Diagnosis of heart failure

Diagnosis of left ventricular heart failure

Clinical examination. In the physical examination of the cardiovascular system, left ventricular failure is manifested by an increase in the left ventricle, percussion - by widening the boundaries of relative cardiac dullness to the left. The decrease in the contractility of the myocardium is manifested by the deafness of the heart tones, mostly the I tone at the tip, and the appearance of additional tones: proto diastolic III tone (due to increased pressure in the left heart and a decrease in myocardial tone) and presystolic IV tone. The latter appears as a result of increased pressure in the left atrium and, as it were, listening to the systole of the atria. Tones III and IV are listened to at the top of the heart, often they merge and form the so-called summation rhythm of the canter. Often, III and IV tones are heard in healthy children, especially with the vagotonic orientation of vegetative support. With normal heart boundaries and the absence of other signs of heart failure, these phenomena can be considered as physiological.

Instrumental methods. Diagnosis of left ventricular failure is also based on data from instrumental survey methods. So, the most informative in this respect are the ECG data: the size of the cavity of the left atrium, the left ventricle, the size of the ejection fraction. With left ventricular failure, these indicators can vary significantly. The pronounced enlargement of the left atrial cavity, as a rule, reflects a high degree of overload of the small circle of blood circulation and coincides with the clinical signs of pulmonary hypertension. The enlargement of the left atrium is in some cases more important than an increase in the left ventricular cavity. Undoubtedly, the most informative echocardiographic index of reducing the contractile function of the left ventricle is to recognize the change in the ejection fraction, on average it is 65-70%, this is the derivative of the end-systolic and end-diastolic diameters of the left ventricle. Thus, the smaller the difference between these values, i.e. The smaller the mobility of the walls of the left ventricle, the more pronounced stagnant phenomena are observed in the left ventricular type.

Essential and mandatory addition in the survey is Doppler EchoCG, which allows to determine the blood flow velocity, pressure in the heart cavities, the presence and volume of pathological blood discharge.

Before clinical use of the echocardiographic method was widely used, the decrease in myocardial contractility was judged by the reduction of cardiac pulsations during cardiac fluoroscopy. And at the present time, the X-ray method of examination should not be forgotten, if only for the reason that unexpected findings can be revealed during the chest x-ray. Therefore, the radiography of the heart in three projections (direct and two oblique) should complement the other methods of examination. An objective indicator of an increase in the size of the heart is an increase in the cardio-thoracic index, determined by the ratio of the width of the heart's shadow to the width of the chest. Normally, the cardiothoracic index does not exceed an average of 50%, although for each age there are certain regulatory indicators. Some exception may be small children, sometimes against the background of flatulence because of the high standing of the diaphragm, an imitation of an increase in the shadow of the heart in a diameter is possible.

Undoubtedly, the ECG was and remains an informative method of examination, since the ECG survey technique is objective and does not depend on the skill and qualification of the researcher to the same extent as Echocardiography and radiography.

Since left ventricular failure necessarily involves an increase (overload) of the left heart, then the corresponding changes are detected on the ECG.

On the ECG signs of overload of the left atrium are recorded: an increase in the duration of the P wave, a change in the shape of the P wave (bicircular in the leads I, V,), the presence of a pronounced negative phase in the lead V; also signs of an overload of the left ventricle: R in V6> R in V5> R in V4> 25 mm; secondary changes in the ST-T segment in the left thoracic leads.

Electrocardiographic signs of augmentation of the left atrium (P-mitrale) appear even with quite pronounced clinical manifestations of left ventricular failure, i.e. To a certain extent, an increase in the left atrium is a demonstration of increased pressure in a small circle of circulation. Increased pressure in a small circle of blood circulation leads to an overload of the right divisions, in particular the right atrium.

According to some features of ECG, it is possible to assume the morphological reason (basis) of the revealed changes. Thus, with an increase in left ventricular muscle mass due to hypertrophy of its walls, a moderate increase in the voltage of the QRS complex, as well as a shift of the ST segment below the isoline (depression), as a sign of concomitant subendocardial left ventricular myocardial ischemia, is possible.

