valves. The murmur can be systolic or diastolic.
Acute pericarditis is an inflammation of the pericardial layers lining the outside of the heart, accompanied by a three-component pericardial friction rub.

Expansion of the cavity of the heart chambers or hypertrophy (thickening) of the myocardium

Symptoms

Physiological heart murmurs can be combined with symptoms such as:

weakness, pale skin, fatigue due to anemia;
excessive irritability, rapid weight loss, trembling of the limbs with thyrotoxicosis;
shortness of breath after exercise and in a lying position, swelling of the lower extremities, rapid heartbeat in late pregnancy;
feeling of rapid heartbeat after physical exertion with additional chords in the ventricle;
dizziness, fatigue, mood swings with vegetative-vascular dystonia, etc.

Pathological heart murmurs are accompanied by cardiac arrhythmias, shortness of breath on exertion or at rest, episodes of nocturnal suffocation (attacks of cardiac asthma), swelling of the lower extremities, dizziness and loss of consciousness, pain in the heart and behind the sternum.

It is important that if the patient notices similar symptoms, he should consult a doctor as soon as possible, because only a doctor’s examination and additional examination can determine the cause of the symptoms described above.

Diagnostics

If a therapist or other doctor hears additional sounds in a patient when the valves are working, he will refer him for a consultation with a cardiologist. Already at the first examination, the cardiologist can guess what explains the murmur in a particular case, but will still prescribe some additional diagnostic methods. Which ones exactly, the doctor will decide individually for each patient.

Loud murmurs are an indicator of a strong heart with defects

During pregnancy, every woman should be examined at least once by a therapist to determine the state of her cardiovascular system. If a heart murmur is detected, or moreover, there is a suspicion of a heart defect, you should immediately consult a cardiologist, who, together with the gynecologist leading the pregnancy, will decide on further tactics.

To determine the nature of the murmur, auscultation (listening with a stethoscope) of the heart remains a relevant diagnostic method, which provides very significant information. So, with physiological causes of noise, it will have a soft, not very sonorous character, and with organic damage to the valves, a rough or blowing systolic or diastolic murmur will be heard. Depending on the point on the chest at which the doctor hears pathological sounds, it can be assumed which of the valves is destroyed:

projection of the mitral valve - in the fifth intercostal space to the left of the sternum, at the apex of the heart;
tricuspid - above the xiphoid process of the sternum in its lowest part;
aortic valve - in the second intercostal space to the right of the sternum;
pulmonary valve - in the second intercostal space to the left of the sternum.

The following additional methods may be prescribed:

- general blood test - to determine the level of hemoglobin, the level of leukocytes during fever;
- biochemical blood test - to determine the performance of the liver and kidneys in case of circulatory failure and blood stagnation in the internal organs;
- blood tests for thyroid and adrenal hormones, rheumatological tests (if rheumatism is suspected).

This is what the data obtained from FCG looks like:

Cardiac ultrasound is the “gold standard” in examining a patient with a heart murmur. Allows you to obtain data on the anatomical structure and disturbances of blood flow through the heart chambers, if any, as well as determine systolic dysfunction in heart failure. This method should be a priority in every patient, both a child and an adult, with a heart murmur.
phonocardiography (PCG) – amplification and recording of sounds in the heart using special equipment,
An electrocardiogram can also suggest whether there are gross disturbances in the functioning of the heart or whether the cause of the heart murmur lies in other conditions.

Treatment

This or that type of treatment is determined strictly according to indications and only after the appointment of a specialist. For example, in case of anemia, it is important to start taking iron supplements as soon as possible, and the systolic murmur associated with this will disappear as hemoglobin is restored.

If the function of the endocrine system organs is impaired, the correction of metabolic disorders is carried out by an endocrinologist using medications or surgical treatment, for example, removal of an enlarged part of the thyroid gland (goiter) or an adrenal tumor (pheochromocytoma).

If the presence of systolic murmur is due to minor anomalies in the development of the heart without clinical manifestations, as a rule, there is no need to take any medications; regular examination by a cardiologist and echocardiography (ultrasound of the heart) once a year or more often as indicated is quite sufficient. During pregnancy, in the absence of serious illnesses, heart function will return to normal after childbirth.

It is important to begin therapy for organic heart lesions from the moment an accurate diagnosis is established. The doctor will prescribe the necessary medications, and in case of heart defects, surgery may be necessary.

In conclusion, it should be noted that a heart murmur is not always caused by a serious illness. But you should still undergo a timely examination to exclude such a disease or, if it is detected, to begin treatment in a timely manner.

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Detection and interpretation of heart murmurs are often difficult and require experience and knowledge of physiology and cardiology. Currently, if a murmur is present, the patient is immediately referred for echocardiography. Murmurs are audible vibrations caused by turbulent blood flow. They are described using a large number of characteristics given in table. 1. Noises vary in intensity (loudness), as described in table. 2.

Table 1.

Description of noise

Intensity (loudness)	Degrees 1-6 (or 1-4) (see table 1)
Duration	Short to long noise
Character (shape)	Crescendo, decrescendo, variable, plateau, crescendo-decrescendo
Time	In relation to the phases of the cardiac cycle, for example mid-systolic, pan-systolic, late systolic, early diastolic
Frequency	High or low frequency
Character	For example, blowing, rough, scratching, gurgling, scraping, etc.
Localization	Maximum intensity
Carrying out	Conducting noise to auscultation points (including the vessels of the neck)
Variability	Variability depending on the phases of breathing

Table 2.

Noise intensity gradations

Degrees 1-6	Degrees 1-4	Description
1	1	Very little noise. Usually only an experienced doctor can listen to him
2	2	Faint but distinct noise
3	3	Loud noise without accompanying vibration
4	4	Loud noise accompanied by subtle shaking
5	4	Loud noise accompanied by distinct shaking
6	4	Loud noise accompanied by shaking, audible when the stethoscope is removed from the surface of the chest

Functional noise

Not all noises are pathological; quite often there are functional noises that occur during hyperkinetic blood circulation, for example in healthy children, as well as during pregnancy, thyrotoxicosis, against the background of fever and anemia. Their presence may require an echocardiogram to ensure that the murmur is truly functional. Such murmurs are always systolic, usually quiet or of moderate intensity, have a “musical” tone, and are not rough or blowing.

Systolic murmurs

Blood flow through pathologically altered structures leads to the formation of noise due to the presence of a pressure gradient (on a pathologically altered valve, in the area of a septal defect, with coarctation, etc.). The louder the noise, the greater the pressure gradient and the higher the blood flow velocity. The murmur does not occur until the expulsion of blood from the left ventricle begins, and reaches a maximum at the moment of greatest blood flow through the narrowed opening. Therefore, in severe stenosis, the peak of the murmur is recorded in late systole. The murmur stops before the start of the second sound, as cardiac output stops. Therefore, the noise has a crescendo-decrescendo shape. This noise is called ejection noise. Since the murmur is dependent on blood flow, it may weaken or disappear when the degree of valve damage is very severe and leads to HF. The systolic murmur of regurgitation on the MV can occur as soon as the isovolemic contraction begins, that is, before the onset of ejection, since the reverse flow of blood occurs simultaneously with the beginning of an increase in pressure in the ventricle and continues until the appearance of the second sound or ends a little earlier. This occurs due to the pressure difference between the LV and LA during systole. Often the second tone is covered by noise. Murmurs of this type, occupying the entire systole, are called pansystolic or holosystolic. Pansystolic murmur also occurs with a ventricular septal defect (VSD). However, in many patients with mitral regurgitation, the valve failure is incomplete, and then the murmur begins in the middle or even at the end of systole and continues until the second sound. Late systolic murmurs may have a crescendo shape, which resembles an ejection murmur, but they arise much later in systole, cover the second sound, and then suddenly stop. It is not difficult for an experienced doctor to determine this, especially in the absence of pronounced tachycardia, but sometimes a systolic click in the middle or end of diastole is mistaken for the second sound, and the murmur is interpreted as diastolic.

Diastolic murmurs

Diastolic murmurs on the AV valves are very difficult to hear. These noises are usually low-frequency and may be mistaken for external noise by an inexperienced physician. Typically, diastolic murmur is a sign of mitral stenosis (sometimes TC stenosis), and these defects are becoming less common in developed countries. The diastolic murmur of mitral stenosis intensifies when the patient is positioned on the left side when listening to the apex area with a phonendoscope cone and/or after physical exertion. Mid-diastolic murmurs intensify immediately before the onset of the next systole, since in presystole the blood flow through the MV increases due to atrial contraction (Table 3). This presystolic enhancement usually disappears as AF progresses, but may sometimes persist.

Table 3.

Differential diagnosis of systolic murmurs

	Cause	Localization	Comment
Systolic ejection murmur	Aortic stenosis	To the left of the sternum in the area of the upper third, also often at the apex. Performed on the carotid arteries	Slow pulse in the carotid arteries, but not always detected in the elderly. The apical impulse is usually elevating, but not displaced. In young people, the noise may be preceded by an ejection tone. The II tone varies, with severe valve calcification there is no splitting
	Pulmonary artery (PA) stenosis	To the left of the upper edge of the sternum	Intensifies on inspiration. Ejection tone, possibly delayed pulmonary component II tone
			Fixed splitting of the second tone. With a large discharge, you can palpate the contracting pancreas along the left edge of the sternum
	Functional	All points. "Musical"	May appear with high cardiac output
Pansystolic	Mitral regurgitation	At the apex, carried into the axillary region	It varies greatly, but with valvular regurgitation it often blows and covers the second sound. Pulsating top. In case of severe defect, mid-diastolic murmur and III tone may appear
	Tricuspid regurgitation	Along the left edge of the sternum	It intensifies on inspiration, the v-wave of the pulse is pronounced in the jugular veins, and pulsation of the liver is possible. Pulsation to the left of the sternum is also possible - a sign of pulmonary hypertension
		Along the left edge of the sternum	Usually rough, often accompanied by trembling. Single II tone with a large defect
Late systolic	Mitral regurgitation associated with damage to subvalvular structures (MVP, chord avulsion)	At the apex, carried into the axillary region, but can also carried out in the back and neck area	Often rough, the murmur may be preceded by a systolic click. Elevating apical impulse, mid-diastolic murmur and III sound with severe mitral regurgitation. Can be confused with an early diastolic murmur if it is preceded by a late click, which is mistaken for the second tone
Presystolic	Mitral stenosis (and also TC stenosis - very rare)	At the apex and left edge of the sternum	Sometimes it is difficult to recognize. The murmur is often mistaken for systolic and associated with mitral regurgitation. It is necessary to carefully compare the noise with the pulsation of the carotid arteries

Early diastolic murmur

Early diastolic murmurs occur due to regurgitation of blood at the AC or PC. They have a decrescendo shape and follow directly the second tone. This results from the fact that the maximum pressure difference between the vessel and the ventricular cavity occurs at the beginning of diastole. Minor aortic regurgitation results in a short, soft early diastolic murmur that is difficult to hear, but the intensity of the murmur may increase as the patient bends forward and exhales. These actions make regurgitation better audible due to the closer location of the heart to the anterior surface of the chest. An increase in noise intensity may be associated with an increase in the degree of the defect, but sometimes paradoxical situations arise. When chronic aortic regurgitation is very severe, backflow of blood from the aorta into the ventricle occurs very quickly and the murmur becomes loud but very short. This phenomenon is even more pronounced with the development of acute aortic regurgitation due to valve damage due to endocarditis, dissecting aneurysm or trauma. Before the defect occurs, the LV is of normal size, and a sudden large volume of regurgitation instantly fills it to its maximum limit, leading to slamming of the MV. This leads to extremely low cardiac output and a very short murmur. Clinical signs include collapse, sinus tachycardia and the appearance of an auscultatory pattern resembling a gallop rhythm. An experienced cardiologist will immediately recognize severe acute aortic regurgitation and prescribe appropriate testing, including emergency echocardiography. Often, emergency surgery for AK can save the patient's life, but if the diagnosis is not made in a timely manner, the consequences can be fatal. Pulmonary hypertension produces an early diastolic murmur that is lower in pitch than that of aortic regurgitation. An early diastolic murmur is heard in the upper part of the sternum along its left edge and follows the loud pulmonary component of the second sound (a sign of pulmonary hypertension).

Systole-diastolic murmurs

Systole-diastolic murmurs are rare in adults. These are murmurs heard throughout the entire cardiac cycle. The systolic component is usually louder than the diastolic component, but there seems to be no interval between them, and they are well named "engine noises" because they are similar to the sound of a running engine. A systole-diastolic murmur may be a sign of a patent ductus arteriosus that was undiagnosed in childhood. However, most often in adults, systolic-diastolic murmur is a sign of an acutely developed fistula between the right and left chambers of the heart. In this case, blood flow occurs in both systole and diastole. The most common example is a rupture of the sinus of Valsalva, although infective endocarditis can lead to the formation of an arteriovenous and right-sided shunt.

