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Systolic heart murmur. Functional systolic murmur 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:

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.

1. The first tone is heard after a long pause, the second tone - after a short one.

2. The first tone is longer (on average 0.11 s), the second tone is shorter (0.07 s.)

3. I tone is lower, II tone is higher.

4. The first sound coincides in time with the apical impulse and with the pulse in the carotid artery.

When auscultating heart sounds, it is necessary to characterize the number of tones, their rhythm, volume, sound integrity. When additional tones are identified, their auscultatory features are noted: relation to the phases of the cardiac cycle, volume, timbre.

Heart sounds can be rhythmic or arrhythmic if the patient has a heart rhythm disorder (extrasystole, atrial fibrillation, etc.). Special auscultatory rhythms (quail rhythm, gallop rhythm) can also be heard.

The volume of tones is estimated based on the ratio of the sound volume of tones I and II at various points.

The volume of the first tone is characterized at the mitral and tricuspid valves, i.e. on those valves that participate in its formation. The volume of the first tone is considered normal if it sounds 1.5-2 times louder than the second tone. If the first tone is heard 3-4 times louder than the second tone, this is regarded as an increase in the first tone. If the 1st tone is the same in volume as the 2nd tone or is quieter than it, the 1st tone is weakened.

The volume of the second tone is characterized in the aorta and pulmonary trunk. Moreover, in a healthy person, the volume of tone 2 at these points exceeds the volume of tone 1 by 1.5-2 times. In addition, the volume of tone II at the listening points of these two valves is the same. If the second tone is heard louder on the aorta or pulmonary trunk, then this condition is characterized as an accent of the second tone on one or another valve.

The volume of heart sounds may depend on the conditions under which sound vibrations are conducted.

Evenly decrease the volume of both tones above the apex of the heart while maintaining the predominance of the first tone is usually associated with noncardiac causes: accumulation of air or fluid in the left pleural cavity, pulmonary emphysema, effusion into the pericardial cavity, obesity.

Attenuation of both tones occurs when the heart muscle is damaged (myocarditis, cardiosclerosis, myocardial infarction).

Boosting both tones observed during physical activity, fever, agitation, thyrotoxicosis, in the initial stages of anemia, and compaction of lung tissue.

The main reasons for the weakening of the first tone above the apex are:

Mitral valve insufficiency (decreased amplitude of movement of deformed valve leaflets, absence of a period of closed valves);

Damage to the heart muscle with weakening of the contractility of the left ventricle due to weakening of the muscle component (myocarditis, myocardial infarction, myocardial dystrophy, dilated myocardiopathy);

Increased diastolic filling of the left ventricle (mitral valve insufficiency, aortic valve insufficiency);

Slowing of contraction of the left ventricle with pronounced hypertrophy (aortic defects, hypertension).

Weakening of the first tone at the xiphoid process occurs with tricuspid valve insufficiency due to weakening of the valve component, with pulmonary valve insufficiency due to weakening of the muscle component.

Strengthening of the first tone at the apex observed with stenosis of the left atrioventricular orifice, as well as with tachycardia and extrasystole, due to low diastolic filling of the ventricles. In patients with complete atrioventricular block, a sudden significant increase in the first sound (Strazhesko's "cannon tone") is periodically heard against the background of pronounced bradycardia, which is explained by the random coincidence of contractions of the atria and ventricles.

Weakening of the second tone over the aorta occurs with aortic valve insufficiency and low blood pressure.

Weakening of the second tone over the pulmonary trunk occurs when the pulmonary valve is insufficient.

Strengthening of the II tone (emphasis of the II tone) over the aorta observed with high blood pressure, or with atherosclerotic thickening of the aortic wall.

Increased P tone (P tone accent) above the pulmonary trunk sometimes normally heard in young people, in older people it is observed with increased pressure in the pulmonary circulation (chronic pulmonary pathology, mitral defects).

When the heart rate changes (pronounced tachycardia), the duration of the systolic and diastolic pauses are approximately equal, a peculiar heart melody appears, similar to the rhythm of a pendulum - pendulum rhythm(with equal volumes of I and II tones) or resembling the fetal heartbeat - embryocardia (I tone is louder than II tone).

In some pathological conditions, above the apex of the heart, along with the main tones, additional, or extratones. Such extratones can be detected in systole and diastole. Diastolic extratones include sounds III and IV, as well as the sound of the mitral valve opening.

