Any change in the position of the heart is due to the rotation of it around three axes: the front-rear (sagittal), longitudinal (long) and transverse (horizontal). The magnitude and direction of the ECG teeth in various leads determine the electrical positions of the heart (Fig. 16).
Fig. 16. Heart rotation scheme around different axes. Arrows show the direction of rotation of the heart: A - around the front-rear axle; B - around the long axis; B - around the transverse axis.
When the heart turns around the front-rear axis (Fig. 16, a), the heart takes either a horizontal or a vertical position that gets the most clear mapping in standard leads. The horizontal position of the heart causes the deviation of its electrical axis to the left, and the vertical position is right. The horizontal and vertical position of the heart is reflected in single-pole leads from the limbs (see above).
The twist of the heart along the long (longitudinal) axis (Fig. 16, b) occurs both clockwise and in the opposite direction and also causes changes in ECG in all leads. Such a rotation is observed under a number of physiological processes: the change of body position, the act of breathing, physical stress, etc.
When the heart rotates around the transverse (horizontal) axis, the top of the heart is shifted or the kaperi or the kice (Fig. 16, B). Rotate the heart around the transverse axis is reflected in single-pole leads from the limbs.
Wilson proposed to determine the electrical position of the heart on the teeth of single-pole inferences and assignments from the limbs. In terms of electrocardiography, 5 heart positions are distinguished: vertical, semi-propical, intermediate, semi-risal and horizontal.
With a vertical electrical position of the heart (angle A is equal to + 90 °), the form of the QRS complex in a one-pole assignment from the left hand is similar from the inference observed in the right positions, and the form of the QRS complex in a one-pole protrusion from the left foot - with the observed in the left positions of infants ( Fig. 17).
Fig. 17. Man's electrocardiogram with a healthy heart in standard thoracic and increased single-pole leads from the limbs with the vertical position of the heart in the chest (the designations are the same as in Fig. 11): 1 - right ventricles; 2 -Ul gastric.
With a half-propical position (the angle α is + 60 °), the form of the QRS complex in a one-pole assignment from the left leg is similar to the observed in the left positions of breasts.
In the intermediate position of the heart (angle A is 4-30 °), the form of the QRS complex in a single-pole protrusion from the left hand and the left leg is similar to the observed in the left positions of breasts.
With a semi-risal heart position (angle A is 0 °), the form of the QRS complex in a one-pole protrusion from the left hand is similar to the observed in the left positions of breasts.
With a horizontal position of the heart (the angle α is -30 °), the form of the QRS complex in a one-pole protrusion from the left hand is similar to the observed in the left positions of infants, and the form of the QRS complex in a one-pole protrusion from the left foot - with the observed in the right positions of infants (rice . eighteen).
Fig. 18. The human electrocardiogram with a healthy heart in standard, chest and enlarged single-pole leads from the limbs with the horizontal position of the heart (the designations are the same as in Fig. 11): 1 - right atrium; 2 - right ventricle; 3 - left ventricle.
In cases where there is no similarity between single-pole breasts and single-pole leads from the limbs, the electrical position of the heart is indefinable. Data x-ray studies have shown that the ECG does not always accurately reflect the position of the heart.
ECG is usually registered in a lying position on the back.
Various positions of the surveyed (vertical, horizontal, on the right or left side), changing the position of the heart, cause a change in ECG teeth.
In the vertical position, the number of heart abbreviations increases, the electrical axis of the heart is rejected to the right. This causes appropriate changes in the magnitude and direction of ECG teeth in standard and breast leads. The duration of the QRS complex decreases. The magnitude of the teeth of T decreases, especially in II and III leads. The RS-T segment in these leads is somewhat shifted down the book.
When positioning on the right side, the electrical axis of the heart is rotated around the long axis counterclockwise, and when it is on the left side - clockwise with appropriate ECG changes.
The shape and direction of the ECG teeth in children differs from the ECG of an adult. In the old age, the teeth of P and T are often reduced. The duration of the R-Q interval and the QRS complex usually on the upper boundary of the norm. With age, the deviation of the electrical axis of the heart is observed. The systolic indicator often slightly increased compared to due.
In women, the amplitude of the R, T and QRS complex is somewhat less in standard and infants. More often there is a shift of the RS-T segment and the negative teeth of T in the III assignment.
The area of \u200b\u200bthe KRS complex is less. The ventricular gradient is less and rejected to the left, the prong U is greater. The duration of the R-Q interval and the QRS complex is on average less. The duration of electrical systole and systolic indicator is greater.
With the prevailing effect on the heart of the parasympathetic department of the autonomic nervous system, the number of heart abbreviations is reduced. The PC is reduced, occasionally increasingly increases. The duration of the R-Q interval slightly increases. The question of the impact of the parasympathetic department for the Tusk T cannot be considered finally clarified. According to one data, the Tusk is decreasing, according to others, it increases. Cut Q-T often decreases.
With the prevailing effect on the heart of the sympathetic department of the autonomic nervous system, the number of heart abbreviations increases. The P teeth usually increases, sometimes decreases. The duration of the P-Q interval decreases. Teeth T, according to one data, increases, on others, decreases.
Positive emotions are little affected by the ECG. Negative emotions (fear, fright, etc.) cause the increase in heart abbreviations, mostly an increase, and sometimes a decrease in the teeth.
During the deep breath due to the offset down the diaphragm, the heart takes a vertical position. The electrical axis deviates to the right, which causes the corresponding ECG changes. It affects the shape of the ECG teeth and enhancing the impact on the heart during the breath of the sympathetic department of the vegetative nervous system. During deep exhalation, the ECG changes are caused by raising the diaphragm, the deviation of the electrical axis of the heart to the left and the prevailing effect on the heart of the parasympathetic department of the autonomic nervous system.
In conventional breathing, these ECG changes are expressed slightly.
Physical stress can cause ECG changes in various ways: to affect the reflex and heart repolarization and directly and directly on the conduction system and contractor myocardium. Usually these paths are combined. ECG changes depend on the degree and duration of these factors.
The pronounced changes of the ECG teeth are observed after a significant physical stress: an increase, and sometimes a non-timbble broadening of the PC; Reducing the duration of the P-Q interval, and sometimes the displacement down due to the leveling of the distribution of the R-TA; a slight decrease in the duration of the QRS complex and often deviation of the electrical axis of the heart to the right, as well as the offset of the RS-T segment; Increased teeth T; Reducing the segment Q-T is proportional to the increase in heart rate; The emergence of an increased teeth U.
The reception of a large amount of food causes the increase in heart rate and reduce the tissue of T (occasionally significant, up to the transition to negative) in II and III leads. Sometimes there is a slight increase in the PC, an increase in the segment of the Q-T and the systolic indicator.
These ECG changes reaches a maximum after 30-60 minutes. After receiving food and after 2 hours disappear.
The changes of the ECG during the day in healthy people are insignificant and concern mainly to the T. T. T. Teeth reaches a maximum value early in the morning, and after breakfast, its smallest.
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Determination of heart turns around the longitudinal axis
To determine the turns of the heart around the longitudinal axis in horizontal plane It is necessary to establish the localization of the transition zone, as well as evaluate the form of the QRS complex in allotment V 6.
Normal heart position in the horizontal plane:
1) the transition zone with the same in the amplitude of the teeth R and S is located in the V 3 assignment;
2) In Decommission V 6, the QRS complex has the form of QRS (Fig. 4.13, a).
