Home Dental treatment The right border of relative dullness of the heart. Right border of relative cardiac dullness Right border

Dental treatment

The right border of relative dullness of the heart. Right border of relative cardiac dullness Right border

1st method. Observing the basic rules of topographic percussion, the finger-pessimeter is installed vertically in the 2nd intercostal space at the level of the right midclavicular line and percussed towards the sternum from a clear sound until a dull tone appears. Using the same technique, percussion is performed along the III-IV intercostal spaces.

2nd method. Since the position of the boundaries of cardiac dullness is influenced by the height of the diaphragm, the upper limit of hepatic dullness is first found. The pessimeter finger is installed horizontally in the intercostal space and percussion is carried out from top to bottom along the intercostal spaces along the right parasternal (midclavicular) line. The transition of the percussion sound from clear to dull corresponds to the desired border of the liver (normally on the 5th rib). Then the pessimeter finger is moved one intercostal space higher (in the 4th intercostal space), placed parallel to the identified right border of the heart (vertically) and percussion is continued in the medial direction. After this, percussion is performed along the III-II intercostal spaces.

Shift of relative cardiac dullness to the right:

Cardiac pathology – hypertrophy and dilatation of the right ventricle and atrium;

Extracardiac pathology – pathologically high position of the diaphragm, left-sided hydro- or pneumothorax, right-sided obstructive atelectasis.

Left border of relative cardiac dullness. Before percussion, the apical impulse is palpated, which is normally located in the IV-V intercostal space.

Observing the basic rules of topographic percussion, a finger-pessimeter is installed vertically in the IV-V intercostal space at the level of the left anterior axillary line and percussed towards the sternum from a clear sound until a dull tone appears. Using the same technique, percussion is then performed along the IV-III-II intercostal spaces.

Shift of relative cardiac dullness to the left:

Cardiac pathology – hypertrophy and dilatation of the left ventricle and atrium, right ventricle (in this case, the left ventricle is pushed to the left by the enlarged right one);

Extracardiac pathology – pathologically high position of the diaphragm, right-sided hydro- or pneumothorax, left-sided obstructive atelectasis.

Increase in relative cardiac dullness in both directions observed with diffuse damage to the heart muscle (myocarditis, dilated cardiomyopathy).

Boundaries of relative cardiac dullness and transverse size of the heart

Border	Child's age
Up to 2 years	2-7 years	7-12 years	Over 12 years old
Right	Right parasternal line	Inward to the right parasternal line	Midway between the right parasternal and right sternal lines	In the middle between the right parasternal and right sternal lines, closer to the latter, hereinafter referred to as the right sternal line
Upper	II rib	2nd intercostal space	III rib	III rib or 3rd intercostal space
left	2 cm outward from the left midclavicular line	1 cm outward from the left midclavicular line	0.5 cm lateral to the left midclavicular line	On the left midclavicular line or 0.5 cm medially from it
Transverse size	6-9 cm	8-12 cm	9-14 cm	9-14 cm

Limits of absolute cardiac dullness. The determination method is almost similar to the described method for establishing the boundaries of relative cardiac dullness. The difference is as follows: after establishing a dull percussion sound along the three boundaries of relative cardiac dullness, it is necessary to continue percussion until a duller sound is identified - this is the boundary of absolute cardiac dullness of the heart, where it is not covered by pulmonary tissue.

2. Absolute cardiac dullness. To determine the boundaries of absolute cardiac dullness, the quietest percussion is used.

Right border absolute cardiac dullness. The pessimeter finger is placed vertically on the already defined right border of relative cardiac dullness in the 4th intercostal space and moved medially until a dull percussion tone appears. Normally, the right border of absolute cardiac dullness is located along the left edge of the sternum.

The left border of absolute cardiac dullness. The pessimeter finger is vertically installed on the already defined left border of relative cardiac dullness in the 5th intercostal space and moved in the medial direction (towards the sternum) until a dull percussion tone appears. Normally, the left border of absolute cardiac dullness is located 1-2 cm inward from the left border of relative cardiac dullness.

The upper limit of absolute cardiac dullness. The pessimeter finger is installed horizontally at the left edge of the sternum in the second intercostal space and percussed downwards until a dull percussion tone appears. Normally, the upper limit of absolute cardiac dullness is located at the level of the fourth rib.

Reducing the limits of absolute cardiac dullness occurs in extracardiac pathologies - pulmonary emphysema, bronchial asthma attack, pneumothorax, pneumopericardium, low diaphragm.

Increasing the limits of absolute cardiac dullness occurs when:

Cardiac pathology – hypertrophy and dilatation of the right ventricle, exudative pericarditis;

Extracardiac pathology - pathologically high standing of the diaphragm, diffuse pneumosclerosis (shrinkage of the lungs), with left- or right-sided pleurisy, obstructive atelectasis, tumors of the posterior mediastinum (approximation of the heart to the anterior chest wall).

Boundaries of absolute cardiac dullness and transverse size of the heart

3.Vascular bundle, which is formed by the aorta and pulmonary artery on one side, the superior vena cava on the other, normally does not extend beyond the sternum. Its boundaries are determined in the second intercostal space sequentially to the right and left from the midclavicular line to the sternum until a dull percussion sound appears. Normal width vascular bundle 5-6 cm.

Displacement of the boundaries of the vascular bundle outward is noted when the aorta expands or lengthens.

4. Transverse size of the heart - this is the sum of the distances from the middle of the sternum to the right border of the heart (up to 1.5 years is determined by the 3rd, after 1.5 years - by the 4th intercostal spaces) and from the middle of the sternum to the left border of the heart (similarly depending on age by 4th and 5th intercostal spaces).

Boundaries of relative cardiac dullness with the child’s age relatively decrease, and the transverse size of the heart increases.

Auscultation

	Heart auscultation sequence
The order of listening to points	Listening place	The area of the heart from which sound phenomena are conducted to a given listening location
First (I)	Apex area	Mitral valve
Second (II)	Second intercostal space to the right of the sternum	Aortic valves
Third (III)	Second intercostal space to the left of the sternum	Pulmonary valves
Fourth (IV)	Place of attachment of the xiphoid process to the sternum, slightly to the right	Tricuspid valve
Fifth (V = Botkin-Erb point*)	Place of attachment of the III-IV left ribs to the edge of the sternum	Valves, mitral and aorta

Normally, sounds I and II are heard in all five places.

First tone is the sum of sound phenomena caused by the following components:

- valvular - vibrations when closing the bicuspid and tricuspid valves, as well as small matter has the opening of the aortic and pulmonary artery valves;

Muscular - contraction of the ventricular muscles;

Vascular - vibrations of the walls of the aorta and pulmonary artery;

Atrial - tension of the atrium muscles.

At the core II tones lies valve component- closure and tension of the semilunar valves of the aorta and pulmonary artery. Of lesser importance are the opening of the atrioventricular valves, vibration of the aortic walls and fluctuations in blood flow.

So I tone occurs at the beginning of ventricular contraction - systole, and is called systolic, second- at the beginning of the filling of the ventricles with blood - diastole, and is called diastolic .

More than half of the children after II tones, i.e. at the beginning of diastole, a quiet and short sound is heard III tone. The reason for its occurrence is stretching muscle wall ventricles when blood enters them. III The tone is best heard in adolescents in a horizontal position in the fifth listening position. In a vertical position it disappears.

In children, more often athletes, a weak sound is sometimes heard IV tone- atrial, associated with contraction of the atria.

The sound of tones in children depends on age.

During the first 2-3 days of the child’s life, in the first place of listening, tone II slightly predominates (i.e., stronger) over I, then these tones level out (become equal in sound strength). From 2-3 months the chest period and throughout life, the first tone becomes stronger than the second.

You can distinguish these tones by several characteristics:

1) from the 2-3rd month of life, the just indicated sign is a significant indicator - I tone is stronger than II;

2) the pause between tones is of no small importance: the duration of systole between I and II tones are shorter, rather than the duration of diastole between the second sound and the subsequent I sound;

3) with weakened heart sounds, tachycardia, the above signs are uninformative. In this case, it is possible to palpate the apex of the heart simultaneously with auscultation - apical impulse matches with I tone- or (at a low pulse rate) you can simultaneously palpate the pulse beat on the carotid artery - it also coincides with the first sound.

In second and third listening places, those. based on the heart, during the 1st year of life, tone I is stronger than tone II. Then these tones are equalized in volume. In the 3rd year of life, the sound of tones changes - tone II prevails over tone I throughout life.

The advantage of sounding the first tone over the second in the chest period is due to low blood pressure and a relatively large lumen of the vessels. Sometimes in children, instead of one tone (I or II), two short tones can be heard. In this case, we are talking about a bifurcation or splitting of the tone.

bifurcation This division of tone is called when there is a short but clearly audible pause between these short tones.

Splitting This is called a variant of dividing a tone when it is heard unclean, seemingly in two parts, but the pause between them is not audible.

The causes of split heart sounds are non-simultaneous contraction of the right and left ventricles or asynchronous closure of the valves.

So, when auscultating the heart, it is necessary to find out presence, characteristics of tones I and II (at 5 points - normally they are clear and rhythmic), distinguish one fromd other, set the intensity of their sound, if available - splitting And bifurcation, as well as possible noise .

Semiotics of disorders determined by auscultation.

Changes in heart sounds

Weakening (muffled) heart sounds at healthy child May be at excessive pressure with the bell of the stethoscope on the chest. Muffledness of extracardiac origin is caused by exhaustion and obesity of the child, edema of the chest wall and emphysema.

With congenital and acquired heart defects, exudative pericarditis and myocarditis, the tones will be muffled due to impaired cardiac activity.

Has great diagnostic value weakening of the first tone at the apex, which is one of the main signs of mitral valve insufficiency (with this defect of both the mitral and other valves, the leaflets are not able to close completely - the sound during auscultation will be quieter). Likewise muffled second tone over the aorta heard in case of aortic valve insufficiency.

Weakening of the second tone over the aorta occurs with stenosis of the aortic valves. Attention! Weakening is possible only with significant calcification and decreased mobility of the valves aortic valve. With this deficiency, due to the aortic component, a weakening of the first sound at the apex is sometimes heard.

There may be weakening I tone at the top with mitral valve stenosis and with decreased mobility of the leaflets.

Increased (emphasis) heart sounds - also frequent auscultatory data. Accent both tones- this is hard work healthy heart with emotional excitement, physical activity, or bending the body forward.

The accent occurs when more high aperture placement, when the pulmonary edges depart from the heart, as well as when thin chest wall. Sometimes it is heard when there is an air cavity close to the heart, when the sounds are amplified due to resonance in it (pulmonary cavity, a large amount of air in the stomach).

Accent I tone at the top(loud, popping) can be heard with mitral stenosis and II tone above the aorta- with stenosis of the aortic valves (the sound of sclerotic valves is enhanced, if - attention! - the mobility of the valves is preserved).

Accent of the second tone over the aorta develops with arterial hypertension (active closure of the aortic valves).

Accent of the second tone over the pulmonary artery- this is a sign of active slamming of the valve flaps, which often occurs against the background of stagnation of blood in the pulmonary circulation and increased pressure in it. Happens when:

Mitral valve stenosis, in which the movement of blood from the left atrium to the left ventricle is difficult;

Mitral valve insufficiency - as a result of the return of part of the blood from the ventricle to the atrium;

Patent ductus botallus - more blood enters the pulmonary artery through the patent ductus arteriosus due to high pressure in the aorta;

Defects of the interatrial and interventricular septa - part of the blood in the right atrium and right ventricle comes from the left atrium and left ventricle, respectively, since the pressure in the latter is greater; and subsequently more blood flows into the pulmonary artery.

