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Abdominal murmur

Introduction
Cause
Examine
Diagnosis

Introduction

Introduction Abdominal vascular murmur: hepatic arterial murmur, hepatic vein murmur, murmur from renal artery stenosis, murmur from abdominal aorta and its branches, murmur from the abdominal aorta and its branches, ridge horn Noise; is a kind of heart murmur. Heart murmur refers to the abnormal sound produced by the vibration of the valve wall 2 or the vascular vibration caused by the end-flow of blood in the heart or blood vessels when the heart contracts or relaxes, in addition to the heart sound and the extra heart sound.

Cause

Cause

Etiology classification

First, apical systolic murmur

Non-pathological apical systolic murmur, rheumatic mitral valve disease, rheumatic mitral regurgitation, infective endocarditis, rheumatoid heart disease, systemic lupus erythematosus, scleroderma. Papillary muscle dysfunction or ligament rupture, (coronary heart disease, myocardial infarction), idiopathic ventral rupture, valve relaxation, mitral valve prolapse syndrome, Marfan syndrome only thick obstructive cardiomyopathy, dilated cardiomyopathy , atrial septal defect, patent ductus arteriosus, endocardial pad defect, pregnancy, hyperthyroidism, anemia, atrial heart disease, athlete's heart syndrome, high altitude heart disease, third degree atrioventricular conduction Block, carcinoid syndrome. Left, depleted, aortic regurgitation, relative mitral regurgitation.

Second, apical area diastolic murmur

Rheumatic mitral valve, rheumatic mitral stenosis, infective endocarditis, rheumatic heart disease, systemic lupus erythematosus, Austin-Flint murmur of aortic regurgitation, left atrial sinus, second Large mitral sacral or thrombosis, constrictive pericarditis, Hurler syndrome, patent ductus arteriosus, Lutembacher syndrome, severe mitral regurgitation, severe aortic regurgitation, large ventricular septal defect Hypertensive heart disease, aortic coarctation, dilated cardiomyopathy, anemia heart disease. Hyperthyroidism, third degree atrioventricular block. Diastolic murmur in the apical region caused by other causes.

Third, aortic valve area systolic murmur

Rheumatic aortic valve disease, rheumatic aortic valve stenosis. Aortic atherosclerosis, hypertensive heart disease, aortic stenosis syndrome, congenital bicuspid aortic valve, aortic coarctation, syphilitic aortitis, aortic aneurysm, Ebstein malformation. Severe aortic regurgitation, complete atrioventricular block. Hypertrophic dysfunction of the aortic valve area caused by hyperthyroidism, anemia, carcinoid syndrome, carotid murmur, and other causes.

Fourth, aortic valve area diastolic murmur

Rheumatic aortic valve inflammation, rheumatic aortic regurgitation, syphilitic aortic regurgitation, and infectivity. Endocarditis, rheumatoid heart disease, systemic lupus erythematosus, Marfan syndrome, aortic atherosclerosis, hypertension-induced aortic annulus enlargement, aortic sinus aneurysm rupture, high ventricular septal defect-induced aorta Avalanche prolapse due to valve prolapse and other causes.

Fifth, the third and fourth intercostal systolic murmurs on the left sternal border

Ventricular septal defect, non-pathological systolic murmur in infants, pulmonary stenosis or funnel stenosis, mitral regurgitation, aortic stenosis, aortic coarctation, atrial septal defect, obstructive primary cardiomyopathy, three The cusp is closed, the patent ductus is not closed, and the right ventricle is a right atrium. Six, pulmonary stenosis systolic murmur

Non-pathological pulmonary systolic murmur, rheumatic pulmonary valve disease, rheumatic pulmonary stenosis, infectivity. Endometritis, congenital pulmonary stenosis, pulmonary artery and branch stenosis. Fallot tetralogy, Lutembacner syndrome, idiopathic pulmonary artery dilatation, primary pulmonary hypertension, secondary pulmonary hypertension (Eisemmenger syndrome), rheumatic mitral stenosis, chronic pulmonary heart disease, plateau Sexual heart disease, straight back syndrome, atrial septal defect, patent ductus arteriosus drainage, pregnancy, hyperthyroidism, anemia, atrial heart disease, carotid murmur.

Seven, pulmonary valve area diastolic murmur

Rheumatoid pulmonary arteritis, rheumatic pulmonary valve insufficiency, infective endocarditis, postoperative pulmonary stenosis, relative pulmonary valve regurgitation due to Granam-stell murmur, primary pulmonary hypertension (rheumatic mitral stenosis) , congenital heart disease left-right shunt), congenital pulmonary aneurysm, anemia heart disease, hyperthyroidism, carcinoid syndrome.

Eight, tricuspid systolic murmur

Rheumatic tricuspid valve, rheumatic tricuspid regurgitation. Infective endocarditis, papillary muscle dysfunction, and valve relaxation. Electrical high radiation injury, Ebstein malformation, pulmonary heart disease, rheumatic heart disease, mitral valve disease and pulmonary hypertension caused by right ventricular enlargement, congenital heart disease, a large number of left-right shunt (atrial septal defect, pulmonary venous malformation drainage), Primary pulmonary hypertension.

Nine, tricuspid valve diastolic murmur

Rheumatic tricuspid valve, rheumatic tricuspid stenosis, mold infectivity. Endocarditis, congenital tricuspid stenosis, right atrial stenosis, right ventricular enlargement due to mitral stenosis, massive reflux of tricuspid regurgitation, large left-right shunt of atrial septal defect, anemia of heart disease, Hyperthyroidism, carcinoid syndrome.

X. Continuous murmur at the bottom of the heart

Intravenous camping, patent ductus arteriosus, and primary pulmonary artery septal defect. Pulmonary arteriovenous and thin sinus aneurysms broke the right ventricle (atrial), congenital coronary arteriovenous thin, complete pulmonary venous malformation, tricuspid atresia, internal thoracic artery anastomosis, ventricular septal defect combined with aortic regurgitation , mitral regurgitation combined with aortic regurgitation, aortic regurgitation and stenosis.

