Muffled heart sounds what. Auscultation of the heart and blood vessels

31.03.2020

The first phonendoscopes were sheets of paper folded in a tube or hollow bamboo sticks, and many doctors used only their own hearing organ. But they all wanted to hear what is happening inside the human body, especially when it comes to such important organlike a heart.

Heart sounds are sounds that are formed during the contraction of the myocardial walls. Normally, a healthy person has two tones, which may be accompanied by additional sounds, depending on what pathological process is developing. A doctor of any specialty must be able to listen to these sounds and interpret them.

Cardiac cycle

The heart beats at a rate of sixty to eighty beats per minute. This, of course, is an average value, but ninety percent of people on the planet fall under it, which means that you can take it as the norm. Each beat consists of two components replacing each other: systole and diastole. The systolic heart tone, in turn, is divided into atrial and ventricular. It takes 0.8 seconds in time, but the heart has time to contract and relax.

Systole

As mentioned above, there are two components involved. First, there is a systole of the atria: their walls contract, blood under pressure enters the ventricles, and the valves of the valves slam shut. It is the sound of the closing valves that is heard through the phonendoscope. This whole process takes 0.1 seconds.

Then comes the ventricular systole, which is a much more complex work than it happens with the atria. To begin with, we note that the process lasts three times longer - 0.33 seconds.

The first period is the tension of the ventricles. It includes asynchronous and isometric contraction phases. It all starts with the fact that an eclectic impulse spreads through the myocardium, It excites individual muscle fibers and makes them contract spontaneously. Because of this, the shape of the heart changes. This causes the atrioventricular valves to close tightly, increasing pressure. Then there is a powerful contraction of the ventricles, and the blood enters the aorta or pulmonary artery. These two phases take 0.08 seconds, and in the remaining 0.25 seconds, blood enters the great vessels.

Diastole

Here, too, everything is not so simple as it might seem at first glance. Relaxation of the ventricles lasts 0.37 seconds and occurs in three stages:

Protodiastolic: After the blood has left the heart, the pressure in its cavities decreases and the valves leading to the large vessels close.
Isometric relaxation: the muscles continue to relax, the pressure drops even more and aligns with the atrial pressure. From this, the atrioventricular valves open, and blood from the atria enters the ventricles.
Filling the ventricles: according to the pressure gradient, the fluid fills the lower ones. When the pressure is equalized, then the flow of blood gradually slows down, and then stops.

Then the cycle is repeated again, starting with systole. Its duration is always the same, but diastole can be shortened or lengthened, depending on the heart rate.

The mechanism of formation of the I tone

As strange as it sounds, 1 heart tone consists of four components:

Valve - he is the leading in the formation of sound. In fact, these are oscillations of the cusps of the atrioventricular valves at the end of the ventricular systole.
Muscular - oscillatory movements of the walls of the ventricles during contraction.
Vascular - stretching of the walls at the moment when blood enters them under pressure.
Atrial - atrial systole. This is the immediate beginning of the first tone.

The mechanism of formation of II tone and additional tones

So, the 2nd heart sound includes only two components: valvular and vascular. The first is the sound that arises from the blows of blood on the valves of the arta and the pulmonary trunk at a time when they are still closed. The second, that is, the vascular component, is the movement of the walls of large vessels when the valves finally open.

In addition to the two main ones, there are also 3 and 4 tones.

The third tone is the vibrations of the ventricular myocardium during diastole, when blood passively flows into the area of \u200b\u200blower pressure.

The fourth tone appears at the end of systole and is associated with the end of the expulsion of blood from the atria.

Characteristic I tone

Heart sounds depend on many causes, both intra- and extracardiac. The sonicity of 1 tone depends on the objective state of the myocardium. So, first of all, the loudness is provided by the tight closure of the heart valves and the speed with which the ventricles contract. Features such as the density of the cusps of the atrioventricular valves, as well as their position in the heart cavity, are considered secondary.

It is best to listen to the first heart sound at its apex - 4-5 intercostal space to the left of the sternum. For more accurate coordinates, it is necessary to conduct percussion chest in this area and clearly define the boundaries of cardiac dullness.

Characteristic of the II tone

To listen to him, it is necessary to place the bell of the phonendoscope over the base of the heart. This point is slightly to the right. xiphoid process sternum.

The loudness and clarity of the second tone also depends on how tightly the valves close, only now they are crescent. In addition, the speed of their operation, that is, the closing and oscillation of the risers, affects the sound reproduced. And additional qualities are the density of all structures involved in the formation of the tone, as well as the position of the valves during the expulsion of blood from the heart.

Rules for listening to heart sounds

Heart sound is probably the most soothing in the world, after white noise... Scientists have a hypothesis that the child hears it in the prenatal period. But in order to detect damage to the heart, simply listening to how it beats is not enough.

First and foremost, auscultation should be done in a quiet and warm room. The position of the person being examined depends on which valve needs to be listened to more carefully. This can be a lying position on the left side, upright, but with the body tilted forward, on the right side, etc.

The patient should breathe rarely and shallowly, and at the request of the doctor, hold his breath. In order to clearly understand where the systole is and where the diastole is, the doctor must, in parallel with listening, palpate the carotid artery, the pulse on which completely coincides with the systolic phase.

Cardiac auscultation procedure

After preliminary determination of absolute and relative cardiac dullness, the doctor listens to heart sounds. It usually starts from the top of the organ. The mitral valve is clearly audible there. Then go to the valves of the main arteries. First to the aortic - in the second intercostal space to the right of the sternum, then to pulmonary artery - at the same level, only to the left.

The fourth listening point is the base of the heart. It is located at the base but can move to the sides. So the doctor needs to check what is the shape of the heart, and the electrical axis to listen accurately

Auscultation is completed at the Botkin-Erb point. Here you can hear She is in the fourth intercostal space on the left at the sternum.

Additional tones

The sound of the heart does not always resemble rhythmic clicks. Sometimes, more often than we would like, it takes on bizarre forms. Some of them, doctors have learned to identify only by listening. These include:

Click mitral valve... It can be heard near the apex of the heart, it is associated with organic changes in the valve leaflets and appears only with acquired heart disease.

Systolic click. Another type of mitral valve defect. In this case, its flaps do not close tightly and, as it were, turn outward during systole.

Perecardton. It is found with adhesive pericarditis. It is associated with excessive stretching of the ventricles due to the mooring lines formed inside.

Quail rhythm. It occurs with mitral stenosis, manifested by an increase in the first tone, an accent of the second tone on the pulmonary artery and a click of the mitral valve.