Carotid murmurs

Systolic murmur on the carotid arteries has the following properties.

1.Can be performed from the heart valves - usually the aortic, although loud mitral murmurs may also be heard in the neck. The same noise will be heard above the surface of the chest.

2. It may occur due to damage to the carotid arteries, in this case it is heard only in the neck. It is sometimes difficult to understand whether there is a combined lesion of the valve and carotid arteries or an isolated lesion of the AV.

Noise irradiation

The irradiation of noises is complex, and in general any noise can be carried out to any point in the chest. However, typical sites include the apical/mitral, pulmonary, aortic, and tricuspid regions, with radiation to the carotid arteries, the back, and/or the axilla. It must be remembered that loud noises during MVP and chord rupture can be carried out anywhere, including to the vessels of the neck, and resemble the noise during aortic stenosis. Moreover, the noise of aortic stenosis in elderly patients is characterized by a louder sound at the apex than at classical auscultation points. This occurs due to emphysema in the elderly and interferes with auscultation, especially at the base of the heart. Aortic murmurs, heard only at the apex, are often carried out on the carotid arteries.

Other auscultatory phenomena

The pericardial friction noise that occurs with pericarditis is caused by the friction of the inflamed pericardial layers against each other with each contraction of the heart. It is an intermittent grinding sound with systolic and diastolic components. It is better heard when the patient is lying on his back, and may disappear when the patient sits down and bends forward - in this position, as a rule, the pain associated with pericarditis decreases. You should always think about the presence of pericarditis when you see a patient sitting on the bed, leaning forward.

Roger Hall, Iain Simpson

History taking and physical examination of patients with cardiovascular diseases

To understand what causes heart murmurs exist, you must first look at their classification. So, systolic murmur in the heart happens:

inorganic;
functional;
organic.

The latter is associated with morphological changes in the heart muscle and valves. It is divided into ejection and regurgitation murmurs, pulmonary aortic narrowing or pulmonary arrhythmia, and valvular abnormalities, respectively.

In the first case, the noise is quite strong and sharp, heard in the second intercostal space on the right and spreads towards the right clavicle. A systolic oscillation is felt at the site where it is heard and on the carotid artery. The time of occurrence is determined by the first sound and intensifies towards the median systole. With a sharp narrowing, the peak of the noise occurs in the second part of systole due to the slow expulsion of blood.

Systolic murmur with enlargement of the aortic mouth is less sharp, there is no trembling. The maximum strength occurs at the beginning of systole, the second sound is intensified and sonorous. In patients of retirement age during atherosclerosis, in addition to the systolic murmur above the aorta, a similar sound is also heard above the apex of the heart, in other words it is called aortomitral systolic murmur.

During narrowing of the pulmonary artery orifice, it is heard in the second left intercostal space and is distributed towards the clavicle on the left. The sound is strong and rough, and there is also some vibration. The second sound bifurcates into pulmonary and aortic components.

Non-closure of the septum between the ventricles is characterized by a loud and rough systolic murmur heard in the fourth and third intercostal spaces. Deviation in the functioning of the mitral valve is accompanied by a murmur above the apex of the heart, which spreads towards the armpits, begins immediately after the first sound and becomes weaker towards the end of systole. At the bottom of the sternum, it is determined by tricuspid valve insufficiency, similar to mitral murmurs, quiet and poorly audible.

Coarctation of the aorta is characterized by a murmur near the base of the heart muscle, which is heard louder in the back and above the scapula on the left, spreading along the length of the spine. It begins after the first tone with a slight lag and ends after the second tone. A patent ductus arteriosus is accompanied by a systolic murmur resulting from the flow of blood into the pulmonary artery from the aorta. This occurs during both cycles, audibility is more distinct under the left collarbone or above the pulmonary artery.

Noise classifications

Functional noises are classified as follows:

with mitral insufficiency, heard above the apex of the heart;
above the aorta when it enlarges;
arising from aortic valve insufficiency;
above the pulmonary artery during its expansion;
during nervous excitement or physical exertion, accompanied by tachycardia and ringing tones;
appearing with fever;
arising from thyrotoxicosis or severe anemia.

By its nature, the noise is distinguishable from a heartbeat, and treatment depends on its volume, frequency and strength. There are six volume levels:

Barely visible.
Disappearing at times.
Constant noise, more sonorous and without trembling of the walls.
Loud, accompanied by vibrations of the walls (can be distinguished by placing your palm).
Loud, which can be heard in any area of the chest.
The loudest one can be easily heard, for example, from the shoulder.

Volume is affected by body position and breathing. For example, when you inhale, the noise increases, as the reversal of blood to the heart muscle increases; When standing, the sound will be much quieter.

Causes

Systolic murmurs can occur in children already in the first year of life, which, as a rule, is a sign of restructuring of the circulatory system.

Quite often, similar symptoms are diagnosed in children. The reasons for the occurrence of noise in adolescence include the rapid growth of the child’s entire body and the restructuring of the endocrine system. The heart muscle does not keep up with growth, and therefore certain sounds appear, which are temporary phenomena and stop as the work of the child’s body stabilizes.

Common phenomena include the occurrence of noise in girls during puberty and the onset of menstruation. Frequent and heavy bleeding may be accompanied by anemia and heart murmurs. In such cases, parents need to take measures to normalize the menstrual cycle after consultation with a pediatric gynecologist.

An excess of thyroid hormones can also cause a heart murmur.

If they are diagnosed in adolescents, doctors first of all refer for an examination of the thyroid gland in order to identify the true causes of the disorders.

Insufficient or overweight in adolescent children affects the functioning of the heart muscle, which is why proper nutrition is so important during the period of active growth of the body.

However, vegetative-vascular dystonia is the most common cause of murmurs. Additional symptoms include headaches, permanent weakness, and fainting.

If such deviations occur in adults over 30 years of age, which is quite a rare occurrence, then I associate them with an organic narrowing of the carotid artery.

Treatment and diagnosis

If murmurs are detected, you should first consult a cardiologist who will conduct a diagnosis and identify the root cause of the deviation. Do not neglect your doctor's recommendations. Health and future life directly depend on the timeliness of actions taken. Of course, each of the subtypes of such manifestations has its own characteristics, however, heart murmurs cannot be attributed to a natural phenomenon.

To detect noise, a specific analysis scheme is used:

First, determine the phase of the heart in which it is heard (systole or diastole).
Next, its strength is determined (one of the degrees of loudness).
The next step is to determine the relationship to heart sounds, that is, it can deform heart sounds, merge with them or be heard separately from the tones.
Then its shape is determined: decreasing, increasing, diamond-shaped, ribbon-shaped.
Consistently listening to the entire area of the heart, the doctor determines the place where the murmur is more clearly audible. Checking the irradiation of a deviation consists of determining its location.
The penultimate stage of diagnosis is to determine the influence of respiratory phases.
After this, the doctor determines the dynamics of the noise over time: it can be a day, a week, a month, etc.

For differential diagnosis, the moment of occurrence of systolic murmurs and their duration are determined using laboratory tests.

As a rule, the following tests are prescribed:

radiography, which allows you to determine thickening of the walls of the heart, hypertrophy or enlarged chambers of the heart;
ECG - determines the level of overload of various areas;
EchoCG - used to detect organic changes;
catheterization

With systolic murmur, symptoms such as fatigue, arrhythmia, shortness of breath, dizziness, and increased heartbeat are also often observed. This manifests itself in human behavior through decreased appetite, depression, and insomnia.

Of course, treatment is directly related to the causes of systolic murmurs. If they are one of the signs of vegetative-vascular dystonia, for example, comprehensive treatment of all symptoms is carried out simultaneously.

The need for additional examinations arises only if such sounds do not go away for a long time and intensify as the child grows and develops. A heart murmur in a child that occurs at age excludes the presence of congenital defects and, as a rule, goes away completely with age without outside intervention.

So, depending on the nature of the phenomenon, treatment can be either medicinal or surgical. In the case of a functional nature of the noise, regular monitoring by a doctor is sufficient.

Systolic heart murmur: causes, symptoms, diagnosis and treatment. Congenital heart defects in children

Not every person has heard of such a concept as systolic sounds. It is worth saying that this condition may indicate the presence of serious pathologies in the human body. A systolic murmur in the heart indicates that there is a malfunction in the body.

What is he talking about?

If a patient experiences sounds inside the body, this means that the process of blood flow in the heart vessels is disrupted. There is a widespread belief that systolic murmur occurs in adults.

This means that a pathological process is occurring in the human body, which indicates some kind of illness. In this case, it is necessary to urgently undergo a cardiac examination.

Systolic murmur is defined as its presence between the second heart sound and the first. The sound is recorded on the heart valves or blood flow.

Division of noise into types

There is a certain gradation of separation of these pathological processes:

Functional systolic murmur. It refers to innocent manifestation. Does not pose a danger to the human body.
Systolic murmur of organic type. Such a noise character indicates the presence of a pathological process in the body.

An innocent type of noise may indicate that there are other processes in the human body that are not related to heart disease. They are mild in nature, do not last long, and have a weakly expressed intensity. If a person reduces physical activity, the noise will disappear. Data may vary depending on the patient's posture.

Noise effects of a systolic nature arise from septal and valvular disorders. Namely, in the human heart there is dysfunction of the partitions between the ventricles and atria. They differ in the nature of their sound. They are hard, tough and stable. A rough systolic murmur is present and its long duration is recorded.

These sound effects extend beyond the boundaries of the heart and are reflected in the axillary and interscapular areas. If a person has subjected his body to exercise, then sound deviations persist after completion. The noise gets louder during physical activity. The organic sound effects that are present in the heart are independent of body position. They can be heard equally well in any position of the patient.

Acoustic value

Heart sound effects have different acoustic meanings:

Systolic murmurs of early manifestation.
Pansystolic murmurs. They also have the name holosystolic.
Mid-late murmurs.
Systolic murmur at all points.

What factors influence the occurrence of noise?

What are the causes of systolic murmur? There are several main ones. These include:

Aortic stenosis. It can be either congenital or acquired. This disease occurs due to narrowing of the aorta. With this pathology, the walls of the valve become fused. This position makes it difficult for blood to flow inside the heart. Aortic stenosis can be considered the most common heart defect in adults. The consequence of this pathology can be aortic insufficiency, as well as mitral disease. The aortic system is designed in such a way that calcification is produced. In this regard, the pathological process intensifies. It is also worth mentioning that with aortic stenosis, the load on the left ventricle increases. At the same time, the brain and heart experience insufficient blood supply.
Aortic insufficiency. This pathology also contributes to the occurrence of systolic murmur. With this pathological process, the aortic valve does not close completely. Infectious endocarditis causes aortic insufficiency. The impetus for the development of this disease is rheumatism. Lupus erythematosus, syphilis and atherosclerosis can also provoke aortic insufficiency. But injuries and congenital defects rarely lead to the occurrence of this disease. A systolic murmur in the aorta indicates that the valve has aortic insufficiency. The reason for this may be expansion of the ring or aorta.
Washing of the acute course is also the reason why systolic murmurs appear in the heart. This pathology is associated with the rapid movement of liquids and gases in the hollow regions of the heart during their contraction. They are moving in the opposite direction. As a rule, this diagnosis is made when the functioning of the dividing partitions is impaired.
Stenosis. This pathological process is also the cause of systolic murmurs. In this case, a narrowing of the right ventricle, namely its tract, is diagnosed. This pathological process occurs in 10% of cases of murmurs. In this situation, they are accompanied by systolic tremors. The vessels of the neck are especially susceptible to irradiation.
Tricuspid valve stenosis. With this pathology, the tricuspid valve narrows. As a rule, rheumatic fever leads to this disease. Patients experience symptoms such as cold skin, fatigue, and discomfort in the neck and abdomen.

Why does noise appear in children?