XI, other parts of the noise

1 head auscultation: benign head murmur, eyeball murmur; 2 neck auscultation: jugular vein camping sound, subclavian artery murmur. Thyroid murmur, supraclavicular artery murmur; 3 chest and back murmur: pleural adhesion murmur, breast murmur; 4 abdominal vascular murmur: hepatic artery murmur, hepatic vein murmur, murmur of renal artery stenosis, abdominal aorta and its branches The noise generated by the pressure, the noise originating from the abdominal aorta and its branches, the pregnancy murmur, the rib horn vascular murmur; 5 limb auscultation: arteriovenous thin, aneurysm. Hemangioma, aortic regurgitation.

mechanism

Heart murmurs are caused by turbulence due to accelerated blood flow or blood flow disorders, and the formation of turbulent flow fields (vortexes) that cause vibrations in the heart wall or blood vessel walls. Experiments have shown that the flow of any liquid is divided into laminar and turbulent phenomena. Under a certain tube diameter, the velocity of the fluid from laminar flow to turbulent flow is also fixed, which is called "Reymold's critical speed". R = R is the value of ad, and if it is greater than the critical number of 2000, the liquid can change from laminar flow to turbulent flow in the lumen. Laminar flow is silent, and turbulence can produce sound energy. The reasons for the noise are common in:

1 blood flow acceleration: blood flow in the vascular lumen is stratified, the central part of the flow rate is the fastest, the farther away from the central part, the slowest, and the edge is the slowest. The species of living is called laminar flow. If the blood flow rate reaches or exceeds the speed at which the laminar flow becomes turbulent, a turbulent flow field is generated, causing vibrations in the heart wall or the blood vessel wall to cause noise. Such as normal people after exercise, fever, anemia, hyperthyroidism and so on.

2 valve stenosis: due to blood flow through the stenosis caused by turbulence. Organic stenosis, such as mitral stenosis, aortic stenosis, etc., relative stenosis, seen in the ventricular cavity or large vessel aorta or pulmonary artery) enlargement caused by relatively narrow valve mouth, and the valve does not change, this is the majority of clinical murmur The principle of production.

3 valve insufficiency: due to blood flow through the closure of the incomplete valve and reflux to produce turbulence. Insufficient organic closure, such as rheumatic mitral regurgitation, aortic regurgitation. The relative insufficiency is caused by the following factors: the papillary muscles and the chordae tend to move to the sides due to the enlargement of the ventricle, such as dilated cardiomyopathy; the papillary muscles and the femoral cord are insufficient due to the papillary muscle ischemia. Mitral valve prolapse occurs in the maximum ventricle of the ventricle, such as coronary heart disease; due to large vessel expansion, the valve muscle ring also expands, such as hypertension, aortic sclerosis.

4 Abnormal channel: There is an abnormal channel between the heart or the large blood vessels, which is caused by the formation of a turbulent flow. Such as ventricular septal defect, patent ductus arteriosus.

5 biological or broken chord: due to interference with blood flow, the turbulent flow field can cause noise, which may be the principle of some music-like murmur formation, such as endocarditis.

Examine

an examination

Related inspection

Abdominal skin examination abdominal vascular ultrasound examination electrocardiogram abdominal auscultation abdominal beat examination

Serum globulin (G, GL0): serum globulin is a mixture of various proteins, including immunoglobulin veneers and complements with multiple defense functions, various glycoproteins, metal-binding proteins, various lipoproteins, and enzymes. Wait. The content of globulin is generally obtained by subtracting albumin from total protein.

Thyroid stimulating hormone (TSH): Thyroid stimulating hormone is a hormone secreted by the pituitary gland to promote the growth and function of the thyroid gland. It has the function of promoting the proliferation of thyroid follicular epithelial cells and the synthesis and release of thyroid hormone.

Lactate dehydrogenase (LDH, LD): Lactate dehydrogenase is a glycolytic enzyme. Lactate dehydrogenase is present in the cytoplasm of all tissue cells in the body, with a high kidney content.

Serous effusion glucose: serous effusion glucose quantitative refers to the detection of glucose content in the effusion to distinguish between leakage and exudate.

Serous effusion protein: serous effusion protein refers to the detection of protein content in the effusion. The measurement method is the same as the method for measuring protein in blood.

Ultrasound diagnosis of cardiovascular disease: Doppler echocardiography can be used to analyze the trajectory of high-speed motion, blood flow direction, and blood flow properties of heart wall thickness, motion velocity, amplitude, slope, and valve.

Anticardiolipin antibodies (ACA): ACA interferes with phospholipid-dependent coagulation processes and is closely related to thrombosis, thrombocytopenia, and recurrent spontaneous abortion.

Anti-myocardial antibody (AMA): The release of cardiac antigens from myocardial damage stimulates autoantibodies produced by the body, and the binding of these antibodies to the heart can lead to new immune damage.

Lipoprotein a (Lp-a): Lipoprotein a is mainly synthesized in the liver. Its main function is to prevent blood clots from damaging and promote the formation of atherosclerosis. The continuous increase of lipoprotein levels is closely related to angina pectoris, myocardial infarction and cerebral hemorrhage. It is an independent risk factor for coronary heart disease.

Serum selenium (Se): Selenium is mainly a component of glutathione peroxidase in the body and has an antioxidant effect. The physiological function of maintaining heart, brain, liver, muscle and immunity.

Serum zinc (Zn): Zinc is one of the main trace elements in the human body. It is involved in the formation of many coenzymes and plays an important role in growth, mental development and maintenance of immune function.

There are physiological changes in serum zinc levels in normal people:

1 poor sex: women are lower than men;

2 age: children are lower, but the range of change is large;

3 days difference: the highest at 8 o'clock in the afternoon and the lowest at 3 to 9 o'clock in the afternoon;

4 diet: about 20% reduction after 3 hours of eating.

