The 4th heart sound is formed due to. IV heart sound

A normal phonocardiogram (PCG) consists of oscillations of the first and second heart sounds. III and IV heart sounds can often be recorded. The V tone is recorded only in certain cases.

The IV heart sound is called atrial; it occurs in presystole during atrial contraction.

The IV tone has the form of two or three low-frequency (16-35 Hz) oscillations of low amplitude, occurring 0.04-0.16 s after the start of registration of the P wave on the ECG. The IV tone ends 0.02-0.04 s before the first tone begins to appear, and in some cases it can merge with it. The IV tone is best heard during stress tests, and can disappear completely at rest.

IV tone consists of two parts:

• The first part corresponds to the tension of the atrium walls.
• The second part corresponds to the expulsion of blood from the atria into the ventricles.

In some cases, a third part with an unclear genesis may arise.

The duration of the IV tone lies in the range of 0.05-0.12 s. The higher the frequency composition of the IV tone and the older the patient’s age, the more the IV tone is regarded as a sign of increased atrial activity and, as a rule, ventricular failure.

Pathological IV tone

The appearance of a pathological IV tone is mainly associated with an increase in its atrial component. A decrease in myocardial contractility causes an increase in the amplitude of the IV tone and the appearance of high-frequency oscillations in its composition. In the case of a small difference between the intraatrial and intraventricular pressure at the beginning of diastole, the ventricles are quickly filled with blood and their walls are rapidly stretched, which is accompanied by an auscultatory increase in the IV sound. With a small difference in pressure in the atria and ventricles, the flow of blood from the atria into the ventricles occurs gradually, and the participation of stretching of the walls of the ventricles in the formation of the IV sound is minimized.

Cases when IV tone is considered pathological:

• when registering with older people;
• when registering in a vertical position;
• if it has a frequency response of more than 70 Hz;
• determined by auscultation;
• registered in the range of all frequencies;
• its amplitude is increased.

Together with the I and II heart sounds, the pathological IV sound forms a presystolic gallop rhythm.

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Dietary regimen is determined color And tone Sun/Earth design.

We have only 6 colors - that means 6 diet regimens. However, each mode is further divided into 2 varieties depending on the tone. There are lower tones - 1, 2, 3 tone, these are the left strategic tones, there are upper tones - 4, 5, 6 these are the right tones.

If you have lower tones (1,2,3) under the color of the Sun/Earth of the design, then you have a “left” active body. You need more food and stimulation.

If the upper ones (4,5,6) - then you have a “right” body, you need less activity and food (overeating is doubly harmful for you!)

Well, now let's turn to practice:

Let's look at the Sun/Earth COLOR of the design, and the left-right tone underneath it. This is not only about nutrition, but also about how a person, in principle, “absorbs” something new... people, situations, information, etc.

Colors

1 color: Appetite (Hunter).

1st color is the bottom color - a primitive digestive system that needs simple food. This is the hunter's diet. The principle here is 1 product at a time. Do not mix or combine products! (i.e. this is a separate diet, when the stomach needs to be given some time before a new product enters it).

If the person is 1st color left(i.e. under his color tones 1, 2, or 3) - then sequential nutrition is recommended.

The left person cannot return to the product in one meal. Only after a large amount of time, which usually passes between meals. That is ate an apple, waited an hour, then ate a potato, waited again... etc.

If the person is 1st color right(i.e. under his color tones 4, 5, or 6) - then alternate meals - you can return to the previous product in one meal... you need a short pause for the taste of the previous product to go away.

All sorts of semi-finished products and mixtures are not suitable for such a person. Natural products, pristine, of course, without additives. Subsistence farming. For example, chocolate is a mixture... The unique brain of a hunter will slow down if it is fed, for example, chocolate.

2 color: Taste (Collector)

This is a rigid nutrition system. 2nd color is a very selective, limited diet, focusing on what is palatable to the individual. Selected only by the person himself, and in no case by any other people.

It can be almost the same products every day... Variety is not healthy!

In one of Ra’s lectures there was an example about a child with the 2nd color: he has an inner feeling that it is tasty for him to eat, and when parents force something into such a child’s mouth, something that in their opinion is good for the child , he spits it out. They push it into him again, and this is how the settings are gradually knocked down.

If 2nd color left- open food. The person eats more varied food than the right person, but selects foods exclusively individually, probably by tasting them.

If 2nd color right- very closed nutrition, closed taste.

2nd color is called - Taste, and on the right side is the closed taste. Those. this is a limited set of foods that the child likes and which, in theory, he can eat every day... The same thing. Those. a varied menu for such a child will not be healthy. Monotony can support his cognition.

3 color: Thirst (Handler)

The 3rd color is called Thirst, it is associated with the manipulation of food through temperature treatment.

Here we are talking about fluid, but, above all, about how the individual intestinal tract can optimally digest food (since fluid always has something in common with temperature). Washing down food with this type is also good. By the way, a troika can “drink” you, because its thirst manifests itself not only in food.

Some triplets need cold food and some need hot food.

If 3rd color left- This is a hot meal.

Food must be above body temperature, and must undergo heat treatment (i.e., it is the chemical changes in the food after it has been cooked that help it be better absorbed). No raw food diet, hunger strikes or cold vegetarian diets! The 3rd left color will wither away from them, become sluggish, lifeless, the brain will work poorly.