The rhythm of the gallop. The reason for its appearance is a decrease in myocardial tone, appears against the background of tachycardia.

Extracardiac causes of strengthening and weakening of tones

The heart beats in the body all my life, without interruption and rest. This means that when it wears out, then outsiders appear in the measured sounds of its work. The reasons for this may be directly related to damage to the heart, or not depend on it.

Strengthening tones is facilitated by:

Cachexia, anorexia, thin chest wall;

Atelectasis of the lung or part of it;

Tumor in the posterior mediastinum that moves the lung;

Infiltration of the lower lobes of the lungs;

Bullae in the lungs.

Weakening of heart sounds:

Excessive weight;

Development of the muscles of the chest wall;

Subcutaneous emphysema;

The presence of fluid in the chest cavity;

Intracardial causes of strengthening and weakening of heart sounds

Heart sounds are clear and rhythmic when the person is at rest or in sleep. If he started to move, for example, climbed the stairs to the doctor's office, then this can cause an increase in the heart sound. Also, an acceleration of the pulse can be caused by anemia, diseases endocrine system etc.

A muffled heart sound is heard with acquired heart defects, such as mitral or aortic stenosis, valve insufficiency. Stenosis of the aorta in the parts close to the heart makes its contribution: the ascending part, the arch, the descending part. Muffled heart sounds are associated with an increase in myocardial mass, as well as with inflammatory diseases of the heart muscle, leading to dystrophy or sclerosis.

Heart murmurs

In addition to tones, the doctor may hear other sounds, the so-called noises. They form from the swirling of the blood flow that passes through the cavities of the heart. Normally, they should not be. All noise can be divided into organic and functional.

Organic ones appear when anatomical, irreversible changes in the valve system occur in the organ.
Functional murmurs are associated with disturbances in the innervation or nutrition of the papillary muscles, an increase in heart rate and blood flow rate, and a decrease in blood viscosity.

Murmurs may accompany heart sounds, or may be independent of them. Sometimes when inflammatory diseases superimposed on the heartbeat, and then you need to ask the patient to hold his breath or bend forward and again carry out auscultation. This simple trick will help you avoid mistakes. As a rule, when listening to pathological murmurs, they try to determine at what phase of the cardiac cycle they arise, find the best listening place and collect the characteristics of the noise: strength, duration and direction.

Noise properties

There are several types of noises by timbre:

Soft or blowing (usually not associated with pathology, often in children);

Rough, scraping or sawing;

Musical.

Distinguish by duration:

Short;

Long;

By volume:

Loud;

Decreasing;

Growing (especially with narrowing of the left atrioventricular opening);

Increasingly decreasing.

The change in loudness is recorded during one of the phases of cardiac activity.

Height:

High-frequency (with aortic stenosis);

Low-frequency (with mitral stenosis).

There are some general patterns in murmur auscultation. Firstly, they are well listened to at the locations of the valves, due to the pathology of which they were formed. Secondly, the noise radiates in the direction of the blood flow, and not against it. And thirdly, like heart sounds, pathological murmurs are best heard where the heart is not covered by the lungs and is tightly attached to the chest.

It is better to listen in the supine position, because the blood flow from the ventricles becomes easier and faster, and diastolic - while sitting, because under the force of gravity, fluid from the atria enters the ventricles faster.

It is possible to differentiate murmurs by their localization and the phase of the cardiac cycle. If a noise in the same place appears both in systole and diastole, then this indicates a combined lesion of one valve. If, in systole, a murmur appears at one point, and in diastole - at another, then this is already a combined lesion of two valves.

When assessing heart sounds, one should try to listen to each component of the cardiac cycle separately: the 1st tone and the systolic interval, and then the 2nd tone and the diastolic interval.

The sounding of heart sounds can change for various reasons. Normal heart sounds are clear. They can gradually weaken, becoming muffled, or deaf (obesity, chest muscle hypertrophy, pulmonary emphysema, fluid accumulation in the pericardial cavity, severe myocarditis) or intensify (asthenics, persons with a thin chest, tachycardia).

The 1st tone is formed as a result of oscillation of the cusps of the mitral and tricuspid valves when they are closed, as well as oscillations of the myocardium and large vessels directly.

Therefore, the 1st tone is composed of three components:

Valve (closing of the mitral and tricuspid valves), which makes the main contribution to the intensity of 1 tone;

Muscular, associated with vibrations of the heart muscle during isometric contraction of the ventricles;

Vascular, caused by vibrations of the walls of the aorta and pulmonary artery at the beginning of the expulsion period.

The 1st tone is assessed at the apex of the heart, where it is always louder in a healthy person, longer than the 2nd tone and lower in frequency. It coincides with the apical impulse and pulsation of the carotid arteries.

The factors that determine the intensity of the 1st tone include:

The position of the valves to the beginning of the systole,

The tightness of the ventricular chamber during the period of isovolumetric contraction (the tightness of the closure of the valves),

Valve closing speed,

Sash mobility,

The speed (but not the strength!) Of the ventricular contraction (the value of the end-diastolic volume of the ventricles, the thickness of the myocardium, the intensity of metabolism in the myocardium);

It follows that the higher the closing speed of the valves, the louder the 1st tone will be (1 tone amplification). So, with tachycardia, when the filling of the ventricles is reduced and the amplitude of movement of the valves increases, the 1st tone will be loud. When an extrasystole appears, 1 tone increases (Strazhesko's cannon tone) due to a small diastolic filling of the ventricles. With mitral stenosis due to the fusion and thickening of the valve leaflets, which quickly and loudly slam, 1 tone will also be strengthened (clapping 1 tone).

Weakening of the 1st tone can occur with dilatation of the ventricles (mitral and aortic valve); damage to the heart muscle (myocarditis, cardiosclerosis), with bradycardia (due to an increase in ventricular filling and a decrease in the amplitude of oscillation of the heart muscle).

Oscillations of the cusps of the aorta and pulmonary artery valves at the time of their closure and the walls of the supravalvular sections of the aorta and pulmonary artery lead to the appearance of a 2nd tone, therefore, this tone consists of 2 components - valvular and vascular. The quality of its sound is assessed only on the basis of the heart, where it is louder, shorter and higher than the 1st tone and follows after a short pause.

The assessment of the second tone is carried out by comparing the intensity of its sounding on the aorta and pulmonary artery.