Serum copper (Cu2+, Cu): Copper is one of the essential trace elements in the human body and is an important component of many enzymes. Copper plays an important role in the central nervous system.

Diagnosis

Differential diagnosis

First, apical systolic murmur

(1) Non-organic apical systolic murmur

When the apex of the apical region is heard, the intensity of the heart is increased or the signs of myocarditis are abnormal, and the noise is generally non-organic.

(B) rheumatic mitral regurgitation

The relative incidence of mitral valve involvement (stenosis and regurgitation) in rheumatic valvular heart disease accounts for 95%-100%, while mitral regurgitation alone accounts for only 20%-40%. Most of them have mitral stenosis. Relative mitral regurgitation is more common. Other rare cases have mitral valve prolapse and coronary heart disease. Mitral annulus and subarachnoid calcification, connective tissue disease, scleroderma. Congenital mitral valve stenosis, obstructive hypertrophic cardiomyopathy, endocardial fibroelastosis, left atrial myxoma and Marfan syndrome.

The main sign is the systolic murmur in the apical region, the intensity is often above 3/6, the sound quality is rough, and spread to the midline of the sacral line (previously the valvular lesion is the main), the exhalation is enhanced, and the murmur often covers the first heart sound. The third heart sound can be heard in the swimming, the second heart sound of the pulmonary artery can be broken into the common division, and the left atrium and the left ventricle are enlarged, so the diagnosis of mitral regurgitation can be determined. Early organic mitral regurgitation, only relatively loud systolic murmur, but also late systole, individual or even limited to early contraction murmur. When the severe closure is incomplete, the reverse flow rate may cause relative stenosis of the mitral valve, and the apical region may have low-pitched, short-duration diastolic murmur. If the reverse flow is large, the systolic noise can be weakened or disappeared. Typical cases are usually diagnosed by clinical examination and chest X-ray. Atypical can be performed by echocardiography, suggesting left atrium and left. The ventricle was enlarged, and the valve was incompletely closed by two-dimensional ultrasound. Doppler ultrasound showed systolic turbulence in the left atrial side of the valve.

(three) relative mitral regurgitation

Where left ventricular dilatation and mitral annulus enlargement, resulting in systolic valve mouth not completely closed, known as relative mitral regurgitation, can occur in hypertensive heart disease, anemia heart lake, aortic valve disease, Dilated cardiomyopathy, myocarditis, etc. The systolic murmur in the apical region is mainly differentiated from the systolic mitral murmur due to the presence of the primary disease and the reduction or disappearance of the murmur after the etiological treatment is improved.

(four) mitral valve prolapse

This disease refers to the mitral leaflets on the papillary muscles (mostly posterior, double-leaved, anterior lobes), which is caused by mitral regurgitation in the late ventricular systole to the left atrium. Found in coronary heart disease, rheumatic valvular heart disease, hypertrophic cardiomyopathy, Marfan syndrome, Turmer syndrome, atrial septal defect, nodular arteritis. Trauma and heart valve surgery. There are no clear causes of X cases, which are called idiopathic mitral valve prolapse. Some cases are familial, and the pathological changes of primary mitral valve prolapse are mitral collagen decomposition, and the stents are one-to-one and the associated tissues are partially degraded. Most patients are asymptomatic or mild; some patients have chest pain, fatigue, palpitations, shortness of breath, dizziness or syncope; individual patients have arrhythmia, congestive heart failure, transient cerebral ischemia, and even sudden death.

Typical signs are a mid- and late-stage murmur in the middle or late stage of the apex or the left sternal border. The middle and late stage of contraction and the middle and late murmurs are called "mitral valve prolapse syndrome". The Karayin is mainly caused by the loose or anatomical abnormality of the floating mitral valve or the valve leaf, which is suddenly caused by the tension or the flipping vibration during the systole. The Karayin is characterized by variability and can be present at any one time, and can also be one or more. In a few cases, the intensity and appearance time can be changed with the change of body position. For example, the click sound appears early and more obvious when standing. Therefore, auscultation should be performed in different positions. The systolic murmur is due to the mitral valve prolapse in the left atrium, resulting in mitral regurgitation and blood reflux. Most of them are late systolic murmurs, generally 3/6-4/6 grades, or full systolic murmurs, a few visible high-frequency accompaniment sounds, sitting systolic murmurs can be converted into "geese sounds."

Echocardiography is a valuable diagnostic method, but it cannot replace auscultation, and negative can not discharge mitral valve prolapse. Left ventricular angiography has a definite diagnosis.

(5) rheumatic mitral valve inflammation

This disease is one of the most common manifestations of rheumatic endocarditis. It often has systolic murmur in the apical region, which is a hairy sample. It is caused by mitral annulus rheumatic inflammation and mitral annulus dilatation caused by complicated myocarditis. Caused by incomplete closure, caused by blood reflux. After anti-rheumatic treatment, the noise can often disappear, and a few can develop chronic rheumatic mitral valve disease.

(6) Primary cardiomyopathy

In patients with dilated primary cardiomyopathy, systolic murmurs occur in the apex of the cerebral apex, and the resulting mitral regurgitation is caused by rheumatic mitral regurgitation. The heart murmur of this disease is obvious in heart failure, and the heart murmur is reduced or disappeared after heart failure is improved. Rheumatic mitral regurgitation is the opposite. Echocardiography showed that the whole heart cavity was enlarged; the wall and interventricular septum were thinned; the wall and interventricular septum movement was weakened; the valve opening was small. The above findings have important value in the diagnosis of this disease.