If 3rd color right- This is cold determination. This is where a raw food diet comes in handy. It is better that the food is not heat-treated and is colder than body temperature. Even cooked food is best refrigerated before eating.

4 color: Touch

What we're dealing with here is the social environment, the environment around you that either stimulates or leaves you alone while eating.

If under the 4th color left tones (1, 2, 3), then food intake should be carried out in a calm environment, if there rights tones (4, 5, 6) - in a lively tone, so that everything around is spinning and spinning.

5 color: Sound (Listener)

5 color, Sound - sensitivity to sounds. The process of nutrition itself fades into the background - what is important here is the acoustically perceived frequencies of the environment, which affect personal health.

If the 5th color left- this is nutrition provided that there are high sound vibrations in the environment.

If the 5th color right- food in absolute silence or in the presence of low sound vibrations.

What a person specifically eats is not important.

6 color: Light (Observer)

The 6th color is sensitivity to Light. Here we distinguish between daytime and nighttime types of nutrition.

If the 6th color left, then you have a daily diet. It is necessary that sunlight (ultraviolet light) falls on the food.

If the 6th color is right, then you need to feed at night, or feed in indirect sunlight.

What is night feeding? This is, firstly, nutrition at dusk or before sunrise, without ultraviolet radiation. Secondly, you need, as Ra said, to “sleep with this food” so that it is absorbed, only then the brain will function correctly. Going to bed on an empty stomach is bad, which does not mean that you need to eat a lot at night. Night people need less food, two times a day is enough, they are right.

You can, of course, cheat - for example, if the rest of the family has a daytime regime, and you have a nighttime regime... you can eat away from the windows, cover yourself with an umbrella from the sun, put ultraviolet protection on the windows, and after eating do not go outside for several hours (if light).

It is interesting that the primitive digestive systems, which include the lower colors (1st, 2nd, 3rd colors) are separate. Food is important, i.e. it's either one product at a time, or something very fixed, seasonal, or temperature manipulation. On the other hand, you can share your meal with a friend, that is, if we have lower colors, the main thing is that everyone on their plate has their own food that suits them, but the setting is not important.

But the top colors are something completely different. There you can at least eat shoes, but under certain conditions. The environment must be appropriate, or, again, this is sensitivity to sound and light...

Tones

1 tone: Immune system/reliability/smell.

Health type - Spleen.

The desire for security in existence. An active desire to identify “unreliability” by smell (smelling food or something unknown and incomprehensible).

Cognition - smell. It is possible and important to focus on it when eating and in general. He can tell you what is dangerous and unsafe for you, and what is healthy. You can smell food.

Tone 2: Immune system/uncertainty/taste.

The tone frequency is concentrated.

Health type - Spleen.

The unknown is inherent in the process of life - therefore, the hope of knowing the unknown is given by taste. It's important to taste things. Taste is your unique cognitive system.

Tone 3: Intelligence/action/external vision.

The tone frequency is periodic.

Health type - Ajna.

Tone 3 is associated with external vision (vision) and eye health in general, especially the right eye.

Visual perception and learning are directed to the nearest visible problem. The ability to look outward, to see patterns, consistency.

Ra had a 3rd tone and a 4th color. His unique cognition is external vision, a logical, strategic way of breaking things down and presenting them visually, seeing a structure, a system. This is how the 3rd tone works, as the quintessence of a generally strategic way of understanding the world.

Tone 4: Intellect/meditation/inner vision.

The tone frequency is periodic.

Health type - Ajna.

Inner vision, meditation. Passive learning through internal mental awareness. Training and education through information.

You have the 4th tone, and this is inner vision, meditation. Perhaps this technique will help you connect with your energy: close your eyes and internally imagine the food in question. And be with it, feel whether you want to eat it or not, whether it tastes good to you or not.

Tone 5: Emotions (feelings)/verdict/feeling.

The tone frequency is cyclic.

Emotionally active discussion when feelings prompt thinking.

When choosing food, it is important to take your time and connect with your feelings to sense whether this food is emotionally comfortable for you right now. Does it feel inviting? But, in general, the 5th tone is something new (in evolutionary terms), it is a very unusual, non-strategic cognition.

Tone 6: Emotions (feelings)/feeling/acceptability.

The tone frequency is cyclic.

Health type - Solar Plexus.

Tone 6 is an amazing tone. Touch. This is something akin to the ability to read information through auric contacts, touch, acceptance, information transmitted through the skin, right tone. Skin contact with food is important. When you pick up food, you pick up information about its structure.

Types of health

We have three types of health, three ways to be healthy, three types of disabilities and three ways to heal. And, accordingly, there are three groups of people.

There is splenic health, mental health and emotional health.

Many people consider splenic health to be the only thing. But that's not true.

The splenic man, being unhealthy, begins to smell bad and at the same time his sense of smell becomes dull. He needs to have his smell analyzed.

If you have mental health, whether you are healthy or not can be determined by the way you look. What matters is how you look (of course, you need to be able to see!) and your vision is also important. Here the visual matters, and also in both directions. If your vision is deteriorating, then you have health problems.

For a person with an emotional type of health, the condition of his skin matters, and not only its appearance, but also the feeling of touching his skin.

And if you have splenic health, and you are treated by a doctor with mental health, then you are lost!