Normally, the 2nd tone on the aorta and pulmonary artery sounds the same. If it sounds louder in the second intercostal space on the right, then they talk about the accent of the second tone on the aorta, and if in the second intercostal space on the left - about the accent of the second tone on the pulmonary artery. The reason for emphasis is most often an increase in pressure in the systemic or pulmonary circulation. With fusion or deformation of the leaflets of the aortic valve or pulmonary artery (with rheumatic heart disease, infective endocarditis) there is a weakening of the second tone over the affected valve.

Splitting and bifurcation of tones. Heart sounds are made up of several components, but on auscultation they are heard as one sound. the human hearing organ is unable to perceive two sounds separated by an interval of less than 0.03 sec. If the valves do not close simultaneously, then two components of the 1st or 2nd tones will be heard during auscultation. If the distance between them is 0.04-0.06 seconds, then this is called splitting, if more than 0.06 s, bifurcation.

For example, bifurcation of the 1st tone is often auscultated with blockade of the right bundle branch block due to the fact that the right ventricle begins to contract later and the tricuspid valve closes later than normal. With blockade of the left bundle branch of His, bifurcation of the 1st tone is heard much less often, since the delay in the oscillation of the mitral component coincides in time with the delay in the tricuspid component.

Physiological splitting / bifurcation of the II tone occurs, which does not exceed 0.06 sec. and appears only during inspiration, which is associated with a lengthening of the period of blood expulsion by the right ventricle due to an increase in its filling during inspiration. It should be emphasized that the pulmonary component of the second tone is often heard in a limited area: in the 2nd - 4th intercostal space along the left edge of the sternum, so it can be assessed only in this area.

For diseases accompanied by a significant increase in pressure in a small or big circle circulation (stenosis or mitral insufficiency, some congenital defects heart) there is a pathological bifurcation of the second tone, which is clearly audible both on inhalation and exhalation.

In addition to the fundamental tones of the heart (1st and 2nd), physiological 3rd and 4th tones can also be heard normally. These are low-frequency tones that occur when the walls of the ventricles (more often left) oscillate as a result of passive (III-rd tone) and active (IV-th) their filling. Physiological muscle tones are found in children (up to 6 years old - IVth tone), adolescents, young people, mostly thin, under the age of 25 (IIIrd tone). The emergence of the III tone is explained by the active expansion of the left ventricle with its rapid filling at the beginning of systole. It is heard at the apex of the heart and at the fifth point.

In patients with lesions of the heart muscle, the auscultated pathological III and IV heart sounds, which are usually combined with a weakening of the sonority of the 1st tone above the apex and tachycardia, therefore the so-called gallop rhythm is formed. Since the third tone is recorded at the beginning of diastole, it is called the protodiastolic canter rhythm. The pathological IV-th tone occurs at the end of diastole and is called the presystolic rhythm of the gallop.

When auscultation of additional heart sounds, it should be remembered that muscle tones are poorly heard through the membrane, so it is better to use a “bell” for auscultation.

Extratones. In addition to muscle tones in diastole, an additional sound can be heard - the tone of the opening of the mitral valve (mitral click), which is determined immediately after the II tone with stenosis of the mitral opening. It is better heard in the position of the patient on the left side and on exhalation in the form of a short high-frequency sound. The combination of "clapping" 1st tone, 2nd tone and mitral click leads to the appearance of a specific three-member rhythm ("quail rhythm"), reminiscent of the phrase "time to sleep" - with an emphasis on the first word

In addition, during diastole, a rather loud tone can be heard, very similar to a mitral click - this is the so-called pericardial tone. It is heard in patients with constrictive pericarditis and, unlike the tone of opening of the mitral valve, is not combined with the “clapping” 1st tone.

In the middle or at the end of the systolic period, an additional tone can also be heard - a systolic click or "click". It can be caused by the bending (prolapse) of the mitral valve cusps (less often the tricuspid valve cusps) into the atrial cavity or by friction of the pericardial sheets with adhesive pericarditis.

The systolic click has a characteristic sound, a short and high pitched tone similar to the sound produced when the lid of a tin can be pulled back.

Lecture number 10.

Auscultation of the heart. Heart sounds are normal and pathological.

Listening (auscultation) of sound phenomena generated during the work of the heart is usually performed using a stethophonendoscope. This method has a great advantage over direct listening, since it makes it possible to clearly localize various sounds and, thanks to this, determine places from education.

Listening to the patient should be carried out in a warm room and with a warm instrument. When working in a cold room or with a cold instrument, the patient experiences muscle tremors. In this case, a mass of side sounds arises, which significantly complicate the assessment of the auscultatory picture. Listening to the patient is carried out with his calm breathing. However, in many situations, when the doctor catches weak sound phenomena, he asks the patient to hold his breath in the phase of maximum expiration. At the same time, the volume of the lungs containing air around the heart decreases, the breathing sounds that arise in the lungs disappear, the sound picture of the working heart is perceived more easily.

In what position of the body should the patient be listened to? It all depends on the auscultatory picture and the patient's condition. Usually, auscultation is performed in an upright position of the patient's body (standing, sitting) or lying on his back. However, many sound phenomena, for example, the pericardial friction noise, are better heard when the patient is tilted forward or in the position on the left side, when the heart is more tightly attached to the anterior chest wall. If necessary, auscultation is performed with a deep breath with straining (Valsalva test). In many cases, auscultation of the heart is repeated after physical exertion. For this, the patient is asked to sit down or lie down, do 10-15 squats, etc.

Along with listening to sound phenomena arising during the work of the heart, the phonocardiography technique is now widely used. Phonocardiography is a graphic recording on paper tape of sound phenomena that occur during the work of the heart, perceived by a sensitive microphone. Sound phenomena are depicted in the form of vibrations of various amplitudes and frequencies. Simultaneously with the recording of sound phenomena, an electrocardiogram is recorded in one standard lead, usually in the second. This is necessary to determine at what phase of cardiac activity the recorded sound occurs. Currently, phonocardiography involves the registration of sounds in 3 - 5 different sound frequency ranges. It allows you to document not only the very fact of the presence of a particular sound, but also its frequency, shape, amplitude (loudness). With the undoubted diagnostic value of the technique, it should be taken into account that the sound picture perceived by ear is sometimes more informative than the graphically recorded one. In some situations, during phonocardiography, the sound energy is distributed over 3 - 5 recorded channels and encrypted as background, while a clear, diagnostically significant sound picture is determined by ear. Therefore, phonocardiography, of course, should be attributed to a valuable, but additional research method.