In most patients with hypertrophic (obstructive) cardiomyopathy, a 2/6-3/6 systolic jet murmur can be heard between the 3rd and 4th ribs of the left sternal border, or with tremor. The disease is often associated with mitral regurgitation, and full systolic murmurs appear in the apical region. It must be differentiated from rheumatic aortic valve disease with mitral regurgitation. The systolic murmur of the disease is weakened when the leg is lifted, the murmur is enhanced after the nitroglycerin is contained, and the fourth heart sound is often heard in the apex. Electrocardiograms often have deep and narrow pathological Q waves, which have implications for diagnosis. Echocardiography suggests that the ratio of asymmetrical ventricular septal hypertrophy to left ventricular thickness is 1.3; left ventricular outflow tract stenosis, apical diastolic murmur

(a) mitral stenosis

Mitral stenosis is generally rheumatic. However, about 1/3 to 1/2 of the adult chronic rheumatic heart valve disease has no clear rheumatic fever history.

In rheumatic mitral stenosis, rumbling or thunder-like diastolic middle and late murmurs are heard at the apex of the apex, which are generally progressive, can be adjusted to a lower limit (in the range of 1 to 4 cm in the apical region), and the left lateral position It is clearer at the end of exhalation or after exercise. The mitral diastolic murmur can be reversed due to extreme clockwise movement, and the murmur is most clearly moved to the left iliac crest. The increase in murmur is due to the strong contraction of the cardiac chamber. When the advanced case is enlarged due to the high atrial enlargement, the atrial contractility is weakened, or atrial fibrillation occurs, the progressive type disappears. The heavier the mitral stenosis, the longer the duration of the murmur, which can account for the entire diastolic phase. For example, mitral stenosis secondary to pulmonary artery dilatation, relative pulmonary regurgitation may occur, and diastolic Graham Steell murmurs may be heard in the pulmonary valve area. The murmur may also be transmitted to the apical region, and attention should be paid to the difference. Diastolic murmurs of mitral stenosis can be alleviated or inaudible in the following situations, such as stenosis and mild circulation, unobstructed, hypotension, chest wall hypertrophy, emphysema. Left atrial failure and/or left ventricular failure, rapid atrial fibrillation, paroxysmal tachycardia, pulmonary hypertension, mitral valve extreme sclerosis, thickening, atrophy (funnel type).

Mitral stenosis diastolic murmur, if there is a first heart sound enhancement and mitral valve open slap sound, can be diagnosed as organic mitral stenosis, apical diastolic tremor must be an organic mitral valve Narrow signs. The disease is more common in women, patients often have mitral valve face, labor dyspnea or repeated hemoptysis history, or history of acute pulmonary edema, more complicated atrial fibrillation. X-ray examination is more reliable in the diagnosis of simple mitral stenosis. Echocardiography is of great value.

Dumb mitral stenosis. In recent years, due to the gradual popularization of echocardiography, two-dimensional echocardiography has considerable specificity in the diagnosis of mitral stenosis. The diagnostic coincidence rate is 100%. There are several groups of dozens of reports in China. Some literatures refer to rheumatic hearts. 6%-8% of valvular diseases are dumb, which is not uncommon. The exact mechanism of dumb mitral stenosis is not known and may be related to the following reasons:

1 because the stenosis is still light and the circulation is not hindered;

2 due to left atrial failure or left ventricular diastolic pressure, resulting in a decrease in interventricular pressure difference, not enough to produce noise or noise is not obvious;

3 mitral stenosis also has atrial septal defect, due to left atrial blood to the right atrial shunt and low left atrial pressure, which reduces the pressure difference between the left atrium and the right atrium, resulting in no obvious noise;

4 pre-systolic murmur, in the event of atrial fibrillation, especially when the ventricular rate is faster, the noise can be weakened or disappeared;

5 concurrent with paroxysmal supraventricular tachycardia, because the heart rate is too fast, the noise can not be obvious; 5 mitral stenosis complicated with pulmonary hypertension, due to pulmonary hypertension, affecting the pulmonary venous return to the left atrium, due to decreased left atrial blood volume, The pressure is reduced, causing the pressure difference in the chamber to decrease, so the noise is not obvious or can not be heard;

1 In the late stage of mitral stenosis, the mitral valve was extremely hardened and atrophied, and the mitral valve could not move. When the funnel-shaped pathological changes were made, the murmur was not obvious.

Because the dumb mitral stenosis can not hear the murmur, it has been misdiagnosed as coronary heart disease, dilated cardiomyopathy, pulmonary heart disease, congenital heart disease and so on. Dummy mitral stenosis Although auscultation is difficult to affirm, left atrial enlargement, right ventricular enlargement, and even left atrial failure still exist. When clinical findings are found, mitral valve opening sound, apical first heart sound hyperthyroidism and pulmonary valve second When the heart sounds hyperthyroidism, an electrocardiogram should be performed to indicate pulmonary P wave and right ventricular hypertrophy. X-ray examination showed enlargement of the left atrium and pulmonary hypertension. Echocardiography can confirm the diagnosis.

(two) aortic valve insufficiency

Significant aortic regurgitation When the ventricle is dilated, a large amount of blood flows from the aorta to the left ventricle, urging the anterior mitral valvular lobes, causing relative mitral stenosis, and hearing the low-pitched rumbling in the apical region. The diastolic murmur, enhanced before the systole, is called the Austin Flint murmur, which is a functional murmur that occurs only in the case of left ventricular failure and reappears when the compensatory function is restored. In recent years, the study suggests that the cause of this pathway is not functional mitral stenosis, overlap of aortic regurgitation jet and mitral flow of human blood flow, diastolic mitral regurgitation or mitral leaf tremor. The aortic regurgitation jet impinges on the left ventricular endocardium to produce a low-grade diastolic murmur. The identification of Freund's murmur and organic mitral stenosis is more difficult. The following conditions contribute to the diagnosis of Freund's noise:

1 Freund's murmur is softer, shorter, and not accompanied by tremors.

2 without mitral valve open slap sound and apex first heart sound hyperthyroidism.

The 3X line and the ECG did not show an increase in the left atrium, but a significant increase in the right ventricle.

4 echocardiography is the most valuable for the identification of the two.