Rotate the heart around the longitudinal axis clockwise (If you monitor the rotation of the heart from below from the top side):
1) The transition zone is shifted to the V 4 leading area;
2) In Decommission V 6, the QRS complex has a form RS (Fig. 4.13, b).
Rotate the heart around the longitudinal axis counterclockwise:
1) The transition zone is shifted to the right to the V 2 assignment;
2) In the V 6, the QRS complex takes the view QR (Fig. 4.13, B).
Heart turns around the longitudinal axis clockwise are often combined with the vertical position of the electrical axis of the heart or the deviation of the heart axis to the right, and the turns counterclockwise - with a horizontal position or deviation of the electrical axis to the left.
In fig. 4.14 and 4.15 shows the ECG on which the edges of the heart 3 are determined around the longitudinal axis against and clockwise.
On the ECG, the vertical position of the atrial and ventricular vectors is noted. Â p \u003d + 75 °. Â QRS \u003d + 80 °. The pronounced qes are drawn to the pronounced q, along with high teeth R in leads II, III and AVF, as well as teeth s in leads I and AVL. Transition zone in V 4 -V 5. These features of the ECG could provide grounds for determining the hypertrophy of the right-hand heart departments, but the lack of complaints, the data of the anamnesis, the results of clinical and radiological studies made it possible to exclude this assumption and consider the ECG version of the norm.
"Practical electrocardiography", V.L.Odovcin
Normal ECG with a horizontal position of the electrical axis of the heart should be distinguished from signs of left ventricular hypertrophy. With the vertical position of the electrical axis of the heart, the Tusk R has a maximum amplitude in the AVF, II and III leads, in the AVL and I leads, a pronounced prong of S is recorded, which is also possible in left pectoral leads. ÂQrs \u003d + 70 ° - + 90 °. Such ...
Turning the heart of the top of the Zada \u200b\u200bis accompanied by the appearance of deep teeth S1 in leads I, II and III, as well as in AVF assignment. A pronounced s in all breasts with a shift of the transition zone left can also be observed. This variant of the normal ECG requires differential diagnostics with one of the ECG variants in the hypertrophy of the right ventricle (S-type). Figure shows ...
The syndrome of premature, or early, repolarization refers to relatively rare variants of the normal ECG. The main feature of this syndrome is the rise of the ST segment, which has a peculiar form by convexing an arc book and begins with a highly located point J on a downward knee of a teeth R or on the final part of the S. Zzbinn at the place of transition of the QRS complex to the descending segment of ST ...
A kind of ECG changes are observed in persons with dextrocardia. They are characterized by the opposite compared to the usual direction of the main teeth. Thus, the negative teeth of the P and T, the main tooth of the QRS complex of the QRS complex is detected, is often registered with a QS complex. Deep teeth of Q in breast leads can be marked, which can give a reason for the erroneous diagnosis of large-scale changes ...
A variant of the norm may be an ECG with shallow negative teeth in V1-V3 leads, in young people up to 25 years old (rarely older) in the absence of dynamics from them compared to previously recorded ECGs. Such teeth are known as "juvenile". Sometimes healthy people on ECG in leads V2 - V4 are highlighted high teeth that ...
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4.2.2. Determination of heart turns around the longitudinal axis
The hearts around the longitudinal axis, conditionally spent through the top and the base of the heart, are determined by the configuration of the QRS complex in breasts, the axes of which are located in a horizontal plane (Fig. 66).
To do this, it is usually necessary to establish the localization of the transition zone, as well as evaluate the form of the QRS complex in the V 6 assignment.
With the normal position of the heart in the horizontal plane (Fig. 56, a), the transition zone is known to be most often in the assignment V 3. In this definition, the same teeth of R and S. are recorded.
In the brand V 6, the ventricular complex usually has the form of QRS. At the same time, the Q and S teeth have a very small amplitude. This, as you remember, is due to the corresponding spatial arrangement of three torque vectors (0.02 C, 0.04 C and 0.06 C) shown in Fig. 56, a.
Fig. 56. The shape of the ventricular complex QRS in breasts when the heart turns around the longitudinal axis (modification of the scheme A.Z. Chernova and M.I. Kechkra, 1979. Explanation in the text.
ak can be seen in fig. 56, B, when turning the heart around the longitudinal axis clockwise (if you follow the rotation of the heart from below from the side of the top), the interventricular partition is relatively parallel to the front breast wall, the transition zone is somewhat left to the left, in the lead area 4. In this case, the heart turns in such a way that the direction of the initial vector of the vector (0.02 (C), due to the excitation of the interventricular septum, is almost perpendicular to the axis of the Holding V 6, and therefore the qog cell is no longer registered in this assignment. On the contrary, the direction of the final torque vector (0.06 s) almost coincides with the axis of the V 6 leading. Vector 0.06 ° C is projected on the negative part of the axis of the title V 6, as a result of which a pronounced S. S was recorded on the ECG in this assignment. The RS type is also fixed in the I standard assignment, while in the III assignment there is a form QR.
Remember! Electrocardiographic signs of heart turn around the longitudinal axis clockwise are:
1) QRS complex RS form in the V 6 assignment, as well as in the I standard assignment;
2) the possible shift of the transition zone to the left in the lead is V 4 - V 5.
When the heart turns around the longitudinal axis counterclockwise (Fig. 56, c), the interventricular partition is perpendicular to the front pectoral wall, so the transition zone can be shifted to the right to the V 2 assignment. The initial torque vector (0.02 C) turns out to be almost parallel axis of the V 6's leading axis, in connection with which there is some deepening of the q teeth in this assignment. Teeth q is recorded now not only in V 5.6, but also in the V 4 (less often in V 3). On the contrary, the direction of the final torque (0.06 (C) is almost perpendicular to the axis of the V 6 leading, so the Tusk S is not expressed in this assignment. The same form has the QRS complex in the I Standard Decommission (QR).
Remember! Electrocardiographic signs of the turn of the heart around the longitudinal axis counterclockwise are:
1) QRs complex QR forms in Deletion V 6, as well as in the I standard assignment;
2) possible displacement of the transition zone to the right to the V 2 assignment.
It should be added that the turns of the heart around the longitudinal axis clockwise are often combined with the vertical position of the electrical axis of the heart or the deviation of the heart axis to the right, and the turns counterclockwise - with a horizontal position or the deviation of the electrical axis of the heart left.
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Signs of the pulmonary heart
Clinical manifestations of the pulmonary heart
The likelihood that the doctor diagnoses the patient with a pulmonary heart depends on how much it realizes that the disease that exists in a patient may entail the pulmonary hypertension. The correct diagnosis is usually placed in the presence of refrigerant circuit in the vessels of the pulmonary circulation, for example, with multiple embolism in the pulmonary trunk. The diagnosis of pulmonary heart is not so obvious in obstructive diseases of the respiratory tract due to the fact that the clinical manifestations of chronic bronchitis and bronchiolites may be less pronounced, and the clinical indices of pulmonary hypertension are not very reliable. Of course, the first attack of pulmonary hypertension and the pulmonary heart, developed secondly due to the presence of chronic bronchitis, can be diagnosed only retrospectively, that is, after the development of the obvious episode of the right-hand deficiency. Diagnostics can be particularly difficult if the systemic venous stagnation and peripheral edema develops secretly, within days or weeks, and not suddenly, as it happens with sharp bronchopal infections. Recently, a lot of attention is paid to the problem of the gradual development of the pulmonary heart and the right-hand deficiency in patients with alveolar hypoventilation, which is one of the manifestations of apnea syndrome in a dream, and not the result of the disease itself.