Thus, just as there are 3 tonal binaries, there are 3 worlds. And the world of the nose is very different from the world of skin and from the world of vision. And to check whether, for example, your child is healthy, you will sniff him, examine him or touch him, depending on which group he belongs to.

To determine your type, you need to look at the Sun/Earth tone of the design.

The 3 tonal binaries are deeply connected to the 3 centers of awareness. 1st and 2nd tones associated with Spleen, 3rd and 4th With Ajnoy And 5th and 6th with center Solar Plexus– these are three categories of awareness, three worlds and three different processes.

In healthy individuals IV tone can also be recorded, but it is more common in pathology. Its appearance is associated with atrial systole; it occurs in presystole after the apex of the P wave in 0.05-0.12 s. On FCG, this tone is normally presented in the form of 1-2 low-frequency, low-amplitude oscillations and is better recorded on the low-frequency channel.

III and IV tones in pathological conditions, they clinically correspond to the gallop rhythm. A distinction is made between diastolic “,” associated with the third tone, and the fourth presystolic tone. The latter occurs with significant overflow of the atria. V tone was described in 1950 by Kalo and M.K. Oskolkova. It is recorded extremely rarely and occurs due to an elastic reaction to rapid filling with blood. This tone is recorded on the low-frequency channel in the form of 1-2 oscillations of low amplitude and follows after the IV tone.

Pathological changes in heart sounds on FCG- increase or decrease in their amplitude and the presence of splitting.
Pathology of the first tone. A decrease in the amplitude of the first tone is determined both by its absolute value and by its ratio to the normal second sound at the apex of the heart and at Botkin’s point. If the amplitude of the first tone is equal to that of the second tone or less (10 mm or less), then we should speak of a weakening of the first tone. The following pathological cardiac factors can lead to its weakening:

Significant destruction of the left atrioventricular valve with severe insufficiency;
- sharp limitation of the mobility of the left atrioventricular valve with mitral disease, even with a predominance of stenosis, with severe calcification, fusion of the chords;
- a significant decrease in the contractile function of the left ventricular myocardium with pronounced dystrophic and cardiosclerotic changes, atrial fibrillation, and active rheumatic myocarditis.

Weakening of the first tone can be observed in connection with extracardiac factors: in obese people with a large fat layer, with emphysema, left-sided exudative pleurisy, exudative pericarditis.

Strengthening the first tone manifests itself on the FCG by an increase in amplitude and an increase in its frequency, which corresponds to the well-known auscultatory concept of the first flapping sound. An increase in the first tone is said to occur if its amplitude at the apex and at the Botkin point is 2 times or more greater than that of the second tone. Strengthening the first tone with mitral stenosis is explained by the shortening of the free edge of the valves, their mobility and compaction. An increase in its intensity is also observed in thyrotoxicosis and anemia. The mechanism of its enhancement in this case is not entirely clear.

Splitting of the first tone, caused by non-simultaneous closure of the left and right atrioventricular valves, occurs with mitral-tricuspid stenosis, blockade of the legs of the atrioventricular bundle, and atrial septal defect.

Heart sounds are waves of sound that occur when all the heart valves work and the myocardial muscle contracts. These heart sounds can be heard with a phonendoscope, and they can also be heard when you put your ear to your chest.

When listening to a specialized specialist, the doctor applies the head (membrane) of the phonendoscope instrument to those places where the heart muscle is located closest to the sternum.

Cardiac cycle

Each element of the heart organ works harmoniously and with a certain sequence. Only such work can guarantee normal blood flow in the vascular system.

Cardiac cycle

At the moment when the heart is in diastole, the blood pressure in the heart chambers is lower than in the aorta. Blood flows first into the atria and then into the ventricles.

When, during diastole, the ventricle is filled with biological fluid to three-quarters of its volume, the atrium contracts, during which the chamber is filled with the remaining volume of blood.

This action in medicine is called atrial systole.

When the ventricles are full, then the valve that separates the ventricles from the atria closes.

The volume of biological fluid stretches the walls of the ventricular chambers, and the walls of the chamber contract quickly and sharply - this action is called systole of the left-sided ventricle and the right-sided one.

When the blood pressure in the ventricles becomes higher than in the blood flow system, then the aortic valve opens and blood under pressure passes into the aorta.

The ventricles become empty and enter diastole. When all the blood has entered the aorta, the semilunar valves close and blood does not flow back into the ventricle.

Diastole lasts 2 times longer than systole, so this time is enough for the myocardium to rest.

The principle of tone formation

All movements in the work of the heart muscle, heart valves, and blood flow when injected into the aorta create sounds.

There are 4 tones in the heart organ:

• № 1 - sound from contraction of the heart muscle;
• № 2 - sound from valve operation;
• № 3 - during ventricular diastole (this tone may not be present, but according to the norm it is allowed);
• № 4 - when the atrium contracts at the moment of systole (this tone may also not be audible).

Valve that creates sound

Tone No. 1 consists of:

• Trembling of the heart muscles;
• The sound of the slamming of the walls of the valve between the atrium and the ventricle;
• Trembling of the walls of the aorta as blood flows into it.

According to the standard indicator, this is the loudest among all audible tones of the cardiac organ.

The second manifests itself after a short period of time after the first.

This happens due to:

• Actuation of the aortic valve valve;
• Triggering of the pulmonary valve walls.