Thus:

1) accent II tones above the aorta are most often a sign of left ventricular hypertrophy (develops against the background of prolonged increased pressure in the systemic circulation);

2) accent II tones above the pulmonary artery are considered a sign of right ventricular hypertrophy (occurs as a result of a prolonged increase in pressure in the pulmonary circulation).

Split (splitting) heart sounds occurs when the valves (mitral and tricuspid, aorta and pulmonary artery) close at the same time or when the left and right ventricles contract asynchronously. Bifurcation can be of physiological and pathological origin:

- physiological the split most often concerns tone II, i.e. associated with non-simultaneous closure of the aortic and pulmonary valves.

Heart murmurs

Noises(English murmer) hearts- these are auscultation-determined additional sounds heard between heart sounds during systole or diastole. In childhood, murmurs are often heard - in 2-10% of newborns school age. On FCG they are detected in almost 100% of healthy children. By auscultation it is necessary to establish the following noise criteria: systolic(heard during systole - a relatively short pause between the 1st and 2nd sounds) or diastolic(heard during diastole - a relatively long pause between the II and I sounds);

When listening to noise needs to be determined :

His relation to the phases cardiac cycle(systole or diastole);

Its character (strength, duration, timbre);

Place of best listening (punctum maximum);

The direction of its conduction, irradiation (outside the heart area).

Some clinicians determine not the dome of the diaphragm, but the edge of the lung - using quiet percussion. You just need to take into account that the edge of the lung lies slightly below the level of the diaphragm: the dome of the diaphragm in a normosthenic is located on the V rib, and the edge of the lung is on the VI rib. In a hypersthenic person, both levels can coincide.

The right border of the heart depends on the position of the dome of the diaphragm, which, in turn, determines the type of constitution in healthy people - in a hypersthenic, the dome of the diaphragm lies higher than in a normosthenic, and lower in an asthenic. When the diaphragm is located high, the heart takes a horizontal position, which leads to some

Rice. 325. Percussion determination of the boundaries of relative cardiac dullness. The percussion is loud.

Stages of percussion.

The right border of relative cardiac dullness is determined, the finger is placed horizontally on the right in the second intercostal space on the midclavicular line, percussion is carried out down to dullness, which corresponds to the dome of the diaphragm (V rib), then, rising to the width of the rib from the dome of the diaphragm, the finger is placed vertically along the midclavicular lines and along the IV intercostal space are percussed to the edge of the sternum until dullness appears, which will correspond to the border of the heart. Normally, the border is located 1 cm to the right from the edge of the sternum.
The left border of relative cardiac dullness is determined: the finger is placed vertically in the 5th intercostal space at the level of the anterior axillary line, that is, to the left of the apical impulse; percussion is carried out along the intercostal space to the apical impulse; the dullness will correspond to the border of the heart. Normally, the border is 1 - 1.5 cm medially from the midclavicular line.
The upper limit of relative cardiac dullness is determined: the finger is placed horizontally in the second intercostal space 1.5 cm from the left edge of the sternum (between the sternal and parasternal lines); percussion is carried out downwards until dullness appears, which corresponds to the upper border of the heart. Normally, the upper border of the heart is located on the third rib.

mu increase in the boundaries of relative cardiac dullness on the right and left. When the diaphragm is low, the heart acquires a vertical position, the right and left borders shift to the sides/midline, that is, the borders of the heart decrease.

The right dome of the diaphragm (relative hepatic dullness) is determined by loud percussion from the third intercostal space along the midclavicular line (possibly parasternally, if a large increase in the borders of the heart is not expected). The plessimer finger is positioned horizontally, its movement after a double blow should not exceed 0.5-1 cm, that is, both intercostal spaces and ribs are percussed in a row. This must also be taken into account, since percussion along the edge gives a somewhat dull (shortened) sound. Women should be asked to move the right mammary gland with her right hand up and to the right. The dome of the diaphragm in a normosthenic is located at the level of the 5th rib or 5th intercostal space. In an asthenic person it is 1 - 1.5 cm lower, in a hypersthenic person it is higher.

After determining the dome of the diaphragm, it is necessary to rise to the 1st rib above, which usually corresponds to the 4th intercostal space, and, placing your finger vertically upward on the midclavicular line, percuss with loud percussion along the intercostal space towards the heart, moving 0.5-1 cm until dullness appears. . A mark is made along the edge of the finger facing the pulmonary sound.

Taking into account the dependence of the right border of the heart on the type of constitution, in asthenic patients it is necessary to additionally perform percussion in the 5th intercostal space, and in hypersthenic patients - in the 3rd intercostal space.

In a normosthenic, the right border of relative cardiac dullness is 1 cm outward from the right edge of the sternum in the IV intercostal space, in an asthenic - at the edge of the sternum in the IV-V intercostal space, in a hypersthenic

1.5-2 cm to the right from the edge of the sternum in the IV-III intercostal space. The right border of the heart is formed by the right atrium.

Left border of the heart. Determination of the left border of relative cardiac dullness begins with visual and palpation determination of the localization of the apex beat, the outer edge of which approximately corresponds to the most distant point of the left contour of the heart. Loud percussion is used. It starts from the mid-axillary line and is carried out horizontally at the level of the apex impulse towards the apex of the heart until a dull sound is obtained. Often, especially in hypersthenics, the left border of relative and absolute cardiac dullness coincides, so the pulmonary sound immediately turns into dull.

Percussion of the left border has the following features. At the beginning of percussion, the pessimeter finger should be pressed tightly against the chest with its lateral surface (the finger should always be in the frontal plane), and the blow to it should be applied strictly sagittally, that is, cutting off orthopercussion should be used, and not percussion perpendicular to the bend of the chest wall (Fig. 326 ). The force of percussion in comparison with percussion of the right border should be less due to the proximity of the heart to the surface. The boundary mark should be made on the outside of the finger, on the side of the pulmonary sound.

The position of the left border of the heart, as well as the right, depends on the type of constitution, therefore in a hypersthenic it is necessary to additionally percussion in the IV intercostal space, and in an asthenic in the VI intercostal space.

In a normosthenic, the left border of relative cardiac dullness is located 1-1.5 cm medially from the midclavicular line and coincides with the outer edge of the apical impulse. In an asthenic person, it can be located up to 3 cm medially from the midclavicular line

nii, in hypersthenics - on the midclavicular line. The left border of the heart is formed by the left ventricle.

The upper limit of relative cardiac dullness is determined from the first intercostal space along a line located 1 cm from the left edge of the sternum (between the sternal and parasternal lines). The plessimeter finger is positioned horizontally so that the middle of the percussed phalanx falls on this line. Impact force is average.

The upper border of the heart is located on the third rib, it does not depend on the type of constitution, it is formed by the conus of the pulmonary artery and the appendage of the left atrium.

The configuration of the heart is determined by loud percussion. To do this, in addition to the most distant points already found (right, left and upper border of the heart), it is necessary to carry out percussion along other intercostal spaces: on the right - in II, III, V, on the left - in

III, IV, VI. The pessimeter finger should be located parallel to the expected border. By connecting all the obtained points of relative cardiac dullness, we get the idea

about the configuration of the heart.

The lower border of the heart is not determined by percussion due to the fusion of cardiac and hepatic dullness. It can be conventionally represented as an oval, closing the lower ends of the right and left contours of the heart, and thus obtaining the complete configuration of the heart, its projection onto the anterior chest wall.

The transverse size of the heart (diameter of the heart, Fig. 315) is determined by measuring with a centimeter tape the most distant points of the cardiac borders to the right and left of the midline and the sum of these two perpendiculars. For a normosthenic man on the right this distance is 3-4 cm, on the left - 8-9 cm, the sum is 9-12 cm. For asthenics and women this size is 0.5-1 cm smaller, for a hypersthenic man - 0.5-2 cm see more. Determining the diameter of the heart very clearly reflects the position of the heart in the chest, the position of its anatomical axis.

In a normosthenic, the anatomical axis is in an intermediate position at an angle of 45°. In an asthenic person, due to the low position of the diaphragm, the heart takes a more vertical position; its anatomical axis is located at an angle of 70°, and therefore the transverse dimensions of the heart are reduced. In a hypersthenic diaphragm,) lies high, because of this the heart takes a horizontal position at an angle of 30°, which helps to increase the transverse dimensions of the heart.

Having acquired certain skills in percussion of the borders of the heart, absolute cardiac dullness can be determined from fragments simultaneously following the determination of relative dullness. For example, having found the right border of relative cardiac dullness with loud percussion, making a mark without lifting the plessimeter finger, they percussion further, but with quiet percussion until a dull sound appears, which will correspond to the border of absolute cardiac dullness on the right. The same is done when examining the upper and left borders.

The right border of absolute cardiac dullness is located at the left edge of the sternum, the upper one is on the IV rib, the left one either coincides with the border of relative cardiac dullness or is located on

1.5 cm inward from it. Absolute cardiac dullness is formed by the right ventricle adjacent to the anterior chest wall.

Determination of the boundaries of relative cardiac dullness

First, the right, left and upper limits of the relative dullness of the heart are determined. Pre-

It is absolutely necessary to obtain an indirect idea of the level of the diaphragm, which affects the results of percussion determination of the size of the relative dullness of the heart. To do this, first determine the lower border of the right lung along the midclavicular line, which is normally located at the level of the VI rib (Fig. 3.63).

The right border of relative dullness of the heart (Fig. 3.64), formed by the right atrium (RA), is found by percussing one rib above the found lower border of the lung (usually in the 4th intercostal space), moving a vertically positioned pessimeter finger strictly along the intercostal space (Fig. 3.65 ).

The left border of relative dullness of the heart (Fig. 3.66), formed by the left ventricle (LV), is determined after preliminary palpation of the apical impulse, usually in the 5th intercostal space, moving from the anterior axillary line towards the heart (Fig. 3.67).

The upper limit of the relative dullness of the heart (Fig. 3.68 and 3.69), formed by the left atrial appendage and the trunk of the pulmonary artery, is determined by percussing from top to bottom, 1 cm outward (3) from the left sternal line (but not along the left parasternal line!) .

1) The right border of the relative dullness of the heart in

normally located along the right edge of the sternum or on 1

cm outside of it.

2) The left border is 1-2 cm inward from the left

howl of the midclavicular line and coincides with the upper

3) The upper limit is normally located at the level

Fig.3.64. Definitions of the right border of relative cardiac dullness:

RA - right atrium; LV - left ventricle; RV - right ventricle; LP - left

atrium; 1 - midclavicular line.

Fig. 3.65. Determination of the right border of relative dullness of the heart.

Fig. 3.66. Scheme for determining the left border of relative dullness of the heart. The designations are the same as in Fig. 3.64.

Fig.3.68. Scheme for determining the upper limit of relative cardiac dullness.

The designations are the same as in Fig. 3.64: 1 - midclavicular line; 2 - left erudinal line;

3 - line along which the upper limit is determined.

Fig.3.70. The location of the right (1), left (2) and upper (3) boundaries of the relative dullness of the heart is normal (diagram), 4 - the boundaries of the vascular bundle.