Why might a child have a heart murmur? There are many reasons. The most common ones will be listed below. So, heart murmurs may occur in a child due to the following pathologies:

Violation of the interatrial septum. In this case, we are talking about the absence of fabric in it. This position leads to the discharge of blood. The volume of blood discharged depends on the size of the defect and the compliance of the ventricles.
Abnormal state of venous return of the lungs of the child's body. There are cases of improper formation of pulmonary veins. The essence of this is that the pulmonary veins do not communicate with the atrium on the right. They can grow together with the veins of the systemic circle.
Aortic coarctation. In this case, we are talking about narrowing of the thoracic aorta. The child is diagnosed with a heart defect. The segmental lumen of the aorta is smaller in size than it should be. This pathology is treated through surgery. If medical care is not provided, as you get older, the narrowing of the aorta will increase.
Pathology of the interventricular septum. This defect also leads to the occurrence of systolic heart murmurs. This pathology can be isolated. That is, it can develop on its own or be combined with other cardiac dysfunctions.
Congenital heart defects in children. An open arterial defect can also cause the presence of systolic murmurs in a child. There is a vessel in the structure of the cardiac system. It is the connecting element between the pulmonary artery and the descending aorta. The function of this organ is to allow the baby to take its first breath after birth. Then, after a short amount of time, the vessel closes. There are cases where this process fails. Then the process of shunting blood from the systemic circulation to the small circulation continues. This is the defect in the functioning of the body. In the case where the breakthrough allows a small blood flow to pass through, this does not particularly affect the child’s health. But if there is a large blood flow, then the baby may experience complications. Namely, there may be an overload in the work of the heart. In this situation, certain symptoms appear in the body, for example, shortness of breath. It also matters what cardiac straits are present in the baby’s body. If their flow is large, then it is possible that the condition of the newborn will be extremely serious. In this situation, in addition to systolic murmurs, the heart itself increases in size. The child is prescribed urgent surgical intervention.

Congenital heart defects in children

It is worth saying a few words about newborn babies. Immediately after birth, a complete examination of the body is carried out. This includes listening to the heart rate. This is done in order to exclude or detect any pathological processes in the body.

With such an examination, there is a possibility of detecting any noise. But they shouldn't always be a cause for concern. This is due to the fact that noises are quite common in newborn babies. The fact is that the child’s body adapts to the external environment. The cardiac system is readjusted, so different noises are possible. Further examination through methods such as x-ray and electrocardiogram will show whether any abnormality is present or not.

The presence of congenital noises in the baby’s body is determined during the first three years of life. Murmurs in newborn babies may indicate that the heart was not fully formed during development before birth for various reasons. In this regard, after birth the baby develops noises. They talk about congenital defects of the cardiac system. In cases where pathologies have a high risk for the child’s health, doctors decide on a surgical method of treating a particular pathology.

Noise features: systolic murmur at the apex of the heart and in other parts of it

It is worth knowing that the characteristics of noise may vary depending on their location. For example, there is a systolic murmur at the aortic apex.

Mitral valve pathology and associated acute insufficiency. In this position, the noise is short-lived. Its manifestation occurs early. If this type of noise is detected, then the patient is diagnosed with the following pathologies: hypokinesis, chord rupture, bacterial endocarditis, etc.
Systolic murmur on the left sternal border.
Chronic mitral valve insufficiency. This type of noise is characterized by the fact that they occupy the entire duration of ventricular contraction. The size of the valve defect is proportional to the volume of blood returned and the nature of the murmur. This noise is better heard if a person is in a horizontal position. As the heart defect progresses, the patient experiences vibration in the chest. There is also a systolic murmur at the base of the heart. Vibration is felt during systole.
Mitral insufficiency of a relative nature. This pathological process is treatable with proper treatment and compliance with recommendations.
Systolic murmur in anemia.
Pathological disorders of the papillary muscles. This pathology refers to myocardial infarction, as well as ischemic disorders in the heart. This type of systolic murmur is variable. It is diagnosed at the end of systole or in the middle. There is a short systolic murmur.

The appearance of heart murmurs during pregnancy in women

When a woman is pregnant, processes such as systolic murmurs cannot be ruled out in her heart. The most common cause of their occurrence is the load on the girl’s body. As a rule, heart murmurs appear in the third trimester.

If they are detected in a woman, the patient is placed under more careful monitoring. At the medical institution where she is registered, her blood pressure is constantly measured, her kidney function is checked, and other measures are taken to monitor her condition. If a woman is constantly under observation and follows all the recommendations that doctors give her, then bearing a child will be in a good mood without any consequences.

How are diagnostic procedures carried out to detect heart murmurs?

First of all, doctors are faced with the task of determining whether there is a heart murmur or not. The patient undergoes an examination such as auscultation. During it, the person must first be in a horizontal position and then in a vertical position. Listening is also performed after physical exercise in a position on the left side while inhaling and exhaling. These measures are necessary to accurately determine noise. Since they can have a different nature of occurrence, an important point is their accurate diagnosis.

For example, in case of pathology of the mitral valve, it is necessary to listen to the apex of the heart. But in case of tricuspid valve defects, it is better to examine the lower edge of the sternum.

An important point in this matter is the exclusion of other noises that may be present in the human body. For example, with a disease such as pericarditis, murmurs may also occur.

Diagnostic options

In order to diagnose noise effects in the human body, special technological means are used, namely: PCG, ECG, radiography, echocardiography. X-ray of the heart is done in three projections.

There are patients for whom the above methods may be contraindicated, since they have other pathological processes in the body. In this case, the person is prescribed invasive examination methods. These include probing and contrast methods.

Samples

Also, to accurately diagnose the patient’s condition, namely, to measure the intensity of noise, various tests are used. The following methods are used:

Loading the patient with physical exercises. Isometric, isotonic, carpal dynamometry.
Listen to the patient's breathing. It is determined whether the noise increases when the patient exhales.
Extrasystole.
Changing the posture of the person being examined. Namely, raising the legs when a person is standing, squatting, etc.
Holding your breath. This examination is called the Valsalva maneuver.

It is worth saying that it is necessary to carry out timely diagnostics to identify murmurs in a person’s heart. An important point is to establish the cause of their occurrence. It should be remembered that systolic murmur may mean that a serious pathological process is occurring in the human body. In this case, identifying the type of noise at an early stage will help to take all necessary measures to treat the patient. However, they also may not have any serious deviations behind them and will pass after a certain time.

It is necessary for the doctor to carefully diagnose the noise and determine the cause of its appearance in the body. It is also worth remembering that they accompany a person at different age periods. These manifestations of the body should not be taken lightly. It is necessary to complete diagnostic activities. For example, if a noise is detected in a woman who is pregnant, then monitoring her condition is mandatory.

Conclusion

It is recommended to check the functioning of the heart even if a person has no complaints about the functioning of this organ. Systolic murmurs may be detected incidentally. Diagnosing the body allows you to identify any pathological changes at an early stage and take the necessary treatment measures.

Systolic murmur

Systolic murmur is a murmur heard during the period of ventricular contraction between the first and second heart sounds.

Hemodynamic changes in the cardiovascular system cause the transformation of the layered blood flow into a vortex, which causes vibration of the surrounding tissue, conducted to the surface of the chest and perceived as sound phenomena in the form of systolic noise.

The presence of an obstruction or narrowing in the blood flow is of decisive importance for the occurrence of vortex movements and the appearance of systolic murmur, and the strength of the systolic murmur is not always proportional to the degree of narrowing. A decrease in blood viscosity, for example in anemia, creates conditions that facilitate the occurrence of systolic murmur.

Systolic murmurs are divided into inorganic, or functional, and organic, caused by morphological changes in the heart and valve apparatus.

Functional systolic murmurs include: 1) systolic murmur of relative mitral insufficiency, heard above the apex of the heart; 2) systolic murmur over the aorta during its expansion; 3) systolic murmur with aortic valve insufficiency; 4) systolic murmur over the pulmonary artery when it expands; 5) systolic murmur, which occurs during nervous excitement or significant physical stress, heard at the base (and sometimes above the apex) of the heart along with tachycardia and increased ringing of tones;

6) systolic murmur during fever, sometimes found over the aorta and pulmonary artery; 7) systolic murmur with severe anemia and thyrotoxicosis, audible over the entire region of the heart.

Systolic murmur, which occurs when the aorta or pulmonary artery dilates, is associated with a relative narrowing of the mouths of these vessels and is most loud at the very beginning of systole, which distinguishes it from systolic murmur with organic stenosis. Systolic murmur in aortic valve insufficiency depends on the increase in left ventricular stroke volume and the rate of blood ejection through the relatively narrowed aortic ostium.

In addition, functional systolic murmurs include the so-called physiological systolic murmur, often heard in young healthy people at the base and sometimes at the apex of the heart. Physiological systolic murmur over the pulmonary artery can be heard in healthy people aged 17-18 years in 30% of cases, mainly in people of asthenic physique. This noise is heard only in a limited area, changes depending on the position of the body, breathing and pressure with a stethoscope, has a quiet, blowing character, and is detected more often at the beginning of systole.

Organic systolic murmurs due to valve defects are divided into ejection murmurs (stenosis of the aortic or pulmonary artery) and regurgitation murmurs (bicuspid or tricuspid valve insufficiency).

The systolic murmur of aortic stenosis is rough and strong, heard in the second right intercostal space at the sternum and extends upward to the right clavicle and neck arteries; systolic tremor is palpable at the listening site and on the carotid arteries; murmur occurs after the first tone, the intensity of the murmur increases towards mid-systole. In the case of severe stenosis, the maximum noise occurs in the second half of systole due to slow expulsion of blood. Systolic murmur with dilatation of the sclerotic aorta is not so rough, there is no systolic tremor, the maximum murmur is determined at the beginning of systole, and the second tone is sonorous or amplified. In elderly people with atherosclerosis, in addition to the systolic murmur over the aorta, a systolic murmur over the apex of the heart can be heard - the so-called aortomitral systolic murmur.

When the mouth of the pulmonary artery is narrowed, a systolic murmur is heard in the second intercostal space on the left; the noise is rough, strong, extends to the left clavicle, accompanied by systolic trembling at the site of auscultation; the second sound is bifurcated with the pulmonary component located before the aortic one. With sclerosis and dilatation of the pulmonary artery, the maximum systolic murmur is heard at the beginning of systole, the second tone is usually significantly enhanced. Sometimes a systolic murmur is heard over the pulmonary artery when the interatrial septum is not closed as a result of expansion of the initial part of the pulmonary artery; in this case, the second tone is usually bifurcated.

When the interventricular septum is not closed due to the passage of blood through a small defect from the left to the right ventricle, a rough and loud systolic murmur appears in the third and fourth intercostal spaces on the left near the sternum, sometimes with a distinct systolic tremor.

Systolic murmur with mitral valve insufficiency is best heard above the apex, spreading to the axillary region; a blowing murmur that begins immediately after the first sound and weakens toward the end of systole.

Systolic murmur with tricuspid valve insufficiency is heard in the lower part of the sternum; it is often very quiet and difficult to distinguish from the coexisting systolic murmur of mitral origin.

The systolic murmur of coarctation of the aorta is heard at the base of the heart, the aortic region and the pulmonary artery, but is often louder on the back in the region of the left suprascapular fossa, spreading along the spine; the noise begins some time after the first tone and may end after the second tone. With a patent ductus arteriosus, the murmur is systolic and diastolic due to the flow of blood from the aorta to the pulmonary artery during both cardiac cycles; The murmur is best heard over the pulmonary artery or under the left clavicle.

If a persistent systolic murmur is detected, the patient should be referred to a doctor for a thorough examination of the cardiovascular system.

Causes of systolic murmur in the heart

Systolic heart murmur is heard between heart sounds at the moment of contraction of its ventricles. The reason that gives rise to this condition is turbulence of the blood flow. Systolic murmurs heard in the heart can be of both functional and organic origin. Vortex movements are caused by the presence of narrowings and obstacles that interfere with the flow of blood, as well as the appearance of reverse blood flow through the heart valves.

What causes functional deviations

The intensity of the noise is not directly related to the degree of constriction. If blood viscosity decreases, conditions are created that promote turbulence. The appearance of functional noise can be caused by the following factors:

mitral insufficiency, when the sound is heard at the apex of the heart;
expansion of the aorta, as well as insufficiency of its valve;
expansion of the pulmonary artery;
physical overstrain and nervous excitement;
fever;
thyrotoxicosis;
anemia.

The dilation of blood vessels is characterized by a narrowing of their mouths, therefore the loudest noises are heard at the beginning of myocardial contraction (systole). Aortic valve insufficiency is related to the speed of blood movement through the narrowed orifice. Physiological noises, heard in a limited area, often appear in late adolescence (17-18 years). They are usually associated with an asthenic body type.

Functional noises in children occur at different ages. During the formation of the heart, its various parts develop unevenly, this causes a discrepancy between the sizes of the chambers of the heart and the sizes of the openings of the blood vessels. Uneven development of valve leaflets can lead to failure of their locking function. These reasons lead to the appearance of turbulence in the blood flow. Murmurs in a preschool child are usually heard over the pulmonary artery, and in schoolchildren - over the cardiac apex.

Organic valve defects and vascular stenosis

Murmurs of organic origin occur in the presence of stenosis of the ostia of blood vessels or insufficiency of the heart valves.