Tone No. 2. It is not as sonorous as the first and is heard between the second ribs on the left side of the heart area, and can also be heard on the right. The pause in sounds after the second is longer, because the beat occurs at the time of heart diastole.

Tone No. 3. This tone is not one of the required beats for the cardiac cycle. But according to the norm, this third tone is allowed, or may be absent.

The third occurs as a result when, during diastole, the walls of the left-sided ventricle shudder while it is filled with biological fluid.

In order to hear it during auscultation, you need to have extensive listening experience. Not by an instrumental method, this tone can only be heard in a quiet room, and also in children, because the heart and chest are located close.

Tone No. 4. Just like the third is not mandatory in the cardiac cycle. If this tone is absent, this is not a myocardial pathology.

Upon auscultation, it can only be heard in children and the younger generation of people with a thin chest.

The reason for the 4th tone is the sound that occurs during the systolic state of the atrium, at the moment when the left and right ventricles are filled with biological fluid.

During normal functioning of the cardiac organ, rhythmicity occurs after the same time intervals. Normally, a healthy organ has 60 beats in one minute, the time interval between the first and second is 0.30 seconds.

The time interval from the second to the first is 0.60 seconds. Each tone is clearly audible, they are loud and clear. The first one sounds low and is long.

The onset of this first tone begins after a pause. The second sounds higher in sound and begins after a short pause, and it is slightly shorter in length than the first.

The third and fourth tones are heard after the second oh, at the moment when diastole of the cardiac cycle occurs.

How are heart sounds heard?

For instrumental listening to heart sounds, as well as listening to the work of the bronchi, lungs and when measuring blood pressure using the Korotkov method, a phonendoscope (stethoscope) is used.

The phonendoscope consists of: an olive, a bow, a sound wire and a head (with a membrane).

To listen to heart sounds, a cardiological type of phonendoscope is used - with increased sound capture by the membrane.

The order of listening to heart sounds during auscultation

During auscultation, the valves of the heart organ are heard, their function and rhythm.

Localization of tones when listening to valves:

• Bicuspid valve at the top of the heart organ;
• Listening to the aortic valve under the second rib on the right side of the heart;
• Listening to the operation of the pulmonary artery valve;
• Recognition of the tonality of the tricuspid valve.

Listening to cardiac impulses and their tone during auscultation takes place in a certain sequence:

• Locality of apical systole;
• Second intercostal space on the right side of the chest edge;
• Second intercostal space on the left side of the chest;
• Bottom of the sternum (locality of the xiphoid process);
• Erb-Botkin localization point.

This sequence when listening to heart sounds is due to damage to the valves of the cardiac organ and will allow you to correctly listen to the tone of each valve and identify the performance of the myocardium. Coherence in work is immediately reflected in the tones and their rhythm.

Changes in heart sounds

Heart sounds are waves of sound, so any deviation or disturbance indicates a pathology of one of the structures of the cardiac organ.

In medicine, the reasons for deviations from the normative indicators of the sound of tones are identified:

• Physiological changes- these are reasons that are associated with the physiology of the person whose heart is being listened to. The sounds will not be clear when listening to a person who is obese. Excess fat on the chest prevents good hearing;
• Pathological change in knocking- these are deviations in the functioning of the cardiac structures or damage to parts of the cardiac organ, as well as the arteries extending from it. A loud knock occurs because the walls of the damper thicken, become less elastic and make a loud sound when closing. The first knock produces a click.

Muffled tones

Muffled knocks are sounds that are not clear and hard to hear.

Pericarditis disease

Faint sounds may be a sign of pathology in the heart organ:

• Diffuse destruction of myocardial tissue - myocarditis;
• Myocardial infarction attack;
• Cardiosclerosis disease;
• Pericarditis disease;
• Pathology in the lungs - emphysema.

If the first knock or the second weakens, and audibility during auscultation in different directions is not the same.

This then expresses the following pathology:

• If there is a muffled sound from above the cardiac organ, then this indicates that pathology is developing - myocarditis, myocardial sclerosis, as well as its partial destruction and valve insufficiency;
• A dull sound in the 2nd hypochondrium indicates that there is a malfunction of the aortic valve, or stenosis of the aortic walls, in which the compacted walls do not have the ability to stretch elastically;

Some changes in the tonality of heart sounds have specific characteristic accents and have a specific name.

With mitral valve stenosis, a sound occurs - called the quail rhythm, where the first knock is heard like a clap and the second immediately occurs.

After the second, an echo of an additional tone occurs, which is characteristic of this pathology.

If the myocardial pathology has progressed to a severe degree of the disease, then a three-beat or four-beat sound occurs - a gallop rhythm. With this pathology, biological fluid stretches the walls of the ventricular chambers, which leads to additional sounds in the rhythm.

Gallop rhythm

• The combined combination of the first, second and third is a protodiastolic rhythm;
• The simultaneous combination of the first tone, the second and the fourth is a presystolic rhythm;
• The quadruple rhythm is the combination of all four tones;
• The total rhythm during tachycardia is the audibility of four tones, but at the moment of diastole the third and 4th sounds merge into one sound.

Enhanced tone sounds

Increased heart sounds are heard in children and thin people because their chest is thin, which allows the phonendoscope to hear better, since the membrane is located next to the heart organ.

