From Big Medical Encyclopedia

NOISE CORDIAL — the noise arising in cardial cavities and in nadklapanny department of the ascending part of an aorta or a pulmonary trunk owing to disturbance of laminarity of a flow of blood in them. As well as other true noise, Sh. of page are result of summation different in the frequency and amplitude of sound vibrations. In rare instances in the frequency characteristic of noise the certain frequency which is naturally changing throughout a cardial cycle and combined with the highest harmonic oscillations that is perceived by an ear as musical noise prevails. Though cardiac sounds (see) by the physical nature also treat noise, on perception they differ from Sh. in page: tone is perceived as an abrupt sound, noise — as more extended sound with less accurate beginning p a zatikhaniye; on FKG the main cardiac sounds identify on their communication with teeth of an ECG.

Listening of noise of heart began with implementation in diagnostic practice of auscultation (see), edges remains by the main method of a research Sh. of page, despite development of a phonocardiography (see). Advantages of auscultation are defined by ability of the person to hear very low sounds (.meny

10 dB) in the big frequency range (from 16 to 20 Ltd companies of Hz), to estimate the timbre of a sound determined by overtones, to reveal low sounds against the background of louder and, at last, to remember a sound picture at a certain pathology and to recognize her from other patient even at considerable changes of character of the making its components. The phonocardiography allows to obtain the objective information about frequency and amplitude characteristic of Sh. of page and to define a ratio them in time with cardiac sounds. For Sh.'s identification by the village the phonocardiographical method can have advantages before auscultation at tachycardia when their listening is complicated because of short duration of a systole and a diastole and decrease in cordial emission. The main shortcomings of a phonocardiography — big sensitivity to hindrances, impossibility to define a timbre of a sound and to register silent high-frequency noises. Sounds of low frequency catch modern phonocardiographs better, than the person, however a wedge, low-frequency Sh.' value of page is not established.

During auscultation of heart to the patient suggest to inhale, exhale and hold the breath several times deeply. In view of the fact that these auscultations often change at change of position of the body investigated it is recommended to listen to Sh. of page in position of the patient not only lying on spin, but also in situation on left, and sometimes and, on a stomach, in a sitting position and standing on the right side. Nek-rye Sh. pages happen not clear or absolutely disappear in the conditions of absolute rest of the studied person and become clearer after an exercise stress. Listening is carried out serially in certain places of precardiac area, in to-rykh as showed a wedge, experience, the noise caused by defeat of separate valves of heart are best of all heard. Classical points for Sh.'s listening by the village over separate valves (fig. 1) are: 1) area of a top of heart — for the two-fold (mitral) valve; though the two-fold valve is projected above — at the place of an attachment of the III edge to a breast, the sounds connected with its work are listened here worse, than at a top of heart since in the place of a projection the mitral valve is covered with a right ventricle; 2) in the second intercostal space at the right edge of a breast — for the valve of an aorta; 3) in the second intercostal space at the left edge of a breast — for the valve of a pulmonary trunk; 4) at the right edge of the lower third of a breast — for the three-leaved valve; 5) in the fourth mezhreberye at the left edge of a breast

of Fig. 1. The scheme of a projection of valves of heart to a front chest wall (And — a projection of the valve of an aorta; L — a projection of the valve of a pulmonary trunk; M — a projection of the mitral valve; T — a projection of the three-leaved valve) and base points of listening of noise of heart: 2 — a top of heart (noise from the mitral valve are carried out); 2 — the second mezhreberye at the right edge of a breast (the valve of an aorta); z — the second mezhreberye at the left edge of a breast (the valve of a pulmonary trunk); 4 — a midsternum over a xiphoidal shoot (the three-leaved valve); 5 — Botkin's point — Erba — the fourth mezhreberye to the left of a breast (diastolic noise of aortal insufficiency and noise of the mitral valve are carried out); the Roman figures designated edges.