When listening to the heart, tones and noises are distinguished. In scientific terminology, those sound phenomena that are usually called tones do not deserve this name, since they, like heart murmurs, are produced by irregular, aperiodic sound vibrations (the intervals between vibrations of each tone are not equal). In this sense, even many heart murmurs (so-called musical) are much closer to real tones.

Normally, physiologically, 2 tones are heard above the heart. Of these, in time, the 1st corresponds to the onset of ventricular systole - the period of closed valves. It is called a systolic tone. The second corresponds in time to the very beginning of the heart's diastole and is called diastolic.

Origin of the first tone complex. Formation of 1 heart tone begins at the very beginning of heart systole. As you know, it begins with atrial systole, pushing the remaining blood into the ventricles of the heart. This component is 1 tone, atrial, quiet, low-amplitude on the phonocardiogram, short. If our ear could perceive separately sounds very close to each other, we would listen to a separate weak atrial tone and a stronger tone that is formed in the phase of ventricular systole. But under physiological conditions, we perceive the atrial component of the 1st tone together with the ventricular one. In pathological conditions, when the time of the systole of the atria and ventricles are separated in time more than usual, we listen to the atrial and ventricular components of 1 tone separately.

In the phase of asynchronous contraction of the heart, the process of excitation of the ventricles, the pressure in which is still close to "0", the process of contraction of the ventricles covers all myocardial fibers and the pressure in them begins to increase rapidly. At this time, a continuous ventricularor the muscle component of 1 tone. The ventricles of the heart at this moment of systole of the heart are 2 completely closed bags, the walls of which tensed around the blood contained in them and, thanks to this, began to oscillate. All parts of the walls vibrate and they all give tone. Hence it is clear that the complete closure of the ventricles of the heart from all sides is the main condition for the formation of the first tone.

The main component of the 1st tone in terms of volume falls at the moment when two - and tricuspid heart valves collapse. These valves have closed, and the semilunar valves have not yet opened. The tone of the part of the walls that is most capable of oscillating, namely the tone of thin elastic leaflet valves, valvecomponent of 1 tone will be dominant in volume. With significant insufficiency of the cusp valves, the tone of the corresponding ventricle will completely disappear by ear.

The first tone is not only conducted from the ventricles and cuspid valves, but also occurs due to the sudden tension and vibration of the walls of the aorta and pulmonary artery when the blood of their ventricles enters them. This component of 1 tone is called vascular... Since this occurs already in the phase of the beginning of ventricular emptying, the first tone also captures the period of the beginning of the expulsion of blood from the ventricles.

So, 1 heart tone consists of 4 components - atrial, muscle, valvular and vascular.

The period of expulsion of blood from the ventricles of the heart consists of two phases - fast and slow expulsion of blood. At the end of the phase of slow expulsion, the ventricular myocardium begins to relax, and its diastole begins. The blood pressure in the ventricles of the heart decreases, and blood from the aorta and from the pulmonary artery rushes back into the ventricles of the heart. She slams the semilunar valves and arises second or diastolic heart sound. The first tone is separated from the second tone by a small pause with an average duration of about 0.2 seconds. The second tone has two components, or two components. The main volume is valvecomponent formed by vibrations of the cusps of the semilunar valves. After slamming the semilunar valves, blood rushes into the arteries of the large and pulmonary circulation. The pressure in the aorta and pulmonary trunk gradually decreases. All pressure drops and blood movement in the aorta and pulmonary artery are accompanied by vibrations of their walls, forming a second, less loud, tone 2 component - vascular component.

The time from the beginning of the relaxation of the ventricles to the collapse of the semilunar valves is called protodiastolic periodequal to 0.04 seconds. The blood pressure in the ventricles at this time drops to zero. The leaflet valves are still closed at this time, the volume of blood remaining in the ventricles, the length of the myocardial fibers have not yet changed. This period is called a period of isometric relaxationequal to 0.08 seconds. Towards its end, the cavities of the ventricles of the heart begin to expand, the pressure in them becomes negative, lower than in the atria. The leaflet valves open and blood begins to flow from the atria to the ventricles of the heart. Begins period of filling the ventricles with bloodlasting 0.25 seconds. This period is divided into 2 phases of fast (0.08 seconds) and slow (0.17 seconds) filling of the ventricles with blood.

At the beginning of the rapid flow of blood into the ventricles due to the impact of the incoming blood on their walls, third heart tone... It is deaf, it is best heard above the apex of the heart in the position of the patient on the left side and follows at the beginning of diastole approximately 0.18 seconds after 2 tones.

At the end of the phase of slow filling of the ventricles with blood, in the so-called presystolic period, lasting 0.1 seconds, atrial systole begins. Oscillations of the heart walls caused by atrial systole and an additional flow of blood pushed out of the atria into the ventricles lead to the appearance of fourth heart tone... Normally, a low-amplitude and low-frequency 4 tone is never heard, but it can be detected on PCG in persons with bradycardia. With pathology, it becomes high, high-amplitude, and with tachycardia, it forms a gallop rhythm.

With normal listening to the heart, only 1 and 2 heart sounds are clearly audible. 3 and 4 tones are normally not audible. This is due to the fact that in a healthy heart, the blood entering the ventricles at the beginning of diastole does not cause loud enough sound phenomena, and 4 tone is actually the initial component of 1 tone and is perceived inseparably from 1 tone. The appearance of a 3 tone can be associated with both pathological changes in the heart muscle and without pathology of the heart itself. Physiological tone 3 is more often heard in children and adolescents. In people over 30 years old, 3 tone is usually not heard due to a decrease in the elasticity of their heart. It appears in cases when the tone of the heart muscle decreases, for example, with myocarditis, and the blood entering the ventricles causes vibration of the ventricular myocardium that has lost its tone and elasticity. However, in cases where the heart muscle is not affected by inflammation, but simply decreases its tone, for example, in a physically very trained person - a skier or football player of a high sports category, who is in a state of complete physical rest, as well as in young people, in patients with vegetative tone, blood entering the relaxed ventricles of the heart can cause physiological 3 tones. The physiological third tone is best heard directly by the ear, without the use of a phonendoscope.

The appearance of 4 heart sounds is unambiguously associated with pathological changes in the myocardium - with myocarditis, impaired conduction in the myocardium.

Places for listening to heart sounds. Despite the fact that heart sounds occur in a limited space, they, due to their strength, are audible over the entire surface of the heart and even beyond. However, on the chest wall, for each of the tones, there are places where they are heard better, and sounds that occur in other places in the heart region are the least disturbing.