Differential diagnosis
The presence of a pulmonary heart is especially important to establish in elderly patients when the likelihood of sclerotic changes in the heart is high, especially if for many years they are worried about cough with a wet branch (chronic bronchitis) and there are obvious clinical manifestations of destroying failure. The determination of the gas composition of blood is most informative if necessary, to determine which of the ventricles (right or left) is the root cause of heart disease, since pronounced arterial hypoxemia, hyperkapinia and acidosis are rarely found in the lack of a left heart, unless simultaneously develop the lung edema.
Additional confirmations of the diagnosis of the pulmonary heart give X-ray and ECG signs of increasing the right ventricle. Sometimes, if the pulmonary heart is suspected, the catheterization of the right heart departments is required. In the case of this study, it is revealed, as a rule, hypertension in the pulmonary trunk, normal pressure in the left atrium (pressure of the pulmonary trunk) and the classical hemodynamic signs of the deficiencies of the right ventricle.
The increase in the right ventricle is characterized by the presence of a heartfold along the left border of the sternum and the IV of the heart tone arising in the hypertrophic ventricle. About the concomitant pulmonary hypertension is assumed in cases where the heart pusher is detected in the second left intercostal age near the sternum, the unusually loud 2nd component II of the heart tone in the same region and sometimes in the presence of noise of lack of valve of the pulmonary trunk. With the development of the deficiency of the right ventricle, the additional tone of the heart often accompanies, which causes the occurrence of the rhythm of the rhythm of the right ventricle. The hydrotorax rarely occurs even after the appearance of explicit right-minded failure. Permanent arrhythmias, such as flickering or fluttering atrial, are also rare, but transient arrhythmias usually arise in the case of severe hypoxia when the respiratory alkalosis appears caused by mechanical hyperventilation. The diagnostic value of electrocardiography at a pulmonary heart depends on the severity of changes in lungs and ventilation disorders (Table 191-3). This is the most valuable in vascular diseases of the lungs or damage to the interstitial tissue (especially in cases where they are not accompanied by the exacerbation of respiratory diseases), or with alveolar hypoventilation in normal lungs. On the contrary, at a pulmonary heart, developed secondly due to chronic bronchitis and emphysema, an increase in the light and episodic nature of pulmonary hypertension and overloading of the right ventricle, the diagnostic signs of the right ventricular hypertrophy are rare. And even if the increase in the right ventricle due to chronic bronchitis and emphysema is quite pronounced, as it happens during exacerbations during the infection of the upper respiratory tract, ECG signs may be inconclusive as a result of rotation and heart offset, increase the distance between the electrodes and the surface of the heart, the predominance of dilatation over hypertrophy with increasing heart. Thus, a reliable diagnosis of increasing right ventricle can be put in 30% of patients with chronic bronchitis and emphysens, in which the right ventricle hypertrophy is detected with autopsy, while such a diagnosis can be easily and reliably installed in a significant majority of patients with a pulmonary heart. Pathology of lungs other than chronic bronchitis and emphysema. Having in mind, it is more reliable criteria for hypertrophy of the right ventricle in a patient with chronic bronchitis and emphysens, the following are presented: S 1 Q 3 -typ, deviation of the electrical axis of the heart of more than 110 °, S 1. S 2. S 3 -typ, R / S ratio in V6 assignment<1,0. Сочетание этих признаков увеличивает их диагностическую ценность.
Table191-3. ECG signs of chronic pulmonary heart
1. Chronic obstructive lung diseases (probable, but not diagnostic signs of increasing the right ventricle) a) "P-Pulmonale" (in leads II, III, AVF) b) deviation of the heart axis to the right more than 110 ° C) R / S ratio in V6< 1. г) rSR в правых грудных отведениях д) блокада правой ножки пучка Гиса (частичная или полная)
2. Diseases of pulmonary vessels or interstitial lung tissue; General alveolar hypoventilation (diagnostic signs of increasing right ventricular) a) classical features in V1 or V3R (dominant R or R with inverted T. Teeth in right-wing infants) b) is often combined with the likely criteria indicated above
Among the probable criteria is difficult to distinguish those that reflect the increase in the right ventricle (hypertrophy and dilatation) on the anatomical changes and changes in the electrical axis of the heart caused by an increase in light airiness. Accordingly, the probable criteria as a supporting circumstance are more useful than diagnostic.
X-ray has a large diagnostic value in suspected an increase in the right ventricle or to confirm such a state than to identify it. Suspicions arise in cases where the patient has signs of the previously predisposing disease of the lungs associated with large central pulmonary arteries and a trimmed peripheral arterial network, that is, the signs of pulmonary hypertension. A series of radiological studies has a large diagnostic value than a single definition of heart sizes, especially in obstructive respiratory diseases, when significant changes in heart dimensions may occur during periods between exacerbations of acute respiratory failure and remission.
In recent years, echocardiography, based on registration of the motion of the pulmonary trunk, began to use pulmonary hypertension. This technique is quite complicated, but it is gaining popularity.
Diagnosis and examination - chronic pulmonary heart
Page 4 of 5
Laboratory and instrumental diagnostics
In clinical analysis of blood in patients with chronic pulmonary heart, in most cases, erythrocytosis is revealed, an increase in hematocrit and hemoglobin content, which is very characteristic of chronic arterial hypoxemia. In severe cases, polycythemia is developing with an increase in the content of platelet and leukocytes erythrocytes. The decrease in ESP is often associated with an increase in blood viscosity, which is also naturally observed in many patients suffering respiratory failure
The described changes in blood tests are naturally not direct evidence of the presence of a pulmonary heart, but they usually indicate the severity of pulmonary arterial hypoxemia - the main level of the pathogenesis of the chronic pulmonary heart
With an electrocardiographic study, signs of hypertrophy of the right ventricle and PP are detected in patients with chronic pulmonary heart. The earliest ECG changes are the appearance in leads II, III, AVF (sometimes in v1) high amplitudes (more than 2.5 mm) with a pointed peak of the P - Pulmonale, and their duration does not exceed 0.10 s.
The ECG signs of the right ventricle hypertrophy be revealed somewhat later. Depending on the level of pressure in the pulmonary artery of the magnitude of the muscular mass of the right ventricle and the severity of the accompanying emphysema of the lungs in patients with a pulmonary heart, three types of ECG changes can be revealed:
rSR '- MUN PABUDED at moderate hypertrophy of the right ventricle when its mass is approaching the mass of LV myocardium or somewhat less (Fig. 1):
- the appearance of the RSR type QRS type V1
- increase the amplitude of the teeth R v1,2. S v5, 6, with an amplitude RV1\u003e 7 mm or
RV1 + S V5,6\u003e 10 5 mm,
transition zone to the left to leads V5, V6 and appearance in leads V5, V5 complex QRS type RS)
III, AVF, VL, V2,
qR - MUN is detected with pronounced hypertrophy of the right ventricle when its mass is somewhat larger than the mass of LV myocardium. For this type of ECG-change characteristic (Fig. 2):
- the appearance of QR or QR or QR type
- an increase in the amplitude of the teeth RV1 and SV5.6, while the amplitude RV1\u003e 7 mm or
RV1 + S V5, 6\u003e 10 5 mm,
transition zone to the left to leads V5, Vb and appearance in leads V5, V6, QRS complex type RS),
keeping (VI) more than 0.03 s,
III, AVF, V1, V2,
Thus, the main differences between these two types of ECG changes in hypertrophy of the right ventricle are in the form of the QRS complex in the V1 assignment.