(three) left atrium liquid tumor

Because the pedicled tumor blocks the mitral valve mouth and produces a rumbling-like diastolic murmur similar to the mitral stenosis, mostly in the middle of diastole or before systole, confined to the apical region, and more than the first heart sound hyperthyroidism. The following symptoms suggest the possibility of left atrial grade liquid tumor: 1 paroxysmal dyspnea, palpitations, hemoptysis, dizziness, acute cardiogenic cerebral ischemic syndrome and other symptoms, not caused by physical activity;

2 small arterial embolism, no evidence of bacterial endocarditis;

3 murmurs are related to body position, often in standing position. Appears when sitting, disappears when lying down;

4 progressive heart failure, strong application. Treatment with ethylbenzene cannot be improved;

5X line examination of left atrial enlargement or deformity;

5 Echocardiography shows an abnormally moving reflex beam in the left atrium.

Third, aortic valve area systolic murmur

The systolic murmur of the aortic valve area is usually organic, mainly aortic stenosis. Most of the organic systolic murmurs are accompanied by systolic tremor.

(a) rheumatic aortic stenosis

The relative incidence of rheumatic heart valve involvement, aortic valve involvement (stenosis and regurgitation) accounted for 30%-50%, simple aortic stenosis syncope and angina pectoris as prominent symptoms, syncope may lead to sudden death. The jet-type systolic murmur of the stenosis of the valve is the loudest in the second intercostal space on the right side of the sternum, and the acoustic sound is bright, accompanied by systolic tremor, which radiates upward to the right neck. When the aorta is extremely narrow, the noise appears to be short and soft.

If there is no severe stenosis, the systolic jet additional sound can be heard, and the second heart sound in the aortic valve area often weakens and disappears (indicating that the severe calcification of the valve sometimes has a single heart sound or a reverse split (due to the partial delay of the second heart sound aortic valve component, It becomes part of the overlap with the pulmonary valve or after the human electrocardiogram shows left ventricular hypertrophy. X-ray examination, echocardiography / catheter examination are helpful for diagnosis.

The diagnosis of aortic stenosis and pulmonary stenosis: 1 murmur of pulmonary stenosis is often limited to the pulmonary valve area; 2 murmur of pulmonary stenosis begins earlier than aortic stenosis (0.09-0.11 seconds after Q wave, then The time of the Q wave is 0.12-0.14 sec); 3 The duration of murmur of pulmonary stenosis is longer than that of aortic stenosis, because the pulmonary valve is closed later than the aortic valve; 4 The murmur of pulmonary stenosis is weakened during inhalation. Increased qi time (because of inhalation, more blood flow, right heart pressure, pulmonary valve in semi-open state, right ventricular contraction, pulmonary valve opening amplitude is small, so the murmur of aortic stenosis is less Affected by breathing.

(two) hypertrophic (obstructive) primary cardiomyopathy

The disease is also called asymmetry of the heart or idiopathic hypertrophic aortic stenosis, the cause is unknown. The pathological feature is that the ventricular muscle is unevenly hypertrophied, mainly involving the left ventricle, ventricular septum, and may also involve the right ventricle. Left ventricular volume is normal or reduced, while left ventricular diastolic pressure is often increased, and pressure gradients appear before and after the outflow tract. Syncope and chest pain (which can be an episode of angina pectoris) are the most characteristic symptoms that occur before the age of 30. Abnormal carotid pulsation is the most attractive first sign, which is characterized by a rapid and short rise of the carotid artery, which is different from normal people. Often there is a apex apex in the apical area. The heart turbidity circle expands to the sides. Auscultation in the 3rd and 4th intercostals of the left sternal border can be heard and 3/6 systolic jet murmur, which may be accompanied by tremor. After inhaling isoamyl nitrite, the systolic murmur is enhanced. The typical ECG changes to left ventricular hypertrophy and deep and abnormal Q waves, which has a diagnostic significance. Echocardiography showed asymmetric cardiac hypertrophy with or without left ventricular outflow tract obstruction, and MRI showed diagnostic value.

Fourth, the third and fourth ribs of the left sternal border ask systolic murmur

(1) Empty space defect

Ventricular septal defects are often caused by dysplasia or dysplasia of the membranous septum. The location of the defect is higher. Low ventricular septal defect is less common due to dysplasia of the muscular septum. Ventricular septal defects can be single, multiple, or sieve-like. The ventricular septal defect is most common in the defect of the membrane. Others are chair defects, atrioventricular pathway defects, muscle defects and Gerbode type defects. The severity of ventricular septal defects can be divided into two clinical categories:

1 small to moderate defect, pulmonary blood flow and pressure and pulmonary vascular resistance normal or near normal, small defect, small flow rate, equivalent to the previous Roger disease, generally asymptomatic;

2 severe defects, pulmonary artery pressure and pulmonary vascular resistance increased, have not reached the level of body arteries, unless heart failure occurs, generally do not appear;

3 Eisenmenger syndrome, the diameter of the defect is > 2cm, and the shunt direction is opposite, and the hair strand appears.

Small or even moderate ventricular septal defects have no hair loss and are often asymptomatic. Common symptoms when the flow rate is large are dyspnea, recurrent bronchitis and developmental stagnation. Infants and young children may develop left heart failure and die more than two years old. The 3rd and 4th intercostals of the left sternal border can be heard with a loud, rough, full-systolic, refractory murmur, often covering the first heart and the second heart, accompanied by tremors. When the defect is large, due to the large left-to-right flow rate, the third heart sound or the middle diastolic rumbling noise can be heard in the apical region due to the increase and enlargement of the left ventricular flow. The appearance of the noise indicates that the pulmonary blood flow exceeds the body blood flow. Times. If the direction of the split is reversed, the noise disappears. However, it should be noted that many congenital mitral valve malformations and ventricular septal defects coexist, which can cause the same mid-diastolic murmur. If there is pulmonary hypertension, the second heart sound can be enhanced and split. Small defect X-ray examination, ECG and echocardiographic changes may not be obvious, and moderate or above defects have obvious corresponding changes. Cardiac catheterization and selective cardiovascular angiography are important. Selective cardiovascular imaging films have great diagnostic value.