Additional III and IV sounds appear with myocardial damage. Their formation is caused by reduced resistance of the ventricular walls, which leads to abnormal vibration during the rapid filling of the ventricles with blood at the beginning of diastole (III sound) and during atrial systole, at the end of diastole (IV sound). These extratones are usually quiet, short, low, and are often combined with a weakening of the first tone at the apex and tachycardia, which creates a unique three-part melody - a gallop rhythm.

Normally, the third tone can be heard in thin people under the age of 20.

In pathology in adults, the physiological third tone intensifies and then the melody of a three-part rhythm appears - protodiastolic "gallop rhythm" .

In children under 6 years of age, a sound (IV tone) may be heard before the first sound, which is caused by the rapid entry of blood into the ventricles from the atria during their contraction.

In adults, the appearance of the IV tone creates a pathological presystolic “gallop rhythm”. Presystolic "gallop rhythm" observed when atrioventricular conduction slows. In this case, there is a significant pause between the sound caused by contraction of the atria and then the sound caused by contraction of the ventricles.

The presence of both III and IV sounds at the same time is usually combined with pronounced tachycardia, therefore both additional tones merge into one sound, creating mesodiastolic "gallop rhythm".

Mitral valve opening tone is a characteristic sign of stenosis of the left atrioventricular orifice. It occurs immediately after the second sound, is better heard on the left side during exhalation and is perceived as a short, abrupt sound, reminiscent of a click. In contrast to bifurcation, the opening tone of the mitral valve is heard at the apex of the heart, and not at the base, and is combined with a melody characteristic of mitral stenosis (flapping 1st tone, diastolic murmur), forming a peculiar three-part rhythm - the “quail rhythm”. The occurrence of a “mitral click” is explained by the tension of the mitral valve leaflets fused along the commissures when they protrude into the cavity of the left ventricle during the opening of the valves in diastole.

In patients with constrictive pericarditis, after the second sound, a loud protodiastolic extratone at the apex, the so-called pericardial tone. Unlike the mitral click, it is not combined with an increased first sound.

Systolic extraton at the apex is most often associated with mitral valve prolapse. It is a sharp, loud, short sound.

Duplication and splitting of tones.

Heart sounds, although they consist of individual components, are perceived as a single sound due to their simultaneous and synchronous occurrence. If this synchrony is disrupted, the tone is perceived as two separate sounds. In the case when the pause between two sounds is barely distinguishable, they speak of splitting, if two parts of the tone are clearly heard - splitting tones.

Splitting of the first tone at the apex observed in healthy people at the end of inspiration or expiration and is associated with a change in blood flow to the heart.

Pathological splitting of the first tone observed when intraventricular conduction is disrupted as a result of delayed systole of one of the ventricles and, consequently, non-simultaneous closure of the atrioventricular valves. This is most often observed with bundle branch block, with a significant weakening of the contractile function of the myocardium or with pronounced hypertrophy of one of the ventricles.

Bifurcation of the second tone occurs when the aortic and pulmonary valves close at the same time. The duration of ventricular systole is determined by the volume of blood ejected and the pressure in the vessel where the blood enters. Thus, with a decrease in blood volume in the left ventricle and with low blood pressure in the aorta, the systole of the left ventricle will end sooner and the aortic valve leaflets will close earlier than the pulmonary valve leaflets. Therefore, bifurcation of the second tone can be observed when the blood supply to one of the ventricles in healthy people decreases or increases during one of the phases of breathing (end of inhalation or exhalation).

In pathology bifurcation of the second sound in the aorta associated with increased pressure in the systemic circulation (hypertension).

Bifurcation of the second tone on the pulmonary trunk associated with increased pressure in the pulmonary circulation (mitral stenosis, chronic lung diseases, stenosis of the pulmonary trunk), pathognomonic for atrial septal defect.

Heart murmurs- Murmurs are divided into intracardiac and extracardiac. They are complex, rich in overtones, longer sounds, heard in pauses between tones or merging with them. differ in their acoustic properties, timbre, and listening phase. Noises heard in the interval between tones I and II are called systolic, after the second tone - diastolic. The group of noises that occur with heart defects, as well as with myocardial damage, are called organic. Murmurs caused by other reasons and not combined with changes in tones, dilation of the heart chambers, or signs of heart failure are called functional. Extracardiac murmurs are included in a separate group.