Aortic stenosis is characterized by a rough sound that can be heard in the direction from the sternum to the cervical arteries of the right side. The maximum sound occurs in the second part of systole. The expansion of the aorta is characterized by the presence of a maximum sound during the initial period of compression. With vascular atherosclerosis, an aortomitral murmur is present, which is heard above the cardiac apex.

If the opening of the pulmonary artery is narrowed, a strong noise is heard in the intercostal space on the left and spreads towards the left clavicle.

Ventricular septal defects are manifested by a rough sound on the left side of the sternum. Incompetence of the mitral valve is manifested by murmur at the top, and of the tricuspid valve at the bottom of the sternum.

In children, congenital heart and vascular defects are associated with murmurs. If persistent noises are detected, the child must be carefully examined.

Diagnostic and treatment methods

In differential diagnosis, it is important to identify the moment of occurrence and duration of systolic murmur. To do this, the necessary laboratory tests are prescribed and the following studies are carried out:

radiography, which reveals enlarged heart chambers, thickening of the walls and cardiac hypertrophy;
ECG, revealing overload of areas of the heart;
EchoCG, used to determine organic changes;
cardiac catheterization (insertion of a thin catheter through a vein or artery), which makes it possible to measure the pressure drop in the area of the heart valves.

In the presence of systolic murmur, symptoms such as shortness of breath, fatigue, dizziness, increased heart rate, and arrhythmia may appear. The patient's psychological condition may be manifested by decreased appetite, insomnia or depression. Depending on the nature of the phenomenon and the causes of its occurrence, drug or surgical treatment is prescribed. Given the functional nature of systolic heart murmur, regular medical monitoring is sometimes sufficient.

If murmurs are detected, you should immediately consult a cardiologist. Diagnostic tests prescribed by the doctor will help identify the cause of abnormalities in the heart. During treatment, you need to follow all the doctor’s recommendations and lead a correct lifestyle. Heart health directly depends on the timeliness of all actions taken.

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Heart murmurs

In pathology, and sometimes in healthy people, in addition to heart sounds, auscultation of the heart makes it possible to detect other sound phenomena called murmurs. They occur when the opening through which blood flows narrows and the speed of blood flow increases. Such phenomena may be caused by an increase in heart rate or a decrease in blood viscosity.

Heart murmurs are divided into:

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

Intracardiac murmurs most often occur as a result of damage to the heart valves, when their valves are not completely closed during the closure of the corresponding hole, or when the lumen of the latter narrows. They can also be caused by damage to the heart muscle.

Intracardiac murmurs can be organic or functional (inorganic). The first ones are most important from a diagnostic point of view. They indicate anatomical lesions of the heart valves or the openings they close.

The heart murmur that occurs during systole, i.e., between the first and second sound, is called systolic, and during diastole, i.e., between the second and the next first sound, it is called diastolic. Consequently, the systolic murmur coincides in time with the apical impulse and the pulse in the carotid artery, and the diastolic murmur coincides with the long pause of the heart.

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

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

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

Rice. 49. Carrying out heart murmurs:

a, b, c - systolic, respectively, with insufficiency of the bicuspid and tricuspid valves, with stenosis of the aortic mouth;

d - diastolic with aortic valve insufficiency.

The localization of any heart murmur corresponds to the place of best auscultation of the valve in the area in which the murmur originated. However, it can be carried out through the blood flow and through the dense heart muscle during its contraction.

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

Systolic murmur with tricuspid valve insufficiency (Fig. 49, b) is clearly audible at the base of the xiphoid process of the sternum. From here it is carried up and to the right, towards the right atrium. This noise is best heard with the patient lying on the right side while holding the breath at the height of inspiration.

Systolic murmur during narrowing of the aortic mouth (Fig. 49, c) is best heard in the second intercostal space to the right of the sternum, as well as in the interscapular space. It, as a rule, has a sawing, scraping character and is carried along the blood flow upward to the carotid arteries. This noise intensifies when the patient is lying on the right side with breath holding in the forced expiration phase.

Early systolic murmur (English):

Average systolic murmur (English):

Innocent systolic ejection murmur:

Late systolic murmur (English):

Late systolic murmur with mitral valve prolapse (English):

Diastolic murmur with mitral stenosis, occurring at the beginning or middle of diastole, is often better heard in the area of the projection of the bicuspid valve (the place where the third rib attaches to the sternum on the left) than at the apex. Presystolic, on the contrary, is better heard in the apex region. It is carried out almost nowhere and is especially well heard in the vertical position of the patient, as well as after physical activity.

Diastolic murmur with aortic valve insufficiency (Fig. 49, d) is also heard in the second intercostal space to the right of the sternum and is carried along the blood flow down to the left ventricle. It is often better heard at the 5th Botkin-Erb point and intensifies when the patient is in an upright position.

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

When the interatrial foramen is not closed, systolic and dastolic murmurs are observed, the maximum audibility of which is detected in the area of attachment of the third rib to the sternum on the left.

With a ventricular septal defect, a grinding systolic murmur occurs. It is heard along the left edge of the sternum, at the level of the III-IV intercostal spaces and is carried into the interscapular space.

When the ductus arteriosus is patent (the aorta is connected to the pulmonary artery), a systolic murmur (sometimes with diastolic) is heard in the second intercostal space on the left. It is less audible over the aorta. This noise is carried out to the interscapular region closer to the spine and to the carotid arteries. Its peculiarity is that it is combined with an enhanced second sound on the pulmonary artery.

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

Murmurs can also occur as a result of expansion of the cavities of the heart without organic damage to the valve apparatus and corresponding openings. For example, an increase in blood pressure in the systemic circulatory system (hypertension, symptomatic hypertension) can lead to expansion of the cavity of the left ventricle of the heart and, as a consequence, to stretching of the left atrioventricular orifice. In this case, the mitral valve leaflets will not close (relative insufficiency), resulting in a systolic murmur at the apex of the heart.

Systolic murmur can also occur with aortic sclerosis. It is heard on the right in the second intercostal space at the edge of the sternum and is caused by the relatively narrow mouth of the aorta compared to its expanded ascending part. This noise intensifies with raised arms (Sirotinin-Kukoverov symptom).

An increase in pressure in the pulmonary circulation, for example, with mitral stenosis, can lead to dilation of the pulmonary artery orifice and, consequently, to the occurrence of a diastolic Graham-Still murmur, which is heard in the second intercostal space on the left. For the same reason, with mitral stenosis, the right ventricle dilates and relative tricuspid valve insufficiency occurs. In this case, in the area of the IV intercostal space on the right near the sternum and at the xiphoid process, a blowing systolic murmur is heard.

When blood flow accelerates as a result of tachycardia, when its viscosity decreases due to anemia, when the function of the papillary muscles is impaired (increased or decreased tone) and in other cases, functional systolic murmurs may occur.

In case of aortic valve insufficiency, a functional diastolic (presystolic) murmur - Flint's murmur - is often heard at the apex of the heart. It occurs when the mitral valve leaflets are lifted by a strong stream of blood flowing from the aorta during diastole into the left ventricle, thereby causing a transient narrowing of the left atrioventricular orifice. Flint's murmur is heard at the apex of the heart. Its volume and duration are inconsistent.

Early diastolic murmur (English):

Average diastolic murmur (English):

Late diastolic murmur:

Functional heart sounds, as a rule, are heard in a limited area (best at the apex and more often in the pulmonary artery) and have a low volume and soft timbre. They are not constant and can appear and disappear with different body positions, after physical activity, and in different phases of breathing.

Extracardiac murmurs include pericardial friction rub and pleuropericardial murmur. Pericardial friction noise occurs during inflammatory processes in it. It is heard during both systole and diastole, is better detected in the area of absolute dullness of the heart and is not carried out anywhere. Pleuropericardial murmur occurs when there is inflammation in the area of the pleura adjacent to the heart. It resembles a pericardial friction noise, but unlike it, it intensifies during inhalation and exhalation, and when holding the breath it decreases or disappears altogether. A pleuropericardial murmur is heard along the left edge of the relative dullness of the heart.

Mitral stenosis (English):

Pericardial friction rub (English):

Heart sounds and murmurs (English):

Formation of a heart murmur (English):

Examples of heart sounds and murmurs in various pathologies (English names):

You can listen to the sounds and murmurs of the heart in normal conditions and in pathology on the website http://www.prodiagnosi.com/old_site/item_41.html

2 comments

1. Guest (7 November,:49) says:

I have these noises in my heart. I wanted to know what it is. Useful information.

2. Guest (May 28,:58) says:

Thank you very much, very useful site! Available information!

Topographic classification of systolic murmurs - Clinical cardiology part 2

Topographic classification of intracardiac and intravascular murmurs

Systolic murmur at the apex of the heart

A systolic murmur at the apex of the heart is a common occurrence. Sometimes it is heard instead of the first tone, in other cases it begins along with this tone, and in some cases it follows either immediately or with some delay after it. Such systolic murmur comes in different shades and varying intensities, starting with a subtle noise, sometimes giving the impression of a rather elongated unclean tone, up to a prolonged loud noise heard during the entire systole. The character of the noise is usually blowing, less often rough, and in rare cases musical. In some cases, it is accompanied by a cat's purring. In general, it is believed that the louder the noise, the more significant its conduction from the apex of the heart in all directions, especially into the left axilla and towards the base of the heart.

Any systolic murmur at the apex should alert the physician to suspicion. At the same time, the explanation of this noise is one of the most difficult problems of cardiac auscultation. The doctor really often finds himself in a difficult position when deciding whether the systolic murmur at the apex indicates an organic valve defect or not.

It is indisputable that only in a small number of cases the cause of systolic murmur at the apex is organic insufficiency of the bicuspid valve, i.e. insufficiency of the bicuspid valve caused by anatomical changes in this valve, which in the vast majority of cases are of rheumatic origin. Less commonly, the case concerns changes in the valve leaflets resulting from atherosclerosis or bacterial endocarditis. Often, although the case concerns an organic heart disease with an enlargement of the left ventricle, as a result of which the valve cannot close correctly (either as a result of increased tension in the tendons of the papillary muscles, or as a result of too much expansion of the left venous opening), however, there are no anatomical features on the valve apparatus changes. Even more often, systolic murmur at the apex accompanies various pathological extracardiac conditions that affect the circulatory organs and can cause pathological murmur, for example, even due to just temporary expansion of the heart. However, most often it concerns a physiological noise conducted to the apex of the heart along the left edge of the sternum from the pulmonary artery. Less commonly, the epicenter of physiological intracardiac murmur is located directly at the apex of the heart. Finally, in some cases it concerns a pathological noise, which is carried to the apex from other places, most often from the area of the left arterial ostium, in rare cases from the area of auscultation of the pulmonary artery, or a ventricular septal defect, or the tricuspid valve.

Systolic murmur at the apex, resulting from organic insufficiency of the bicuspid valve, in typical cases is of medium intensity, sometimes even loud and prolonged, and it is heard throughout the entire systolic phase (holosystolic, pansystolic). Most often, this murmur is heard instead of the first sound; more correctly, due to its intensity, it covers the first sound, of course, since the latter is not modified due to concomitant mitral stenosis. In reality, the first tone is always present, as can be seen from phonocardiograms. The noise may be harsh, blowing, whistling or rustling. Sometimes he can be rude and even musical. It can also be quiet or even very quiet, and can be so short that it gives the impression of a long and impure first tone. The best listening location is usually located directly at the apex of the heart or slightly more cranially. Usually the noise is carried out in all directions, especially in the left axillary region and dorsally and is best heard under the lower angle of the left scapula. In some cases, it is heard on the chest, louder at the back than at the front. Sometimes the noise can be traced from the lower angle of the left scapula down to the base of the lungs, or is also heard over the cranial parts of the chest from behind, especially on the left side, but unlike systolic noise with aortic stenosis, it is weaker in these places than under the left spatula. The conduction of systolic murmur from the apex in the dorsal direction, although it usually occurs with organic mitral insufficiency, however, is neither an absolutely reliable sign of the described defect nor an unconditional rule. Therefore, it is impossible to reject the diagnosis of organic mitral regurgitation only for the reason that the murmur is heard only in the front of the chest. Often the noise is carried out from the apex of the heart to the fourth or third left intercostal space to the edge of the sternum and its second epicenter may be located in these places. Sometimes the indicated second place of best listening is located in the second left intercostal space parasternally. With a very loud noise, it is usually heard in the entire region of the heart and also in the area of the great vessels; sometimes it can also be heard over the vessels of the neck. As a rule, such breathing noise changes little. When the patient is in a supine position, it is louder than in a standing position and intensifies when lying on the left side. Relatively rarely, the noise is accompanied by a cat's purring at the apex of the heart. Usually, a cat's purring is regarded as a sign of an organic defect. However, there are exceptions to this rule. If the left atrium is enlarged like an aneurysm, a cat's purr may be felt to the right of the sternum.