Mitral valve stenosis

If pathology is observed, then this is expressed in the brightness and volume of tones and in specific localization:

• The loud and ringing first sound in the upper part of the heart organ indicates a pathology of the atrioventricular left-sided valve, namely narrowing of the walls of the valve. This sound is expressed during tachycardia, sclerosis of the mitral valve, because the valve flaps have become thickened and lost their elasticity;
• The second sound in this place means a high level of blood pressure, which is reflected in the small blood circulation. This pathology leads to the fact that the valve flaps on the pulmonary artery quickly slam shut because they have lost elasticity;
• A loud and ringing sound in the second hypochondrium indicates the pathology of high aortic pressure, stenosis of the aortic walls, as well as the progression of atherosclerosis.

Arrhythmia of heart sounds

Tones that do not have rhythm (arrhythmia) indicate that there is a clear deviation in the blood conducting system of the cardiac organ.

Pulsation occurs at different time intervals because not every contraction in the heart passes through the entire thickness of the myocardium.

The disease atrioventricular block manifests itself in the uncoordinated work of the atria and the left and right ventricles, which produces a tone - a cannon rhythm.

This sound occurs during simultaneous systole of all cardiac chambers.

Atrioventricular block

Does not have a coherent rhythm and split tones. This happens when one tone is divided into 2 short ones. This pathology is due to the fact that the work of the heart valves is not harmonious with the myocardium itself.

Splitting of one tone occurs due to:

• The mitral valve and tricuspid valve do not close at the same time. This occurs with the disease tricuspid stenosis of the tricuspid valve, or with stenosis of the walls of the mitral valve;
• The conduction of electrical impulses to the ventricles and atria by the heart muscle is impaired. With insufficient conductivity, arrhythmia occurs in the functioning of the ventricular chambers and the atrium chamber.

The arrhythmia and demarcation of the second number of knocks, when the valves slam shut at different moments, indicate abnormalities in the heart.

In the coronary vascular system:

• High blood pressure in the pulmonary circulation provokes oxygen starvation;
• Severe arterial hypertension (hypertension);
• Hypertrophy of the walls of the left ventricle, with pathology of the mitral valve, as well as stenosis of this valve. The systole of the mitral valve leaflets closes later, which leads to disturbances in the aortic valve.

In case of coronary heart disease, the change in tone depends on the stage of the disease and on the damage to the myocardium and the condition of the valves.

At the primary stage of development of the disease, the tones are not very deviated from the norm, and the signs of ischemia are weakly expressed.

Angina pectoris manifests itself in attacks. At the time of an attack of angina pectoris, with ischemic heart disease (coronary heart disease), the heartbeat becomes slightly muffled, the rhythm in tones disappears, and a gallop rhythm appears.

With further progression of angina, dysfunction of the heart muscle and valves between the myocardial chambers does not occur at the time of an angina attack, but occurs on an ongoing basis.

Conclusion

A change in the rhythm of the heartbeat is not always a sign of heart disease or diseases of the blood vessel system, and irregularity can also manifest itself in thyrotoxicosis, infectious diseases - diphtheria.

Many pathologies and viral diseases affect the rhythm of cardiac impulses, as well as the tone of these impulses.

Additional heart sounds also appear not only in heart disease. Therefore, to establish the correct diagnosis, it is necessary to undergo an instrumental examination of the myocardium, the vascular system, and also listen to all the sounds of the cardiac organ using a phonendoscope.

Auscultation of the heart. Normal and pathological heart sounds.

Ex. questions:

1. The mechanism of formation of the first tone, its characteristics in a healthy person, physiological variants.

2. The mechanism of formation of the second tone, its characteristics in a healthy person, physiological variants.

3. The mechanism of formation of the III and IV physiological heart sounds, their characteristics.

4. Reasons for strengthening and weakening of the first heart sound in pathology.

5. Reasons for strengthening and weakening of the second heart sound in pathology.

6. Reasons for strengthening and weakening of both heart sounds in normal and pathological conditions.

7. Splitting and bifurcation of the first tone: causes, mechanisms of formation in pathology.

8. Splitting and bifurcation of the second tone: causes and mechanisms of occurrence in normal and pathological conditions.

9. Pathological III and IV tones: causes and mechanisms of formation, clinical characteristics, FCG diagnostics.

10. Mitral valve opening tone: causes and mechanism of formation, clinical characteristics, FCG diagnostics

11. Gallop rhythm: variants, causes and mechanisms of occurrence, clinical characteristics, FCG diagnostics.

12. Pendulum-shaped rhythm, causes and mechanism of formation, clinical characteristics, diagnostic significance.

Auscultation of the heart.

There are two main phases of the cardiac cycle: systole and diastole.

Systole is the contraction of the ventricles. By the time of systole, the ventricles are filled with blood, the AV valves are open, and the semilunar valves are closed.

Systole begins with a phase of asynchronous contraction of the ventricles, when only individual myocardial fibers contract, which leads to an increase in pressure in the ventricular cavity and closure of the AV valves.

After the closure of the atrioventricular valves (the period of closed valves), the phase of isometric ventricular tension begins, as a result of which intraventricular pressure significantly increases and the semilunar valves of the aorta and pulmonary artery open.

A period of rapid expulsion of blood from the ventricles into the great vessels begins. At the beginning of the ejection period, the pressure in the ventricles is much higher than in the large vessels. Then, with an increase in blood volume in the great vessels, the pressure in the ventricles decreases, and in the great vessels increases. This leads to a gradual decrease in the speed of blood movement from the ventricles to the aorta and pulmonary artery, and the slow expulsion phase begins.