Having identified a murmur during auscultation of the heart at standard points, it is necessary to determine:

The phase of the cardiac cycle in which it is heard;

Duration of the murmur (short, long) and what part of the cardiac cycle phase it occupies (protodiastolic, presystolic, pandiastolic, early systolic, etc.);

Timbre of noise (blowing, scraping, etc.);

The point of maximum noise volume and the direction of its conduction (left axillary fossa, carotid arteries, Botkin-Erb point);

Variability of noise depending on the phases of breathing and body position.

Following these rules often allows one to differentiate organic noises from functional ones.

Systolic organic murmurs occur with atrioventricular valve insufficiency, stenosis of the aorta and pulmonary trunk.

Systolic murmur at the apex heard with mitral valve insufficiency. The mechanism of its occurrence is as follows: during systole, the valves, deformed due to scar changes, do not completely close the hole, blood returns from the ventricles to the atrium through a narrow gap, and a vortex occurs - the noise of regurgitation. The noise is loud, rough, prolonged, has a decreasing character, is combined with a weakened 1st tone, and the 3rd tone is often detected. It intensifies in a position on the left side when holding your breath while exhaling, after physical activity, and radiates to the left axillary fossa.

Systolic murmur on the aorta heard when:

1) stenosis of the aortic mouth - ejection noise. This noise is usually loud, low, continuous, and extends to the carotid artery.

2) in elderly people, a systolic murmur may be heard on the aorta associated with atherosclerotic changes in the aortic valves.

Organic systolic murmur over the pulmonary trunk rarely heard. Its causes may be: stenosis of the mouth of the pulmonary trunk, atrial septal defect (soft, short-lived murmur), patent ductus arteriosus (systole-diastolic murmur, the systolic component of which is rough, loud, extends to the entire precordial region, neck vessels and into the axillary fossa) .

Systolic murmur due to tricuspid valve insufficiency is heard at the xiphoid process, has a decreasing character, is not always combined with a weakened first tone, is carried out on both sides of the sternum, and intensifies with inspiration (Rivero-Corvallo symptom).

The loudest and roughest systolic murmur is heard with a ventricular septal defect (Tolochinov-Roger disease). The epicenter of the sound is at the left edge of the sternum in the III-IV intercostal space, is better heard in the supine position, spreads to the left axillary fossa, interscapular space.

Diastolic murmurs- heard with narrowing of the atrioventricular orifices, insufficiency of the aortic and pulmonary valves.

Diastolic murmur over the apex of the heart heard with mitral orifice stenosis. In this case, blood enters diastole from the atria into the ventricles through a narrowed opening - a turbulence occurs, which is heard as noise. It is heard at the beginning of diastole (decreasing proto-diastolic), or at the end of it (increasing presystolic), and with severe mitral stenosis it becomes pan-diastolic. Usually heard in a limited area, better detected in a position on the left side, combined with the “quail rhythm”.

Diastolic murmur due to aortic valve insufficiency usually soft, decreasing, best heard at the Botkin-Erb point, in a standing position with the torso tilted forward or lying on the right side, combined with a weakened II tone. In this case, in diastole, the blood returns back through the not tightly closed valve leaflets from the aorta to the left ventricle - a vortex occurs, i.e. a noise that is loud at first and then gradually becomes less pronounced (decrescendo form).

Diastolic murmurs over the pulmonary trunk and at the xiphoid process are rarely heard and are associated with stenosis of the right atrioventricular orifice and pulmonary valve insufficiency, respectively.

Sometimes murmurs are heard over the entire region of the heart in one phase of cardiac activity, which makes diagnosis difficult. In this case, it is recommended:

1) listen to noise irradiation points, as mentioned above;

2) auscultation can be performed by moving the stethoscope along the line connecting the two points of listening to noise, from one valve to the other. A weakening or increasing volume of noise as you approach the second valve indicates damage to one valve. Above the valve, where it is heard weaker, the noise is wired. When, when moving the stethoscope, the noise first weakens and then intensifies again, one should think about damage to two valves.

Functional noise- are not associated with damage to the valves, valve orifices, or heart muscle. The following functional noises are distinguished:

Express;

Anemic;

Dystonic.