Experience gained in the surgical treatment of patients with mitral disease has shown that there is some relationship between the presence and intensity of systolic murmur in the apex of the heart, on the one hand, and the presence of mitral regurgitation and the size of regurgitation, on the other hand. If the systolic murmur was not heard before the intervention, then regurgitation was usually not detected during the operation. Therefore, if it is not possible to detect a systolic murmur at the apex, then mitral regurgitation can be almost completely excluded, since mitral regurgitation without an audible systolic murmur is extremely rare. However, the degree of mitral regurgitation cannot always be determined by the intensity of the systolic murmur. A loud systolic murmur may be heard with very minor regurgitation. This is observed especially with mitral insufficiency combined with mitral stenosis. Conversely, with significant mitral valve insufficiency, a quiet murmur may be heard.

On a phonocardiogram, systolic murmur due to mitral insufficiency is recorded as a group of oscillations that occupy the entire systole phase up to the aortic component of the second sound or even cover it and go beyond these limits. Quite often, the amplitude of oscillations increases towards the end of the systolic pause. Sometimes the oscillations have approximately the same amplitude throughout the entire systole. In rare cases, the amplitude of oscillations during systole decreases and a short pause may be observed between the end of the noise and the beginning of the second sound. The frequency of oscillations of systolic murmur is slightly higher than the frequency of oscillations of the first tone. It can be 150-200 Hz. Relatively often, a protodiastolic gallop sound is detected, which is sometimes mixed with an additional mitral sound, and in such cases it is mistakenly assumed that mitral stenosis is combined with mitral insufficiency.

It has already been said several times that recognizing mitral regurgitation from just auscultatory data is often difficult, since the systolic murmur at the apex is very significant. By means of a phonocardiographic study, indicating the exact beginning and end of the murmur, it can be established that the murmur in this case does not immediately follow after the first tone (the absence of a pause is regarded as a characteristic sign of a murmur due to mitral insufficiency), but occupies only part of the systole, therefore, the matter concerns protosystolic, mesosystolic or telesystolic murmurs. The last mentioned noises in most cases have no clinical significance. However, murmurs that fill the entire systole or most of it and are heard at the apex of the heart are not always a sign of mitral insufficiency.

Detection of systolic murmur at the apex, however, does not allow one to immediately come to the conclusion that the matter concerns organic insufficiency of the bicuspid valve. It can even be argued that if there are any arguments against this diagnosis, in all likelihood, the matter does not concern this defect. Clinical experience indicates that none of the above properties of noise in itself, or even all of them together, make it possible to differentiate with complete confidence a noise due to organic valve disease from other pathological and even physiological systolic murmurs heard at the apex. Undoubtedly, in some cases even physiological noise has properties that are usually considered characteristic of pathological noise.

In general, it can be said that a weak, short, intermittent systolic murmur at the apex, which is influenced by breathing and body position and which is not carried into the axilla, is usually of no clinical significance, as confirmed by autopsy data. However, it cannot be denied that even such seemingly insignificant noise, which gives the impression of physiological noise, sometimes accompanies heart disease, often even very serious. For example, with coronary heart disease, a systolic murmur is often heard at the apex, even without a distinct enlargement of the heart. The main thing that deserves attention is the noise that appears in patients who have had a myocardial infarction. Clinical experience shows that during acute myocardial infarction, a systolic murmur often appears, indicating relative insufficiency of the bicuspid valve. Therefore, some authors indicate that systolic murmur at the apex, appearing after 40 years of age, raises suspicion of heart disease. The fact is that it may be the only physical sign of coronary heart disease in elderly people, and therefore such patients should always be examined X-ray and electrocardiographic studies. With rheumatic heart disease, sometimes only a weak systolic murmur is also heard at the apex, and by its strength and properties it is impossible to determine whether or not the cause of the murmur is damage to the valve apparatus. However, even in the case when no signs of heart disease are detected, it is necessary to look for further possible causes of such systolic murmur at the apex, since many pathological extracardiac processes accompanied by systolic murmur at the apex can be as serious a disease as heart disease.

Since it is impossible to establish any absolutely reliable sign characterizing systolic murmur due to organic insufficiency of the bicuspid valve, when diagnosing this defect it is necessary to base it on the anamnesis and the entire clinical picture. However, it should be taken into account that many people with rheumatic valve disease do not realize that they have had rheumatic disease. If there is a history of rheumatic disease, then, of course, any systolic murmur at the apex raises suspicion of damage to the bicuspid valve, but often the final conclusion must be postponed to a later date.

Not long ago, a view arose according to which organic mitral valve insufficiency of rheumatic origin, after a certain period of time from the onset of rheumatic heart disease, in rare cases remains isolated, i.e., without mitral stenosis. Some authors even believed that the diagnosis of mitral regurgitation is unfounded if there are also no signs of mitral stenosis. True, when the valve apparatus of the left venous ostium is damaged by a rheumatic process, in most cases, sooner or later, signs of mitral stenosis appear. However, before this happens, several years, and sometimes even 10-15 years, may pass from the moment the first manifestations of the rheumatic process appear. There is no doubt that in most cases it would not be a mistake, given a non-enlarged heart, normal rhythm and the absence of any signs of mitral stenosis in the person being examined, to reject the diagnosis of hemodynamically serious organic mitral regurgitation, despite the presence of a systolic murmur at the apex of the heart and the fact that Many years have passed since the onset of rheumatic disease. However, since in young individuals with a history of rheumatic fever, physical signs of mitral stenosis may join physical signs of bicuspid valve insufficiency after many years, significant anatomical damage to the mitral valve cannot be reliably excluded, even in cases where the systolic murmur is weak and in all cases Its properties resemble physiological rather than pathological noise. In some of these patients, where all signs were absent, with the exception of the seemingly meaningless systolic murmur at the apex, after some time signs of subacute bacterial endocarditis appeared, and thus only during this period the actual origin of the systolic murmur at the apex was revealed. Sometimes, even at autopsy, the morphology of the valve leaflets does not allow one to decide whether there was bicuspid valve insufficiency during life or not. Of course, if physical signs of mitral stenosis are present, it is highly likely that the apical systolic murmur is caused by anatomical damage to the bicuspid valve.

It sometimes happens that auscultatory signs of mitral stenosis disappear over time and only the systolic murmur continues to be heard, sometimes even the last indicated physical sign disappears. However, we should not forget that both noises - both systolic and diastolic - appearing in the active phase of rheumatic carditis can be caused only by the expansion of the left ventricle due to damage to the heart muscle by the rheumatic process, and not by deformation of the valve apparatus.

The louder, longer, and more persistent the murmur, the more likely it is to be caused by anatomical damage to the valve apparatus. Recently, it has been increasingly emphasized that any autochthonous loud noise at the apex should still be regarded as a sign raising suspicion of organic heart disease - even in the absence of any anamnestic and objective signs of rheumatic heart disease - until another explanation is found for the noise. All such patients, until this suspicion can be refuted, should be given antibiotics to prevent the occurrence of subacute bacterial endocarditis during any operations or even minor interventions in the throat, oral cavity, nose, ears and genitourinary organs. If there are doubts about the nature and significance of the murmur, further observation of auscultatory phenomena on the heart and other cardiac examination data can help resolve the problem.

From a diagnostic point of view, it is first of all necessary to remember that cardiac enlargement is one of the most important signs of organic heart disease and indicates that the murmur in this case is, in all likelihood, pathological.

The origin of a noise carried to the apex from some other area of auscultation of the heart and large vessels can, in most cases, be established by topographic auscultation. Particularly noteworthy are tricuspid systolic murmur and aortic systolic murmur, which are often carried out to the apex of the heart, and in rare cases, their epicenter is even located in these places. Sometimes it can be especially difficult to explain systolic murmur at the apex of the heart in patients with aortic valve disease. Everyday clinical experience suggests that systolic murmur usually accompanying diastolic murmur due to aortic insufficiency, without the simultaneous presence of organic aortic stenosis, often spreads from the base of the heart to the apex and is often the cause of an erroneous diagnosis of concomitant mitral insufficiency. With significant aortic insufficiency with large regurgitation, and especially in the stage of decompensation, gradual expansion of the left ventricle may be the cause of the appearance of autochthonous systolic murmur at the apex due to relative insufficiency of the bicuspid valve. However, unlike systolic murmur conducted to the apex from the aorta, its timbre is usually different, and the epicenter is usually located in the apex of the heart. The differentiation of noise arising from organic mitral insufficiency from noise due to organic aortic stenosis, which is usually also carried out in the region of the apex of the heart, is helped mainly by the study of noise propagation. A typical systolic mitral murmur is usually heard well at the base of the lungs, especially on the left side, much weaker at the base of the heart, and it is no longer heard at the vessels of the neck. Significant noise passing to the neck indicates aortic stenosis. There are cases when the epicenter of the rough systolic murmur in aortic stenosis is to the left of the sternum, and sometimes even, although rarely, at the apex it is louder than in the area of auscultation of the left arterial ostium. Despite this, spreading the noise to the neck usually helps the doctor make the correct diagnosis. If during auscultation it is possible to distinguish two systolic murmurs from each other, and their epicenters are located in different places and one of the murmurs is conducted into the vessels of the neck, and the other spreads back to the base of the lungs, then, in all likelihood, the matter concerns two autochthonous murmurs - aortic and mitral - with combined mitral-aortic disease.

Systolic murmur in the area of auscultation of the pulmonary artery

Systolic murmur in the area of auscultation of the pulmonary artery is the most common of all cardiac murmurs. This region contains the epicenters of most physiological intracardiac and most pathological cardiac murmurs arising from extracardiac causes.

In the vast majority of cases, this noise is physiological. It has already been said that it occurs especially often in children and young adults with not too thick chest coverings. Such noise is usually gentle, blowing, but in some cases rough. It begins in early systole, without blocking the first sound, and usually fills most of the systole. Noise does not have great conductivity.

It often appears or intensifies with physical stress and is best heard when the person being examined is lying down, especially towards the end of a deep exhalation, while in a standing position it may disappear. It is often combined with physiological splitting and even bifurcation of the second tone, and sometimes also with an intensification of this tone. The mechanism of occurrence of systolic murmur over the pulmonary artery in healthy individuals is not precisely known. In most cases, it is believed that noise occurs as a result of physiological, even if only temporary, expansion of the pulmonary artery when the pressure in this vessel increases under various physiological conditions.

Less commonly, the noise is pathological. Pathological murmur over the pulmonary artery is usually louder than physiological murmur and can also be heard well in a standing position. The second tone above the pulmonary artery is often significantly accentuated. The described noise can be heard:

a) when the pulmonary artery is compressed or displaced, for example, by pleural exudate or enlarged mediastinal lymph nodes;

b) with expansion of the pulmonary artery due to increased pressure in the pulmonary circulation with mitral disease, with chronic left heart failure, with acute and chronic cor pulmonale and with rare primary endarteritis of the pulmonary artery;

c) in pathological conditions accompanied by tachycardia and acceleration of blood flow, such as hyperthyroidism;

d) with pulmonary artery stenosis and with some other congenital heart defects, combined with dilatation of the pulmonary artery trunk.

The noise that accompanies congenital narrowing of the pulmonary artery can be loud, prolonged, superficial, rough, sometimes musical and, in rare cases, distant. The first heart sound is usually covered by a murmur, and the second heart sound may also be auscultated as weakened or not heard at all. In extremely rare cases, an intensification of this tone is heard. With its acoustic properties and relationship to the phases of the cardiac cycle, it resembles the noise of narrowing of the left arterial ostium. It differs from this noise in its epicenter and relatively lower conductivity. The place of best listening is in the second left intercostal space at the sternum, or at some distance from the edge of this bone towards the left, or on the third rib and in the third intercostal space to the left of the sternum if it is not the arterial ostium itself that is affected, but the infundibular part of the right ventricle. Sometimes the noise is limited to a relatively small area on the anterior chest wall, but even in such cases it is usually heard from behind, in the interscapular space, mainly on the left side and in the left supraspinatus fossa. Compared to an aortic murmur, it is either not carried out at all, or is carried out only to a small extent on the vessels of the neck.

Determining the meaning of systolic murmur over the pulmonary artery is made difficult to a certain extent by the fact that systolic murmurs from other areas of auscultation, especially from the aortic region, are carried into this area of auscultation. It can be difficult to differentiate the murmur and cat purr due to aortic stenosis from the murmur and cat purr resulting from pulmonary stenosis, since in both of these cases the murmur can be heard equally loudly on both sides of the sternum and their epicenter may be right in the middle of the sternum. White attaches the main importance to the fact that a typical aortic murmur spreads from the sternum over a long distance in all directions and retains its strength, with the exception of the base of the lungs, where it is weak, while the murmur with pulmonary artery stenosis, although carried out relatively small, but can be heard well from the lungs.