Fig.3.71. Determination of heart diameter:

1 - right border of the heart; 2 - left border of the heart; 3 - anterior midline .

Measuring the diameter of the heart. To measure the diameter of the heart, determine the distance from the right and left borders of the relative dullness of the heart to the anterior midline (Fig. 3.71). Normally, they are 3-4 cm and 8-9 cm, respectively, and the diameter of the heart is cm.

Determining the boundaries of the vascular bundle. The vascular bundle, which includes the aorta, superior vena cava and pulmonary artery (Fig. 3.72), is quite difficult to determine by percussion. Percussion is performed with quiet percussion, moving a vertically positioned finger-pessimeter along the 2nd intercostal space on the right (Fig. 3.73a) and on the left (Fig. 3.73b) towards the sternum. Normally, the boundaries of the vascular bundle are

Fig.Z.72. Determination of the boundaries of the vascular bundle. 1 - midclavicular line .

fall with the right and left edges of the sternum, its width does not exceed cm.

Determining the configuration of the heart. To determine the configuration of the heart, the boundaries of the right and left contours of the relative dullness of the heart are additionally identified, percussing on the right in the third intercostal space, and on the left in the third and fourth intercostal spaces (Fig. 3.74).

By connecting all the points corresponding to the boundaries of relative dullness, we get an idea of the configuration of the heart (Fig. 3.75). Normally, along the left contour of the heart between the vascular bundle and the left ventricle, an obtuse angle, the so-called waist of the heart, is clearly defined (3).

Fig.3.73. Determination of the boundaries of the vascular bundle on the right (a) and on the left (b).

Fig.3.74. Scheme for determining the configuration of the heart .

Fig.3.75. Normal heart configuration.

1 - contours of relative dullness; 2 - absolute stupidity; 3 - heart waist.

Fig.3.76. Defining boundaries absolute stupidity hearts: 1 - midclavicular line; 2 - anterior midline; 3 - left chest line; 4 - absolute dullness of the heart .

Determination of the boundaries of relative dullness of the heart, Propaedeutics of internal diseases

When determining the boundaries of relative dullness of the heart, the right boundary is first established, then the left, and then the upper.

To identify the right border of relative dullness of the heart, along the right midclavicular line, the upper border of absolute dullness of the liver (or the lower border of the lung) is established, which is normally located in the VI intercostal space (Fig. 39, a). After this, going up to the IV intercostal space (to get away from hepatic dullness masking cardiac dullness), the pessimeter finger is placed parallel to the desired border and moved towards the heart along the IV intercostal space (Fig. 39, b). A change in percussion sound from clear pulmonary to dull will indicate reaching the limit of relative dullness of the heart. It should be noted that the pessimeter finger should be moved a short distance each time so as not to miss the boundaries of cardiac dullness. The first appearance of dullness indicates that the inner edge of the finger has crossed the border and is already within the location of the heart. The right border is marked along the outer edge of the finger, facing the clear percussion sound. It is formed by the right atrium and is normally located in the IV intercostal space, protruding 1-1.5 cm beyond the right edge of the sternum.

Rice. 39. Determination of the boundaries of relative dullness of the heart:

a - preliminary stage (establishing the upper limit of absolute liver dullness);

b, c, d - definition of the right, left and upper boundaries, respectively;

d - dimensions of the diameter of the relative dullness of the heart.

Before establishing the left border of the relative dullness of the heart, it is necessary to determine the apical impulse (see Fig. 38), which serves as a guide. If it cannot be detected, percussion is performed in the 5th intercostal space starting from the anterior axillary line towards the sternum. The plessimeter finger is placed parallel to the desired boundary and, moving it, percussion blows of medium strength are applied until dullness appears. The mark of the left border of relative dullness is placed along the outer edge of the pessimeter finger, facing the clear percussion sound. Normally, it is formed by the left ventricle, is located in the 5th intercostal space at a distance of 1-1.5 cm medially from the left midclavicular line (Fig. 39, c) and coincides with the apical impulse.

When determining the upper limit of the relative dullness of the heart (Fig. 39, d), a pessimeter finger is placed near the left edge of the sternum parallel to the ribs and, moving it down along the intercostal spaces, blows of medium force are applied until dullness appears. A mark is placed along the upper edge of the pessimeter finger, facing the clear percussion sound. The upper limit of the relative dullness of the heart is formed by the contour of the pulmonary artery and the appendage of the left atrium and is normally located on the third rib along the left parasternal line.

Normally, the distance from the right border of relative dullness to the anterior midline is 3-4 cm, and from the left - 8-9 cm. The sum of these distances (11-13 cm) represents the diameter of the relative dullness of the heart (Fig. 39, e) .

The limits of relative cardiac dullness may depend on a number of factors, both extracardiac and cardiac in nature. For example, in people of asthenic physique, due to the low position of the diaphragm, the heart takes a more vertical position (a hanging “drip” heart) and the limits of its relative dullness decrease. The same is observed with prolapse of internal organs. In hypersthenics, due to the opposite reasons (higher position of the diaphragm), the heart takes a horizontal position and the limits of its relative dullness, especially the left one, increase. During pregnancy, flatulence, and ascites, the limits of relative dullness of the heart also increase.

The shift in the boundaries of the relative dullness of the heart, depending on the size of the heart itself, occurs primarily due to the increase (dilatation) of its cavities and is only to some extent determined by the thickening (hypertrophy) of the myocardium. This can happen in all directions. However, significant expansion of the heart and its cavities is prevented forward by the resistance of the chest wall, and downward by the diaphragm. Therefore, expansion of the heart is possible mainly backwards, upwards and to the sides. But percussion reveals only expansion of the heart to the right, up and to the left.

An increase in the right border of the relative dullness of the heart is most often observed with expansion of the right ventricle and right atrium, which occurs with tricuspid valve insufficiency and narrowing of the mouth of the pulmonary artery. With stenosis of the left atrioventricular orifice, the border shifts not only to the right, but also upward.

A shift of the left border of the relative dullness of the heart to the left occurs with a persistent increase in blood pressure in big circle blood circulation, for example, with hypertension and symptomatic hypertension, with aortic heart defects (aortic valve insufficiency, aortic stenosis). With aortic defects, in addition to the displacement of the left border of the relative dullness of the heart to the left, it also shifts down to the VI or VII intercostal space (especially with aortic valve insufficiency). A shift of the left border of relative dullness to the left and up is observed with bicuspid valve insufficiency.

Rice. 40. Normal (a), mitral (b) and aortic (c) configurations of the heart.

To determine the configuration of the heart, percussion is performed sequentially in each intercostal space: to the right of IV and above II, to the left of V and above - to II. In this case, the pessimeter finger is positioned, as usual, parallel to the expected dullness. The percussion blow should be of medium strength. The points obtained during percussion are connected to each other and, thus, the configuration of the heart is revealed (Fig. 40, a). It may vary depending on the nature of his pathology. Thus, with mitral heart defects (mitral valve insufficiency, mitral stenosis), the heart acquires a “mitral configuration” (Fig. 40, b). Due to the expansion of the left atrium and left ventricle, the waist of the heart is flattened due to an increase in the size of the left atrium. With aortic defects (aortic valve insufficiency, narrowing of the aortic opening), with pronounced forms of hypertension, the heart, as a result of isolated expansion of the left ventricle, acquires an “aortic configuration” - the appearance of a “boot” or “sitting duck” (Fig. 40, b). In the case of combined and combined defects, all parts of the heart may enlarge. When there is a very sharp displacement of the boundaries of the heart in all directions, it is called “bull”.

The purpose of percussion is to determine the boundaries of the heart and its configuration. Due to the fact that the heart is partially covered by pulmonary tissue, relative and absolute dullness of the heart is distinguished by percussion. Most often, relative dullness is determined, corresponding to the true boundaries of the heart; absolute dullness, implying the borders of the heart not covered by the lungs, is defined less frequently in practice.

To determine relative dullness, the most commonly used method is loud percussion, in which the plessimeter finger (third finger of the left hand) is pressed tightly to the skin, and the hammer finger (slightly bent third finger of the right hand) delivers quick and short blows of equal force to the second phalanx of the finger. - plessimeter.

When performing percussion, it should be borne in mind that the size of the heart in a vertical position of the patient is smaller than in a horizontal position.

Determination of the boundaries of relative cardiac dullness:

left border of the heart

find the apical impulse;

place a pessimeter finger outward from the apical impulse perpendicular to the intercostal space and percussion towards the sternum until the sound becomes dull (NB! It is the moment of dullness in the sound that gives grounds to mark the desired point);

if the apical impulse is not detected, percussion begins in the 5th intercostal space along the anterior axillary line;

right border of the heart

determine the lower border of the right lung along the midclavicular line;

place a finger-pessimeter on the 1st intercostal space above the found border perpendicular to the intercostal space and percussion towards the sternum until the sound becomes dull;

upper border of the heart

place a pessimeter finger perpendicular to the sternum on the left under the collarbone and percussion downwards until the sound becomes dull.

Normal limits of relative cardiac dullness:

left border – coincides with the apical impulse and is determined 1–2 cm inward from the left midclavicular line;

right border - 1 cm outward from the right edge of the sternum;

the upper border is on the 3rd rib.

A shift in the boundaries of cardiac dullness is observed mainly in the following conditions:

an increase in the size of the heart (it should be borne in mind that a significant increase in the right parts can lead to a displacement of the left ventricle to the left);

accumulation of liquid or gas in the pleural cavities;

The purpose of percussion is to determine the boundaries of the lungs and their mobility (topographic percussion) and compare the percussion sound from the left lung and the right lung (comparative percussion). The study usually begins with comparative percussion: from the apex of the lungs downwards, first in front and then behind. The pessimeter finger is located parallel to the intercostal spaces, with the exception of the interscapular region, where it is placed parallel to the spine.

A change in percussion sound can be caused primarily by the following conditions: decreased airiness lung tissue; complete absence of air or filling of the pleural cavity with fluid; increased airiness of the lung tissue; the presence of air in the pleural cavity; the presence of pleural cords.

With topographic percussion, the boundaries of the lungs are determined.

Normal location of the lung borders:

the upper borders of the lungs are normally located 3–4 cm above the collarbones;

the lower boundaries of the right and left lungs are presented in the table.

Determination of mobility of the lower boundaries of the lungs:

find the lower border of the lungs along the midclavicular, anterior axillary and scapular lines;

ask the patient to take a deep breath and hold his breath;

again determine the border of the lungs along one of the lines;

on the patient’s next deep breath, determine mobility along the other line, etc.

The difference in centimeters between the first and second measurements is the amount of mobility of the lower edge of the lung and normally ranges from 2–3 cm along the scapular and midclavicular lines to 3–4 cm along the anterior axillary line.

In the same way, you can determine the mobility of the lower borders of the lungs during exhalation.

A decrease in the mobility of the lower edge of the lungs is observed, as a rule, in the following conditions: inflammatory processes in the lungs; congestive congestion of the lungs; emphysema; fluids in the pleural cavities; fusion or obliteration of the pleural layers.

Percussion of the liver in everyday practice most often consists of determining the lower limit of the relative dullness of the liver.

Determination of the left border: the pessimeter finger is placed perpendicular to the edge of the left costal arch at the level of the 7th–9th ribs and percussed to the right until a dull sound appears.

Determination of the right border: a pessimeter finger is placed in the area of the right half of the abdomen along the anterior axillary line parallel to the intended edge of the liver and percussed upward until a dull sound appears.