(the fifth point, or Botkin's point — Erba) — for listening of diastolic noise of aortal insufficiency, and in some cases and the noise connected with defeats of the mitral valve. Projections of the valve of an aorta and the valve of a pulmonary trunk to a front wall of a thorax almost match. Therefore if in the second mezhreberye to the left of a breast noise is heard, it is necessary to move gradually a head of a ste-tofonendoskop in the direction of a blood flow in an aorta, i.e. in the second mezhreberye to the right of a breast where the noise arising in the field of the valve of a pulmonary trunk are not carried out. At Sh.'s identification by the village auscultation is not limited to standard points: listen to all precardiac area, the left sidewall of a thorax at the level of a top of heart, mezhlopa-exact area and area of a projection of the descending aorta to a front wall of a stomach. At a phonocardiographic research the microphone have in standard points of auscultation.

Theory of formation of noise of heart. Sh.'s origin of page remains a subject of a discussion. However it is established that a necessary condition of emergence of noise in fluxion is transition laminar (quiet layered) a blood flow in not laminar, or turbulent (with turbulences). Conditions of transition of streamline flow of liquid to turbulent are defined by critical values of number of Reynolds (the attitude of the work of linear parameters of section of the conductor of current of liquid, its density and peripheral speed towards viscosity of the proceeding liquid), a cut for blood makes apprx., 1000. Achievement of critical values of number of Reynolds and, therefore, formation of the turbulent flows creating noise are promoted increase in speed of a blood-groove (e.g., at thyrocardiac heart), decrease in viscosity of blood (e.g., owing to anemia), and also change of geometrical parameters of section of a bed of a blood-groove, in particular local narrowing of openings, through to-rye proceeds blood (e.g., at the mitral or aortal stenosis limited on an extent a stenosis of a large artery).

Noise appear only at formation of the whirlwinds having sufficient energy. If narrowing of a valve opening is rather small, and the pressure gradient distalny and proksimal-it an obstacle is insufficient for formation of a conic stream (see below), in the current blood rather arranged whirlwinds, energy are formed to-rykh it is sufficient for emergence of noise (e.g., at a moderate inborn subaortic stenosis). According to most of researchers, also the effect of a nozzle, jet blow of blood about the surface located perpendicular to a blood-groove and emergence of periodic vibrations at a flow belong to origins of Sh. of page blood of the small educations located perpendicular to a blood flow with a smooth surface (a chord, fibrinous thread, etc.). The effect of a nozzle consists that the blood proceeding with high speed through a narrow opening in a wide cavity forms a so-called, conic stream, and on borders between this stream and the blood which is in a cavity there are small turbulences (e.g., at a stenosis of valve openings, septal defects). Emergence of noise from jet blow of blood about the surface located perpendicularly to it is caused by emergence of vibration of a surface and small turbulences in a stream of blood; the arising noise is carried out in the direction of a blood flow (e.g., at a patent ductus arteriosus, defects of an interventricular partition). Emergence of periodic vibrations of blood at a flow of a smooth obstacle can be connected with elastic deformation of the last. Directly behind an obstacle hydrostatic pressure decreases that conducts to the shift of an obstacle in the direction of a blood flow; then under the influence of elastic forces it is returned to the initial position. Repetition of this process leads to emergence of periodic vibrations. Consider that this mechanism is the cornerstone of emergence of musical noise.,

By origin Sh. of page can be divided on organic — the hearts tied with organic lesion of valves or walls of heart or vessels departing from it (defects of partitions, aneurisms), and functional. Carry III to the last. the pages arising at change of a ratio of the sizes of cavities and valve openings of heart with formation so * naz. relative stenoses shsh insufficiency of valves (see the Heart diseases acquired), and the noise connected with acceleration of current or decrease in viscosity of blood (e.g., at a thyrotoxicosis, anemia). Refer to functional also the so-called innocent noise of heart which are quite often observed at healthy people, especially at children's and young age. The origin of «innocent» noise is not quite clear.