S - MUN ECG changes is often observed in patients with severe emphysema lungs and chronic pulmonary heart when the hypertrophied heart sharply shifts the kice predominantly due to emphysema. At the same time, the ventricular depolarization vector is projected into negative parts of the axes of breasts and leads from the limbs (signs of the head of the heart around the transverse axis of the stopper) This explains the essential features of the changes in the QRS V complex of these patients (Fig. 3):
- in all breastless leads from V1 to VB, the QRS complex has the form of RS or RS with a pronounced teeth S
- in leads from the limbs is often registered by Sisiisiii syndrome (sign
gate of the heart around the transverse axis of the top for the hollow)
arrow (displacement of the transition zone to the left to leads V5, V6I appearance in leads V5, V6 complex QRS type RS)
Fig.1. ECG patient with chronic pulmonary heart Fig.2 ECG patient with chronic pulmonary heart
Fig. 3. ECG patient with chronic pulmonary heart (P-Pulmonale and S- type of hypertrophy of the right ventricle)
It should be noted that with all three types of ECG-changes, the diagnosis of PJ hypertrophy is indirectly confirmed by the presence of signs of hypertrophy of PP observation of the pulmonary heart, pulmonary hypertension, right ventricle
Rotate Heart clockwise
The rotation of the heart around its longitudinal axis, carried out through the base and top of the heart, according to GRANT, does not exceed 30 °. This rotation is considered by the top of the heart. The initial (q) and finite (s) vectors are projected on the negative half of the axis of the title V., so the QRSv6 complex has the form QRS (the bulk of the loop QRS K + V6). The same form has a QRS complex in leads I, II, III.
Ti Ti Negative, shallow. Tavf prong positive. TV1 smoothed. The TV2-V6 is a positive, low increases somewhat to the V3, V4 assignment.
ECG a healthy woman Z., 36 years old. Sinus (respiratory) arrhythmia. The number of reductions 60 - 75 in 1 min. Interval R-Q \u003d 0.12 seconds. P \u003d 0.08 sec. QRS \u003d 0.07 seconds. Q - T \u003d 0.35 seconds. R,\u003e R1\u003e R1II. AQRS \u003d + 44 °. AT \u003d + 30 °. Corner QRS - T \u003d 14 °. Ar \u003d + 56 °. Complex QRS1, V5, V6 type QR. QRSIII type RR's. The RV1 is slightly increased (6.5 mm), but RV1 Other teeth and ECG segments without deviation from the norm. PP (1.8 mm)\u003e P1\u003e RPG vector P is aimed down to the left of the axis of the lead. The average QRS vector in the horizontal plane (breast leads) is parallel to the axis of the V4 leading (the highest R in the V4 assignment). TIII smoothed, TAVF positive. Materials for accommodation and wishes, please send to the address Sending material to accommodate you agree that all rights to it belong to you When quoting any information, back link to MedUniver.com - Mandatory All information provided is subject to mandatory advice by the attending physician. The administration reserves the right to delete any information provided by the user. The rotation of the heart around its longitudinal axis, carried out through the base and top of the heart, according to GRANT, does not exceed 30 °. This rotation is considered by the top of the heart. The initial (q) and finite (S) vectors are projected on the negative half of the axis of the leading axis V. Therefore, the QRSv6 complex has the form QRS (the main part of the QRS K + V6 loop). The same form has a QRS complex in leads I, II, III. The turn of the heart clockwise corresponds to the position of the right ventricle somewhat more kpeed, and the left ventricle is somewhat more expensive than the usual position of these heart chambers. At the same time, the interventricular partition is almost parallel to the frontal plane, and the initial QRS vector reflecting the electromotive force (EMF) of the interventricular partition is oriented almost perpendicular to the frontal plane and to the axes of assignments I, V5 and V6. It also slightly deflects up and left. Thus, when you turn the heart clockwise around the longitudinal axis, the RS complex is recorded in all breasts, and in standard leads - RSI and QRIII complexes. ECG healthy man M, 34 years old. Rhythm sinus, correct; The heart rate is 78 in 1 min. (R-R \u003d 0.77CEK.). Interval P - Q \u003d 0.14 seconds. P \u003d 0.09 sec. QRS \u003d 0.07 seconds. (Qiii \u003d 0.025 sec.), D. \u003d 0.34 seconds. RIII RII RI SOI. AQRS \u003d + 76 °. AT \u003d + 20 °. Ap \u003d + 43 °. ZQRS - T \u003d 56 °. Teeth PI-III, V2-V6, AVL, AVF positive, not higher than 2 mm (II lead). PV1 Teeth is two-phase + -) with a greater positive phase. QRSR complex type RS, QRSIII type QR (q expressed, but not advanced). Complex QRSV | _ "Type RS. QRSV4V6 type RS or RS. The transition zone of the QRS complex in the V4 assignment (norm). The RS segment - TV1 _ V3 is shifted up at no more than 1 mm, in other leads it is at the level of the isoelectric line. Ti Ti Negative. Shallow. Tavf prong positive. TV1 smoothed. The TV2-V6 is a positive, low increases somewhat to the V3, V4 assignment. Vector analysis. The lack of Qiv6 (RSI, V6 type) indicates the orientation of the initial QRS vector forward and left. This orientation may be associated with the location of the interventricular partition parallel to the thoracic wall, which is observed when the heart is rotated clockwise around its longitudinal axis. The normal location of the QRS transition zone shows that in this case, the hourly turn is one of the variants of the normal ECG. The weakly negative TIII teeth with a positive TAVF can also be regarded as the norm. Conclusion. Option of normal ECG. Vertical position of the electrical axis of the heart with a turn around the longitudinal axis clockwise. The interventricular partition is almost perpendicular to the frontal plane. The initial QRS vector is oriented to the right and slightly downwards, which determines the presence of a pronounced KI, V5V6 teeth. In these leads there is no teeth S (form qri, v5, v6, since the base of the ventricles occupies the more rearmost position and the final vector is oriented back and left. ECG healthy woman Z. 36 years. Sinus (respiratory) arrhythmia. The number of reductions 60 - 75 in 1 min. Interval R-Q \u003d 0.12 seconds. P \u003d 0.08 sec. QRS \u003d 0.07 seconds. Q - T \u003d 0.35 seconds. R, R1 R1II. AQRS \u003d + 44 °. AT \u003d + 30 °. Corner QRS - T \u003d 14 °. Ar \u003d + 56 °. Complex QRS1, V5, V6 type QR. QRSIII type RR's. The RV1 is slightly increased (6.5 mm), but RV1 SV1, and RV2 SV2. The described changes in the QRS complex are associated with the rotation of the initial vector of the right and final vectors to the left, up and forth. This position of the vectors is due to the rotation of the heart counterclockwise around the longitudinal axis. Other teeth and ECG segments without deviation from the norm. RP (1.8 mm) P1 RPG vector P is aimed down, to the left of the axis II of the lead. The average QRS vector in the horizontal plane (breast leads) is parallel to the axis of the V4 leading (the highest R in the V4 assignment). TIII smoothed, TAVF positive. Conclusion. A variant of the normal ECG (turning the heart around the longitudinal axis counterclockwise). In the ECG analysis protocol, information on the turns around the longitudinal (as well as transverse) axis of the heart according to ECG data is noted in the description. They are inappropriate to include in conclusion ECG, since they either make up the option of the norm, or are the symptom of the hypertrophy of the ventricle, which should be written in conclusion. When evaluating the ECG, the edges of the heart are also distinguished around the longitudinal axis passing from the base to its top. Rotate with right ventricle forward shifts the transition zone to the left, the teeth s are deepened in leads V 3. V 4. V 5. V 6. The QS complex may be registered in the V 1 allocation. This turn is accompanied by a more vertical arrangement of the electrical axis, which causes the appearance of QR I and S III. Rotate to the left ventricle forward shifts the transition zone to the right, which causes an increase in the teeth R in the leads V 3. V 2. V 1 The disappearance of the teeth S in the left chest leads. This turn is accompanied by a more horizontal location of the electric axis and the registration of QR I and S III in leads from the limbs. The third version of the turns of the heart is associated with its rotation around the transverse axis and is indicated as a turn of the top of the heart forward