In addition to signs of an increase in the left atrium and left ventricle, signs of right atrial overload are seen in the form of a pointed positive phase of the P wave and signs of subendocardial left ventricular ischemia in the form of ST segment depression in V6 lead.

In these leads also possible (but not necessarily) the appearance of a deepened tooth 0. Because of the relative deficiency of coronary blood flow.

In cases of cardiosclerosis, for example, with congestive cardiomyopathy or chronic myocarditis with an outcome in cardiosclerosis, the voltage of QRS complexes can be reduced in standard leads, and in the leads V1-V3-4, the appearance of QS form is possible .

Diagnosis of right ventricular heart failure

Clinical examination. In the physical examination of the cardiovascular system, percussion expansion of the boundaries of relative cardiac dullness to the right is possible, but even with a large increase in the right ventricular cavity, the bisternal heart hump is more pronounced. Palpation is determined by epigastric pulsation associated with an increase and volume overload of the right ventricle (cardiac shock).

Auscultative changes in the heart depend on the nature of the underlying disease. In the presence of pulmonary hypertension, there are some characteristic changes in the II tone in the second intercostal space on the left. This may be a splitting of the II tone, which is normal in healthy individuals on inhalation, because during the inhalation the closure of the pulmonary artery valve is delayed. This "normal" splitting of the second tone on inspiration is heard only in the second intercostal space on the left in the lying position. If the splitting of the second tone is heard at the top, then the patient has pulmonary hypertension. With further increase in pulmonary hypertension, the aortic and pulmonary component of tone II merge, the second tone becomes more accentuated and acquires a metallic tint under high pulmonary hypertension, which is characteristic of primary pulmonary hypertension, as well as secondary, in particular for Aizenmenger syndrome.

An interesting auscultative symptom is the noise along the left edge of the sternum, with the point of maximum listening in the lower third of the sternum arising from tricuspid regurgitation due to the relative insufficiency of the tricuspid valve. If the cause of right ventricular failure is pale vices, in particular an interventricular septal defect, then this noise merges with the main noise (discharge noise) and does not differentiate. If the right ventricular failure appeared for other reasons, for example because of hypertrophic cardiomyopathy, then the noise of tricuspid regurgitation is listened. But significantly decreases with a decrease in the degree of heart failure in parallel with a decrease in the size of the liver (usually on the background of drug treatment).

Instrumental methods.

Echocardiographic and radiographic signs of right ventricular failure are reflected by an increase in the cavity of the right ventricle and the right atrium.

When assessing the severity of heart failure, one should not forget about the general methods of physical examination, in particular about the characteristics of blood pressure. The indices of arterial pressure in heart failure may indicate the severity of the patient's condition. Thus, a decrease in cardiac output leads to a decrease in systolic pressure. However, with good pulse pressure (40-50 mm Hg), the patient's well-being (not a condition - as an indicator of the nearest prognosis depending on the underlying disease) can be satisfactory or even good. With an increase in the total peripheral resistance of blood vessels (OPSS) due to a slowing of blood flow, an increase in the volume of circulating blood and other factors that determine the formation of heart failure, diastolic pressure rises, which necessarily affects the patient's well-being, as the cardiac output decreases. Perhaps the appearance of nausea or vomiting, abdominal pain (right ventricular failure), the appearance or increase in the severity of wet cough (left ventricular failure).

Differential diagnosis of heart failure

Differential diagnosis of the syndrome of heart failure is difficult only for inattentive examination and underestimation of individual symptoms of the condition. So. Quite often in practical work one has to deal with the situation when long-term complaints of abdominal pain and vomiting that arise, as a rule, after physical exertion, are regarded as signs of gastroenterological pathology, although for an adequate assessment of the condition one needs only to conduct a competently complete physical examination of the patient.

There is another extreme: complaints of increased fatigue, perhaps shortness of breath with adequate physical exertion in untrained children and adolescents are considered as a sign of cardiac decompensation.

In some cases (severe course of some childhood infections, complicated pneumonia, sepsis, etc.), heart failure is a complication of the underlying disease. Symptoms of heart failure undergo reverse development against the background of recovery from the underlying disease.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14]