The phonocardiographic recording of systolic murmur in pulmonary artery stenosis, in its configuration and location in the cardiac cycle, resembles the phonocardiographic recording of systolic murmur in aortic stenosis. In the literature, there is a desire to differentiate valvular and infundibular pulmonary artery stenosis using phonocardiographic recording. It is indicated that with valvular stenosis there is a short pause between the first tone and the beginning of the noise, the vibrations of which can reach the greatest amplitude in mesosystole, and in such cases the noise has a characteristic oblique shape. However, in most cases, this murmur reaches its maximum intensity only in the telesystole immediately before the aortic component of the second sound. In such cases, it is not diamond-shaped. The pulmonary component of the second sound is usually delayed and has a small amplitude, much less than the aortic component of the second sound. Sometimes the pulmonary component of the second tone is not recorded at all. This phenomenon is observed with very significant stenosis of the pulmonary artery. With infundibular pulmonary artery stenosis, the murmur is protomesosystolic and ends before the second sound, which is continuous, intensified and purely aortic. However, the described phonographic differences between both types of pulmonary artery stenosis are somewhat sketchy and require a somewhat critical assessment. In particular, weaker noises often do not have the above properties. In addition, pulmonary artery stenosis can be both infundibular and valvular, as is often seen with tetralogy of Fallot.

Systolic murmur in the area of auscultation of the aorta

Systolic murmur in the area of auscultation of the aorta is also common. Sometimes it is heard in individuals who do not show any signs of circulatory disease or other pathological condition. In such cases, it is usually soft, quiet, without significant conduction, changes greatly with breathing and changes in the body position of the person being examined, and is not accompanied by a cat’s purring. The mechanism of occurrence of such a systolic murmur, usually classified as murmurs of no clinical significance, is unknown.

In adults, however, systolic murmurs in the aorta are so often combined with organic damage to the cardiovascular system that, in general, they should be classified as pathological murmurs. There is no doubt that with changes in the aorta and aortic valves, a soft, quiet, blowing systolic murmur without significant conduction, reminiscent of the murmur that appears in the area of the pulmonary artery in completely healthy individuals, is often detected. Consequently, if a seemingly unimportant noise is heard over the aorta, for which no explanation can be found when examining the patient, then minor changes in the aortic valves cannot be ruled out, for example, rheumatic, the presence of a bicuspid aortic valve, etc.

It should be recalled that autochthonous aortic murmur is often mistaken for a murmur conducted into the aorta from the area of auscultation of the pulmonary artery.

Pathological systolic murmurs with an epicenter in the area of auscultation of the aorta are usually detected when the aorta is dilated without anatomical damage to the aortic valves. Changes in the aortic wall alone are not sufficient to cause a murmur. These noises arise from changes in the cross-sectional area of the blood flow. Blood leaving the left arterial ostium enters the dilated aorta and changes the nature of blood flow. This happens with atherosclerosis of the aorta, with syphilitic aortitis, which is extremely rarely observed in our country at present, with aortic insufficiency and with hypertension.

Systolic murmur, heard very often in elderly people with aortic atherosclerosis, usually spreads from the area of auscultation of the aorta obliquely down through the sternum to the area between the area of the apex of the heart and the sternum, as well as to the area of the apex of the heart (“souffle en echarpe” according to the designation of French authors ). It is often loud, but, as a rule, it is not accompanied by a cat's purring.

Systolic murmur heard in the area of auscultation of the aorta, which almost always accompanies diastolic murmur due to aortic valve insufficiency, in most cases does not indicate simultaneous organic aortic stenosis, but is based on an increase in the stroke volume of the left ventricle during aortic insufficiency with a corresponding expansion of the aorta and left ventricle; thus, the normally patent left arterial ostium is relatively narrow compared to the dilated adjacent sections. The epicenter of the noise occurs in the second right intercostal space at the edge of the sternum. The murmur is sometimes carried out into the vessels of the neck and very often into the area of the apex of the heart. In some cases it is gentle and quiet, and in other cases it is very loud, rough, holosystolic. The noise covers the first tone and has significant conduction; it easily raises suspicion of organic stenosis of the left arterial ostium, especially in cases when it is accompanied by a cat's purring, which, however, is relatively rare.

Aortic systolic murmur accompanying aortic insufficiency and systolic murmur with aortic dilatation alone cannot be differentiated with complete confidence from systolic murmur due to organic aortic stenosis, even from phonocardiographic recording. For the diagnosis of organic aortic stenosis, X-ray detection of calcifications of the aortic valves may be decisive. Systolic murmur, heard with simple dilatation of the aorta, is usually accompanied by a distinct and sometimes even enhanced second sound above the aorta.

A further cause of systolic murmur in the aortic area is organic stenosis of the left arterial ostium, most often of rheumatic origin. In such cases, it is usually combined with aortic valve insufficiency, and often also with other valve defects. The murmur can also be caused by isolated aortic stenosis with calcification of the valves, the etiology of which still has different views. In typical cases, the noise is prolonged, very loud, rough and even cutting, and is usually auscultated as if at the very ear of the listener; often it is musical, squeaking, moaning or meowing. As a rule, it is strongest in the second or third right intercostal space. Often the noise sounds very loud in the middle of the sternum at the height of the second, third or fourth intercostal space, and in some cases its epicenter is in the second left intercostal space near the sternum. A fairly loud noise usually drowns out the first sound and is heard throughout systole. The second tone is often not heard. Of all cardiac murmurs, it appears to have the greatest conductivity. A very important property of this aortic murmur is considered to be its conduction in the cranial direction to the medial part of the right clavicle and into the carotid arteries, especially the right, above which it is heard when a stethoscope is very lightly applied to the neck. Sometimes the noise in the neck is louder than in the aortic region itself. In the caudal direction, the noise extends to the entire cardiac region and to the epigastric region. Sometimes the murmur has a second epicenter at the apex of the heart and in such cases raises suspicion of mitral regurgitation. Further, it is also heard on the back, where it reaches its greatest strength in the right supraspinatus fossa of the scapula. This systolic murmur is one of the loudest cardiac murmurs in general and in typical cases it is heard even at some distance from the chest wall. In most cases, it is possible to detect a systolic tremor (a cat's purr) above the epicenter of the noise, especially when carefully palpating the entire area of the sternum and adjacent areas of the corresponding intercostal spaces with a hand placed flat on the chest wall. A cat's purring usually intensifies, just like the noise, in a sitting position or when bending the body forward and exhaling deeply, and sometimes also after performing some movements.

The described noise is not pathognomonic for organic aortic stenosis, since other pathological noises heard over the aorta may also have similar properties, even in the absence of anatomical changes in the left arterial ostium. However, in most cases they are not as rough as typical murmurs caused by organic aortic stenosis, and only very rarely are they remote. Conversely, with organic aortic stenosis, the systolic murmur above the aorta may be weak or not audible at all, for example, in heart failure, with a very high degree of aortic stenosis and in some cases of aortic stenosis combined with advanced mitral stenosis.

On the phonocardiogram, the systolic murmur with aortic stenosis has a typical configuration. The beginning of the noise is sometimes separated from the end of the first tone by a short pause, but in some cases the noise is immediately adjacent to the first tone. Sometimes an additional protosystolic tone is recorded before the noise (“claquement protosystoliqm aortique” according to Lian).

Rice. 326. Phonocardiogram and sphygmogram of the carotid artery of a patient with aortic insufficiency. The phonocardiogram shows a decreasing diastolic murmur, accompanied by a systolic murmur limited to protosystole, i.e., the rapid ejection phase (systolic ejection murmur).

Rice. 32c. Phonocardiograms of a patient with mitral disease. The phonocardiogram shows a telesystolic murmur due to mitral insufficiency (I), which very clearly increases after the administration of neosynephrine (II), which is regarded as a sign of the organic nature of the systolic murmur.

Fluctuations in systolic murmur initially, as a rule, are of small amplitude, then increase sharply, reach a maximum approximately in the middle of systole and then decrease to very small fluctuations, ending just before the beginning of the second sound. The symmetrical increase and decrease in the amplitude of oscillations and their maximum in the mesosystolic period gives the noise in typical cases a diamond shape (“diamond shaped”) or a spindle shape (“spindelformig”) (Fig. 32).

It has already been said that this configuration of systolic murmur is not a constant phenomenon in organic aortic stenosis and is not specific to this defect. The second tone is almost always recorded on the phonocardiogram, but it can originate from the pulmonary artery. Sometimes the curve shows a bifurcation of the second sound, the second part of which may be the aortic component of the second sound, which is delayed due to the lengthening of the left ventricular systole. It must also be added that the systolic murmur with congenital aortic stenosis does not have any graphic features that would distinguish it from the systolic murmur with acquired aortic stenosis.

From all that has been said, it follows that in practice it is impossible to make a diagnosis of organic aortic stenosis only on the basis of the detected murmur, but that this requires further physical signs, such as, for example, systolic tremors, weakening and even disappearance of the second sound above the aorta, changes in the quality of the pulse on the radial artery (pulsus parvus, longus, rarus), which are best detected on the sphygmogram, then electrocardiographic signs of increased load of the left ventricle, X-ray symptoms of left ventricular enlargement, post-stenotic dilatation of the aorta and calcification of the aortic valves. Still, however, there is no doubt that systolic murmur may be the only physical sign of organic aortic stenosis for a long time. As a result of this, such a defect quite often remains undetected during life due to the insufficient presence of physical signs and is established only at autopsy. A loud and rough systolic murmur in the aorta is therefore of great importance and, if present, it is necessary to look for further signs of aortic stenosis. The presence of a cat's purring is more important for the diagnosis of an organic defect than the noise itself, however, it is also not an absolutely reliable sign. Sometimes the only solution is to identify calcifications of the valve leaflets.

Systolic murmur in the area of auscultation of the tricuspid valve

Systolic murmur in the area of auscultation of the tricuspid valve often causes great difficulties when analyzing auscultation data. Most often it is a noise carried into this area from other places, mainly from either the mitral or aortic ostia. Much less often, the case concerns autochthonous noise resulting from relative or organic insufficiency of the tricuspid valve.

With relative insufficiency of the tricuspid valve without anatomical damage to the valve apparatus, sometimes above the lower part of the sternum or at its left edge at the height of the fourth and fifth intercostal spaces, a gentle, soft, noisy noise is heard, in most cases quiet, and sometimes also clearly low, subtle noise throughout the entire systole or most of it. A characteristic sign of systolic murmur due to tricuspid valve insufficiency is considered to be an increase in murmur during deep inspiration and its weakening or even disappearance during exhalation. Noise transmission is usually small. It is indicated that if the noise is carried out, then for the most part it spreads to the left of the sternum, without reaching the area of the apex of the heart.

With a significant enlargement of the right ventricle, a systolic murmur, regarded as a murmur due to relative tricuspid valve insufficiency, can be heard even in the apex of the heart, and in such cases it may be difficult to differentiate it from a systolic murmur due to mitral insufficiency. Under such circumstances, evidence of the tricuspid origin of the systolic murmur is indicated by the fact that the murmur is of greater intensity in the area of auscultation of the tricuspid valve than in the area of the apex of the heart, and that upon reaching the axilla it quickly disappears. Physical signs may be heard in the axilla and dorsally under the inferior angle of the left scapula, indicating pure mitral stenosis without accompanying systolic murmur. Observation of changes in auscultation data during cardiotonic treatment may help explain the origin of systolic murmur at the apex, since the murmur resulting from relative tricuspid valve insufficiency may disappear along with the elimination of signs of heart failure. Determining the origin of the systolic murmur at the apex can be really difficult in the simultaneous presence of mitral and tricuspid insufficiency.

However, everyday clinical experience shows that in the vast majority of cases of relative tricuspid valve insufficiency, no independent noise appears in the area of auscultation of this valve, even in the presence of clear signs of tricuspid insufficiency in the veins of the neck and from the liver. Based on the fact that the murmur over the tricuspid valve sometimes sounds different than over the other mouth of the heart, one cannot assume that this is not the same murmur, since it is known that when the murmur is carried out, its character can change. Some authors doubt the existence of independent noise at all with relative insufficiency of the tricuspid valve, considering the systolic noise heard in some such cases in the area of the tricuspid valve as noise carried into this area from other places, most often from the mitral region.