Phases of a cardial cycle, in to-rye are listened noise, define

Fig. 2. The diagrammatic representation of the electrocardiogram (ECG) and the phonocardiogram (FKG) of the first (I) and second (U) cardiac sounds with distribution of phases of a systole (between I and II tones) and diastoles (between II and I tones) on time slices (are divided by a dotted line), on which designate the cordial noise heard in these intervals: 1 — presystolic; 2 — protosi-

stolicheskiya; 3 — mesosystolic; 4 — telosistolicheskiya, or preddiastoliche-skiya; 5 — protodiastolic; 6 — mesodiastolic; 7 — golosistolicheskiya;

8 — golodiastolicheskiya.

designation Sh. of page as systolic (fig. 2), i.e. listened between I and II cardiac sounds (in a phase of a systole), and diastolic, listened during a big (diastolic) pause between II and the I tone. Depending on what part of a systole is occupied by systolic noise, they are divided into the about-tosistolichesky, arising in a phase tension and systoles occupying an initial part, the mezosisto-lichesky, arising in a sphygmic interval and listened in the middle of a systole, and telosistolichesky, or prediastolic, occupying a final part systoles. The noise occupying all systole carry the name pansystolic, or golosistolichesky. Diastolic noise respectively subdivide into the diastoles occupying an initial part — protodiastolic, its middle part — me zodiastolichesky and a final part of a diastole — presystolic noise. The highways of page arising during a systole and proceeding after the II cardiac sound carry the name of sistolodiastolichesky noise.


pages, CORDIAL At Sh.'s listening, with the diagnostic purpose define the place of the best listening and the direction of carrying out noise, its loudness, a timbre, height. Noise can be short and long, accruing (crescendo), decreasing (decrescendo, diminuendo), narasta-yushche-decreasing (rhomboid) etc. On height and a timbre noise can be rough, gentle, blowing, scraping, sawing, rolling etc. The noise having clearly distinguishable main tone are called musical. Sh.'s loudness of page is in direct dependence on the speed of a blood-groove, and also on conditions of carrying out a sound on a thorax. At thin people with a thin chest wall, and also at children noise happen louder, than at full persons. Emphysema of lungs reduces sonority of noise at the expense of the air gap separating heart from a front chest wall.

Intensity of noise happens very various (from almost inaudible to heard at distance) and not always reflects degree of defect or weight of a heart trouble. Very loud noise are often listened at not too big defects with rather good forecast while at severe defeat of the valve device of heart noise can be hardly caught. At heart failure intensity of many noise caused by organic valve defect decreases, and sometimes these noise even disappear and instead of them can appear new, connected with relative insufficiency of the valve or a relative stenosis. To a large extent Sh.'s intensity of page depends on the size of a stroke output. The more systolic volume, the is stronger noise. Dependence of force of noise on heart rate is explained by it. The more heart rate and, therefore, the less systolic volume, the is weaker noise. It is especially noticeable at diastolic noise, to-rye often are not listened at heart rate St. 100 in 1 min. At the same time at an exercise stress, a hyperphrenia, fever when the circulation time of blood raises, force of noise, despite increase of serdtsebiyeniye, usually increases; at the same time it is often possible to listen to the noise which are not defined in usual conditions. Due to the respiratory fluctuations of cordial emission Sh.'s intensity of page can change on phases of breath; sharply endocardiac noise, both valve, and vnekla-panny weaken, at a natuzhivaniye after a deep breath. Highways of page caused by valve defects most well are listened in horizontal position of the patient, but in general they depend on change of position of a body less, than functional noise.

Diagnostic value of cordial noise. The noise arising at organic heart diseases have the features of an origin and sounding reflecting the nature of pathology. Depending on a type of defect noise forms in certain phases of a cardial cycle therefore diagnostic value has already definition of a phase of a cardial cycle, in a cut noise is listened.