or backward. Rotate the top of the heart forward is determined on the registration of the Zubes Q in standard leads and the AVF assignment. What is associated with the release of the vector of depolarization of the interventricular partition into the frontal plane and the orientation of it up and right. Turning the top of the heart back is determined by the appearance of teeth S in standard leads and AVF assignment. What is associated with the release of the vector depolarization of the rear-blooded departments into the front plane and the orientation of it up and right. The spatial arrangement of the structures of the initial and final forces depolarization of ventricles has the opposite direction, and their simultaneous registration in the frontal plane is impossible. With three (or four) sy syndrome, there are no teeth of S in these leads. In the syndrome of three (or four) s it becomes impossible to register the keys in the same leads. The combination of the above turns and deviations of the electrical axis of the heart causes the possibility of determining the electrical position of the heart as a normal, vertical and semi-propical, horizontal and semi-rizonal. It should be noted that the definition of the electrical position of the heart has more historical than practical interest, while the definition of the direction of the electric heart axis makes it possible to diagnose intraventricular conduction disorders and indirectly determines the diagnosis of other pathological changes in the ECG. You are interested in holding children's holidays in Ufa. Our agency will help to make any holiday magic and unforgettable for your child. When you turn the heart around the longitudinal axis clockwise (if you look from the top side) the right ventricle goes back and up, and the left is back and down. This position is an option for the vertical position of the heart axis. On the ECG, a deep q teeth appears in allocating III, and occasionally and in the assignment of AVF, which can simulate signs of focal changes in the posteriorofragmal region of the left ventricle. Simultaneously in leads I and AVL, a pronounced teeth S (the so-called syndrome Q III S I) is detected. In leads I, V 5 and V 6 there is no prong Q. The transition zone can shift to the left. These changes are also with an acute and chronic increase in the right ventricle, which requires the relevant differential diagnosis. The figure shows the ECG of a healthy woman 35 years of asthenic physique. There are no complaints about heart and lung functions. In the history of diseases capable of due to the hypertrophy of the right heart, no. In physical and x-ray examination of pathological changes in the heart and the lungs have not been detected. On the ECG, the vertical position of the atrial and ventricular vectors is noted. Â p \u003d +75. Â QRS \u003d +80. The pronounced qes are drawn to the pronounced q, along with high teeth R in leads II, III and AVF, as well as teeth s in leads I and AVL. Transition zone in V 4 -V 5. These features of the ECG could provide grounds for determining the hypertrophy of the right-hand heart departments, but the lack of complaints, the data of the anamnesis, the results of clinical and radiological studies made it possible to exclude this assumption and consider the ECG version of the norm. Rotate the heart around the longitudinal axis counterclockwise (i.e., left ventricle forward and up), as a rule, combined with the deviation of the top left and is a rather rare version of the horizontal position of the heart. For this option, a pronounced Q of Q in leads I, AVL and left chest along with pronounced teeth s in leads III and AVF are characterized. Deep K can might imitate signs of focal changes in the side or front wall of the left ventricle. The transition zone is usually shifted to the right. A typical example of this option is the norm to serve as presented in the drawing of a patient 50 years with a diagnosis: chronic gastritis. On this curve, a pronounced Q of Q in leads I and AVL and a deep teeth s in Deletion III are registered. Practical electrocardiography, V.L.Odovcin Normal ECG with a horizontal position of the electrical axis of the heart should be distinguished from signs of left ventricular hypertrophy. With the vertical position of the electrical axis of the heart, the Tusk R has a maximum amplitude in the AVF, II and III leads, in the AVL and I leads, a pronounced prong of S is recorded, which is also possible in left pectoral leads. ÂQrs \u003d + 70 - +90. Such # 8230; Turning the heart of the top of the Zada \u200b\u200bis accompanied by the appearance of deep teeth S1 in leads I, II and III, as well as in AVF assignment. A pronounced s in all breasts with a shift of the transition zone left can also be observed. This variant of the normal ECG requires differential diagnostics with one of the ECG variants in the hypertrophy of the right ventricle (S-type). The figure shows the # 8230; The syndrome of premature, or early, repolarization refers to relatively rare variants of the normal ECG. The main sign of this syndrome is the rise of the ST segment, which has a peculiar form by convexing an arcon and begins with a highly located point J on a downward knee of a tooth R or on the final part of the S. Zzbinn at the place of transition of the QRS complex to the descending segment ST # 8230; A kind of ECG changes are observed in persons with dextrocardia. They are characterized by the opposite compared to the usual direction of the main teeth. Thus, the negative teeth of the P and T, the main tooth of the QRS complex of the QRS complex is detected, is often registered with a QS complex. Ceffs of q may be occurred in infants, which can give a reason for the erroneous diagnosis of large-scale changes. # 8230; A variant of the norm may be an ECG with shallow negative teeth in V1-V3 leads, in young people up to 25 years old (rarely older) in the absence of dynamics from them compared to previously recorded ECGs. Such teeth are known as juvenile. Sometimes healthy people have an ECG in leads V2 # 8212; V4 marked high teeth of T, which # 8230; The electrical axis of the heart (EOS) is the term used in cardiology and functional diagnostics, reflecting the electrical processes occurring in the heart. The direction of the electrical axis of the heart shows the total amount of bioelectric changes occurring in the heart muscle with each reduction. The heart is a three-dimensional organ, and in order to calculate the direction of EOS, cardiologists represent the chest in the form of a coordinate system. Each electrode during removal registers bioelectric excitation occurring in a particular area of \u200b\u200bmyocardium. If it is possible to calculate the electrodes on the conditional coordinate system, then the angle of the electric axis can be calculated, which will be located where the electrical processes are most stronger. The conductive heart system is the sections of the heart muscle consisting of the so-called atypical muscle fibers. These fibers are well innervated and provide synchronous reduction of the organ. The reduction in myocardium begins with the occurrence of an electrical pulse in a sinus node (which is why the correct rhythm of a healthy heart is called sinus). From the sinus unit, the impulse of electrical excitement passes to the atrocaded-ventricular node and further along the Gisa beam. This bundle passes in the interventricular partition, where it is divided into the right, heading towards the right ventricle, and the left legs. The left feet of the Gis beam is divided into two branches, front and back. The front branch is located in the front sections of the interventricular partition, in the front-winding wall of the left ventricle. The rear branch of the left leg of the Gis beam is located in the middle and lower third of the interventricular partition, the posterior and lower wall of the left ventricle. It can be said that the rear branch is to be several left front. The myocardium conductive system is a powerful source of electrical pulses, which means that electrical changes preceding the heart abbreviation occur in the heart before. With violations in this system, the electrical axis of the heart can significantly change its position.What will be said next. The mass of the heart muscle of the left ventricle is normal significantly larger than the mass of the right ventricle. Thus, the electrical processes occurring in the left ventricle are in total stronger, and the EOS will be directed to it. If