(B) pulmonary stenosis or funnel stenosis

The murmur of pulmonary stenosis or funnel stenosis is similar to that of Roger's disease, and it is difficult to identify clinically. The murmur of the ventricular septal defect is most loud in the posterior midline of the sternum or slightly to the left, while the murmur of the pulmonary stenosis is in the pulmonary valve area or slightly below. The narrow murmur of the funnel is the loudest in the 3rd and 4th ribs of the left sternal border, but the murmur of the ventricular septal defect is often the full systole and covers the second heart sound; the murmur of the pulmonary stenosis is the mid-systolic, and the second is the pulmonary valve. . The sound has not been covered by noise. If the pulmonary valve is severely stenotic, the component of the pulmonary heart valve of the second heart sound is weakened or disappeared. Mild pulmonary stenosis can produce additional sounds, and when the middle is narrow, the second heart sounds split and widen. When the ventricular septal defect is large, there may be a middle diastolic murmur in the mitral valve area. When the blood flow of the pulmonary valve increases, the pulmonary valve area may be swollen. X-ray film helps identify one. Pulmonary stenosis with right ventricular enlargement, X-ray examination of rare lung texture, lung field abnormally clear; ventricular septal defect with right ventricular enlargement increased hilar shadow.

(3) Obstructive primary cardiomyopathy

The disease is often an autosomal dominant genetic disease, and occasionally acquired pathological features of ventricular muscle uneven hypertrophy, cardiac hypertrophy mainly involving the left ventricle, ventricular septum, may also involve the right ventricle, occasionally concentric hypertrophy. The disease has also been called idiopathic hypertrophic aortic stenosis, primary hypertrophic obstructive cardiomyopathy, and idiopathic cardiac hypertrophy.

Syncope and chest pain (which can be an episode of angina) are the most characteristic symptoms of the disease and occur more than 30 years old. Abnormal carotid pulsation is an attractive sign. In the front area, the apex of the apex is pulsating, and the left and right sides of the heart are enlarged, and some cases are only enlarged to the left side.

A 2/6-3/6 systolic jet murmur can be heard between the 3rd and 4th ribs of the left sternal border, or accompanied by tremor, and the fourth heart sound can often be heard. ECG shows left ventricular hypertrophy and deep abnormal Q waves, suggesting a diagnostic significance. The heart sound map can record the mid- and late-stage high-frequency diamonds mixed with isoamyl nitrite, and the systolic murmur amplitude increases, and the heart rate increases; the amplitude of the squat position or the injection of Putilol decreases. Echocardiography can show asymmetric cardiac hypertrophy or with left ventricular outflow obstruction.

(four) atrial septal defect

The large atrial septal defect has a large flow rate, and the murmur is similar to the ventricular septal defect. The permanent complication is also a rough systolic murmur at the left sternal border, accompanied by tremor, which is clinically difficult to distinguish from a large ventricular septal defect (see This section is below).

Five, aortic valve area diastolic murmur

(a) rheumatic aortic valve insufficiency

In the second intercostal space on the right sternal border, but more common in the third and fourth intercostals of the left sternal border (second aortic valve auscultation area), and high-pitched puncture-like diastolic conduction to the fifth intercostal space and apex, Mid-term or full-time declining murmur. It is easy to hear when standing up in a lying position. If the noise is not obvious, the patient's upper body can be tilted forward, and the auscultation is easier to hear when the breath is held at the end of deep exhalation. Aortic valve double lesion is a typical lesion of rheumatism. The apex may have a diastolic murmur (Austin Flin murmur). Obvious aortic regurgitation often has water impulses, arterial sounds, and microvascular pulsations. Pulse pressure and Du's double accent are important indicators for measuring the severity of aortic regurgitation and the magnitude of adverse flow.

The patients were mostly between 10 and 40 years old and had a history of rheumatic fever. Most of them had mitral stenosis or aortic stenosis. X-ray examination showed enlargement of the left ventricle, ascending aorta dilation, and prolonged flexion as a "shoe heart" or "aortic heart". Echocardiography: M-type showed aortic valve opening and closing speed increased, aortic valve diastolic phase was divided into second and third line spacing > lmm, diastolic mitral anterior lobe with fine tremor; two-dimensional ultrasound showed that the aortic valve could not be closed Closed; Doppler ultrasound showed diastolic turbulence under the aortic valve.

The differential diagnosis of rheumatic and arteriosclerotic aortic regurgitation has important reference value for medical history and age of onset. The onset of disease between 10 and 40 years old is generally rheumatic; the onset of disease is atherosclerotic in those over 50 years old. Rheumatic aortic regurgitation often has no aortic dilation and often involves mitral valve disease. Syphilis and arteriosclerotic aortic regurgitation often cause aortic dilation, but there is no sign of mitral valvular disease such as left atrial enlargement. If the patient has a history of sexually transmitted diseases, Hua and Kang's reaction are positive, then the syphilis is undoubted. However, a negative reaction cannot exclude syphilitic aortitis.

(B) syphilitic aortic valve insufficiency

The clinical manifestations of syphilitic aortic regurgitation are roughly the same as those of rheumatic patients, sometimes difficult to identify. The disease occurs mostly after middle age, the patient has a history of sexually transmitted diseases, most of the Hua and Kang's reactions are positive, and the diastolic murmur is transmitted to the right edge of the sternum, such as the systolic murmur of the aortic valve area, the tone is low, and there is no Signs of stenosis. X-ray shows aortic widening, and the degree of left ventricular enlargement is more obvious than rheumatic aortic regurgitation (due to rheumatism combined with different degrees of aortic stenosis, reducing reflux blood to human syphilis complicated with coronary artery There are more stenosis in the mouth, and angina pectoris is more common. In the case of syphilis, heart failure often deteriorates rapidly.