The difference between functional noise and organic noise:

More often these are systolic murmurs, not associated with the first sound;

They are heard in a limited area and do not radiate to other areas;

The sound is quiet, short, blowing, soft, with the exception of noises associated with dysfunction of the papillary muscles;

Labile, i.e. can change timbre, duration, arise or, conversely, disappear under the influence of various factors, changes in body position;

Not always accompanied by a change in basic tones, the appearance of additional tones, expansion of the boundaries of the heart, signs of circulatory failure, and are not accompanied by “cat purring”;

Low amplitude, low frequency;

Reduce or disappear during treatment.

Functional systolic murmurs are most characteristic of childhood and adolescence. They are due to the following reasons:

Incomplete correspondence of the rates of development of various cardiac structures;

Dysfunction of papillary muscles;

Abnormal development of chordae.

Systolic functional murmurs:

Relative insufficiency of the mitral valves. Occurs with severe dilatation of the left ventricle with expansion of the fibrous ring of the valves (dilated myocardiopathy, aortic defects, hypertension). Unlike the noise during a defect, this noise is softer, shorter lasting, and does not radiate.

Muscle noise occurs when the heart muscle is damaged (myocarditis, myocardiosclerosis, myocardial infarction) and is heard at the apex. The mechanism of its occurrence: non-simultaneous contraction of muscle fibers occurs, while the muscle component of the first tone increases in duration and creates the impression of noise.

Anemic noise. With anemia of various etiologies, blood thinning and blood flow speed accelerate. In this condition, the systolic murmur is heard over the entire region of the heart, but is better heard on the vessels, aorta and pulmonary trunk, where blood turbulence occurs, and intensifies when the patient moves from a horizontal to a vertical position, after physical exertion.

Diastolic functional murmurs:

Flint noise- functional diastolic murmur heard at the apex of the heart in patients with aortic valve insufficiency. With this defect, blood returning from the aorta to the left ventricle lifts the mitral valve leaflet, thereby creating a relative stenosis of the left atrioventricular orifice. At this time, the blood, when passing from the left atrium to the ventricle through a narrowed opening, swirls creating a functional noise that is heard in the diastole phase at the apex of the heart.

Graham-Still noise associated with expansion of the mouth of the pulmonary artery and stretching of its valve ring. This noise of relative pulmonary valve insufficiency is sometimes detected in patients with severe hypertension of the pulmonary circulation and is heard as a soft diastolic murmur in the second intercostal space on the left.

Coombs noise: Early diastolic murmur heard in the zone of absolute cardiac dullness near the apex. The mechanism of its occurrence is as follows: an increase in the speed of blood flow from the atrium to the left ventricle, with a decreased tone of the latter (the blood seems to freely “fall” into the cavity of the ventricle without encountering resistance).

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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

Systolic heart murmur can be heard in adults, but children are more often susceptible to this disease. Doctors say that most cases of detection of this disease occur in young or adolescent children, about 90%. The younger generation 20-29 years old is also at risk. According to doctors, if systolic heart murmur is diagnosed in an adult, then this is a serious reason to conduct a thorough cardiological examination of the patient.

The pathogenesis of this disease has been well studied by medicine. Only a specialist can listen to the sounds produced by the main organ and identify deviations from the norm. Systolic murmurs in the heart region are a pathology caused by a disorder in this department. The doctor can recognize this manifestation during ventricular contraction, after the first sound. The formation of these sounds is associated with the blood flow occurring through the narrowed opening of the ventricular valves.

Also, systolic murmur can appear due to an obstruction to natural blood circulation in the organ or when blood circulates in the opposite direction. Such pathology is divided into an organic pathological process, which is characterized by development due to changes in the heart or its valves, as well as inorganic (or functional). Doctors say that both types of the disease are unfavorable for the patient.

Noise classification:

Systolic murmur at the apex of the heart.
Above the area of the aorta, which is observed when it enlarges.
Appearing with aortic valve insufficiency.
Axillary, when the sound spreads beyond the organ and is heard in the area between the shoulder blades and the axillary area.
Above the artery of the lungs, during the period of its expansion.
Occurs during nervous excitement or during physical exertion. Often accompanied by the manifestation of tachycardia, ringing tones.
Diagnosed during fever.
Appearing due to severe anemia or thyrotoxicosis.