Normal location of the left border of the liver:

The right border of the liver is normally located along the lower border of the right costal arch, but can shift 1–2 cm lower during percussion in an upright position of the body, as well as in people of asthenic physique.

An enlarged liver is early symptom heart failure, and it is important to monitor its size over time. The persistence of increased liver size against the background of achieved compensation of cardiac activity is the basis for suspecting independent liver disease (hepatitis) and carrying out appropriate diagnostic procedures(biochemical tests, analysis for viral hepatitis, etc.).

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Physical examination: cardiac percussion

The cardiac percussion method makes it possible to detect signs of dilatation of the ventricles and atria, as well as expansion of the vascular bundle. The boundaries of relative and absolute cardiac dullness, vascular bundle, and heart configuration are determined.

Determination of the boundaries of relative dullness of the heart. First, the right, left and upper limits of the relative dullness of the heart are determined. It is known that the right border of the relative dullness of the heart, formed by the RA, is normally located along the right edge of the sternum or 1 cm outward from it; the left border (LV) is located 1-2 cm medially from the left midclavicular line and coincides with the apical impulse; the upper border, formed by the LA appendage or pulmonary trunk, is normally located at the level of the third rib. It should be remembered that the increase in the size of the relative dullness of the heart occurs mainly due to dilatation of individual cavities of the heart; myocardial hypertrophy alone (without dilatation), as a rule, does not change the percussion dimensions of the heart.

Determination of the boundaries of the vascular bundle. The vascular bundle, which includes the aorta, superior vena cava and pulmonary artery, is quite difficult to determine by percussion. Normally, the boundaries of the vascular bundle coincide with the right and left edges of the sternum, its width does not exceed 5-6 cm.

Determination of heart configuration. To determine it, the boundaries of the right and left contours of the relative dullness of the heart are additionally identified, percussing on the right in the third intercostal space, and on the left in the third and fourth intercostal spaces. By connecting all the points corresponding to the boundaries of relative dullness, we get an idea of the configuration of the heart. Normally, along the left contour of the heart between the vascular bundle and the LV, an obtuse angle is clearly defined - the “waist of the heart”.

Determination of the boundaries of absolute cardiac dullness. When determining boundaries, the quietest percussion is used. Percussion is performed from the previously found boundaries of relative dullness of the heart towards the area of absolute dullness. The right border of absolute cardiac dullness is normally located along the left edge of the sternum, the left border is 1-2 cm medially from the left border of relative cardiac dullness, and the upper border is at the level of the IV rib.

The most common causes of changes in the boundaries and configuration of the heart are presented in table. 1.

Table 1. Interpretation of cardiac percussion results

Complaints, anamnesis, physical examination

To accurately interpret changes when analyzing an ECG, you must adhere to the decoding scheme given below.

In routine practice and in the absence of special equipment for assessing exercise tolerance and objectifying the functional status of patients with moderate and serious illnesses heart and lungs, you can use the walking test for 6 minutes, corresponding to submaximal.

Electrocardiography is a method of graphically recording changes in the potential difference of the heart that arise during the processes of myocardial excitation.

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Boundaries of the heart during percussion: normal, causes of expansion, displacement

Percussion of the heart - a method for determining its boundaries

The anatomical position of any organ in the human body is determined genetically and follows certain rules. For example, the stomach of the vast majority of people is on the left side. abdominal cavity, the kidneys are on the sides of the midline in the retroperitoneal space, and the heart occupies a position to the left of the midline of the body in the human chest cavity. The strictly occupied anatomical position of the internal organs is necessary for their full functioning.

During an examination of a patient, a doctor can presumably determine the location and boundaries of a particular organ, and he can do this with the help of his hands and hearing. Such examination methods are called percussion (tapping), palpation (palpation) and auscultation (listening with a stethoscope).

The boundaries of the heart are determined mainly using percussion, when the doctor uses his fingers to “tap” the front surface of the chest, and, focusing on the difference in sounds (voiceless, dull or voiced), determines the estimated location of the heart.

The percussion method often makes it possible to suspect a diagnosis even at the stage of examining the patient, before prescribing instrumental research methods, although the latter still play a leading role in the diagnosis of diseases of cardio-vascular system.

Percussion - determining the boundaries of the heart (video, lecture fragment)

Normal values for the boundaries of cardiac dullness

Normally, the human heart has a cone shape, is directed obliquely downwards, and is located in the chest cavity on the left. On the sides and top the heart is slightly covered by small sections of the lungs, in front by the anterior surface of the chest, behind by the mediastinal organs, and below by the diaphragm. A small “open” area of the anterior surface of the heart is projected onto the anterior chest wall, and its boundaries (right, left and upper) can be determined by tapping.

boundaries of relative (a) and absolute (b) dullness of the heart

Percussion of the projection of the lungs, whose tissue has increased airiness, will be accompanied by a clear pulmonary sound, and tapping the area of the heart, whose muscle is more thick fabric, accompanied by a dull sound. This is the basis for determining the boundaries of the heart, or cardiac dullness - during percussion, the doctor moves his fingers from the edge of the anterior chest wall to the center, and when the clear sound changes to a dull sound, he marks the border of dullness.

The boundaries of relative and absolute dullness of the heart are distinguished:

The boundaries of relative dullness of the heart are located along the periphery of the projection of the heart and indicate the edges of the organ, which are slightly covered by the lungs, and therefore the sound will be less dull (dull).
The absolute border marks the central area of the projection of the heart and is formed by an open area of the anterior surface of the organ, and therefore the percussion sound is more dull (dull).

Approximate values of the limits of relative cardiac dullness are normal:

The right border is determined by moving the fingers along the fourth intercostal space on the right in left side, and are usually noted in the 4th intercostal space along the edge of the sternum on the right.
The left border is determined by moving the fingers along the fifth intercostal space on the left to the sternum and marking along the 5th intercostal space 1.5-2 cm inward from the midclavicular line on the left.
The upper border is determined by moving the fingers from top to bottom along the intercostal spaces to the left of the sternum and is marked along the third intercostal space to the left of the sternum.

The right border corresponds to the right ventricle, the left border corresponds to the left ventricle, and the upper border corresponds to the left atrium. The projection of the right atrium cannot be determined using percussion due to the anatomical location of the heart (not strictly vertical, but obliquely).

In children, the boundaries of the heart change as they grow, and reach the values of an adult after 12 years.

Normal values in childhood are:

Reasons for deviations from the norm

Focusing on the boundaries of relative cardiac dullness, which gives an idea of the true boundaries of the heart, one can suspect an enlargement of one or another cardiac cavity due to any diseases:

A shift to the right (expansion) of the right border accompanies myocardial hypertrophy (enlargement) or dilatation (expansion) of the cavity of the right ventricle, expansion of the upper border - hypertrophy or dilatation of the left atrium, and a displacement of the left - the corresponding pathology of the left ventricle. Most often there is an expansion of the left border of cardiac dullness, and the most frequent illness, leading to the fact that the boundaries of the heart are expanded to the left - this is arterial hypertension and the resulting hypertrophy of the left chambers of the heart.
With a uniform expansion of the boundaries of cardiac dullness to the right and left, we are talking about simultaneous hypertrophy of the right and left ventricles.

Diseases such as congenital heart defects (in children), previous myocardial infarction (post-infarction cardiosclerosis), myocarditis (inflammation of the heart muscle), dishormonal cardiomyopathy (for example, due to pathology of the thyroid gland or adrenal glands), long-term arterial hypertension. Therefore, an increase in the boundaries of cardiac dullness may lead the doctor to think about the presence of any of the listed diseases.

In addition to an increase in the boundaries of the heart caused by myocardial pathology, in some cases there is a shift in the boundaries of dullness caused by the pathology of the pericardium (heart lining) and neighboring organs - the mediastinum, pulmonary tissue or liver:

Pericarditis often leads to a uniform expansion of the boundaries of cardiac dullness - inflammatory process pericardial sheets, accompanied by the accumulation of fluid in the pericardial cavity, sometimes in a fairly large volume (more than a liter).
Unilateral expansion of the borders of the heart towards the affected side is accompanied by pulmonary atelectasis (collapse of a non-ventilated area of lung tissue), and towards the healthy side - accumulation of fluid or air in the pleural cavity (hydrothorax, pneumothorax).
Displacement of the right border of the heart to the left side is rare, but still observed in severe liver damage (cirrhosis), accompanied by a significant increase in liver volume and its upward displacement.

Can changes in the boundaries of the heart manifest clinically?

If the doctor reveals expanded or displaced borders of cardiac dullness during examination, he should find out in more detail from the patient whether he has some symptoms specific to diseases of the heart or neighboring organs.

Thus, heart pathology is characterized by shortness of breath when walking, at rest or in a horizontal position, as well as edema localized on the lower limbs and face, chest pain, heart rhythm disturbances.

Pulmonary diseases are manifested by cough and shortness of breath, and skin covering acquires a bluish coloration (cyanosis).

Liver diseases may be accompanied by jaundice, abdominal enlargement, stool disorders and edema.

In any case, expansion or displacement of the borders of the heart is not normal, and the doctor should pay attention to the clinical symptoms if he detects this phenomenon in the patient for the purpose of further examination.

Additional examination methods

Most likely, after detecting the expanded boundaries of cardiac dullness, the doctor will prescribe further examination - an ECG, chest x-ray, ultrasound of the heart (echocardioscopy), ultrasound of the internal organs and thyroid gland, and blood tests.

When might treatment be needed?

Directly expanded or displaced borders of the heart cannot be treated. First, you should identify the cause that led to an enlargement of the parts of the heart or displacement of the heart due to diseases of neighboring organs, and only then prescribe the necessary treatment.

In these cases, surgical correction of heart defects, coronary artery bypass grafting or stenting may be necessary. coronary vessels to prevent recurrent myocardial infarction, as well as drug therapy– diuretics, antihypertensives, rhythm-lowering and other drugs to prevent the progression of enlargement of the heart.

After this, going up to the IV intercostal space (to get away from hepatic dullness masking cardiac dullness), the pessimeter finger is placed parallel to the desired border and moved towards the heart along the IV intercostal space (Fig. 39, b). A change in percussion sound from clear pulmonary to dull will indicate reaching the limit of relative dullness of the heart. It should be noted that the pessimeter finger should be moved a short distance each time so as not to miss the boundaries of cardiac dullness. The first appearance of dullness indicates that the inner edge of the finger has crossed the border and is already within the location of the heart. The right border is marked along the outer edge of the finger, facing the clear percussion sound. It is formed by the right atrium and is normally located in the IV intercostal space, protruding 1-1.5 cm beyond the right edge of the sternum.

Rice. 39. Determination of the boundaries of relative dullness of the heart:

a - preliminary stage (establishing the upper limit of absolute liver dullness);

b, c, d - definition of the right, left and upper boundaries, respectively;

d - dimensions of the diameter of the relative dullness of the heart.

A shift of the left border of the relative dullness of the heart to the left occurs with a persistent increase in blood pressure in the systemic circulation, for example with hypertension and symptomatic hypertension, with aortic heart defects (aortic valve insufficiency, aortic stenosis). With aortic defects, in addition to the displacement of the left border of the relative dullness of the heart to the left, it also shifts down to the VI or VII intercostal space (especially with aortic valve insufficiency). A shift of the left border of relative dullness to the left and up is observed with bicuspid valve insufficiency.