It could be assumed that the places of the best listening to heart sounds correspond to the points of their origin. However, this assumption is valid only for pulmonary tone. In reality, the points of the best listening of the heart valves do not coincide with the points of their projection onto the chest wall. In addition to the proximity of the place of origin of sounds, the propagation of sounds through the bloodstream, the density of adherence to the chest wall of that part of the heart in which the sounds are formed, also plays an important role. Since there are 4 valve openings in the heart, there are also 4 places for listening to heart sounds and murmurs arising in the valve apparatus.

The mitral valve is projected onto the area of \u200b\u200battachment 3 of the left costal cartilage to the sternum, but a relatively thick layer of lung tissue, characterized by poor sound conductivity, the proximity of the semilunar valves make it unprofitable to listen to the mitral valve, which forms 1 tone, in this place. First heart tone heard best at the apex of the heart. This is due to the fact that in the region of the apex of the heart, we put the phonendoscope on that part of the chest, behind which lies the apex of the heart formed by the left ventricle. Left ventricular systolic tension is more severe than right ventricular tension. The chordae of the mitral valve are also attached in the area close to the apex of the heart. Therefore, 1 tone is heard better in the area of \u200b\u200badherence to the chest of the apex of the left ventricle.

When the right ventricle expands and the left ventricle is pushed backward, 1 tone begins to be heard better above the right ventricle of the heart. The tricuspid valve, which generates the first tone, is located behind the sternum on the line connecting the place of attachment to the sternum of 3 costal cartilage on the left and 5 cartilage on the right. However, it is heard better slightly below the place of projection of the atrioventricular tricuspid valve onto the chest wall, at the lower end of the sternum body, since in this place the right ventricle is directly adjacent to the chest wall. If the patient bottom part the sternum is somewhat depressed, it is not possible to place the phonendoscope tightly on the chest in this place. In this case, you should move the phonendoscope slightly to the right at the same level until it snuggles to the chest.

Second heart tone is best heard from the heart. Since the second tone is predominantly valvular, it has 2 points of the best auscultation - at the point of auscultation of the pulmonary valves and at the point of auscultation of the aortic valves.

The sound phenomena of the pulmonary artery valve, which form the 2nd heart sound, are best heard over the place of the chest wall, which is located closest to the orifice of the pulmonary artery, namely in the second intercostal space to the left of the sternum. Here, the initial part of the pulmonary artery is separated from the chest wall only by the thin edge of the lung.

The valves of the aorta are embedded deeper than them, located slightly inward and below the valves of the pulmonary artery, and even closed by the sternum. The tone generated by the collapse of the aortic valves is transmitted along the blood column and the walls of the aorta. In the 2nd intercostal space, the aorta is closest to the chest wall. To assess the aortic component of tone 2, a phonendoscope should be placed in the second intercostal space to the right of the sternum.

Carrying out auscultation of the heart, a certain order of listening is observed. There are 2 rules (orders) of auscultation of the heart - the "eight" rule and the "circle" rule.

The Rule of Eight involves listening to heart valves in descending order of frequency of their damage in rheumatic lesions. The heart valves are listened to according to the "figure of eight" rule in the following sequence:

1 point - the apex of the heart (listening point of the mitral valve and left atrioventricular opening),

2 point - 2 intercostal space at the right edge of the sternum (listening point of the aortic valve and the aortic mouth),

3 point - 2 intercostal space at the left edge of the sternum (listening point of the pulmonary artery valve and its mouth),

4 point - the base of the xiphoid process (listening point of the tricuspid valve and the right atrioventricular opening).

5 point of Botkin - Erba –3 intercostal space at the left edge of the sternum (additional listening point of the aortic valve, corresponding to its projection).

During auscultation according to the "circle" rule, the "internal" valves of the heart (mitral and tricuspid) are first listened to, and then the "external" valves of the heart (aortic and pulmonary arteries), then the 5th point of Botkin - Erb is listened to. The heart valves are listened to according to the "circle" rule in the following sequence:

1 point - apex of the heart,

2 point - the base of the xiphoid process,

3 point - 2 intercostal space at the right edge of the sternum,

4 point - 2 intercostal space at the left edge of the sternum,

5 point Botkin - Erba - 3 intercostal space at the left edge of the sternum.

Listening to the sounds of the heartdetermine the correctness of the rhythm, the number of basic tones, their timbre, sound integrity, the ratio of loudness of 1 and 2 tones. When additional tones are identified, their auscultatory features are noted: attitude to the phases of the cardiac cycle, loudness and timbre. To determine the melody of the heart, you should mentally reproduce it using syllabic phonation.

Difference 1 from 2 heart tone. 1 tone is longer and slightly below 2 tone. At the sites of listening to the leaflet valves, it is usually stronger than 2 tones. The 2nd tone, on the contrary, is somewhat shorter, higher and stronger than the 1st one at the sites of hearing the semilunar valves. At the base of the heart, heart tones are best conveyed by syllables. Bu "\u003d tu" n,

and on the ventricles Boo "\u003d dumb.

It should be noted that in some perfectly healthy people, 2 tone is stronger than the 1st one and at the sites of listening to the leaflet valves. Sometimes, with rapid and, especially, irregular, arrhythmic activity of the heart, 1 tone can be difficult to distinguish from the 2nd.

Change in the strength of heart sounds.

Heart tones can change in strength, character, split, additional tones can occur and a kind of heart rhythms can form. Changes in heart sounds may depend on the following main factors: 1. Changes in the contractile function of the ventricles, 2. Changes physical properties valves, 3. Changes in the level of blood pressure in the aorta and pulmonary artery, 4. From non-simultaneous occurrence of individual components, 5. From external factors - changes in the properties of the sound-conducting medium - the lungs and chest wall, the state of organs adjacent to the heart.

Weakening heart sounds... The strength of heart tones is weakened, first of all, in healthy people with a thick chest wall, with powerful muscle development and, especially, with excessive development of subcutaneous fatty tissue, in patients with edema, subcutaneous emphysema in the heart. Even more important for weakening the loudness of heart sounds is the development of pulmonary emphysema, since emphysematous lung tissue has a low sound conductivity. With severe emphysema of the lungs, heart sounds become barely audible. In patients with hydrothorax, pneumothorax, hydropericardium, a sharp decrease in the volume of heart sounds also occurs.