During the period of pumping blood by the heart, you can listen to the tones that are formed during the opening, as well as during the closing of the valves of the organ - this is considered a beating. These sounds may be uniform, or they may be disordered. In the periods between them, doctors sometimes determine noises; they are caused by a change in the direction of blood circulation and fluctuations in the speed regime during its movement.

For the first time, such violations can be recorded in an infant in the maternity hospital. Functional type noises that are detected in a newborn are a completely normal phenomenon, due to the peculiarities of the transformation of blood circulation. Dr. Komarovsky urges parents not to be alarmed if their child is diagnosed with such a pathology, because this does not mean that the baby is at risk of heart disease or another deadly disease. Usually these manifestations disappear without leaving a trace. This condition cannot be ignored either; the child must be examined regularly and taken to consultations with specialists.

Reasons

Etiology of systolic heart murmur:

Disturbances in the septum between the atria. By such a defect, doctors mean the absence of part of the septum between the atria, which leads to the discharge of blood. The level of blood excretion depends on the compliance of the heart ventricles, as well as the volume of the destructive process.
Systolic heart murmur in a small child is sometimes heard due to an open arterial defect. This means that the vessel that is created to connect the descending aorta to the pulmonary artery is short in length.
Coarctation of the aorta. Thus, doctors formulate a congenital heart defect, which is accompanied by segmental narrowing of the lumen of the thoracic aorta. This condition is dangerous, since the aorta will become thinner as the patient grows older.

Violation of the structure of the septum located between the ventricles. The reason for this pathology is that the heart defect has its own characteristics. The disorder occurs in the area between the two ventricles of the organ.
Abnormal venous pulmonary return. In this case, we can talk about abnormal development of the pulmonary veins; they do not communicate with the area of the right atrium.

Often, murmurs are detected when the apex of the heart is heard. This deviation also has its reasons. The characteristics of such sound effects vary, depending on the reasons that caused the pathology.

Features of the noise of the organ apex

Cause	Description
Incomplete closure of the valve during systole	Characteristic noise deviations are heard, but not for long. The echocardiography results described chord rupture, identification of a zone of hypokinesis, and signs of endocarditis of a bacterial nature.
Insufficient closure of the mitral valve, occurring chronically	You can listen to this type of noise throughout the entire cycle of contraction of the ventricles of the organ. Such a heart defect is dangerous due to the possibility of a noticeable vibration of the sternum wall, which is formed during systole.
Relative insufficiency when closing the bicuspid valve	Dilatation of the entire left ventricle becomes the most common provoking factor of this pathology. When listening, the noise persists throughout the entire period of contractile activity of the ventricles.
Disorder of papillary muscle activity	Diagnostics show that there are manifestations of myocardial infarction, as well as ischemic disorders. Doctors characterize such noises as changeable.
Mitral valve dysfunction	You need to listen to such noises with the patient in an upright position. The patient's condition affects the nature of the heart sound. A similar pathology at the apex of the organ is detected in the middle part of systole or is called a mesosystolic click.

If a heart murmur is detected, which is heard on the left side of the sternum, doctors may suspect several reasons for this deviation.

congenital stenosis of pulmonary artery tissue;
disturbances in the structure of the septum between the ventricles of the organ;
obstructive cardiomyopathy;
tetarda falao.

In the chest on the right, a systolic murmur may indicate that there is a narrowing of the aortic lumen. Such sounds are different from others; they can acquire a rough, scratching and intense timbre. During listening, the patient should sit, as in this position the examination is more accurate. Diagnostics shows expansion of the aortic lumen, as well as calcification of the valve apparatus of this area.

What pathologies provoke:

During puberty, doctors often detect systolic murmurs; this is due to the fact that the teenager begins to grow rapidly, and the heart muscle cannot keep up with such an accelerated pace. Due to the changes, characteristic sounds appear in the main organ, but they disappear on their own when all body processes stabilize.

Girls are also susceptible to the occurrence of systolic heart murmurs when a period of hormonal changes occurs. Most often, such conditions are detected during the onset of the menstrual cycle and resolve without treatment. Excess weight in adolescents also often becomes a provoking factor for the appearance of characteristic sounds when listening to the organ.

Symptoms in adults and children

An adult can identify dangerous symptoms in himself and report this to his doctor. If the problem concerns children, then parents need to closely monitor their condition, since heart disease is very dangerous. It is necessary to identify the pathology in time and begin treatment if required.