Rice. 40. Normal (a), mitral (b) and aortic (c) configurations of the heart.

Anatomy of the borders of the heart

The location of any organ in human body genetically determined and subject to certain rules. For example, in humans, the heart is usually located on the left side of the chest, and the stomach is on the left side of the abdominal cavity. The location and boundaries of any internal organ can be determined by a specialist by palpating and listening to the heart. The boundaries of the heart are determined by tapping the chest with your fingers. This method is called cardiac percussion.

Although instrumental studies are the most informative in identifying heart disease, tapping often helps diagnose preliminary diagnosis still during initial examination sick.

Anatomy

Usually the human heart is located on the left side of the chest, slightly obliquely, and along appearance resembles a cone. The organ is partially covered from above and from the sides by the lungs, in front by the chest, below by the diaphragm, and behind by the mediastinal organs.

The anatomy of the borders of the heart is revealed by the sound that the doctor hears when tapping the chest wall:

percussion of the cardiac region is usually accompanied by a dull sound;
tapping the lung area - clear pulmonary.

During the procedure, the specialist gradually moves his fingers from the front of the sternum to its center, and marks the border at the moment when the pulmonary sound is replaced by a characteristic dull sound.

Determining the boundaries of the heart

Types of borders

It is customary to distinguish two types of boundaries of cardiac dullness:

The absolute border is formed by an open area of the heart, and when it is tapped, a duller sound is heard.
The boundaries of relative dullness are located in places where the heart is slightly covered by areas of the lungs, and the sound that is heard when tapping is dull.

Norm

The boundaries of the heart normally have approximately the following values:

The right border of the heart is usually found in the fourth intercostal space on the right side of the chest. It is determined by moving the fingers from right to left along the fourth space between the ribs.
The left one is located along the fifth intercostal space.
The upper one is located along the third intercostal space on the left side of the chest.

The upper cardiac border indicates the location of the left atrium, and the right and left borders indicate the location of the ventricles of the heart, respectively. When tapping, it is not possible to identify only the location of the right atrium.

In children

The normal border of the heart in children varies according to the stages of maturation, and becomes equal to the values adults when the child reaches twelve years of age. Thus, up to two years, the left border is located 2 cm outward in the left part of the midclavicular line, the right border is along the right parasternal line, and the upper border is in the area of the second rib.

From two to seven years, the left border is located 1 cm outward from the left part of the midclavicular line, the right one moves to the inner part of the right parasternal line, and the upper one is located in the second intercostal space.

From the age of seven until the age of twelve, the left border is located on the left along the midclavicular line, the right border is along the right edge of the chest, and the upper one shifts to the area of the third rib.

Table of normal heart boundaries

Reasons for deviations

The norm of cardiac boundaries in adults and children gives an idea of where the cardiac boundaries should be. If the borders of the heart are not located where they should be, one can assume hypertrophic changes in any part of the organ due to pathological processes.

The causes of cardiac dullness are usually as follows:

Pathological enlargement of the myocardium or right cardiac ventricle, which is accompanied by a significant expansion of the right border.
Pathological enlargement of the left atrium, which results in displacement of the upper cardiac border.
Pathological enlargement of the left ventricle, due to which the left border of the heart expands.
Hypertrophic changes in both ventricles simultaneously, in which both the right and left cardiac boundaries are displaced.

Of all the listed deviations, the most common is a shift of the left border, and it is often caused by persistent high pressure, against the background of which a pathological enlargement of the left side of the heart develops.

In addition, changes in the cardiac boundaries can be provoked by pathologies such as congenital cardiac anomalies, previous myocardial infarction, an inflammatory process in the heart muscle, or cardiomyopathy, which developed as a result of disruption of normal functioning. endocrine system and hormonal imbalance against this background.

In many cases, expansion of the cardiac borders is due to disease of the heart lining and abnormalities in the functioning of neighboring organs - for example, the lungs or liver.

Uniform expansion of the boundaries is often caused by pericarditis - inflammation of the pericardial layers, which is characterized by excess fluid in the pericardial cavity.

Unilateral displacement of the borders of the heart to the healthy side most often occurs against the background of excess fluid or air in the pleural cavity. If the cardiac borders are shifted to the affected side, this may indicate collapse of a certain area of lung tissue (atelectasis).

Due to pathological changes in the liver, which are accompanied by a significant increase in the organ’s size, there is often a shift of the right cardiac border to the left.

Normal and hypertrophied heart

Dullness of the heart

If, during an examination, a specialist reveals abnormally changed borders of the heart in a patient, he tries to determine as accurately as possible whether the patient has manifestations characteristic of cardiac pathologies or diseases of nearby organs.

Symptoms of cardiac dullness in most cases are as follows:

Heart disease is characterized by swelling of the face and legs, irregular heartbeat, chest pain and symptoms of shortness of breath both when walking and at rest.
Pathologies of the lungs are accompanied by cyanosis of the skin, shortness of breath and cough.
Liver dysfunction can be manifested by an enlarged abdomen, stool disturbances, edema and jaundice.

Even if the patient does not have any of the above symptoms, violation of the boundaries of the heart is an abnormal phenomenon, so the specialist must prescribe the necessary additional examination to the patient.

Typically, additional diagnostics include an electrocardiogram, chest x-ray, ultrasound examination of the heart, endocrine glands and abdominal organs, as well as a blood test of the patient.

Treatment

Treatment of enlarged or displaced boundaries of the heart is impossible in principle, since the main problem is not so much the violation of the boundaries as the disease that provoked it. Therefore, first of all, it is necessary to determine the cause that caused hypertrophic changes in the cardiac sections or displacement of the heart due to diseases of nearby organs, and only then prescribe suitable therapy.

The patient may need surgical intervention in order to eliminate heart defects, stenting or bypass surgery to prevent recurrent infarction.

In addition, sometimes drug treatment is prescribed - diuretics, drugs to reduce heart rate and lowering blood pressure, which are used to prevent further enlargement of the heart.

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Boundaries of the heart during percussion: normal, causes of expansion, displacement

Percussion of the heart - a method for determining its boundaries

The anatomical position of any organ in the human body is determined genetically and follows certain rules. For example, the stomach in the vast majority of people is located on the left in the abdominal cavity, the kidneys are on the sides of the midline in the retroperitoneal space, and the heart occupies a position to the left of the midline of the body in the human chest cavity. The strictly occupied anatomical position of the internal organs is necessary for their full functioning.

Percussion - determining the boundaries of the heart (video, lecture fragment)

Normal values for the boundaries of cardiac dullness

boundaries of relative (a) and absolute (b) dullness of the heart

Percussion of the projection of the lungs, whose tissue has increased airiness, will be accompanied by a clear pulmonary sound, and tapping the area of the heart, whose muscle is a denser tissue, will be accompanied by a dull sound. This is the basis for determining the boundaries of the heart, or cardiac dullness - during percussion, the doctor moves his fingers from the edge of the anterior chest wall to the center, and when the clear sound changes to a dull sound, he marks the border of dullness.

The boundaries of relative and absolute dullness of the heart are distinguished:

The boundaries of relative dullness of the heart are located along the periphery of the projection of the heart and indicate the edges of the organ, which are slightly covered by the lungs, and therefore the sound will be less dull (dull).
The absolute border marks the central area of the projection of the heart and is formed by an open area of the anterior surface of the organ, and therefore the percussion sound is more dull (dull).

Approximate values of the limits of relative cardiac dullness are normal:

The right border is determined by moving the fingers along the fourth intercostal space from the right to the left, and is usually marked in the 4th intercostal space along the edge of the sternum on the right.
The left border is determined by moving the fingers along the fifth intercostal space on the left to the sternum and marking along the 5th intercostal space 1.5-2 cm inward from the midclavicular line on the left.
The upper border is determined by moving the fingers from top to bottom along the intercostal spaces to the left of the sternum and is marked along the third intercostal space to the left of the sternum.

In children, the boundaries of the heart change as they grow, and reach the values of an adult after 12 years.

Normal values in childhood are:

Reasons for deviations from the norm

Focusing on the boundaries of relative cardiac dullness, which gives an idea of the true boundaries of the heart, one can suspect an enlargement of one or another cardiac cavity due to any diseases:

A shift to the right (expansion) of the right border accompanies myocardial hypertrophy (enlargement) or dilatation (expansion) of the cavity of the right ventricle, expansion of the upper border - hypertrophy or dilatation of the left atrium, and a displacement of the left - the corresponding pathology of the left ventricle. The most common is an expansion of the left border of cardiac dullness, and the most common disease that leads to the borders of the heart being expanded to the left is arterial hypertension and the resulting hypertrophy of the left chambers of the heart.
With a uniform expansion of the boundaries of cardiac dullness to the right and left, we are talking about simultaneous hypertrophy of the right and left ventricles.

Pericarditis, an inflammatory process of the pericardial layers, accompanied by the accumulation of fluid in the pericardial cavity, sometimes in a fairly large volume (more than a liter), often leads to a uniform expansion of the boundaries of cardiac dullness.
Unilateral expansion of the borders of the heart towards the affected side is accompanied by pulmonary atelectasis (collapse of a non-ventilated area of lung tissue), and towards the healthy side - accumulation of fluid or air in the pleural cavity (hydrothorax, pneumothorax).
Displacement of the right border of the heart to the left side is rare, but still observed in severe liver damage (cirrhosis), accompanied by a significant increase in liver volume and its upward displacement.

Can changes in the boundaries of the heart manifest clinically?

Thus, heart pathology is characterized by shortness of breath when walking, at rest or in a horizontal position, as well as swelling localized in the lower extremities and face, chest pain, and cardiac arrhythmias.

Pulmonary diseases are manifested by cough and shortness of breath, and the skin becomes bluish in color (cyanosis).

Liver diseases may be accompanied by jaundice, abdominal enlargement, stool disorders and edema.

Additional examination methods

When might treatment be needed?

In these cases, surgical correction of heart defects, coronary artery bypass surgery or stenting of coronary vessels may be necessary to prevent recurrent myocardial infarction, as well as drug therapy - diuretics, antihypertensives, rhythm-slowing and other drugs to prevent the progression of enlargement of the heart.

Right border of the heart

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DETERMINATION OF THE BORDERS OF THE HEART AND THE WIDTH OF THE VASCULAR BAND

When studying the cardiovascular system, percussion determines the boundaries of the heart and the width of the vascular bundle.

The heart is mostly located in the left half of the chest and can be schematically represented as an obliquely located cone, the apex of which corresponds to the apex of the heart and is directed down and to the left, and the base is directed upward. Accordingly, the right, upper and left borders of the heart are distinguished, which are determined in this sequence.

The heart muscle and the blood it contains are airless, low-elastic media. Therefore, over the area of the anterior chest wall to the left of the sternum, to which the heart is directly adjacent, a dull sound occurs upon percussion (absolute cardiac dullness). The lungs surrounding the heart on both sides and above, on the contrary, are elastic media containing air and produce a clear pulmonary sound when percussed. On the right and above, the heart is partially covered by the thin edges of the lungs, therefore, during percussion, a dull percussion sound appears here, which is like a transition between a clear pulmonary sound and the sound of absolute cardiac dullness. This sound is called relative cardiac dullness.

Thus, when determining the right and upper borders of the heart, first a clear pulmonary sound turns into the sound of relative cardiac dullness (the border of relative cardiac dullness), and this, in turn, turns into the sound of absolute cardiac dullness (the border of absolute cardiac dullness).