(3) Marfan syndrome

It is rare in clinical practice and is caused by congenital general connective tissue abnormalities, mostly hereditary. have:

1 skeletal deformities, including slender limbs, spider-like fingers, funnel chest, straight back, high-rise, over-extension of joints, etc.;

2 eye symptoms, especially lens ectopic;

3 cardiovascular signs, can cause changes in aortic dilation, aneurysm formation and aortic regurgitation. The cardiovascular disease of this syndrome can be based on family history and age of onset. Diagnosis of skeletal malformations and eye symptoms.

Six, pulmonary stenosis systolic murmur

(a) non-pathological pulmonary systolic murmur

Non-pathological pulmonary systolic murmurs are common in children and young adults, and a low-key, soft, squeak-like murmur is heard in the 2nd (or 3rd) intercostal space on the left sternal border, with a loudness of 2/6, without There is tremor that begins in the early stages of contraction and does not cover the first heart sound. It is clear when inhaling in the supine position. Often accompanied by a second heart sound enhancement or division in the pulmonary valve area. The mechanism is due to the expansion of the pulmonary artery when blood enters the pulmonary artery, and the turbulence of blood in the pulmonary artery. The heart does not increase, the electrocardiogram and echocardiogram are normal. This murmur has no clinical significance, and some people call it "physiological" systolic murmur.

(two) straight back syndrome

Straight back syndrome is not uncommon. Because the congenital thoracic vertebrae straightens and the normal physiological back bend disappears, the heart is squeezed into the narrow thoracic cavity. The sternum directly oppresses the right ventricular outflow tract, and the blood flow forms turbulence in the large blood vessels at the bottom of the heart. Loud systolic jet murmurs can be heard at the bottom of the heart. Usually, the pulmonary valve area is the loudest, with the second heart sound hyperthyroidism and division. It is often misdiagnosed as pulmonary stenosis, atrial septal defect, and primary pulmonary artery dilatation. The diagnosis of straight back syndrome lies in the recognition of its characteristics. If there are suspicious cases, the paralyzed patients sit straight and make X-ray chest positive lateral radiographs. Except that the thoracic vertebrae are straightened, the rest are normal, and the heart and large blood vessels are not abnormal. A diagnosis can be made.

(three) atrial septal defect

Atrial septal defect is the most common congenital heart disease, accounting for the first place in 1085 congenital heart disease, and women are 2-4 times more likely than men. Secondary hole defects are the most common, accounting for about 90% of all types of atrial septal defects. The tone was softer or rougher in the second intercostal space on the left sternal border. The loudness was in the 2/6-3/6-stage jet systolic murmur, which was enhanced during inhalation. The murmur was caused by an increase in pulmonary blood flow.

Generally, there is no tremor, and the noise is irregular diamond shape, and the initial part is often accompanied by a contraction jet sound. The second heart sound splits and widens, and the other auscultation characteristics of the disease are fixed at the time of exhalation. When combined with pulmonary hypertension and relative pulmonary regurgitation, the pulmonary valve area may have diastolic murmur; when the flow rate is large, diastolic murmurs may be heard in the tricuspid region and apical region; for example, the pulmonary valve region has tremor, and;Lutembacher X95%

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5 The intensity of the noise is proportional to the average speed of ventricular ejection;

5 When the ventricular ejection begins, the aorta or pulmonary artery expands, so most jet murmurs are often accompanied by contraction jets.

2. Systolic reflux murmur

"The blood flow is caused by the rapid reflux of the ventricular systole from a high pressure chamber to a low pressure chamber. See:

1 when the atrioventricular valve is incompletely closed;

2 ventricular septal defect or perforation;

3 main pulmonary artery communication with pulmonary hypertension.

Characteristics of systolic reflux murmur:

1 time limit occupies the entire systolic period, which is a full systolic murmur;

2 pitches are high;

3 forms are mostly consistent and may also have variations;

4 intensity is proportional to the reverse flow rate (except for ventricular septal defect);

5 conduction is more extensive.

3. Diastolic filling murmur

Due to the narrowing of the atrioventricular valve, blood flow occurs through the narrow atrioventricular valve. Its characteristics:

1 appeared earlier, mostly in the early stage of diastole;

2 noise reduction type;

3 pitch is high, the loudness is low, and it is sighing;

4 is the clearest between the 2J or 4 ribs on the left sternal border;

5 without tremor;

5 The second sound of the pulmonary valve is obviously advancing and slack.

4. Continuous murmur

The murmur is a continuous murmur between the systolic and diastolic phases without interruption. The murmur has an increasing systolic phase and a diminished diastolic phase, so that a rhomboid murmur with a second heart sound as a magnolia is formed. Continuous murmurs must be distinguished from recurrent contractile diastolic two-stage murmurs, which often have a second heart sound between the two-stage murmurs. Its noise is seen in:

1 There is a shunt between the blood vessels or the heart chamber. Since the aortic pressure is higher in the systolic or diastolic phase than in the blood vessels or the heart, the shunt flows continuously in the systolic and diastolic phases, thus producing Continuous jets, such as arterial catheters that are not heard;

2 blood flow through extremely narrow blood vessels; 3 blood flow rate increases through normal or dilated blood vessels, also produces continuous murmurs, such as jugular vein camp sounds. The continuous murmur is very loud, just like the sound of the machine running, and it can also be low-light and campfire.

5. Dual-stage murmur

Also known as "returning murmur", it refers to the systolic and diastolic murmurs coexisting, but the two can be clearly separated. Can be seen in syphilitic aortic regurgitation (systolic murmur is due to ascending aortic wall destruction, dilatation and intimal smoothness), Valsalva tumor destruction, rheumatic aortic regurgitation and stenosis, Coronary artery and coronary venous fistula, intrathoracic arteriovenous fistula, pulmonary valve insufficiency and stenosis.