Manifestations in adults:

swelling of the lower extremities;
shortness of breath and difficulty breathing when lying down;
general weakness;
pale skin;
dizziness;
after physical activity, the patient may feel an increased heartbeat;
sudden change of mood.

Often people suffering from this disease experience attacks of suffocation at night. Fainting may also indicate such an illness. Pain in the sternum area is not always reported by patients, but in some cases it occurs.

Manifestations in children:

Children who have a heart murmur need to be examined. Sometimes the only way to help children is through surgery, so there is no time to waste.

Treatment and prognosis

Diagnostics plays a vital role in stabilizing the condition of patients. There are several methods to find out the exact cause of the pathology.

Examination methods:

ECG (electrocardiogram);
auscultation;
chest x-ray;
angiography;
cardiac catheterization;
echocardiogram;
special testing.

This syndrome is better identified during examination by auscultation. This diagnostic method should be carried out for every patient with abnormalities.

Therapy consists of prescribing medications. If treatment does not bring tangible improvement, then the doctor raises the question of surgical intervention.

Preparations:

Diuretics, which are necessary to stabilize blood pressure levels and remove excess fluid from the patient’s body.
Anticoagulants are prescribed to prevent the formation of blood clots, which often cause strokes and heart attacks.
ACE inhibitors. Needed to improve heart function and normalize blood pressure.
Beta blockers. They improve heartbeat and are used to stabilize blood pressure.
Statins. They are drugs that reduce the level of bad cholesterol in the blood and prevent the formation of new atherosclerotic plaques. This helps improve the functioning of the entire heart department.

When systolic murmurs are detected in a person’s heart, doctors talk about a favorable prognosis, but there are exceptions.

Normally, a person’s heart should work without the presence of noise, but there are situations when sounds arise under the influence of non-pathological factors, this problem is completely solvable and not scary. Only an experienced cardiologist will be able to understand each individual case and accurately identify the presence or absence of the disease.

Systolic heart murmur can seriously worsen a person’s health and life. When making such a diagnosis, you should not be afraid; you need to undergo all examinations and receive treatment if necessary. Modern medicine can help in this case. There are a number of medications that can normalize the condition of such patients, and if the situation is severe, surgery will improve the prognosis.

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Functional systolic murmur the childhood type can be determined at the age of 20-25 and even 30 years, and, as a rule, in persons with a thin chest and asthenic constitution.
On the issue of origin In children, most authors agree that it is caused by the so-called functional (relative) stenosis of the pulmonary artery and accelerated blood flow through its mouth. According to the amazing laws of nature, in the human heart, despite the rapid movement of blood through the atrioventricular openings and the mouths of large vessels, no noise occurs.

This due to the ratio of the size of the holes, the speed of blood flow and the physical properties of blood. The exception, obviously, is children's functional systolic murmur. According to Kubat (1965), in children there is a discrepancy between the rate of development of the right ventricle and the pulmonary artery, resulting in its relative narrowness. In the presence of a frequent rhythm and accelerated blood flow, acoustic conditions are created for noise to occur.
These same conditions, obviously, are also observed in persons with an asthenic constitution, and the thin chest wall contributes to good conduction of noise to the surface of the chest.

First confirmation The fact that this noise is associated with the pulmonary artery is the fact that it is optimally determined in the II-III intercostal space to the left of the sternum. The murmur may increase with exercise due to increased blood flow through the pulmonary artery. It is also audible and better recorded in the supine position, which is explained by the greater blood flow to the right.

Final proof the genesis of functional systolic murmur was the recording of an intracardiac phonocardiogram. American researchers used cardiac catheterization in a number of doubtful cases in order to differentiate the functional nature of the murmur or its connection with a congenital defect. At the same time, an intracardiac phonocardiogram was recorded. Catheterization data showed the absence of a defect, and on the intracardiac phonocardiogram, systolic murmur was recorded with the microphone positioned at the mouth of the pulmonary artery. In this case, the noise had the same characteristics as on a conventional external phonocardiogram.

Currently our experience and the experience of other researchers makes it possible to give a fairly accurate description of the functional systolic murmur in the pulmonary artery, which helps to correctly recognize it in most patients. In this case, of course, one should take into account the medical history, clinical picture, electrocardiogram and X-ray data. In doubtful cases, it is advisable to use dynamic observation over several years.