Sisto Lodiasto liches-to and e noise arise with defect of partitions of heart or the shunt between large vessels, and also at increase in a blood-groove through a vessel. The most frequent reason of such noise — an open arterial channel (see). Noise begins right after the I tone (fig. 3) with small derogation from it. In process of increase of pressure in

Fig. 3. The scheme of the phonocardiographic representation of cordial noise (the shaded sites) at some heart diseases in the ratio with first (i) and the second (II) cordial tones: 1 — the decreasing protosystolic noise at mitral insufficiency; 2 — rhomboid mesosystolic noise at an aortal stenosis; 3 — golosistolichesky noise at defect of an interventricular partition; 4 — spindle-shaped golosistolichesky noise at a stenosis of a pulmonary trunk;

5 — presystolic and protodiastolic noise at a mitral stenosis; 6 — sistolodiastolichesky noise at an open arterial channel.

to an aorta the loudness of noise increases. The pressure gradient between an aorta and a pulmonary trunk reaches a maximum at the end of a systole, and in the same time the maximum sounding of noise is noted. Noise terminates in the middle or at the beginning of a diastole. Often it is followed by trembling, loud, is heard over all area of heart, but has the maximum intensity in the second left mezhreberye from where irradiates in the third mezhreberye; in position of the patient lying noise amplifies. Aneurism of a sine of Valsal-vy at break it in a right ventricle is followed by the sistolodiastolichesky noise listened to the left of a breast. The diastolic component of noise is louder than systolic.

Systolic noise are listened most often since they are formed at the most different heart diseases, including myocardites (see), a cardiosclerosis (see), a cardiomyopathy (see), and also at anemia, a hyperkinetic syndrome; they make the greatest part of «innocent» noise at almost healthy faces and, besides, can be important auskultativny symptoms of the most widespread valve heart diseases — insufficiency of atrioventricular valves or a stenosis of the mouth of an aorta or a pulmonary trunk (see the Heart diseases acquired), and also defect of partitions of heart.

At mitral insufficiency systolic noise arises owing to regurgitation of blood from a left ventricle in the left auricle. It begins at once after the weakened I tone and proceeds up to the beginning of the II tone, i.e. often happens pansystolic. Noise can be equally authoritative throughout all systole, but can amplify by its end, often has the blowing character. Mitral insufficiency at an atherosclerotic cardiosclerosis is often shown by the late blowing systolic noise. Damage of papillary muscles at an acute myocardial infarction (see), a traumatic separation of papillary muscles leads to formation acute mitralnoh insufficiency; at the same time rough and long systolic noise is listened, to-ry begins with a separation from the I tone, has the rhomboid form, is carried out sometimes on vessels of a neck and to interscapular space. Late systolic noise (i.e. listened in the middle and the end of a systole) is quite often listened at patients with sclerous regeneration of papillary muscles, and also at a prolapse of the mitral valve.

Systolic noise of tricuspid insufficiency is better listened at the basis of a breast, often amplifies at height of a breath and quite often differs in the changing intensity unlike stable noise of mitral insufficiency. Inconstancy of noise is more characteristic of relative tricuspid insufficiency. At improvement of a condition of the patient noise of organic insufficiency does not change or even amplifies in connection with increase in contractility of a myocardium of a right ventricle whereas noise of relative insufficiency becomes more silent or disappears.

Systolic noise in the second mezhreberye to the right of a breast is characteristic of an aortal stenosis (ejection murmur). Most often it has the spindle-shaped form, begins about a nek-eye a separation from the I tone (fig. 3), comes to an end before the II tone, often irradiates on a top of heart and carotid arteries. Systolic noise of an aortal stenosis usually is followed by the trembling of a chest wall defined palpatorno («cat's purring»). The systolic ejection murmur in the second left mezhreberye is listened at a stenosis of the mouth of a pulmonary trunk (see Heart diseases inborn). Sometimes it is best of all heard in the third or fourth mezhreberye to the left of a breast.