6. Effects of body position, breathing, exercise and drugs on noise

Position, breathing, exercise, and medication can augment or attenuate certain noises and contribute to the diagnosis of the lesion.

(1) Position: Changing the position can aggravate or attenuate some heart sounds or murmurs. For example, when the second heart sound splits in the supine position, the third heart sound is more obvious in the left lateral position. The diastolic murmur of aortic regurgitation is more audible when the upper body is slightly tilted forward and the end of deep breath is at the end of the breath; the diastolic murmur of pulmonary regurgitation is more clearly in the supine position.

(2) Breathing: Breathing can change the blood output of the left and right ventricles and the position of the heart, and affect the intensity of the noise. When inhaling deeply, the pressure in the thoracic cavity decreases, the blood volume in the venous return increases, and the blood volume in the pulmonary circulation increases. Therefore, the right heart discharge increases correspondingly to the left heart, and the heart shifts along the long axis in the deep inhalation, resulting in the tricuspid The flap is closer to the murmur enhancement of the insufficiency of the insufficiency; in the case of deep exhalation, the opposite is true, and the mitral regurgitation and stenosis as well as the aortic stenosis and dysfunction of the ablation are enhanced. In the second aspect of Valsalva's action, because the obstruction hinders venous return to the heart, the left heart discharge is reduced, and almost all the murmurs are alleviated, while the murmur of hypertrophic obstructive cardiomyopathy is enhanced, and the murmur originating from the right heart may be temporarily Sexual enhancement, the murmur originating from the left heart gradually increased in the later period.

(3) Exercise: short-term exercise, such as long-length fists, quick squat test, etc.) can increase heart rate, increase circulation flow rate and flow rate, and enhance most organic systolic murmurs. Exercise increases the blood volume of the pulmonary venous return to the left atrium, which can increase the murmur caused by mitral stenosis. For example, the rumbling diastolic dysplasia of the mitral stenosis is enhanced after the activity, and the vein camp sound of the neck disappears. .

(4) drugs: changes in vascular resistance, blood volume and blood flow velocity through drug tests can affect the intensity of noise. Commonly used drugs are dilated blood vessels and vasoconstrictor drugs, such as isoamyl nitrite enhances jet murmur; while norepinephrine reduces it. The latter can enhance the murmur of mitral regurgitation, aortic regurgitation, and ventricular septal defect. These methods do not necessarily produce typical expected results, and decisions cannot be made solely on this basis.

Fourth, other cardiac signs

When diagnosing heart murmur, the heart disease changes should be observed at the same time to improve the diagnostic value of auscultation, such as apical period apical rumbling murmur, and the presence of first heart sound enhancement and mitral open slap sound, it is definitely Qualitary mitral stenosis. If there is a loud and rough noise, and the heart does not increase or slightly increase, it is almost caused by valve damage or shunting inside and outside the heart. If there are tachycardia, heart sound hyperthyroidism, pulse pressure increase, pulse pulsation and other high power cycle performance, the noise is mostly functional. The murmur that occurs when the heart is significantly enlarged, in addition to organic murmurs, should also consider functional murmurs.

Five, equipment inspection

X-ray films, electrocardiograms, and heart sound maps should be performed when the nature, cause, and location of the heart murmur are not clear. Echocardiography is the preferred instrumentation method. Ultrasound Doppler flow map can measure blood flow velocity and blood flow state; determine valvular stenosis, reflux and intracardiac shunt, and can quantitatively analyze shunt and reverse flow; calculate cardiac output and other functions; The way of encoding is displayed on the screen. MRI can replace invasive cardiovascular angiography.

Serum globulin (G, GL0) - serum globulin is a mixture of various proteins, including immunoglobulin veneers and complements with multiple defense functions, various glycoproteins, metal-binding proteins, various lipoproteins, and enzymes. Classes, etc. The content of globulin is generally obtained by subtracting albumin from total protein.

Thyroid Stimulating Hormone (TSH) -- Thyroid stimulating hormone is a hormone secreted by the pituitary gland to promote the growth and function of the thyroid gland. It promotes the proliferation of thyroid follicular epithelial cells and the synthesis and release of thyroid hormone.

Lactate dehydrogenase (LDH, LD) -- Lactate dehydrogenase is a glycolytic enzyme. Lactate dehydrogenase is present in the cytoplasm of all tissue cells in the body, with a high kidney content.

Serous effusion glucose - serous effusion glucose quantification refers to the detection of glucose content in the effusion to distinguish between leakage and exudate.

Serous effusion protein - serous effusion protein refers to the detection of protein content in the effusion. The measurement method is the same as the method for measuring protein in blood.

Ultrasound diagnosis of cardiovascular disease - Doppler echocardiography can be used to analyze the trajectory of high-speed motion, blood flow direction, and blood flow properties of heart wall thickness, velocity, amplitude, slope, and valve.

Anticardiolipin antibodies (ACA) -- ACA can interfere with phospholipid-dependent coagulation processes and is closely related to thrombosis, thrombocytopenia, and recurrent spontaneous abortion.

Anti-Myocardial Antibody (AMA) -- The release of cardiomyocytes from myocardial damage stimulates autoantibodies produced by the body. These antibodies bind to the heart and can cause new immune damage.

Lipoprotein a (Lp-a) -- Lipoprotein a is mainly synthesized in the liver. Its main function is to prevent blood clots from damaging and promote atherosclerosis. The continuous increase of lipoprotein levels is closely related to angina pectoris, myocardial infarction and cerebral hemorrhage. It is an independent risk factor for coronary heart disease.

Serum selenium (Se) -- Selenium is mainly a component of glutathione peroxidase in the body and has an antioxidant effect. The physiological function of maintaining heart, brain, liver, muscle and immunity.

Serum zinc (Zn)-Zinc is one of the main trace elements in the human body. It is involved in the formation of many coenzymes and plays an important role in growth, mental development and maintenance of immune function.