A systolic murmur heard above the lower part of the sternum or in the fourth and fifth intercostal spaces on the right at some distance from the edge of the sternum may be a sign of organic tricuspid valve insufficiency, usually of rheumatic origin, which is much less common than relative tricuspid insufficiency. The intensity of the noise may vary. Sometimes the noise is quite loud, prolonged, blowing or rough, and sometimes weak, gentle, rustling or blowing. It often cannot be distinguished from a systolic murmur resulting from bicuspid valve regurgitation, the epicenter of which is at the apex of the heart. However, in some cases it differs from systolic mitral murmur not only in its intensity, but also in its timbre. Further, it also needs to be differentiated from systolic murmur resulting from aortic valve disease, since this murmur, just like mitral systolic murmur, is sometimes well conducted into the area of the tricuspid valve. In the literature, it is stated that systolic murmur due to organic insufficiency of the tricuspid valve spreads from the area of auscultation of the tricuspid valve, both in the cranial direction, along the right edge of the sternum, and downwards into the epigastric region, and also towards the right axillary region. The murmur intensifies with deep inspiration and weakens with exhalation, while the intensity of systolic murmur with mitral regurgitation does not increase significantly during inspiration and may even, on the contrary, weaken.

Systolic murmur due to organic insufficiency of the tricuspid valve, according to our experience, is characterized by significant variability and its intensity can vary in the same patient. Sometimes it is completely distinct, but after a few days it is almost unheard of. Quite often, an autochthonous systolic murmur in the area of the tricuspid valve is not heard even with a significant tricuspid organic defect, especially in the stage of decompensation of the defect. It is believed that lower pressure values in the right heart compared to pressure values in the left heart are the reason that the systolic murmur with tricuspid valve insufficiency is heard less frequently than the systolic murmur with bicuspid valve insufficiency.

Systolic murmur with organic tricuspid valve insufficiency is sometimes accompanied by a cat's purr, palpable in the fourth or fifth intercostal space on the right at the edge of the sternum or somewhat laterally, not far from the right parasternal line. The noise sometimes becomes clear after the patient performs any movement, especially when moving to a lying position on the right or left side. The noise also either intensifies or only begins to appear when pressing on the enlarged liver or just when pressing on the abdomen. A cat's purring, similar to the noise, is also easily subject to changes, sometimes it can disappear completely, especially in heart failure.

A phonocardiogram recorded in the area of auscultation of the tricuspid valve may show a systolic murmur throughout the entire systole. In terms of its strength, such noise either decreases (decrescendo) or maintains almost the same intensity throughout its entire length. Its graphic configuration, as a rule, does not differ substantially from the configuration of the systolic murmur recorded in the region of the mitral valve during mitral regurgitation.

It is sometimes difficult to decide whether the systolic murmur over the tricuspid valve is an expression of organic or relative tricuspid valve insufficiency. The detection of autochthonous systolic tremor over the tricuspid valve indicates an organic defect. However, this sign is not absolutely reliable, as we had the opportunity to verify in one patient, who during her life for a long time had a completely distinct systolic cat purr, limited to the tricuspid region, and at autopsy a relative insufficiency of the tricuspid valve was discovered with extreme expansion of the right atria. Differential diagnosis can be facilitated by monitoring the course of the disease. It is very likely that the murmur, which is believed to be caused by relative insufficiency of the tricuspid valve, which usually develops only in a high stage of heart failure, will disappear along with other signs of tricuspid insufficiency if the functioning of the right heart can be significantly improved. Conversely, with decompensation of organic insufficiency of the tricuspid valve, the physical signs of this defect - independent noise and cat purring - may become less distinct and even disappear, and when the functioning of the right ventricle improves, they may appear again. However, it must be added that organic disease of the tricuspid valve is almost always combined with other organic heart defects and physical signs of damage to the tricuspid valve are often lost in the overall picture of the combined heart disease, especially with decompensation.

Systolic murmur due to ventricular septal defect

Systolic murmur with ventricular septal defect. A loud, prolonged, sharp and even rough noise with an epicenter in the third or fourth left intercostal space at the edge of the sternum is a constant auscultatory phenomenon that accompanies an isolated ventricular septal defect and is called Roger's disease in the literature; The noise itself is called Roger noise. However, even before Roger, it was noted by Kerner, and therefore it would be more fair to call it Kerner-Roger noise. The murmur usually covers the first sound and is heard throughout systole. As a rule, it is accompanied by a cat's purring. The noise undoubtedly results from the penetration of blood under pressure through a narrowed opening from the left ventricle to the right. Throughout the entire ventricular systole, the noise retains its full intensity and has a completely special timbre. Muller (I. Muller) successfully designated this noise with the name “Pressstrahlgerdusch”. The noise is so unique in its tone and localization in the heart area that it immediately leads the doctor to the correct diagnosis. The noise is usually carried out from the epicenter area in all directions. It is carried out especially well by bone tissue, and to places very distant from the heart area. It can usually be heard very well with a stethoscope placed on the ribs, the collarbone, the head of the humerus, and even the olecranon. The murmur is usually transmitted to the peripheral arteries and is then heard in the brachial arteries, and sometimes also in the arteries of the neck. However, the conduction of noise into the carotid arteries is not nearly as typical for Roger's noise as for systolic noise in aortic stenosis. The noise usually also extends into the pulmonary artery and its branches; in this case, quite often it can be found on the back in the interscapular space and under the shoulder blades, especially under the left shoulder blade. This is one of the loudest noises and can often be heard even from a distance. Cat purring and noise is louder when lying down than when standing or sitting. Their intensity, as a rule, increases when performing movements. On the contrary, breathing and the Valsalva maneuver have no effect on the intensity of noise and cat purring.

On a phonocardiogram, you can find that the murmur begins at the beginning of systole and its fluctuations cover the first heart sound. As a rule, it occupies the entire systole up to the second sound. Usually the noise is characterized by high, slightly irregular fluctuations of an increasing-decreasing nature, and their graphic configuration resembles organ pipes (Fig. 33). Fluctuations in the maximum noise amplitude vary from case to case; they may appear in protosystole, mesosystole, or telesystole.

If in the area of auscultation of the pulmonary artery a systolic murmur and a bifurcation of the second tone are heard, and at the same time the electrocardiogram reveals a picture of incomplete blockade of the right bundle branch, and skiascoscopic examination reveals signs of dilatation of the pulmonary artery and increased pulsation of the pulmonary vessels in the roots of the lungs, then first In all cases, it is necessary to take into account the possibility of an atrial septal defect. The given signs indicate ostium secundum persisfcens. Systolic murmur in the area of the pulmonary artery is a variable sign with this congenital heart defect. Of the 78 patients we examined, this noise was absent in 21 patients. The intensity of the noise often fluctuates from day to day. It usually increases with physical stress. In heart failure, the murmur often disappears. Usually it is not as loud as Roger's noise, and in itself is not decisive for the diagnosis of atrial septal defect.

Systolic murmur with an epicenter at the apex of the heart, together with the presence of X-ray and electrocardiographic signs of left ventricular hypertrophy, may be a manifestation of ostilum primum persistens, accompanied by a malformation of the mitral valve. In addition, the case may concern a developmental defect called ostium atriovenfcriculare commune persistentens.

With an atrial septal defect, a systolic murmur is recorded on a phonocardiogram taken from the pulmonary artery area, even in cases where it is not detected by auscultation. Fluctuations are of smaller amplitude than fluctuations in the systolic murmur that accompanies an isolated atrial septal defect. The graphical representation of noise can be of different configurations. The maximum amplitude of oscillations can be located in protosystole or mesosystole. Often there is a bifurcation of the second tone in the area of the pulmonary artery.

These are sounds of great length that differ from tones in duration, timbre, and volume. The mechanism of formation is due to turbulent blood movement. Normally, blood flow in the heart and through the cavities is laminar. Turbulence appears when the normal relationship between three hemodynamic parameters is disrupted: the diameter of the valve openings or vascular lumen, blood flow speed, and blood viscosity.

Reasons:

1. morphological (anatomical changes in the structure of the heart, valve apparatus, blood vessels). May be in the form:

Stenosis (narrowing)

Leaf valve insufficiency

Congenital defects in the structure of the heart

2. hemodynamic factors (the presence of a large pressure gradient between the cavities of the heart or the heart cavity and the vessel).

3. rheological – decreased blood viscosity – anemia, polycythemia.

Noise classification:

by place of formation: intracardial, extracardial, vascular.

due to the formation of intracardiac – organic and functional.

in relation to the phases of the cardiac cycle - systolic and diastolic.

due to their occurrence - stenotic, regurgitant.

There are proto-, pre-, mesosystolic (-diastolic), pansystolic (-diastolic).

in shape - decreasing, increasing, diamond-shaped (increasing-decreasing) and decreasing-increasing.

Organic intracardial murmurs.

They are caused by damage to the valvular apparatus of the heart, that is, narrowing of the valve openings or incomplete closure of the valves. In this case, incomplete closure can be caused by an anatomical lesion or a functional disorder, therefore they are divided into organic and functional.

Organic murmurs are the most important, as they are a sign of anatomical damage to the valvular apparatus of the heart, that is, they are a sign of heart disease.

When listening to noise, its analysis is carried out in the following sequence:

Relation of murmurs to phases of the cardiac cycle

Epicenter of noise

Relationship with heart sounds

Irradiation zone

Intensity, duration, pitch, timbre.

Organic systolic murmurs are heard when, expelled from the ventricle, blood encounters a narrow opening, passing through which it creates noise. Systolic organic murmurs are divided into regurgitant and stenotic.

Regurgitation occur when:

Mitral valve insufficiency - heard at the apex of the heart, accompanied by a weakening of the first sound and an accentuation of the second sound on the pulmonary artery. It is well carried into the axillary fossa, and is better auscultated in a horizontal position on the left side. Decreasing in nature, closely related to the 1st tone. The duration of the murmur depends on the size of the valve defect and the rate of contraction of the left ventricular myocardium.

tricuspid valve insufficiency. The same picture is heard at the base of the xiphoid process.

ventricular septal defect – rough, sawing noise. It is best heard along the left edge of the sternum in the 3rd-4th intercostal space.

Stenotic systolic murmur.

aortic stenosis.

The 2nd intercostal space is heard at the left edge of the sternum. Eddy turbulent currents form on the aorta. Irradiates with the blood flow to all large arteries (carotid, thoracic, abdominal aorta). It is heard in the lying position on the right side. Rough, sawing, waxing and waning noise.

pulmonary artery stenosis - in the 2nd intercostal space on the left, the properties are the same.

Organic diastolic murmurs.

It is heard in cases when, during diastole, blood entering the ventricles encounters a narrowed opening on its way. They are most pronounced at the beginning and, unlike systolic ones, do not radiate.

Protodiastolic The murmur is heard above the apex of the heart, is a sign of mitral stenosis, and is accompanied by an increase in the first sound, accentuation, splitting or bifurcation of the second sound in the PA. Mitral valve opening tone. With mitral stenosis, a diastolic murmur is heard at the end of diastole, before the first sound. The mechanism of formation is associated with the flow of blood into the cavity of the left ventricle through the narrowed mitral orifice in the phase of atrial systole.

If the diastole is short, then the interval is shortened and the noise decreases and increases.

Diastolic murmur at the base of the xiphoid process is a sign of tricuspid valve stenosis.

Based on the heart, a diastolic murmur can be heard in cases of aortic or pulmonary valve insufficiency. With aortic valve insufficiency, the first sound is weakened, the second sound on the aorta is weakened.

Diastolic murmur in aortic insufficiency is better heard at Botkin's point, with more pronounced murmur - in the 2nd intercostal space to the right of the sternal edge. Diastolic murmur in the 2nd intercostal space on the left is a sign of pulmonary valve insufficiency. An organic defect is extremely rare; more often it is a sign of relative insufficiency of the pulmonary valves, which develops with dilatation of the orifice of the pulmonary artery with increased pressure in the systemic circulation - functional Diastolic Graham-Still murmur.

If there is both a systolic and diastolic murmur at the first point of auscultation, one should think about a combined heart defect (a combination of stenosis and insufficiency).

When auscultating noises, it cannot be done in only one position. It is necessary to listen to the patient in a vertical position, horizontal position, and in certain separate positions in which the speed of blood flow increases and, therefore, the noise is better determined. Increased noise in aortic insufficiency with arms thrown back behind the head - SpSirotinina-Kukoverova.

When auscultating noise, attention is paid to the timbre, shades of noise - soft, gentle, scraping, sawing, chondral squeak– at the apex of the heart in the presence of chordal abnormalities or separation of tendon threads.

Functional noise.