you integrate the position of the heart on the coordinate system, then the left ventricle will turn out to be +30 + 70 degrees. This will be the normal position of the axis. However, depending on individual anatomical features and physique the position of the EOS in healthy people ranges from 0 to +90 degrees: The features of the structure for each person are very individual, practically does not occur pure asthenics or hyperstics, more often are intermediate types of physique, therefore the electric axis may have an intermediate value (semi-risal and semi-propal). All five position options (normal, horizontal, semi-risal, vertical and semi-propical) are found in healthy people and are not pathology. So, in the conclusion of the ECG, an absolutely healthy person can be said: "EOS vertical, rhythm sinusov, heart rate - 78 per minute", What is an option for the norm. Heart turns around the longitudinal axis help determine the position of the organ in space and, in some cases, are an additional parameter in the diagnosis of diseases. The definition of the "rotation of the electrical axis of the heart around the axis may well meet in the descriptions to electrocardiograms and is not something dangerous. In itself, the EOS position is not a diagnosis. but there are a number of diseases under which the heart axis displacement is observed. To significant changes in the position of the EOS lead: So, the deviation of the electrical axis of the heart to the left may indicate (GLL), i.e. An increase in it in size, which is also not an independent disease, but may indicate the overload of the left ventricle. This state often occurs with a long time and is associated with a significant resistance of blood flow vessels, as a result of which the left ventricle should be reduced with greater force, the mass of the ventricular muscles increases, which leads to its hypertrophy. Ischemic disease, chronic heart failure, cardiomyopathy also cause left ventricular hypertrophy. hypertrophic changes in myocardial left ventricle - the most common cause of the deviation of the EOS left In addition, the GLB is developing with damage to the left ventricle valve apparatus. To this state, the stenosis of the mouth of the aorta leads, in which the blood release from the left ventricle is difficult, the lack of aortic valve, when part of the blood returns to the left ventricle, overloading it with the volume. These vices can be both congenital and acquired. The most commonly acquired heart defects are a consequence of transferred. Left ventricular hypertrophy is found in professional athletes. In this case, a consultation of a sports physician of high qualifications is necessary to address the issue of the possibility of continuing sports. Also, the EOS is rejected to the left and different. Deviation of email The axis of the heart to the left together with a number of other ECG signs is one of the indicators of the blockade of the front branch of the left feet of the Gis beam. The displacement of the electrical axis of the heart to the right may indicate the hypertrophy of the right ventricle (GPG). Blood from the right ventricle enters the lungs, where it is enriched with oxygen. Chronic respiratory diseases, accompanied, such as bronchial asthma, chronic obstructive pulmonary disease with long flow cause hypertrophy. Stenosis of the pulmonary artery and deficiency of the tricked valve lead to the hypertrophy of the right ventricle. As in the case of the left ventricle, the AGH is caused by ischemic heart disease, chronic heart failure and cardiomyopathy. The deviation of the EOS to the right occurs with the full blockade of the rear branch of the left leg of the Gis beam. None of the above diagnoses can be exhibited on the basis of only the displacement of the EOS. The position of the axis is only an additional indicator in the diagnosis of one or another disease. With the deviation of the axis of the heart, leaving the limits of normal values \u200b\u200b(from 0 to +90 degrees), consultation of a cardiologist and a number of studies are needed. But still the main reason for the displacement of the EOS is myocardial hypertrophy. The diagnosis of hypertrophy of a particular heart of the heart can be exhibited by results. Any disease that leads to the displacement of the heart axis is accompanied by a number of clinical signs and requires an additional survey. The situation should be alarmed when, with the previously existing position, the EOS arises its sharp deviation to the ECG. In this case, the deviation is likely to indicate the occurrence of the blockade. In itself, the displacement of the electrical axis of the heart does not need treatment, refers to electrocardiological features and requires, first of all, to determine the cause of the occurrence. Only a cardiologist can determine the need for treatment.
Electrocardiography (ECG) remains one of the most common methods of examining the cardiovascular system and continues to develop and improve. Based on the standard electrocardiogram, various ECG modifications are proposed and widely used: Holter monitoring, high resolution ECG, samples with dosage exercise, drug samples. The concept of "drive of an electrocardiogram" means registration of an ECG when the electrodes are applied to certain areas of the body with different potentials. In practical work, in most cases, it is limited to the registration of 12 assignments: 6 from the limbs (3 standard and 3 "single-pole reinforced") and 6 breast - single-pole. The classic method of assignments proposed by Enthoven is the registration of standard assignments from the limbs denoted by Roman numbers I, II, III. Enhanced leads from the limbs were proposed by Goldberg in 1942. They register the potential difference between one of the limbs on which the active positive electrode of this lead is installed (right hand, left hand or left foot), and the average potential of two other limbs. Data data is indicated as follows: AVR, AVL, AVF. The designations of enhanced assignments from the limbs occur from the first letters of the English words: a - augmented (reinforced), V - voltage (potential), R - Right (right), L - left (left), F - FOOT (foot). Single-pole breasts are denoted by the Latin letter V (potential, voltage) with the addition of the number of the active positive electrode indicated by Arabic numbers: overcoming V 1 is an active electrode located in the fourth intercostalie on the right edge of the sternum; V 2 - in the fourth intercostal in the left edge of the sternum; V 3 - between V 2 and V 4; V 4 - in the fifth intercole on the left median-crook; V 5 - in the fifth intercole on the front axillary line; V 6 - in the fifth intercole in the middle axillary line. With the help of breasts, you can judge the condition (value) of the heart chambers. If the usual registration program 12 of generally accepted devices does not sufficiently reliably diagnose one or other electrocardiographic pathology or requires the clarification of some quantitative parameters, additional leads are used. It may be a lead V 7 - V 9, right breasts - V 3R -V 6R. ECG is registered in a special room remote from possible sources of electrical interference. The study is carried out after a 15-minute rest of an empty stomach or no earlier than 2 hours after meals. The patient must be spread to the belt, the shin should be released from clothes. It is necessary to use the electrode paste to ensure good skin contact with the electrodes. Bad contact or the appearance of muscle tremors in a cool room can distort the electrocardiogram. The study is usually carried out in a horizontal position, although at present it has also been examined in a vertical position, since the change in vegetative support leads to a change in some electrocardiographic parameters. It is necessary to register at least 6-10 cardiac cycles, and in the presence of arrhythmias much more - on a long tape. On a normal ECG, 6 teeth are distinguished by the letters of the Latin alphabet: p, q, r, s, t, u. The electrocardiogram curve (Fig. 1) reflects the following processes: atrial systole (Teeth P), artizentricular conductor (PR interval or, as It was previously denoted - interval p-Q), ventricular systole (QRST complex) and diastole - the interval from the end of the teeth T to the start of the R. All teeth and intervals are characterized by morphologically: teeth - height (amplitude), and intervals - temporary duration expressed in milliseconds. All intervals are frequency-dependent values. The ratio between the