By the end of systole, the pressure in the vessels is higher than in the ventricles, which forms a reverse flow of blood in the vessels, while the leaflets of the semilunar valves fill with blood and slam shut. From the moment the semilunar valves close, ventricular diastole begins.

After the closure of the semilunar valves, the phase of isometric ventricular relaxation begins. At this point, the atria are filled with blood, the ventricles are empty, and the valves are closed (closed valve period). According to the pressure gradient, blood from the atria rushes into the ventricles, and the AV valves open.

The period of ventricular filling begins. At the beginning of this period, blood quickly moves along the pressure gradient into the ventricles (a period of rapid passive ventricular filling). As the ventricles fill with blood, the flow rate decreases - the phase of slow passive filling of the ventricles. To move additional blood volume, atrial systole occurs at the very end of diastole (a period of rapid active filling of the ventricles).

During the work of the heart, sound phenomena occur that can be detected by auscultation. These are heart sounds. The opening of the heart valves is normally not accompanied by the appearance of sound; heart sounds are formed by the closing of the valves and vibrations of the myocardium and blood vessels. When auscultating the heart, 2 tones are normally heard at all points of auscultation.

The first sound is called systolic, as it is heard at the beginning of systole. According to the mechanism of formation, it consists of 4 components:

1. the main component is the valve component, formed by the sound of the closing of the cusps of the mitral and tricuspid valves at the beginning of systole - in the phase of asynchronous contraction, and the mitral valve closes first, and a little later the tricuspid valve. But the time between the closure of the mitral and tricuspid valves is 0.02 s and is not distinguishable by the ear: this is the time of physiological asynchrony.

2. muscular component – ​​caused by fluctuations of the ventricular myocardium in the phase of isometric ventricular tension;

3. vascular component - caused by fluctuations in the initial parts of the aorta and pulmonary artery under the influence of the blood flow moving from the ventricles to the great vessels in the rapid expulsion phase.

4. atrial component – ​​caused by vibrations of the ventricular myocardium during atrial systole. This component precedes the valve component of the first tone.

The second sound is called diastolic; it is heard at the beginning of diastole.

Consists of 2 components:

1. the valve component is formed by the sound of the slamming of the valves of the semilunar valves of the aorta and pulmonary artery;

2. the vascular component is associated with vibration of the walls of the aorta and pulmonary artery under the influence of the blood flow directed towards the ventricles.

The semilunar valves do not close simultaneously; the time between the closure of the aortic and pulmonary valves is also 0.02 s - this is the time of physiological asynchrony.

When analyzing heart sounds, it is necessary to be able to distinguish between the first and second sounds:

· The first tone occurs after a longer pause, i.e. diastole, II tone - after a short pause, i.e. systole.

· The first sound is louder than the second at the apex and at the 4th point of auscultation (there is a projection of the mitral and tricuspid valves, the closure of which produces the first sound). The first tone is longer and lower. The second sound is louder than the first at the base of the heart - at the 2nd and 3rd points of auscultation (projection points of the semilunar valves), it is shorter and higher.

· In case of tachycardia, especially in children, when systole is equal to diastole, the following technique will help to distinguish between sounds I and II: auscultation in combination with palpation of the pulse in the carotid artery; the tone that coincides with the pulse in the carotid artery is I.

III and IV physiological tones.

Their appearance is associated with vibrations of the ventricular myocardium under the influence of blood moving from the atria to the ventricles during ventricular diastole. The conditions for the occurrence of III and IV physiological tones are high myocardial tone. These tones can be heard in adolescents and young adults with a thin chest wall and a hyperkinetic type of hemodynamics (increased speed and increased strength during physical and mental stress). They are better heard by direct auscultation at the apex of the heart.

The third sound is protodiastolic, it appears at the beginning of diastole 0.14-0.20 s after the second sound. With high myocardial tone in the phase of rapid passive filling of the ventricles, the myocardium begins to oscillate and vibrate under the influence of blood flow. It is a weak, low, short sound.

The IV tone is presystolic, it appears at the end of diastole and precedes the I tone. Very quiet, short sound. It is heard in individuals with high ventricular myocardial tone and increased tone of the sympathetic nervous system. The IV tone is caused by vibrations of the ventricular myocardium when blood enters them in the phase of atrial systole - the phase of active filling of the ventricles (as the 4th component of the I tone). Most often heard in an upright position in athletes and after emotional stress. This is due to the fact that the atria are sensitive to sympathetic influences, therefore, with an increase in the tone of the sympathetic nervous system, there is a slight advance of atrial contractions from the ventricles and therefore the fourth component of the 1st sound begins to be heard separately from the 1st tone and is called the 4th tone.

Changes in the sonority of heart sounds.

The simultaneous strengthening or weakening of sounds I and II is primarily due to extracardiac reasons.

The reasons for the increase in both tones are normal:

1. Thin chest wall – with poor development of muscles and pancreas

2. Physical and emotional stress, while heart rate increases, diastole shortens, and diastolic filling of the ventricles decreases. The force of contraction of the ventricles and the speed of blood flow increase, which leads to increased sounds.

In pathology, the intensification of both tones is due to extracardiac reasons:

1. Reduced airiness of the lung tissue at the site of the projection of the heart onto the chest wall - pneumosclerosis, inflammatory infiltration.