The weakening of heart sounds can be associated not only with external, in relation to the heart, causes, but also with cardiac pathology. Heart sounds weaken with a decrease in the speed and strength of the contractions of the ventricles of the heart due to the weakness of the myocardium. This can be observed in severe infectious diseases occurring with high myocardial intoxication, in myocarditis, in patients with hypertrophy and dilatation of the ventricles of the heart. Since the loudest component of any heart sound is the valve component, if one or another heart valve fails to close, the tone that forms during the operation of the valve sharply weakens, up to complete disappearance. In patients with insufficiency of the mitral or tricuspid valves, 1 tone sharply weakens. In patients with insufficiency of the valves of the aorta or pulmonary artery, a weakening of 2 tones is noted. Weakening of 2 heart sounds is observed in patients with a drop in blood pressure in the large or in the small circles of blood circulation, when the semilunar valves slam less than usual.

Amplification of all heart sounds observed with: 1) a thin chest wall, 2) when the heart is adjacent to the chest wall with a larger area than usual, for example, with wrinkling of the lungs, 3) with anemia, when, due to a decrease in blood viscosity, heart sounds become clapping, sharp, 4) in those cases when the speed and strength of myocardial contraction increases, for example, when physical activity, in patients with thyrotoxicosis, with neuropsychic arousal. With insufficient filling of the ventricles with blood, for example, with narrowing (stenosis) of the mitral orifice, the opening of the tricuspid valve, with an extraordinary contraction of the heart (with extrasystole), contractions of the poorly filled ventricles of the heart occur faster than usual. Therefore, such patients also have a sharp increase in 1 tone.

Gain 2 tone, or as they say more often, the accent of 2 tones over the aorta and pulmonary artery, is common and has significant diagnostic value. In children and people under the age of 20, the 2nd tone above the pulmonary artery is normally louder than above the aorta. In the elderly, the 2 tone above the aorta becomes louder than above the pulmonary artery. Strengthening of 2 tones above the aorta, its emphasis, is noted with an increase in blood pressure. When the aortic valve leaflets are compacted and, especially, with sclerosis of the aorta itself, the 2nd tone reaches significant strength and acquires a metallic hue. Similarly, an accent of 2 tones on the pulmonary artery will appear in patients with pulmonary hypertension of any origin - with heart defects, with acute or chronic pulmonary pathology, ranging from croupous pneumonia to pulmonary emphysema.

Split tones. Tone bifurcation is a phenomenon when one of two heart tones decomposes into 2 parts, which are freely captured by our ear as separate sounds. If this interval is very small and is not perceived by ear as separate sounds, then one speaks of a split tone. All transitions are possible between the split tone and its splitting, therefore there is no clear distinction between them.

Splitting 2 tones. Non-simultaneous closure of the semilunar valves is the result of different durations of systole of the left and right ventricles. The systole ends the sooner, the less blood the ventricle has to transfer to the aorta or pulmonary artery, the easier they are filled and the lower the blood pressure in them.

Above the base of the heart, a split 2 tone can occur in a healthy person at the end of inhalation and at the beginning of exhalation as a physiological phenomenon. As a pathological phenomenon, bifurcation is often observed with mitral valve defects, and especially often with mitral stenosis. This bifurcation of the 2nd tone is best heard in the 3rd intercostal space on the left at the sternum. With mitral valve stenosis, the left ventricle is poorly filled with blood in the diastole phase and less blood is ejected into the aorta than usual. Consequently, the systole of the left ventricle of the heart decreases in time against the usual value. At the same time, these patients have high pulmonary hypertension, which means that the systole of the right ventricle takes longer than usual. As a result of these changes in hemodynamics, there is a non-simultaneous slamming of the valves of the aorta and pulmonary trunk, audible as a bifurcation of 2 tones. Thus, the bifurcation of 2 tones in the aorta and in the pulmonary artery causes the following conditions: 1) an increase in pressure in one of the vessels and normal pressure in the other, 2) low pressure in one of the vessels and normal in the other, 3) high pressure in one vessel and low in the other, 4) increased blood filling in one of the ventricles, 5) decreased blood filling of one of the ventricles, 6) increased filling of one from the ventricles and decreased filling of the other ventricle of the heart.

Splitting 1 tone... It is heard when the normal tone is always followed by a faint, abnormal tone. This phenomenon can occur in 10% of healthy people with auscultation in the supine position. As a pathological phenomenon, bifurcation of 1 tone occurs with aortic sclerosis and with high blood pressure in the systemic circulation.

Mitral valve opening tone.In patients with mitral stenosis, with a correct heart rate (without atrial fibrillation), an increase in the number of heart sounds is observed, resembling a bifurcation of the 2nd tone, since the third additional tone quickly follows the 2nd normal heart tone. This phenomenon is best heard above the apex of the heart. In healthy people, in the phase of rapid filling of the ventricles of the heart with blood, the leaflets of the mitral valve are silently pushed aside by the blood. In patients with stenosis of the mitral valve at the beginning of the diastole phase, when the ventricles begin to fill quickly with blood, the shortened and sclerosed mitral valve leaflets form a funnel-shaped diaphragm. They cannot open freely and move away to the walls of the ventricle, they sharply tense under the pressure of blood and generate a tone for opening the mitral valve. In this case, a kind of three-member heart rhythm is formed, called quail rhythm. The first component of this three-part rhythm is the first tone. It is followed by a second tone at regular intervals. Almost immediately after the second tone, the tone of the opening of the mtral valve follows after a short interval. A rhythm arises that can be conveyed by sounds Ta-tara, reminiscent, in the figurative expression of old clinicians, the cry of a quail "it's time to sleep." The quail rhythm is heard with normo- or bradycardia. Only in the absence of tachycardia by ear can one distinguish the difference in intervals between the first - second and second - third components of the formed three-member rhythm.

The rhythm of the gallop. The bifurcation of the first tone is sometimes very sharp. The part split off from the main tone is separated from it by some, clearly audible, interval and is heard as a separate independent tone. Such a phenomenon is no longer called a split tone, but a gallop rhythm, reminiscent of the sound of the hooves of a galloping horse. This peculiar three-member rhythm appears against the background of tachycardia. The intervals between the first - second and second - third tones are perceived to be the same by ear, the interval between the third and the first sound of the next triad following it is perceived to be somewhat larger. The resulting rhythm can be transmitted by sounds such as ta-ra-ra, ta-ra-ra, ta-ra-ra. The gallop rhythm is best defined above the apex of the heart and in 3 to 4 intercostal spaces to the left of the sternum. It is heard better directly with the ear than with a phonendoscope. The rhythm of the gallop increases after a slight physical effort, when the patient moves from vertical to horizontal position, as well as at the end of inhalation - at the beginning of exhalation in a slowly and deeply breathing person.