The boundaries of relative cardiac dullness correspond to the true boundaries of the heart.

On the left, the heart is not covered by the lung, so the clear pulmonary sound immediately turns into the sound of absolute cardiac dullness. The area of absolute cardiac dullness is formed mainly by the right ventricle adjacent directly to the anterior chest wall. Only a narrow strip of absolute dullness along the left contour of the heart is formed by the left ventricle.

The lines along which the size of the heart are determined are chosen in such a way that the expansion of each of the percussion boundaries reflects the increase in certain chambers of the heart: the right border - the right ventricle; upper - left atrium; left - left ventricle. The percussion method cannot detect an increase in the size of the right atrium.

Adjacent to the heart below is Traube’s “semilunar space”, which is limited on the right by the left edge of the liver, on the left by the spleen and below by the left costal arch. In the projection of this space there is an air “bubble” of the stomach, so percussion produces a tympanic sound.

In accordance with the rules of topographic percussion, when determining the boundaries of the heart, the finger-pessimeter is placed parallel to the desired boundary and percussed in the direction from clear sound to dull sound, i.e. from lungs to heart. To determine the boundaries of relative cardiac dullness, percussion blows of medium strength are used, and when determining the boundaries of absolute cardiac dullness, quiet percussion blows are used.

Percussion is best performed with the patient in an upright position or in a sitting position with legs down. The patient's breathing should be shallow and even. The found percussion border is fixed with a pessimeter finger and its coordinates on the chest are determined: the right border - by palpation of the edges of the sternum; top - by counting the ribs; left - by measuring the distance to the left midclavicular line. It should be remembered that the percussion boundary corresponds to the edge of the pessimeter finger facing towards a clearer sound.

The right border of the heart is usually determined at the level of the IV intercostal space. However, you must first make sure that the level of determination of the right border of the heart lies in a sufficiently wide zone of clear pulmonary sound. To do this, first find the lower percussion border of the right lung along the midclavicular line. The plessimeter finger is placed directly under the right collarbone and parallel to it so that middle phalanx the finger was on the right midclavicular line (the woman, if necessary, is asked to lift and move the right mammary gland outward with her right hand). Using quiet percussion blows, they percussion along the indicated line along the ribs and intercostal spaces in the direction from top to bottom until the border of the transition of a clear pulmonary sound into a dull one is detected (Fig. 30a).

Clinical experience shows that the distance from the IV intercostal space to the VI rib is sufficient so that dense liver tissue does not affect the accuracy of determining the right border of the heart. An upward expansion of the border of the liver is observed extremely rarely, since it is suspended in the abdominal cavity by ligaments and, with enlargement, mainly the lower border of the zone of hepatic dullness expands. More realistic reasons that can interfere with the determination of the right border of the heart may be right-sided pleural effusion or massive consolidation of the right lung, since a dull percussion sound is detected above them. Similar pathological processes will prevent the determination of other cardiac boundaries.

To determine the right border, the pessimeter finger is placed along the right midclavicular line so that its middle phalanx is located in the fourth intercostal space. Using percussion blows of medium strength, they percussion at this level towards the sternum, displacing the finger-pessimeter at a distance of 0.5-1 cm with each pair of blows and holding it in a position parallel to the desired border (Fig. 30b). The transition of a clear pulmonary sound to a dull one corresponds to the right border of relative cardiac dullness. Normally, it is located along the right edge of the sternum.

Further, using already quiet percussion blows, they continue percussion at the same level until the border of transition of a dull sound into a dull sound is detected, which corresponds to the right border of absolute cardiac dullness. Normally, it runs along the left edge of the sternum.

If an enlargement of the right border of the heart is detected, percussion is performed in a similar way at the level of the 5th intercostal space to establish a possible connection between this phenomenon and effusion into the pericardial cavity.

The upper border of the heart is determined by the left parasternal line. The pessimeter finger is placed directly under the left clavicle and parallel to it so that the middle phalanx of the finger is on the indicated line. Using percussion blows of medium strength, they percussion along this line along the ribs and intercostal spaces in the direction from top to bottom (Fig. 30c). The transition of a clear pulmonary sound to a dull one corresponds to the upper limit of relative cardiac dullness, which is normally located on the third rib. Then, using already quiet percussion blows, they continue to percussion along the same line downwards until a dull sound appears, which corresponds to the upper limit of absolute cardiac dullness. Normally it is located on the 4th rib.

The left border of the heart is determined at the level of the intercostal space in which the apex beat is visually or palpably determined. If there is no apical impulse, then by counting the ribs to the left of the sternum, the fifth intercostal space is found and percussion is performed at this level. Before performing percussion on a woman, the doctor, if necessary, asks her to lift the left mammary gland with her right hand.

It is difficult to determine the left border of the heart, since you have to percussion along the rounded surface of the chest. The pessimeter finger is installed longitudinally along the left anterior axillary line so that, firstly, its middle phalanx is located in the intercostal space selected as the percussion level, and, secondly, the finger itself is located strictly in the frontal plane and pressed tightly to the chest with its palmar surface and ulnar edge. Percussion is performed at the level of the selected intercostal space towards the sternum, delivering quiet percussion blows in the sagittal plane, i.e. strictly perpendicular to the back surface of the plessimeter finger. After each pair of percussion blows, the finger-pessimeter is shifted in the medial direction by a distance of 0.5-1 cm, while maintaining its longitudinal position and holding it strictly in the frontal plane (Fig. 30d). The transition of a clear pulmonary sound directly into the sound of absolute cardiac dullness (bypassing the sound of relative cardiac dullness) indicates the detection of the left border of the heart. Normally, it is located at the level of the 5th intercostal space, 1.5-2 cm medially from the left midclavicular line and coincides with the location of the outer edge of the apical impulse.

In order to determine the degree of mobility of the heart in the chest, it is advisable to repeat the study of the right and left borders in a supine position, and then on the right and left sides.

A uniform expansion of the boundaries of relative and absolute cardiac dullness to the right indicates hypertrophy and dilatation of the right ventricle, and upward - about dilatation of the left atrium. With hypertrophy and dilatation of the left ventricle, the left border of the heart expands. Moderate expansion of the left border of the heart can also occur with pronounced dilatation of the right ventricle. Simultaneous expansion of the left and right borders of the heart most often indicates dilatation of both ventricles.

When fluid accumulates in the pericardial cavity, expansion of the left and right borders of the heart also occurs, often with the disappearance of the zone of relative cardiac dullness on the right. However, in this case, the most pronounced expansion of the right border of the heart is determined not in the IV, but in the V intercostal space. In addition, with significant effusion into the pericardial cavity, the left border of the heart sometimes does not coincide with the apex beat, but is located outside of it.

The results of determining the percussion boundaries of the heart can be influenced by pathological processes in the respiratory system. Patients with pulmonary emphysema are characterized by a uniform narrowing of the boundaries of the zone of absolute cardiac dullness or even its complete disappearance.

Cicatricial wrinkling or collapse (atelectasis) of a section of lung tissue adjacent to one or another part of the heart, on the contrary, leads to an expansion of the corresponding border of absolute cardiac dullness. Moreover, if these processes in one of the lungs are widespread and lead to a displacement of the mediastinum, the right and left borders of the heart shift towards the lesion.

When fluid or air accumulates in one of the pleural cavities, the mediastinum shifts to the healthy side. In this case, during percussion on the side opposite to the effusion or pneumothorax, an expansion of the border of the heart is noted, while on the affected side, percussion phenomena caused by the pathological process will interfere with the determination of the border of the heart: a dull sound when pleural effusion and tympanitis - with pneumothorax.

When performing percussion in a horizontal position of the patient, the borders of the heart are slightly wider than when performing percussion in a standing position. Moreover, in the lateral lying position, the right and left borders of the heart shift to the corresponding side by 2-3 cm.

The absence of a displacement of the borders of the heart, as well as a displacement of the apical impulse when changing body position, indicates the presence of adhesions of the pericardium with the surrounding tissues. With dextrocardia, the borders of the heart are projected onto the right half of the chest and are, as it were, a mirror image of the borders already described when it is located on the left side.

The pessimeter finger is positioned longitudinally along the midclavicular line so that its middle phalanx lies in the 2nd intercostal space.

Using quiet percussion blows, they percussion at this level towards the edge of the sternum, holding the pessimeter finger in a longitudinal position and shifting it after each pair of blows by 0.5-1 cm until the border of the transition of a clear pulmonary sound into a dull sound is detected (Fig. 31) .

Normally, the width of the vascular bundle does not extend beyond the edges of the sternum. The expansion of the percussion boundaries of the vascular bundle is observed mainly with the expansion of the aorta, which makes up its main part.

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Reasons for the decline
What does pressure 110 over 50 mean?
Is there any danger
What to do for quick help
Treatment

Low blood pressure is a common occurrence. Young people and children most often suffer from low blood pressure. Blood pressure of 110 over 50 is a reason to worry, what does this indicator mean and what to do in this case?

Blood pressure is a biological marker of a person's well-being. When it deviates from normal values, it becomes clear that something is wrong with the body. Low blood pressure (hypotension) is no less dangerous than hypertension (high blood pressure).

Reasons for the decline

Nothing happens in the body just like that. And any change is influenced by certain factors. There are two groups of reasons that can affect the occurrence of hypotension:

Physiological (excessive physical exercise, climate change, fatigue, etc.). They are isolated in nature unless there is repeated exposure from the outside;
Pathological (aortic valve stenosis, vegetative-vascular dystonia). It is diseases and pathological conditions provoke hypotension.
The development of hypotension is influenced by long bed rest. For example, after a major operation, a patient requires long-term rehabilitation. And during the entire period of rehabilitation, he got up only a few times. This will cause a forced reduction in pressure.
In some cases, reduce arterial pressure may pharmacological drugs.

The symptoms of hypotension can be easily differentiated:

body temperature decreases;
pallor of the skin is observed;
sweating increases;
patients complain about excessive tearfulness and irritability a sharp decline performance, apathy;
dizziness;
headache in the temporal zone;
floaters before eyes.

Such symptoms are alarm bells. To determine blood pressure readings, you need to use a tonometer. Electronic models will determine the pressure level in a matter of seconds. It should be noted that the considered level of blood pressure in adults almost never leads to the appearance of clinical symptoms. 100/50 - slight hypotension, which may be a variant of the norm.

What does pressure 110 over 50 mean?

Such indicators are not always a warning sign. There are situations in medicine when such indicators can be both normal and pathological.

If the child is under 10 years old, then the lower limit (50) is a normal physiological indicator. But the upper limit indicates the development of hypertension. It is worth worrying if a small child has such pressure;
If a teenager (12-16 years old) is examined, the situation is different. At this age, the upper limit corresponds to the norm. But the lower limit indicates the development of hypotension. It is worth paying attention to the health status of the teenager and identifying the cause.

In old age, a pressure of 110/50 indicates the development of chronic hypotension. After all, most often older people have hypertension. What does it mean? Hypotension at this age indicates disturbances in the functioning of the cardiovascular system associated with a slower heartbeat.

A blood pressure of 110 over 50 during pregnancy may be normal. In this case, the woman’s well-being remains unchanged, she does not show any complaints, and remains cheerful. When hypotension during pregnancy is accompanied by deterioration of the condition, complaints, or loss of consciousness, it is necessary to immediately consult a specialist. There is a threat to the life of both mother and child.