2. An air resonating cavity in the lung adjacent to the heart - sound amplification occurs in it.

3. Tumor of the posterior mediastinum, in which the heart approaches the chest wall.

4. Increase in heart rate during fever, thyrotoxicosis - diastolic filling of the ventricles decreases.

The reasons for the weakening of both tones are normal:

1. Thick chest wall - with excessive development of muscles and adipose tissue.

2. In a dream. At the same time, heart rate decreases, diastolic filling of the ventricles increases, and blood flow speed decreases. In the supine position, the heart moves away from the anterior chest wall and the sonority of the tones weakens.

In pathology, weakening of the 1st and 2nd sounds is mainly due to extracardiac reasons:

1. Increased airiness of the lung tissue at the site of the projection of the heart onto the chest wall - with pulmonary emphysema.

2. Left-sided exudative pleurisy or pneumothorax, moving the heart away from the anterior chest wall.

3. Effusion pericarditis.

The intracardial reason for the simultaneous weakening of both tones is a decrease in the contractility of the ventricular myocardium. Causes: myocardial dystrophy, myocarditis, myocardiopathy, cardiosclerosis. At the same time, the speed of blood flow and the force of myocardial contraction decrease, which leads to a weakening of the first sound, the volume of blood entering the aorta and pulmonary artery decreases, which means that the second sound weakens.

Auscultation of the heart is performed at the following points:

1. the area of ​​the apex of the heart, which is determined by the location of the apex beat. This is the projection point of the mitral valve;

2. II intercostal space at the right edge of the sternum. The aortic valve is heard here;

3. II intercostal space at the left edge of the sternum. The pulmonary valve is heard here;

4. Place of attachment of the xiphoid process to the body of the sternum. The tricuspid valve is heard here

5. Botkin-Erb point – III intercostal space 1-1.5 cm outward from the left edge of the sternum. Here, sound vibrations are heard that occur during the operation of the aortic valve, and less commonly, the mitral valve.

During auscultation, the points of maximum sound of heart sounds are determined:

I tone – area of ​​the apex of the heart (I tone is louder than II)

II tone – area of ​​the base of the heart.

The sonority of the second tone to the left and right of the sternum is compared.

In healthy children, adolescents, and young people of asthenic body type, an increase in the second tone on the pulmonary artery is observed (quieter on the right than on the left). With age, an increase in the second tone above the aorta (second intercostal space on the right) is observed.

The reasons for an isolated change in the sonority of the first or second tone are often intracardial.

Strengthening of the first tone is associated primarily with a decrease in diastolic filling of the ventricles. Reasons:

Mitral stenosis. Thickening of the mitral valve leaflets leads to an increase in the sonority of the valve component of the first sound, a decrease in the diastolic blood volume in the LV leads to an increase in the rate of myocardial contraction and an increase in the muscular and vascular components of the first sound. The first sound in mitral stenosis is called the flapping first sound.

Tachycardia

Extrasystole. Strengthening of the first tone is determined at the moment of extraordinary contraction of the heart after a short diastole.

Atrial fibrillation, tachyform. Shortening of diastole.

Complete AV block, when there is a complete separation in time of contraction of the ventricular myocardium and the atrium myocardium. At the moment when the contraction of the atria coincides with the contraction of the ventricles, the first sound is intensified - the Strazhesko cannon tone.

If at the top the 1st tone is equal in volume to the 2nd or quieter than the 2nd tone, the 1st tone is weakened. Reasons:

Mitral or tricuspid valve insufficiency. The absence of a period of closed valves leads to a sharp weakening of the valve component. Diastolic overflow of the ventricles leads to a weakening of the muscular and vascular components of the first sound.

Aortic valve insufficiency - during diastole more blood enters the left ventricle - the speed of its contraction and the speed of blood flow decreases.

Stenosis of the aortic mouth - I tone weakens due to pronounced hypertrophy of the LV myocardium, a decrease in the rate of myocardial contraction due to the presence of increased afterload.

Diseases of the heart muscle, accompanied by a decrease in myocardial contractility (myocarditis, cardiomyopathies, cardiosclerosis), but if cardiac output decreases, then the second tone also decreases.

Myocardial hypertrophy, for example, with hypertension, hypertrophic cardiomyopathy. At the same time, the rate of myocardial contraction decreases.

Changing the volume of tone II.

Normally, the sonority of the second tone at the second and third points of auscultation is the same. This is explained by the fact that although the pressure in the aorta is higher than the pressure in the pulmonary artery, the aortic valve is located deeper. If at the second or third points of auscultation there is an increase in the II tone, this is called an accent of the II tone. It may be over the aorta or pulmonary artery.

Reasons for the accentuation of the second tone over the pulmonary artery:

1. Physiological reason - in children and young people under 25 years of age. The reason is the more superficial location of the pulmonary valve and the higher elasticity of the aorta, lower pressure in it. With age, blood pressure in the BCC increases; The PA moves posteriorly, the accent of the 2nd tone above the LA disappears.

2. In pathology, an increase in the second tone over the PA is caused by an increase in pressure in the ICC and is observed with mitral heart defects, chronic respiratory diseases, and primary pulmonary hypertension.

Reasons for the accentuation of the second tone over the aorta:

Increased blood pressure

Atherosclerosis of the aorta, increased tone II appears due to sclerotic compaction of the aortic valve leaflets and aortic walls.