The additional third tone at the canter rhythm is usually muffled and short. It can be positioned in relation to the main tones as follows.

An additional tone can be heard during a long pause closer to the first tone. It is formed by the separation of the atrial and ventricular components of the first tone. It is called the presystolic rhythm of the gallop.

An additional tone can be heard in the middle of a large pause of the heart, i.e. in the middle of diastole. It is associated with the appearance of 3 heart sounds and is called the diastolic rhythm of the gallop. Phonocardiography made it possible to distinguish protodiastolic (at the beginning of diastole) and mesodiastolic (in the middle of diastole) gallop rhythms. The protodiastolic gallop rhythm is caused by severe damage to the ventricular myocardium, most often by failure of the previously hypertrophied left ventricle. The appearance of an additional tone in diastole is caused by the rapid expansion of the flabby muscle of the left ventricle when it is filled with blood. This variant of the gallop rhythm can occur in normo- and even bradycardia.

An additional tone can be heard immediately after the first tone. It is caused by the different-time excitation and contraction of the left and right ventricles of the heart in violation of conduction along the legs of the His bundle or along their branches. It is called the systolic rhythm of the gallop.

If with high tachycardia there are 3 and 4 heart sounds, then a short interval between them can lead to the fact that the four-membered heart rhythm recorded on the phonocardiogram is perceived as a three-membered rhythm by ear and a summed meso-diastolic gallop rhythm appears (summation of 3 and 4 sounds).

They do not always coincide with the anatomical localization of their sources - the valves and the holes they close (Fig. 45). So, the mitral valve is projected at the place of attachment of the third rib to the sternum on the left; aortic - in the middle of the sternum at the level of III costal cartilage; pulmonary artery - in the II intercostal space on the left at the edge of the sternum; tricuspid valve - in the middle of the line connecting the attachment points to the sternum of the cartilage III of the left and V of the right ribs. Such closeness of the valve openings to each other makes it difficult to isolate sound phenomena in the place of their true projection onto the chest. In this regard, the locations of the best conduction of sound phenomena from each of the valves have been determined.

Fig. 45. Projection of the heart valves on the chest:
A - aortic;
L - pulmonary artery;
D, T - two- and three-leafed.

The place of listening to the bicuspid valve (Fig. 46, a) is the area of \u200b\u200bthe apical impulse, ie, the V intercostal space at a distance of 1-1.5 cm medially from the left mid-clavicular line; aortic valve - II intercostal space on the right at the edge of the sternum (Fig. 46, b), as well as the 5th point of Botkin - Erb (the place of attachment of the III-IV rib to the left edge of the sternum; Fig. 46, c); pulmonary valve - II intercostal space on the left at the edge of the sternum (Fig. 46, d); tricuspid valve - the lower third of the sternum, at the base of the xiphoid process (Fig. 46, e).

Fig. 46. \u200b\u200bListening to heart valves:
a - bivalve in the apex;
b, c - aortic, respectively, in the II intercostal space on the right and at Botkin's point - Erb;
d - pulmonary valve;
d - tricuspid valve;
e - the order of listening to heart sounds.

Listening is carried out in a certain sequence (Fig. 46, e):

apical impulse area; II intercostal space on the right at the edge of the sternum;
II intercostal space on the left at the edge of the sternum;
the lower third of the sternum (at the base of the xiphoid process);
botkin point - Erba.

This sequence is due to the frequency of heart valve damage.

The order of listening to heart valves:

In practically healthy individuals, when listening to the heart, two tones are usually determined - the first and second, sometimes the third (physiological) and even the fourth.

Normal I and II heart sounds (eng.):

First tone is the sum of the sound phenomena that occur in the heart during systole. Therefore, it is called systolic. It occurs as a result of vibrations of the tense muscle of the ventricles (muscle component), closed cusps of the bicuspid and tricuspid valves (valve component), the walls of the aorta and pulmonary artery in the initial period of blood flow into them from the ventricles (vascular component), atria during their contraction (atrial component).

Formation and components of the I tone (eng.):

Second tone caused by the collapse and resulting vibrations of the valves of the aorta and pulmonary artery. Its appearance coincides with the onset of diastole. Therefore, it is called diastolic.

II heart tone (eng.):

There is a small pause between the first and second tones (no sound phenomena are heard), and the second tone is followed by a long pause, after which the tone appears again. However, students beginning training often have great difficulty distinguishing between the first and second tones. To facilitate this task, it is recommended that healthy people with slow heart rates be listened to first. Normally, the first tone is heard louder at the apex of the heart and in the lower part of the sternum (Fig. 47, a). This is due to the fact that sound phenomena from the mitral valve are better conducted to the apex of the heart and the systolic tension of the left ventricle is more pronounced than that of the right. The second tone is heard louder at the base of the heart (in places where the aorta and pulmonary artery are auscultated; Fig. 47, b). The first tone is longer and lower than the second.

Fig. 47. Places of the best listening to heart sounds:
a - I tone;
b - II tone.

Listening alternately to obese and thin people, one can make sure that the volume of heart sounds depends not only on the state of the heart, but also on the thickness of the surrounding tissues. The greater the thickness of the muscle or fat layer, the lower the volume of the tones, both of the first and the second.

Fig. 48. Determination of I heart sound by the apical impulse (a) and by pulse carotid artery (b).

Heart sounds should be learned to differentiate not only by the relative loudness at the apex and base of it, by their different duration and timbre, but also by the coincidence of the appearance of the first tone and pulse on the carotid artery or the first tone and apical impulse (Fig. 48). Pulse on radial artery it is impossible to navigate, since it appears later than the first tone, especially with a frequent rhythm. It is important to distinguish between the first and second tones not only in connection with their independent diagnostic significance, but also because they play the role of sound cues for determining noise.

Third tone caused by vibrations of the walls of the ventricles, mainly the left (with rapid filling with blood at the beginning of diastole). It is heard with direct auscultation at the apex of the heart or somewhat inwardly from it, and it is better in the patient's lying position. This tone is very quiet and may not be picked up in the absence of sufficient auscultation experience. It is better heard in young people (in most cases near the apical impulse).

III heart tone (eng.):

Fourth tone is the result of vibrations of the walls of the ventricles during their rapid filling at the end of diastole due to atrial contraction. Rarely heard.