Is there any danger

The state of hypotension carries a certain danger. Hypotension during pregnancy, in the elderly, and with heart disease can cause unpredictable symptoms. Symptoms manifest themselves individually, but hypotension does not go unnoticed for anyone. And this affects not only the emotional state.

Hypotension can provoke:

loss of consciousness: at best, you can get a bruise. At worst - a fracture or dislocation due to a fall, loss of the fetus during pregnancy;
insufficient functioning of the heart vessels, which affects its performance;
oxygen starvation of the body, which leads to insufficient functioning of all organs and systems;
development of sensitivity to changes climatic conditions. This makes life very difficult for some patients;
Women experience menstrual irregularities, and men may suffer from decreased potency.

It should be noted that the blood pressure indicators under consideration do not lead to the development of the conditions indicated in the first two points of the list. Similar changes occur with more significant hypotension.

What to do for quick help

Considering the possibility of encountering a hypotensive attack, it is worth remembering a few rules:

If not urgent need should not be given to the patient medications(unless the hypotension is chronic and the person knows very well what medications are prescribed).
In case of severe condition (loss of consciousness, severe pallor, convulsions), you should immediately call an ambulance team.
With significant hypotension accompanied by certain clinical symptoms, it is allowed to use over-the-counter medicines(Caffeine 1 tablet, Citramon 1 tablet).

Simple ways to help with mild degree hypotension:

Lay the person down, raise the legs higher than the body.
Thoroughly ventilate the room, loosen tight clothing on the victim.
Brew strong tea with sugar and give it to the victim to drink.
Advise the person to breathe slowly and deeply.

Treatment

Drug therapy for hypotension is carried out after consultation with a specialist. The patient is examined by a therapist, cardiologist and other doctors as necessary. After tests, instrumental examination and a final diagnosis, therapy is prescribed.

Spend enough time outdoors (walking, playing sports);
Properly organize work and rest schedules;
Give up bad habits (smoking, alcohol);
Eat balanced and healthy. Limit spicy, salty foods. In the winter-spring period, enrich the body with vitamin complexes;
Be examined by a doctor every six months.

If you suspect hypotension, you should not think that it will go away on its own. It won’t work, and it will add another bag of problems. Timely visit to the therapist, compliance with medical recommendations and healthy image life - this is what can defeat hypotension.

Boundaries of the heart during percussion: normal, causes of expansion, displacement

Percussion of the heart - a method for determining its boundaries

The boundaries of the heart are determined mainly using percussion, when the doctor uses his fingers to “tap” the front surface of the chest, and, focusing on the difference in sounds (voiceless, dull or voiced), determines the estimated location of the heart.

Percussion - determining the boundaries of the heart (video, lecture fragment)

Normal values for the boundaries of cardiac dullness

The boundaries of relative and absolute dullness of the heart are distinguished:

The boundaries of relative dullness of the heart are located along the periphery of the projection of the heart and indicate the edges of the organ, which are slightly covered by the lungs, and therefore the sound will be less dull (dull).
The absolute border marks the central area of the projection of the heart and is formed by an open area of the anterior surface of the organ, and therefore the percussion sound is more dull (dull).

Approximate values of the limits of relative cardiac dullness are normal:

The right border is determined by moving the fingers along the fourth intercostal space from the right to the left, and is usually marked in the 4th intercostal space along the edge of the sternum on the right.
The left border is determined by moving the fingers along the fifth intercostal space on the left to the sternum and marking along the 5th intercostal space 1.5-2 cm inward from the midclavicular line on the left.
The upper border is determined by moving the fingers from top to bottom along the intercostal spaces to the left of the sternum and is marked along the third intercostal space to the left of the sternum.

In children, the boundaries of the heart change as they grow, and reach the values of an adult after 12 years.

Normal values in childhood are:

Reasons for deviations from the norm

Focusing on the boundaries of relative cardiac dullness, which gives an idea of the true boundaries of the heart, one can suspect an enlargement of one or another cardiac cavity due to any diseases:

A shift to the right (expansion) of the right border accompanies myocardial hypertrophy (enlargement) or dilatation (expansion) of the cavity of the right ventricle, expansion of the upper border accompanies hypertrophy or dilatation of the left atrium, and displacement of the left accompanies the corresponding pathology of the left ventricle. The most common expansion of the left border of cardiac dullness occurs, and the most common disease that leads to the borders of the heart expanding to the left is arterial hypertension and the resulting hypertrophy of the left heart.
With a uniform expansion of the boundaries of cardiac dullness to the right and left, we are talking about simultaneous hypertrophy of the right and left ventricles.

Diseases such as congenital heart defects (in children), previous myocardial infarction (post-infarction cardiosclerosis), myocarditis (inflammation of the heart muscle), dishormonal cardiomyopathy (for example, due to pathology of the thyroid gland or adrenal glands), long-term arterial hypertension. Therefore, an increase in the boundaries of cardiac dullness may lead the doctor to think about the presence of any of the listed diseases.

Pericarditis, an inflammatory process of the pericardial layers, accompanied by the accumulation of fluid in the pericardial cavity, sometimes in a fairly large volume (more than a liter), often leads to a uniform expansion of the boundaries of cardiac dullness.
Unilateral expansion of the borders of the heart towards the affected side is accompanied by pulmonary atelectasis (collapse of a non-ventilated area of lung tissue), and towards the healthy side - accumulation of fluid or air in the pleural cavity (hydrothorax, pneumothorax).
Displacement of the right border of the heart to the left side is rare, but still observed in severe liver damage (cirrhosis), accompanied by a significant increase in liver volume and its upward displacement.

Can changes in the boundaries of the heart manifest clinically?

Pulmonary diseases are manifested by cough and shortness of breath, and the skin becomes bluish in color (cyanosis).

Liver diseases may be accompanied by jaundice, abdominal enlargement, stool disorders and edema.

In any case, expansion or displacement of the borders of the heart is not normal, and the doctor should pay attention to the clinical symptoms if he detects this phenomenon in the patient for the purpose of further examination.

Additional examination methods

Most likely, after detecting the expanded boundaries of cardiac dullness, the doctor will prescribe an additional examination - an ECG, chest x-ray, ultrasound of the heart (echocardioscopy), ultrasound of the internal organs and thyroid gland, blood tests.

When might treatment be needed?

Topography of the heart - educational lecture (video)

What to do if blood pressure does not decrease after taking the pills?

Hypertension is a real epidemic modern society. This disease affects approximately one third of all people over 50 years of age. The disease, once established in the body, cannot be completely cured. The only way to avoid dangerous complications is to constantly take medications.

Any hypertensive patient eventually considers himself a “professor” in this area, as he is constantly faced with the problem of choice effective drug and dosages. But everyone has cases when blood pressure does not decrease when taking the usual pills.

Why? This is what our article is dedicated to.

A short excursion into physiology

Blood pressure (BP) is created by the pressure of blood on the walls of the arteries, which exceeds atmospheric pressure. This is one of the main markers of the vitality of the organism. A change in the indicator indicates, at a minimum, trouble, and at a maximum, a serious condition, life-threatening person.

The indicator is described by two numbers:

Systolic - recorded in vascular system at the moment of blood ejection. It is also called the top one. Characterizes, first of all, the work of the heart: with what frequency and force this organ contracts;
Diastolic is the residual pressure that is recorded at the moment of complete relaxation of the heart muscle. Depends on the elasticity of blood vessels, heart rate and volume of pumped blood.

The normal value of the indicator is known to everyone - 120/80 mm Hg. Art. But not everyone knows that doctors allow deviations of these values up to 140/90 mm Hg. Art. Only if the patient persistently exceeds these limits is the onset of hypertension indicated.

Basic antihypertensive drugs

We do not set out to make a complete review of tablets used to treat hypertension. This is a huge area of cardiology that is dealt with by specialists. But for a better understanding of the problem it may be useful general characteristics antihypertensive drugs.

First line

The most common and effective means with which to begin treatment:

ACE inhibitors (angiotensin-converting enzyme): Enap, Lisinopril, Captopril, Moex. Their main mechanism of action is dilation of peripheral blood vessels. The advantage is that they do not affect the activity of the heart (do not change heart rate and cardiac output), therefore they are prescribed without fear for heart failure;

Diuretics: “Hypothiazide”, “Indap”, “Veroshpiron”. Increase urine output, which leads to a decrease in circulating blood volume. Often used in combination with the first group;

β-blockers: Atenolol, Betakor, Bisoprolol, Nebilong. Acting on myocardial receptors, they reduce cardiac output. Prescribed for concomitant angina and arrhythmias;
Angiotensin II receptor inhibitors (Sartans): Lozap, Irbetan, Vazar. Relatively new drugs that provide a persistent hypotensive effect throughout the day. They do not cause the typical side effects of ACE inhibitors (no dry hacking cough);

Calcium channel antagonists: Verapamil, Diltiazem, Amlodipine. Cause typical side effects: facial redness, heart rhythm disturbances, headache.

Second line

Prescribed in the presence of severe side effects, individual intolerance to first-line drugs, or for financial reasons, when the patient cannot afford to take expensive modern drugs for life.

α-blockers: Prazosin, Phentolamine - are less selective, therefore they have many complications (risk of stroke, heart failure). The only positive aspect is the ability to lower cholesterol levels, which is important for all hypertensive patients. Rarely prescribed;
Rauwolfia alkaloids: “Reserpine”, “Raunatine”. They have many side effects, but are cheap, so they are still used by patients, often for self-medication;
α2-agonists central action: “Clonidine”, “Methyldopa”, “Dopegit”. Act on the central nervous system. Adverse reactions are typical (drowsiness, lethargy, headaches). But for certain groups of patients they are simply irreplaceable: safe in pregnant women (Methyldopa), since they do not penetrate the placental barrier;

Direct acting vasodilators: Dibazol, Apressin. Due to the dilation of blood vessels, they cause a quick effect, but long-term use leads to insufficient oxygen supply to the brain. It is used more often in the form of one-time injections as an aid.

We have given only some of the names of the drugs; there are many more. All products are freely sold in pharmacies without a prescription. Doses and dosage regimens should be prescribed only by a cardiologist.

Reasons for the ineffectiveness of tablets

All reasons for the lack of effect of antihypertensive therapy can be divided into medical and subjective. The latter are associated with mistakes that patients make when treating hypertension. Let's look at them in more detail.

What depends on the patient

Treatment of hypertension is a complex, long-term process in which there are no details. If you take the doctor’s recommendations lightly, your blood pressure remains high after taking the pills:

Failure to comply with the dose and dosage regimen. A situation often arises: after a month of prescribed treatment, the patient’s well-being improves, and he decides to “save” a little - he begins to take either a reduced dose or reduce the frequency of administration. This is wrong because everything modern drugs for hypertension are depot medications. They are designed to prevent a surge in pressure, and not to fight a fait accompli. If the dosage is not followed, no accumulation occurs in the body. active substance and another pill taken sporadically may not work;

Self-replacement of medication. For the same reason, hypertensive patients independently look for analogues of the prescribed pills. Often, out of ignorance, they buy products with a different mechanism of action, guided only by price. As a result, the pressure does not decrease, since each case of hypertension is individual and requires careful selection effective remedy treatment;
Alcohol and other bad habits. Not a single drug will help a patient who continues to ruin his health and stimulate the development of the disease harmful substances. Alcohol, nicotine, and drugs nullify any competent treatment of this disease;
Poor nutrition and lifestyle. In most cases, the doctor explains to the patient that half the success of fighting high blood pressure lies in changes in diet and lifestyle. It is necessary to exclude caffeine (coffee, strong tea), salt (sodium retains water and leads to an increase in circulating blood volume), stress and heavy physical labor. The latter factors “work” through the central nervous system, which gives the command to spasm blood vessels during the body’s response to stress. Traditional antihypertensive drugs cannot cope with this mechanism, so blood pressure does not decrease;

Accompanying illnesses. Obesity, diabetes, kidney pathology and other chronic diseases always aggravate hypertension. If a person does not treat concomitant pathologies, then blood pressure will always increase even with specific therapy;
Concomitant use of medications that reduce the effect of antihypertensive drugs. Often the patient does not attach importance to this information and does not communicate it to the cardiologist. In the meantime, drugs such as Aspirin, Indomethacin, Voltaren, Diclofenac, Ortofen and even some drops for the common cold block most antihypertensive drugs.