Reasons for weakening of the second tone

– insufficiency of the pulmonary valve, stenosis of the orifice of the pulmonary artery.

Above the aorta:

Severe arterial hypotension

Aortic valve insufficiency - in this case, the leaflets of the aortic valve do not close, therefore, the valve component of the second sound is weakened.

Stenosis of the aortic mouth - as a result of a decrease in the speed of blood flow through the narrowed opening of the aortic valve, the vascular component of the second sound is weakened.

Splitting and splitting tones.

In healthy people, there is asynchronism in the work of the right and left ventricles; normally it does not exceed 0.02 seconds; this difference is indistinguishable by the ear, and we hear one tone.

If the time between contraction of the right and left ventricles increases by more than 0.02 s, then each tone is not perceived as a single sound. If the asynchronism time increases within 0.02-0.04 seconds, this is splitting. If the asynchronism time is 0.05 sec. and more - this is a bifurcation - a more noticeable doubling of tone.

The reasons for splitting and splitting tones are the same, the only difference is time.

Physiological cause of splitting and bifurcation of the first tone:

You can listen at the end of expiration, when intrathoracic pressure increases and blood flow from the ICC vessels to the left atrium increases, resulting in increased blood pressure on the atrial surface of the mitral valve. This slows down its closure, which leads to auscultation of the cleft.

Pathological bifurcation of the first tone occurs when:

1. blockade of one of the bundle branches, this leads to a delay in the contraction of one of the ventricles.
2. ventricular extrasystole. In this case, the ventricle in which the impulse originated contracts faster.
3. Severe myocardial hypertrophy, more often of the left ventricle (with aortic hypertension, aortic stenosis). In this case, the hypertrophied ventricle contracts more slowly.

Splitting and bifurcation of the second tone.

Functional splitting or bifurcation of the second tone is observed more often than the first; it occurs in young people at the end of inhalation or the beginning of exhalation, during physical activity. The reason is the non-simultaneous end of systole of the left and right ventricles.

Pathological splitting or bifurcation of the second tone is more often observed in the pulmonary artery. The mechanism is associated with an increase in pressure in the ICB and a delay in the closure of the pulmonary valve compared to the aortic valve. Causes: mitral valve defects, primary pulmonary hypertension, emphysema and other chronic respiratory diseases. As a rule, an increase in the II tone on the LA is accompanied by splitting or bifurcation of the II tone on the LA.

Pathological III and IV tones. The condition for their occurrence is a sharp decrease in the contractility of the myocardium - “flabby myocardium”.

The third tone appears after 0.12-0.20 seconds. after the second sound, that is, at the beginning of diastole, in the phase of rapid filling of the ventricles. If the ventricular myocardium has lost its tone, when the ventricular cavity is filled with blood, the muscle easily and quickly stretches, the ventricular wall vibrates, and sound is produced. The diagnostic value of the pathological III tone is severe myocarditis, myocardial dystrophy.

Pathological IV sound occurs before the I tone at the end of diastole during atrial systole. The conditions for its occurrence are: a sharp decrease in the tone of the ventricular myocardium and the presence of overcrowded atria. Rapid stretching of the wall of the ventricles, which have lost their tone, when a large volume of blood enters them in the atrial systole phase causes myocardial vibrations and a fourth pathological tone appears.

III and IV sounds are better heard at the apex of the heart, on the left side. The emergence of a gallop rhythm is associated with the appearance of III and IV pathological tones.

The gallop rhythm was first described by Obraztsov in 1912 - “the cry of the heart for help.” It is a sign of a sharp decrease in myocardial tone and a sharp decrease in the contractility of the ventricular myocardium. So named because it resembles the rhythm of a galloping horse.

Signs:

1. tachycardia,
2. weakening of I and II tones,
3. the appearance of pathological III or IV tones.

Highlight:

· protodiastolic gallop rhythm – three-part rhythm due to the appearance of the third pathological tone,

Presystolic – due to the appearance of IV pathological tone,

· mesodiastolic – when an additional tone appears in the middle of diastole (with severe tachycardia, sounds III and IV merge, a summation tone is heard in the middle of diastole).

Mitral valve opening tone.

– a sign of mitral stenosis. With mitral stenosis, the cusps of the mitral valve are fused with each other; when blood flows from the atria into the ventricles, the opening of the mitral valve is accompanied by a strong tension of the cusps, a sound is formed - the tone of the opening of the mitral valve, it appears 0.07-0.12 seconds after the second sound.

The quail rhythm, or melody of mitral stenosis, is a rhythm caused by the appearance of the opening tone of the mitral valve, including:

Loud, clapping I tone,

Accent and splitting or bifurcation of the II tone on LA,

Mitral valve opening tone.

The quail rhythm is best heard at the apex of the heart.

Pendulum rhythm.

The condition for its occurrence is a sharp decrease in myocardial tone. In this case, both phases of cardiac activity - systole and diastole - are balanced in time. This occurs either due to shortening of diastole or due to lengthening of systole. I and II tones are weakened and are equal in sonority to each other. The pendulum-like rhythm is reminiscent of the sound of a clock pendulum swinging. If the pendulum-like rhythm is accompanied by tachycardia, this indicates embryocardia, that is, the melody resembles the heartbeat of a fetus.