IV heart tone (eng.):

You can listen to heart sounds and murmurs in normal and pathological conditions on the website

From early childhood, everyone is familiar with the actions of a doctor when examining a patient, when the heart rate is listened to with the help of a phonendoscope. The doctor listens especially carefully to heart sounds, especially fearing complications after infectious diseases, as well as for complaints of pain in this area.

With normal heart function, the duration of the resting cycle is about 9/10 seconds, and consists of two stages - the contraction phase (systole) and the rest phase (diastole).

During the relaxation stage, the pressure in the chamber changes to a lesser extent than in the vessels. Fluid under slight pressure is injected first into the atria and then into the ventricles. At the moment of filling the latter by 75%, the atria contract and forcibly push the remaining volume of fluid into the ventricles. At this time, they talk about atrial systole. At the same time, the pressure in the ventricles rises, the valves close, and the atria and ventricles are isolated.

The blood presses on the ventricular muscles, stretching them, causing a powerful contraction. This moment is called ventricular systole. After a fraction of a second, the pressure rises so much that the valves open and the blood flows into the vascular bed, completely emptying the ventricles, in which a period of relaxation begins. At the same time, the pressure in the aorta is so high that the valves close and do not release blood.

The duration of diastole is longer than systole, so there is enough time for the rest of the heart muscle.

Norm

The human hearing aid is very sensitive, it picks up the most subtle sounds. This property helps doctors determine by the pitch of the sound how serious the disturbances in the work of the heart are. Sounds during auscultation occur due to the work of the myocardium, valve movements, blood flow. Heart sounds normally sound consistent and rhythmic.

There are four basic heart sounds:

occurs when the muscle contracts. Created by vibration of a strained myocardium, noise from the operation of valves. It is heard in the region of the apex of the heart, near the 4th left intercostal space, occurs synchronously with the pulsation of the carotid artery.
occurs almost immediately after the first... Created due to flapping valve flaps. It is more deaf than the first and is audible from both sides in the second hypochondrium. The pause after the second tone is longer and coincides with diastole.
optional tone, normally its absence is allowed... It is created by vibration of the walls of the ventricles at the moment when there is additional blood flow. Sufficient listening experience and absolute silence are required to determine this tone. You can hear it well in children and adults with a thin chest wall. It is more difficult for obese people to hear it.
another optional heart sound, the absence of which is not considered a violation. It occurs when the ventricles are filled with blood at the time of atrial systole. It is perfectly heard in people of thin physique and children.

Pathology

Violations of the sounds that occur when the heart muscle works can be caused various reasons, grouped into two main ones:

Physiologicalwhen the changes are associated with certain characteristics of the patient's health. For example, fat in the listening area degrades the sound, so the heart sounds are muffled.
Pathologicalwhen changes affect various elements of the cardiac system. For example, the increased density of the atrioventricular leaflets adds a click to the first tone and the sound is louder than usual.

Pathologies that arise in the work are primarily diagnosed during auscultation by a doctor when examining a patient. By the nature of the sounds, they judge a particular violation. After listening, the doctor must record the description of the heart sounds in the patient's chart.

Muffled heart sounds are considered to have lost the clarity of the rhythm. With a weakening of muffled tones in the area of \u200b\u200ball points of auscultation leads to the assumption of the following pathological conditions:

serious myocardial damage - extensive, inflammation of the heart muscle, proliferation of connective scar tissue;
exudative pericarditis;
disorders not associated with cardiac pathologies, for example, pulmonary emphysema, pneumothorax.

With the weakness of only one tone at any place of listening, the pathological processes leading to this are called more precisely:

dull first tone, listened to at the apex of the heart, indicates inflammation of the heart muscle, its sclerosis, partial destruction;
deaf second tone in the area of \u200b\u200bthe second intercostal space on the right speaks of or narrowing of the mouth of the aorta;
deaf second tone in the area of \u200b\u200bthe second intercostal space on the left shows insufficiency of the pulmonary valve.

There are such changes in the tonality of the heart that experts give them unique names. For example, "quail rhythm" - the first clapping tone changes to the second usual, and then the echo of the first tone is added. Severe myocardial diseases are expressed in a three-membered or four-membered "gallop rhythm", that is, blood fills the ventricles, stretching the walls, and vibrational vibrations create additional sounds.

Simultaneous changes in all tones at different points are often heard in children due to the peculiarity of the structure of their chest and the proximity of the heart to it. The same can be observed in some adults of the asthenic type.

Typical violations are listened to:

high first tone at the top of the heart appears with the narrowness of the left atrioventricular opening, as well as with;
high second tone in the second intercostal space on the left indicates a growing pressure in the pulmonary circulation, therefore there is a strong flapping of the valve leaflets;
high second tone in the second intercostal space on the right shows an increase in pressure in the aorta.

Interruptions in the heart rhythm indicate pathological conditions of the system as a whole. Not all electrical signals pass equally through the thickness of the myocardium, therefore, the intervals between heartbeats are of different duration. When the atria and ventricles work inconsistently, a "cannon tone" is heard - a simultaneous contraction of the four chambers of the heart.

In some cases, auscultation of the heart shows a separation of the tone, that is, the replacement of a long sound with a pair of short ones. This is due to a violation of the coordination in the work of muscles and heart valves.

The division of the 1st heart sound occurs for the following reasons:

closure of the tricuspid valve and mitral valve occurs in a temporary rupture;
contraction of the atria and ventricles occurs in different time and leads to a violation of the electrical conductivity of the heart muscle.
The division of the 2nd heart sound occurs due to the difference in the timing of the closing of the valve cusps.

This condition indicates the following pathologies:

excessive increase in pressure in the pulmonary circulation;
proliferation of tissues of the left ventricle with mitral stenosis.

With ischemia of the heart, the tone changes depending on the stage of the disease. The onset of the disease is poorly expressed in sound disturbances. In the periods between attacks, deviations from the norm are not observed. The seizure is accompanied by a rapid rhythm, indicating that the disease is progressing, and heart sounds in children and adults are changing.

Health professionals pay attention to the fact that changes in heart tones are not always an indicator of cardiovascular disorders. It happens that the causes are a number of diseases of other organ systems. Muting tones, the presence of additional tones indicates such diseases as endocrine diseases, diphtheria. An increase in body temperature is often expressed in a violation of the heart tone.

A competent doctor always tries to collect a complete history when diagnosing a disease. In addition to listening to heart sounds, he interrogates the patient, carefully examines his card, and prescribes additional examinations according to the alleged diagnosis.