Systolic noise at defect of an interventricular partition loud, lingering, sharp and even rough, is followed by trembling, epicenter to-rogo is in the third or fourth mezhreberye at the left edge of a breast (see Heart diseases inborn). Noise usually blocks the I tone and is heard throughout all systole. It has the cart-rastayushche-decreasing (spindle-shaped) character, possesses absolutely special timbre, is carried out extensively. In horizontal position noise louder, is often heard at distance, is carried out to interscapular space. After introduction of a phenylephine hydrochloride it becomes more intensive; sublingual reception of nitroglycerine reduces its intensity.

At defect of an interatrial partition systolic noise begins right after the I tone; it is not intensive, blowing, is followed by bifurcation of the II tone. Intensity of noise increases at an exercise stress, but does not reach that degree, edges happens at defects of an interventricular partition.

Diastolic noise are practically always connected with organic pathology of heart. Most often they are caused by aortic incompetence or a pulmonary trunk or a stenosis of atrioventricular openings.

Diastolic noise of aortal insufficiency begins at the very beginning of a diastole, in the period of the II tone, to-ry is often replaced or blocked by this noise. A high-frequency noise (see Auscultation), gentle, usually blowing (seldom he is musical). Duration of noise depends on weight of aortal insufficiency. At small aortal insufficiency diastolic noise short (protodiastolic), reveal it hardly, only in the absence of extraneous noises; at more expressed aortal insufficiency it borrows 1/2 — 2/3 diastoles, is characterized by the decreasing intensity; at heavy aortal defects noise quite often occupies all diastole. Many researchers consider that at heavy aortal insufficiency noise usually more intensively. He is listened in a classical point of auscultation of the aortal valve or in the fifth point, best of all caught in position of the patient lying on a stomach at quet superficial breathing.

The calming-down diastolic noise in the second (is more rare in the third) a mezhreberye to the left of a breast is a sign of pulmonary insufficiency.

In nek-ry cases noise amplifies during a breath. At the relative insufficiency of the valve of a pulmonary trunk arising owing to pulmonary hypertensia including and at a mitral stenosis, defect of an interatrial partition, Eyzenmenger's complex (see Heart diseases inborn, defect of an interventricular partition) the silent blowing diastolic noise called by Graham Steel's noise is listened. He begins right after the II tone and is listened on the limited site in the second mezhreberye at the left; in cases of bifurcation of the II tone noise begins from its second component.

Diastolic noise of a mitral stenosis arises right after the second component of the doubled II tone, has presystolic strengthening, quite often musical, is followed by trembling of a chest wall. Noise is usually low-frequency, it is better listened on a top of heart at horizontal position of the patient on the left side, amplifies after an exercise stress. Noise can occupy all diastole; at the same time at first it decreases, then, approximately from the middle of a diastole, proceeds with a constant amplitude to presystoles of the ichesky strengthening connected with an auricular systole. This results from the fact that in a phase of a rapid inflow of a left ventricle blood with high speed directs through a narrow opening, creating the noise which is calming down in process of reduction of speed of a flow and again amplifying at its additional acceleration connected with an auricular systole. At a ciliary arrhythmia presystolic strengthening of noise is absent. Along with diastolic noise strengthening of the I tone and bifurcation of the II tone is defined that creates a so-called melody of a mitral stenosis.

Diastolic noise decides on presystolic strengthening also at a myxoma (see) left auricles (see Heart); it differs in inconstancy, its emergence and intensity depend on position of a body and speed of a blood-groove.

At the expressed organic aortal insufficiency there is a functional stenosis of the left atrioventricular opening because the stream of blood, regurgi-tiruyushchy in a left ventricle, raises a shutter of the mitral valve. At the same time on a top of heart diastolic noise with presystolic strengthening (Flint's noise) is listened. Noise does not happen such long and loud as at an organic mitral stricture, is not followed by strengthening of the I tone and a mitral click.