Sometimes the reason for blood pressure resistance to drugs lies in a defect in the tonometer or non-compliance with the rules for measuring pressure. Devices require regular verification in specialized medical equipment laboratories. The procedure is carried out only while sitting, the feet are flat on the floor, and the arm is in a relaxed, bent state. The tonometer cuff is located strictly at the level of the heart.

What depends on the doctor

Medical errors leading to prescription ineffective drugs, are not uncommon. After all, for a complete selection the right medicine time is required: the patient must go to the hospital, where, after a full examination, the doctor will individually select an antihypertensive drug under constant supervision and laboratory control.

You don't see this approach very often. And a quick appointment at the clinic does not facilitate the collection of a detailed medical history. As a result, the patient leaves with recommendations that most often “work” according to the experience of this cardiologist.

For a competent purpose antihypertensive drug The doctor is required to:

Collect a detailed medical history (the time of onset of the first health problems, information about concomitant diseases, what medications were prescribed for treatment, what kind of lifestyle the patient leads, and even where he works). Such a conversation takes time, but half the success depends on it;
Conduct additional research. Often a person is unaware of the presence of a disease leading to a secondary increase in blood pressure. This can be not only heart disease, but also kidney, adrenal gland, thyroid and many others;
It is imperative to schedule a follow-up visit for the patient if inpatient examination is not possible. During the second meeting, which usually takes place after a week, it becomes clear how the drug works, whether it causes side effects or is well tolerated.

Medicines tend to be addictive. If today pills normalize blood pressure, then after a year they often become ineffective. The patient needs to visit a cardiologist regularly to adjust the prescribed treatment.

What to do if blood pressure does not decrease

Any hypertensive patient should know the algorithm of their actions if blood pressure does not drop after taking the usual pills. Not only his health, but often his life depends on this.

Continue to fight your blood pressure on your own if it does not exceed 180/100 mmHg. Art. If the numbers are large, call an ambulance, otherwise the risk of stroke and heart attack increases many times over;
Emergency therapy drugs - Captopril and Nifedepine, which are available in tablets and sprays, act within 30 minutes. But the effect lasts only a few hours. If your blood pressure has risen to high levels, it is better to consult a doctor after taking these medications, as the crisis may recur;
Acupuncture. Experience Chinese medicine effective in some cases. We find the depression under the earlobe, first press on it, then draw along the skin to the middle of the collarbone. We do everything symmetrically on both sides several times;
Blood pressure due to stress requires additional treatment sedatives. The lightest are tinctures of valerian, motherwort, and peony;
Thermal procedures for calf muscles(mustard plasters, hot baths, compress with apple cider vinegar for 10 minutes) lead to blood redistribution and a slight decrease in pressure. Contraindications - varicose veins veins

You shouldn’t get carried away with folk methods for a long time. If after such procedures the pressure does not decrease within an hour, seek qualified medical help.

Normal configuration of the heart: normal boundaries of relative and absolute dullness, normal length and diameter of the heart, the waist of the heart is not changed, cardiophrenic angles are determined (especially the right one).

The width of the heart is the sum of two perpendiculars lowered onto the length of the heart: the first - from the point of transition of the left border of the vascular bundle of the heart to the upper limit of the relative dullness of the heart and the second - from the point of the hepatic-cardiac angle.

The diameter of the relative dullness of the heart is 11-13 cm. The contours of cardiac dullness can be marked with dots on the patient’s body, marking the boundaries of dullness according to the emerging dullness. By connecting them, the contours of relative dullness are obtained.

Diagnostic value. Normally, the width of the vascular bundle is 5-6 cm. An increase in the size of the diameter of the vascular bundle is observed with atherosclerosis and aortic aneurysm.

LIMITS OF RELATIVE AND ABSOLUTE DULLNESS OF THE HEART. DETERMINATION TECHNIQUE. DIAGNOSTIC VALUE. HEART SIZES. LENGTH, TRANSVERSE OF THE HEART, WIDTH OF THE VASCULAR BAND IN NORMAL AND IN PATHOLOGY. DIAGNOSTIC VALUE.

Limits of relative dullness of the heart.

Right border. First, find the level of the diaphragm on the right in order to determine general position hearts in the chest. Along the midclavicular line, deep percussion determines the dullness of the percussion sound corresponding to the height of the dome of the diaphragm. Make a mark along the edge of the pessimeter finger facing the clear sound. Count the edge. Next, the lower border of the pulmonary margin is determined by quiet percussion. They also make a mark and count the edge. This is done in order to determine the position of the heart. The further description of the technique refers to the normal position of the diaphragm dome. Usually the border of the lung is at the level of the VI rib, and the dome of the diaphragm is located 1.5-2 cm higher in the V intercostal space. The next stage of the study - the finger-pessimeter is installed vertically, parallel to the desired border of the heart along the midclavicular line, in the 4th intercostal space, and percussed with deep palpagoral percussion towards the sternum until the sound becomes dull. It is first recommended to count the ribs and make sure that percussion is carried out in the fourth intercostal space. Next, without removing the pessimeter finger, make a mark along its outer edge and measure the distance of this point to the right edge of the sternum. Normally, it does not exceed 1.5 cm. Now let us explain why percussion should be carried out no higher than the fourth intercostal space. If the dome of the diaphragm is located at the level of the VI rib, the right border must be determined along the V intercostal space, V rib, IV intercostal space and IV rib. By connecting the resulting points, we can make sure that the IV intercostal space is the point of relative dullness of the heart that is furthest to the right. You should not percussion higher, since the base of the heart, the third costal cartilage, and the right atriovasal angle are already close there.

Upper border of the heart. Deep palpation percussion is used to examine from the first intercostal space down a line parallel to the left edge of the sternum and spaced 1 cm from it. Having detected a dullness, a mark is made along the outer edge of the pessimeter finger. IN normal conditions the upper border is located on the third rib (upper, lower edge or middle). Next, you need to count the ribs again and make sure that the examination is correct by repeated percussion. The superior border is formed by the left atrial appendage.

Left border of the heart. Percussion begins from the anterior axillary line in the 5th intercostal space and moves medially to the area where the apical impulse was found. The pessimeter finger is positioned vertically, i.e., parallel to the desired boundary. When a distinct dullness of the percussion sound is obtained, a mark is made along the outer edge of the finger facing the clear pulmonary sound. Under normal conditions, this point is located medially to the midclavicular line. The left contour of the heart can be obtained by percussing in a similar way in the IV intercostal space, along the IV, V, VI ribs. In cases where the apex beat of the heart is not detected, it is recommended to percussion not only in the 5th intercostal space, but also at the level of the 5th and 6th ribs, and, if necessary, along the 4th and 6th intercostal spaces. With pathology, it is possible to identify various pathological configurations of the heart if you also add percussion in the third intercostal space.

Standing height of the right atrioventral angle. The pessimeter finger is installed parallel to the ribs on the found right border so that the first phalanx reaches the right sternal line. Percuss with quiet upward percussion until slight dullness occurs. A mark is made along the lower edge of the phalanx. Normally, it should be located on the third costal cartilage at its lower edge, approximately 0.5 cm to the right of the right edge of the sternum. Let me explain; the right border of the heart was determined by deep percussion by dullness of sound. When determining the atriovasal angle, superficial percussion is used, in which the sound here becomes pulmonary. Dullness of sound at the level of the atriovasal angle is caused by the structures of the vascular bundle, in particular the superior vena cava and the nearby aorta. If the described method for determining the height of the right atriovasal angle does not produce results, you can use the second method: continue to the right the upper border of the heart and with quiet percussion percussion to the right of the midclavicular line along the third rib to the sternum until dullness. If this method does not provide convincing data, you can take a conditional point: the lower edge of the third costal cartilage at the right edge of the sternum. With good percussion technique, the first method gives good results. The practical value of determining the right atriovasal angle lies in the need to measure the length of the heart.

Measuring the size of the heart.

According to M.G. Kurlov: the length of the heart is the distance from the right atriovasal angle to the leftmost point of the heart contour. The diameter of the heart is the sum of two distances: the right and left borders of the heart from the midline of the body. According to Ya.V. Plavinsky: The patient's height is divided by 10 and 3 cm is subtracted for the length and 4 cm for the diameter of the heart. The limit of absolute dullness of the heart. The boundaries of absolute dullness of the heart and the part of the right ventricle not covered by the lungs are determined by quiet percussion. The upper limit is examined along the same line as the upper limit of the relative dullness of the heart. It is good to use threshold percussion here, when the pulmonary sound is barely audible in the zone of relative dullness of the heart and completely disappears as soon as the pessimeter finger takes a position in the zone of absolute dullness. A mark is made along the outer edge of the finger. Under normal conditions, the upper limit of absolute cardiac dullness passes along the fourth rib. The right tranche of absolute cardiac dullness is determined along the same line along which the right border of relative cardiac dullness was examined. The pessimeter finger is placed vertically in the fourth intercostal space and, using the minimal percussion method, is moved inward until the pulmonary sound disappears. A mark is made along the outer edge of the pessimeter finger. In normal conditions, it coincides with the left edge of the sternum.

Measurement of the width of the vascular bundle. The vascular bundle is located above the base of the heart behind the sternum. It is formed by the superior vena cava, aorta and pulmonary artery. The width of the vascular bundle is slightly greater than the width of the sternum. Minimal percussion is used. The pessimeter finger is placed on the right along the midclavicular line in the 2nd intercostal space, and percussion is directed towards the sternum. A mark is made along the outer edge of the finger. The same study is carried out in the 2nd intercostal space on the left, then in the 1st intercostal space on the left and right. Under normal conditions, the width of the vascular bundle is 5-6 cm. Fluctuations are possible from 4-4.5 to 6.5-7 cm depending on the gender, constitution and height of the patient. An increase in the width of the vascular bundle can occur with an aneurysm of the aorta, its ascending section and arch, with tumors of the anterior mediastinum, mediastinitis, compaction of the lungs in the study area, enlarged lymph nodes

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LIMITS OF RELATIVE AND ABSOLUTE DULLNESS OF THE HEART. DETERMINATION TECHNIQUE. DIAGNOSTIC VALUE. HEART SIZES. LENGTH, TRANSVERSE OF THE HEART, WIDTH OF THE VASCULAR BAND IN NORMAL AND IN PATHOLOGY. DIAGNOSTIC VALUE.

Limits of relative dullness of the heart.

Measuring the size of the heart.

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Normal values for the boundaries of cardiac dullness

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Normal values for the boundaries of cardiac dullness