They are heard in pathological conditions not associated with anatomical changes in the valve apparatus. Sometimes they can be heard normally. Reasons:

disturbance of hemodynamics, which leads to an increase in the speed of blood flow (physiological and emotional stress, fever. The noises that are heard in adolescents are physiological youthful noises, the result of a discrepancy in the growth of blood vessels in length and width).

violation of the rheological properties of blood - anemia (decreased blood viscosity, adhesion of elements in the blood to each other, the appearance of turbulent currents).

weakening of the tone of the papillary and circular muscles - with a decrease in the tone of the papillary muscles, tendons of the chord and the cusp of the mitral valve and tricuspid valve. Sag into the atrium, does not completely close the AV opening. So during atrial systole, blood flows from the ventricle into the atrium, so functional murmurs are heard. The circular muscle covers the AV ring; when stretched, there is relative valve insufficiency.

stretching of the valve opening during dilatation of the cavities of the heart or blood vessels (aorta, pulmonary artery). The cause is myocarditis, myocardial dystrophy, dilated myocardiopathy.

Functional murmurs are divided into myocardial and vascular, physiological (juvenile) and pathological. The vast majority of functional murmurs are systolic. Only 2 functional diastolic murmurs are known - Graham-Still diastolic murmur(relative insufficiency of the pulmonary valves), noiseFlint- at the top. The mechanism of its formation is associated with the development of functional stenosis of the mitral orifice during aortic valve insufficiency. It is not accompanied by the appearance of a mitral valve opening tone, and the quail rhythm is not heard.

Differences between functional noise and organic noise.

functional ones are heard more often in systole

they are heard above the apex and LA

unstable: disappear and appear, appear in one position and disappear in another.

never occupy the entire systole, are often heard in the middle, and are not associated with heart sounds.

are not accompanied by changes in the volume of tones, splitting and other signs of heart defects.

do not have characteristic irradiation

in volume and timbre they are softer, gentler, more blowing.

not accompanied by cat purring

physiological ones increase with physical activity, organic noises do not change

Extracardiac murmurs.

Noises that occur regardless of the operation of the valve apparatus and are mainly caused by the activity of the heart. These include pericardial friction murmur, pleuropericardial murmur, and cardiopulmonary murmur.

Pericardial friction rub occurs when:

the presence of irregularities, roughness on the surface of the pericardial sheets: with pericarditis, tuberculosis, leukemic infiltration, hemorrhage into the thickness of the pericardial sheets, uremia - the death knell of the uremic.

increased dryness of the pericardial leaves - dehydration with persistent vomiting, diarrhea.

Signs:

heard above the zone of absolute cardiac dullness

heard in both systole and diastole

does not necessarily correspond with (..) phase of the cycle.

not carried out in other places, listened only at the place of formation.

increases with pressure with a stethoscope and when the body is tilted forward or in a knee-elbow position.

Pleuropericardial murmur heard with inflammation of the left pleura covering the top and left. When the heart contracts due to a decrease in its volume, the lungs at the point of contact with the heart straighten, so a friction noise against the pleura is heard. It is heard along the left edge of relative cardiac dullness. It intensifies with deep breathing and is accompanied by the presence of pleural friction noise in other places distant from the heart.

Cardiopulmonary murmur occurs near the left border of the heart, is detected in the form of faint sounds heard during systole. This noise is due to the fact that during systole the heart decreases in volume and allows the area of the lung adjacent to it to expand. The expansion of the alveoli in connection with the inhalation of air creates this noise. It is heard more often to the left border of relative cardiac dullness with cardiac hypertrophy or an increase in the rate of myocardial contraction.

Vascular murmurs. After palpation of the arteries, they are auscultated; they try not to squeeze the wall of the arteries, since normally, without pressure with a stethoscope, the first sound is heard above the carotid, subclavian, and femoral arteries. Normally, no sounds are heard on the brachial artery. In pathological conditions, tones begin to be heard over smaller vessels. In case of aortic valve insufficiency above the large arteries (femoral), instead of the first sound, the second sound is heard, which is called double tone Traube. When listening to the femoral artery when pressing with a stethoscope, instead of the first sound, the second sound can be heard - double Vinogradov-Durazier noise. If a noise is heard over any artery without pressure, this is a sign of a sharp narrowing of the artery - atherosclerosis, congenital anomaly or compression from the outside, or an aneurysm.

Auscultation of arteries.

Renal arteries - when narrowed, vasoadrenal (renovascular) renal arterial hypertension develops. It is heard near the navel, absent 2 cm from it and along the edge of the rectus abdominis muscle at the level of the navel.

The celiac artery is heard just below and to the right of the xiphoid process.

Normally, neither tones nor noises are heard above the veins. In case of severe anemia as a result of sudden thinning of the blood above the jugular veins, the sound of a top.

Auscultation of the thyroid gland.

Normally, no murmurs are heard. In thyrotoxicosis and thyroiditis, due to an increase in the number of vessels, unevenly dilating arteries in the gland tissue and an increase in blood flow speed, a systolic murmur is heard.

Normally, heart sounds give the acoustic impression of a single short sound. In pathology, conditions are created for repeated multiple oscillations - for the emergence of noises that are perceived as sounds of a varied timbre. The main mechanism for the formation of noise is the passage of blood through a narrowed opening. An increase in blood flow speed contributes to the formation of noise; the blood flow speed depends on increased excitability and increased activity of the heart. The narrower the hole through which the blood passes, the stronger the noise, but with very strong narrowing, when the blood flow decreases sharply, the noise sometimes disappears. The noise intensifies as the contraction force increases and weakens as it decreases. Also, the acceleration of blood flow is associated with a decrease in blood viscosity (anemia). Types of noise Noises are divided into organic and functional. Organic noises are associated with pathological changes in the heart (valve apparatus changes: leaflets, tendon threads, capillary muscles), the size of the holes changes. The cause may be stenosis of the opening, which impedes the flow of blood to the next section; valve insufficiency, when the valve apparatus cannot completely close the opening to prevent the backflow of blood. Organic murmurs occur more often with valve defects and congenital heart defects. Functional noises are observed mainly in anemia, neuroses, infectious diseases, and thyrotoxicosis. The cause of the noise is the acceleration of blood flow (anemia, nervous excitement, thyrotoxicosis) or insufficient innervation or nutrition of the muscle fibers or capillary muscles of the heart, as a result of which the valve is not able to tightly close the corresponding hole. Functional murmurs differ from organic ones in their localization (determined on the pulmonary artery, apex of the heart); they are shorter in duration; depend on the psycho-emotional state and physical activity; as a rule, they intensify in a horizontal position; when listening, they are tender, blowing, weak; they are transient in nature (they decrease as the condition improves). Based on the time the noise appears during systole or diastole, systolic and diastolic murmurs are distinguished. Systolic murmur is heard in the vast majority of functional murmurs; with mitral and tricuspid valve insufficiency; with stenosis of the aortic mouth; with stenosis of the pulmonary artery; with atherosclerotic lesions of the walls and aortic aneurysm; with an open interventricular foramen. Systolic murmur appears in the first minor pause and corresponds to ventricular systole; the first sound is often absent, but may persist. Diastolic murmur is heard with aortic valve insufficiency; pulmonary valve insufficiency; non-closure of the ductus botallus; with stenosis of the left atrioventricular orifice. Diastolic murmur appears in the second major pause and corresponds to ventricular diastole.

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

Systolic murmur:

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

Most of the systolic murmurs are heard over the heart, especially over the pulmonary artery and aorta, and are a consequence of anemia, tachycardia\with hypothyroidism, high temperature\these are random accidental noises. Only on the basis of systolic murmur can one not make a diagnosis of the heart. It is important to differentiate accidental ones murmurs from pathological ones. The first ones are usually softer and are heard at the base of the heart and partly over the entire surface of the heart. systolic murmur at the apex conducted in the direction of the left axillary cavity and in the direction of the place where the aortic valves are heard - a sign of blood regurgitation through the left venous opening - the cause of insufficiency 2-leaf valve, which could be caused by endocarditis, dilatation of the left ventricle, cardiosclerosis, aortic insufficiency. with true insufficiency of the 2-leaf valve, a weakening of the 1st tone is observed, systolic murmur, expansion of the left ventricle and left ventricle, displacement of the apical impulse down and out and an intensified 2nd tone above the pulmonary artery. More often, the systolic murmur is blowing loud begins with a weakened 1st tone and continues throughout the entire systole.

A noise heard to the left of the sternum in the 3rd-4th intercostal space occurs during a heart attack and is a sign of septal perforation. A similar noise is observed with a congenital defect of the interventricular septum\murmur erysipelas\

A murmur heard above the aorta and conducted in the direction of the shoulder of the occipital neck is characteristic of aortic stenosis. If significant stenosis, the 2nd sound may be absent or audible, but it will be delayed. For this lesion, there is always a pause between the end of the noise and the 2nd tone.

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

Systolic murmur may also be caused by pulmonary artery stenosis; in this case, it is heard before the appearance of the 2nd sound

When the RV is overloaded, a relative stenosis of the pulmonary artery occurs and it is heard in the 3rd intercostal space along the left edge of the sternum. A systolic murmur above the site where the pulmonary artery is heard is not a pathological sign, especially at a young age.

Systolic murmur along the right edge of the sternum can occur with insufficiency of the 3-leaf valve. With its insufficiency, a positive venous pulse and a large pulsating liver are observed.

Tetralogy of Fallot is characterized by an intense systolic murmur heard over almost the entire surface of the heart, while the 2nd tone is very weakened or inaudible. This disease is congenital; its symptoms are cyanosis, shoe-shaped heart\clog\erythrocytosis, drum fingers, developmental delay.

Systylic murmur of a musical nature occurs with sclerotic narrowing of the aortic orifice or with sclerotic changes in the mitral valve. Less often with dissecting aortic aneurysm. A systolic noise heard over the vessels is characteristic of an aortic aneurysm. atherosclerotic narrowing and aortitis

Acquired and congenital heart defects. Clinical and physical landmarks.

Acquired defects:

Stenosis of the mitral (left ventricle and left atrium) orifice: signs of pulmonary hypertension (up to pulmonary edema), right ventricular hypertrophy. Palpation - “cat purring” (diastolic trembling), pulse on the left hand > pulse on the right. Auscultation - quail rhythm (clapping 1st tone + click of the mitral valve opening + increased 2nd tone), diastolic murmur at the mitral valve point, diastolic murmur at the pulmonary artery point.

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

Aortic stenosis: signs of hypertrophy of the left ventricle, left atrium, stagnation in the pulmonary circle (orthopnea, pulmonary edema, cardiac asthma). Auscultation – weakened 2nd sound, splitting of the 2nd tone, “scraping” systolic murmur, click of the jet hitting the aortic wall.

Aortic valve insufficiency: physically – “carotid dance”, S. de Mussy, capillary pulse, pulsation of the pupils and soft palate. Auscultation - cannon tone (Traube) on the femoral artery, systolic murmur on the femoral artery, weakened or enhanced (can be either way) 1st tone, diastolic murmur, mid-diastolic (presystolic) Austin-Flint murmur.

Congenital defects:

VSD: 3 degrees: 4-5 mm, 6-20 mm, >20 mm. Signs: developmental delay, congestion in the ICB, frequent lung infections, shortness of breath, liver enlargement, edema (usually of the limbs), orthopnea. Auscultation - systolic murmur to the left of the sternum.

ASD: The discharge of blood is always from left to right. Auscultation – splitting of the 2nd tone, systolic murmur on the pulmonary artery.

Botall's duct(m/n pulmonary artery and aorta): systolic and diastolic “machine” murmur.

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

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

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

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

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

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

hemodynamic, which occurs in heart failure of the left ventricular type.

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

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

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

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

Obstruction in allergic diseases is caused mainly by spasm of small bronchi and bronchioles (tonic type) and to a lesser extent by hypersecretion and edema. Significant difficulties are presented by the differential diagnosis between asthmatic bronchitis and obstructive bronchitis of infectious origin. In favor of asthmatic bronchitis is evidenced by a family history of allergic diseases, a burdened personal allergy history (skin manifestations of allergies, “minor” forms of respiratory allergosis - allergic rhinitis, laryngitis, tracheitis, bronchitis, intestinal allergosis), the presence of a connection with the occurrence of the disease with a causally significant allergen and the absence of such a connection with the infection, the positive effect of elimination, recurrence of attacks, their uniformity. The wedge picture is characterized by the following signs: absence of intoxication phenomena, remote wheezing or “sawing” nature of breathing, expiratory shortness of breath with the participation of auxiliary muscles, in the lungs there are predominantly dry wheezing and a few wet ones, the number of which increases after relief of bronchospasm. An attack usually occurs on the first day of the disease and is eliminated in a short time: within one to three days. In favor of asthmatic bronchitis, the positive effect of the administration of bronchospasmolytics (adrenaline, aminophylline, berotec, etc.) is also evidenced. The cardinal sign of bronchial asthma is an attack of suffocation.