heart rate and the duration of one or another interval is provided in the respective tables. All elements of standard electrocardiogram have clinical interpretation. Analysis of any ECG should be started with the verification of the technique of its registration: to eliminate the presence of various interference, distorting the ECG curve (muscular tremor, poor contact of the electrodes with the skin), it is necessary to check the amplitude of the control millcolute (it must correspond to 10 mm). The distance between the vertical lines is 1 mm that when the tape is moving at a rate of 50 mm / s corresponds to 0.02 C, and at a speed of 25 mm / s - 0.04 s. In pediatric practice, a speed of 50 mm / s is preferable, since on the background of physiological age tachycardia, errors are possible when counting the intervals at a speed of the tape 25 mm / s. In addition, it is advisable to shoot an ECG with the change of the patient's position: in wedge and orthostability, since the change in the nature of the vegetative support can contribute to the change in some electrocardiogram parameters - change the characteristics of the rhythm driver, changing the nature of the rhythm, changing the heart rate, change the characteristics conductivity. The overall scheduling scheme of ECG includes several components. The determination of the source of the excitation is made to determine the polarity of the Tongo P and in its position relative to the QRS complex. Sinus rhythm is characterized by the presence of a standard assignment of positive teeth of the P preceding each QRS complex. In the absence of these signs, non-census rhythm is diagnosed: the atrial, rhythm of the AV-compound, ventricular rhythms (idioventricular), flicculative arrhythmia. Calculation of the number of heartbreaks is carried out using various methods. The most modern and simple method is calculated using a special line. In the absence of such, you can use the following formula: Heart rate \u003d 60 r-R,
where 60 is the number of seconds per minute, R-R is the range of interval, expressed in seconds. With incorrect rhythm, it can be limited to the definition of the minimum and maximum heart rate by specifying this scatter in "CONCLUSION". The regularity of heart abbreviations is estimated when comparing the duration of the R-R intervals between consistently registered cardiac cycles. The R-R interval is usually measured between the peaks of R (or S) teeth. The scatter of the obtained values \u200b\u200bshould not exceed 10% of the average duration of the R-R interval. It is shown that the sinus arrhythmia of one or another severity is observed in 94% of children. Conditionally allocated by V degree of severity of sinus arrhythmia: I degree - sinus arrhythmia absent or fluctuations in the heart rate in the listing of 1 min do not exceed 5 cuts; II degree - weakly pronounced sinus arrhythmia, rhythm fluctuations in the range of 6-10 reductions in 1 min; III degree - moderately pronounced sinus arrhythmia, rhythm fluctuations in the range of 11-20 abbreviations in 1 min; IV degree - severe sinus arrhythmia, rhythm fluctuations in the range of 21-29 abbreviations in 1 min; V Degree - sharply pronounced sinus arrhythmia, rhythm fluctuations in the range of 30 or more cuts in 1 min. Sinus arrhythmia is a phenomenon inherent in healthy children of all ages. In addition to the physiologically observed sinus arrhythmia, the wrong (irregular) heart rhythm can be observed at various options for arrhythmias: extrasystole, fliccity arrhythmias and others. The assessment function requires measuring the duration of the teeth P, which characterizes the speed of the electrical pulse at the atria, the duration of the P-Q interval (P-R) (the rate of conducting at the atria, Av-node and the GIS system) and the total duration of the QRS ventricular complex (excitation of ventricles). An increase in the duration of intervals and teeth indicates the slowdown in the corresponding department of the conductive heart system. The interval P-Q (P-R) corresponds to the time of passing the pulse from the sinus node to the ventricles and fluctuates depending on the age, gender and the frequency of heart abbreviations. It is measured from the beginning of the pronsess of P before the start of the tooth Q, and in the absence of a tooth q - before the start of the teeth R. Normal fluctuations in the P-R interval are between 0.11-0.18 s. The newborn P-R interval is 0.08 C, in breast - 0.08- 0.16 s, have more older - 0.10-0.18 s. The slowdown in atrioventricular conductivity may be due to the vagus influence. The P-R interval may be shortened (less than 0.10 seconds) as a result of an accelerated pulse, innervation disorders due to the presence of an additional way to quickly carry out between the atrium and ventricles. Figure 3 shows one of the options for shortening the P-R interval. On this electrocardiogram (see Fig. 2), the signs of the Volff-Parkinson-White phenomenon are determined, including: the shortening of the P-R interval is less than 0.10 s, the appearance of the delta wave on the rising knee of the QRS complex, the deviation of the electrical axis of the heart is left. In addition, secondary ST-T-changes may be observed. The clinical significance of the phenomenon represented consists in the possibility of forming a supertoday paroxysmal tachycardia by the Re-Entry mechanism (pulse repeated) mechanism, since additional conducting paths have a shortened refractory period and are restored to the pulse faster than the main path. Heart turns around the axis of the axis. It is customary to distinguish between the three conventional axes of the heart, as an organ in three-dimensional space (in the chest). The sagittal axis is an old-facing, perpendicular to the frontal plane, passes from the front back through the center of the heart of the heart. The turn counterclockwise along this axis leads a heart into a horizontal position (displacement of the electrical axis of the QRS complex to the left). Rotate clockwise - to a vertical position (displacement of the electric axis QRS to the right). The longitudinal axis is anatically running from the top of the heart to the right venous hole. When turning clockwise along this axis (with a review from the side of the heart), the right ventricle occupies most of the front surface of the heart, when turning against a clockwise arrow - left. The transverse axis passes through the middle of the base of the ventricles perpendicular to the longitudinal axis. When turning around this axis, the heart shift is observed with the top or the top back. The main direction of the electromotive power of the heart is the electrical axis of the heart (EOS). Heart turns around the conditional front-length (sagittal) axis are accompanied by a deviation of the EOS and a significant change in the configuration of the QRS complex in standard and reinforced single-pole leads from the limbs. Heart turns around the transverse or longitudinal axes refer to the so-called positional changes. The EOS definition is carried out on tables. This is compared to the algebraic amount of teeth R and S in I and III standard leads. The following options for the position of the electrical axis of the heart are distinguished: The nature of the arrangement of the heart in the chest, and, accordingly, the main direction of its electrical axis is largely determined by the characteristics of the physique. In children who are distinguished by asthenic physique, the vertical arrangement of the heart takes place. In children of the hyperstandic constitution, as well as with a high standing diaphragm (meteorism, ascites) - horizontal, with deviation of the top left. The more significant turns of the EOS around the axis of the axis both to the right (more than + 90 °) and left (less than 0 °) are usually due to pathological changes in the heart muscle. A classic example of the deviation of the electric axis to the right may be the situation when the interventricular septum defect or at the Fallo tetrade. An example of hemodynamic changes leading to the deviation of the electrical axis of the heart to the left is the lack of aortic valve. A simpler method for the estimated definition of the EOS direction is to find a lead from the limbs in which the highest tooth R (without a s or with a minimum teeth S). If the maximum teeth R in the I declaration is the horizontal position of the EOS, if in the II of the definition is a normal position if the AVF is vertical. Registration of the maximum teeth R in the AVL