Quite often at children the spindle-shaped diastolic noise separated by an interval from the II tone and lasting no more than 0,2 sec. (Koombs's noise) decides on insufficiency of the mitral valve and defect of an interventricular partition at considerable dilatation of auricles or ventricles; he is listened about a top of heart only with the III tone.

Diagnostic differentiation of cordial noise. Highway of page should be distinguished first of all from extracardiac (paracardiac) noise, to-rye, unlike endocardiac, are caused by the processes happening out of cardial cavities (most often in a pericardium, a pleura, lungs). The pericardial rub, cardiopulmonary and plevroperikardialny noise have the greatest looking alike of Sh. of page. The pericardial rub comes to light at perikardita (see), a myocardial infarction (see) usually in the form of the short scratching sounds during a systole or a diastole or in both phases. Cardiopulmonary (cardiopneumatic) noise arise in those parts of lungs, to-rye adjoin to heart. Change of the sizes and position of heart during a systole causes the bystry movement of air in sites of lungs, adjacent to it, generating a high-frequency noise. Cardiopulmonary noise are quite often listened at persons with the reduced perednezadny size of a thorax, at young people with the excited cordial activity (so-called hyperkinetic type of cordial activity), and also at the expressed hypertrophy of heart. Usually they are listened during a systole, and at breath holding, as a rule, disappear. Plevroperikardialny noise, i.e. the friction murmurs arising at dry pleurisy (see) in zones of contact of a pleura with a pericardium, amplify during a breath. At differentiation of the nature shumo'v it is necessary to remember also «noise of a water-mill» at an air embolism (see), various vascular noise (see).

Considerable difficulties arise sometimes at organic and functional Sh.' differentiation by the village. For distinguishing of organic and «innocent» noise various receptions (an exercise stress, change of position of a body) and a pharma-stake were offered. tests. Reception of nitroglycerine causes strengthening of systolic noise of an aortal stenosis, weakening of noise of mitral regurgitation and strengthening of systolic noise of tricuspid insufficiency. Functional pulmonic systolic noise is listened in the second mezhreberye at edge of a breast. Noise usually has the spindle-shaped form and occupies the first half of a systole, always blowing, is better heard in situation (yulny lying, amplifies under the influence of loading, at fever. The exhalation improves the audibility of this noise. «Innocent» aortal systolic noise arises owing to systolic vibration of the stretched root of an aorta. He occupies the middle of a systole, is listened in the second intercostal space, at the right edge of a breast, usually carried out to a top of heart.

Diagnosis of the nature of Sh. of page is more exact at dynamic assessment of noise. At improvement of cardiac performance organic Sh. pages usually become clearer. However any of characteristics of noise, as well as various methods of listening, do not allow to judge with full confidence Sh.'s nature of page. It is possible to claim, however, that the noise heard in a phase of a diastole, and also the noise occupying all systole never happen «innocent». Therefore if there is a doubt in the nature of noise, comprehensive inspection of the patient and dynamic observation is necessary.

Bibliography: Vinogradov A. V. Differential diagnosis of internal diseases, t. 2, page 763, M., 1980; Kassirsky I. A. and To and with with both r with to and y G. I, Sound symptomatology of the acquired heart diseases, M., 1964; Olya

S. F's nickname. Theory of cordial noise, M., 1961; R and sh m e r R. Dinamika

of cardiovascular system, the lane with English, M., 1981; Nightingales V. V. and Kassirsky G. I. Atlas of a clinical phonocardiography, M., 1983; Match-in of a JI. M. The quick reference guide on a phonocardiography, M., 1962; X about l l -

so To. and Wolf D. The atlas and the guide to a phonocardiography and ridiculous mechanocardiographical methods of a research, the lane with it. M, 1964.

J1. A. Kublanov.