assignment indicates the deviation of the EOS to the left, in the III assignment - the deviation of the EOS to the right, if the maximum prog r in the AVR assignment is impossible to determine the position of the EOS. Analysis of the teeth P includes: a change in the amplitude of the PC; Measurement of the duration of the river r; Determination of polarity of teeth P; Determination of the shape of the teeth R. The amplitude of the R teeth is measured from the insulation to the top of the teeth, and its duration - from the beginning to the end of the teeth. Normally, the amplitude of the teeth P does not exceed 2.5 mm, and its duration is 0.10 s. Since the sinus unit is located in the upper part of the right atrium between the mouths of the upper and lower hollow veins, the ascending part of the sinus node reflects the state of excitation of the right atrium, and the descending state is the state of excitation of the left atrium, while it is shown that the excitation of the right atrium occurs before the left at 0 02-0.03 p. Normal teeth P in the form rounded, gently, with symmetric lifting and descent (see Fig. 1). The cessation of the excitation of atrial (atrial repolarization) does not find reflections on the electrocardiogram, as it merges with the QRS complex. With a sinus rhythm, the direction of the teeth p is positive. For normostas, the prong r is positive in all leads, besides the AVR lead, where all the teeth of the electrocardiogram are negative. The greatest magnitude of the R - in the second standard assignment. In persons of the asthenic physique, the magnitude of the PC increases in III standard and AVF leads, while in the AVL assignment, the P may even become negative. With a more horizontal position of the heart in the chest, for example, in hyperstoles, the PC is incremented in leads I and AVL and decreases in leads III and AVF, and in the standard III pinch, the P may become negative. Thus, in a healthy person, the teeth P in leads I, II, AVF is always positive, in leads III, AVL - can be positive, two-phase or (rarely) negative, and in AVR assignment is always negative. The QRST complex corresponds to an electric ventricular electrical systole and is calculated from the start of the q tooth to the end of the T. T. The components of the ventricular electrical systole: Actually the QRS complex, ST segment, T. T. The width of the initial ventricular complex of QRS characterizes the duration of the excitation of the myocardium of the ventricles. In children, the duration of the QRS complex ranges from 0.04 to 0.09 seconds, in breast-age children - not wider than 0.07 p. Teeth Q is a negative prong before the first positive QRS. A positive tooth Q can be only in one situation: a congenital dextcardia, when it is turned up in the i standard assignment. The tooth Q is due to the propagation of excitation from the AV-compound to the interventricular partition and the papillary muscles. This most non-permanent ECG Teeth may be absent in all standard leads. Teeth q must meet the following requirements: in leads I, AVL, V 5, V 6, do not exceed 4 mm in depth, or 1/4 of its R, and also not exceed 0.03 s duration. If q is not responding to these requirements, it is necessary to eliminate the states caused by the shortage of coronary blood flow. In particular, children often as congenital pathology of coronary vessels acts as an abnormal extinguishing of the left coronary artery from the pulmonary artery (Aolka from LA or BLANDDA-White-Garland syndrome). With this pathology, the "coronary" prong q is most often resistant to the AVL assignment (Fig. 3). On the represented electrocardiogram (see Fig. 3), the deviation of the electrical axis of the heart left is detected. In the assignment of AVL, the tooth Q is 9 mm, with a height of its r \u003d 15 mm, the duration of the q - 0.04 s. At the same time, in the I standard assignment, the duration of the teeth Q is also 0.04 s, in the same assignment - pronounced changes in the final part of the ventricular complex in the form of depression of the S-T interval. The estimated diagnosis is the abnormal extinguishing of the left coronary artery from the pulmonary artery - the echocardiographically was confirmed, and then during coronaryography. At the same time, in breast-age children, the deep q teeth can be instructed by III, AVF, and in the AVR assignment, the entire ventricular complex may have a kind of QS. The river r consists of an ascending and descending knee, always directed upward (except in cases of congenital dextcardia), reflects the biopotentials of the free walls of the left and right ventricles and the tops of the heart. A large diagnostic value is the ratio of teeth R and S and the change in the prong of R in breasts. In healthy children, in some cases there is a different magnitude of the R in the same assignment - electrical alternation. Tusk S, as well as the qoger Q, is a non-permanent negative ECG Teeth. It reflects a few late coverage by the excitation of remote, basal portions of myocardium, supraventricular scallops, arterial cone, subepicarordial myocardial layers. Teeth t reflects the process of rapid repolarization of the myocardial of ventricles, i.e. the process of restoring myocardium or cessation of excitation of the myocardium of ventricles. The state of the teeth T, along with the characteristics of the RS-T segment, is the marker of metabolic processes in the myocardium of ventricles. In a healthy child, the tissue T is positive in all leads, except AVR and V 1. At the same time, in leads V 5, V 6, the Tus M must be 1/3-1 / 4 of its R. The RS-T segment is a segment from the end of QRS (the end of the cloth R or S) before the start of the T - corresponds to the period of full coverage of the ventricular excitation. Normally, the displacement of the RS-T segment up or down is permissible in leads V 1 -V 3 not more than 2 mm. In leads that are most distant from the heart (in standard and single-pole from the limbs), the RS-T segment must be on the insulation, the possible offset up or down is not more than 0.5 mm. In the left chest leads, the RS-T segment is recorded on an isolated. The switching point of the QRS to the RS-T segment is denoted as the RS-T point - junction j (junction - compound). The T-P horizontal interval is t-p, the corresponding period when the heart is at rest (diastole period). Tusk U appears after 0.01-0.04 ° C after ton, it has the same polarity and ranges from 5 to 50% of the height of the T. T. So far, the clinical value of the Tusque U is clearly not defined. Q-T interval. The duration of the ventricular electrical systole has an important clinical significance, since the pathological increase in the electric system of ventricles can be one of the markers of the appearance of arrhythmia's life. Heart hypertrophy is a compensatory adaptive myocardial reaction, expressed in increasing the mass of the heart muscle. Hypertrophy evisurates in response to an increased load in the presence of acquired or congenital heart defects or with an increase in pressure in a small or large circulation circle. Electrocardiographic changes are due to: an increase in the electrical activity of the hypertrophied heap department; slowdown in the electrical impulse on it; ischemic, dystrophic and sclerotic changes in the changed heart muscle. However, it should be noted that the term "hypertrophy" as widely used in the literature does not always strictly reflect the morphological essence of changes. Often the dilatation of heart chambers has the same electrocardiographic signs as hypertrophy, during morphological verification of changes. When analyzing the ECG, the transition zone should be taken into account (Fig. 4) in breast leads. The transition zone is determined by the assignment in which the teeth R and S, i.e. their amplitude on both sides of the isoelectric line are equal (see Fig. 4). In healthy older children, the transition zone of QRS is usually determined in leads V 3, V 4. When changing the ratio of the vector forces, the transition zone moves towards their predominance. For example, with hypertrophy of the right ventricle, the transition zone moves to the position of the left breasts and vice versa. Electrocardiographic signs of overloading of the left atrium form an electrocardiographic complex of signs, called in the literature of R-Mitrale. An increase in the left atrium is a consequence of mitral regurgitation in congenital, acquired (due to rheumlock or infectious endocarditis), relative mitral insufficiency or mitral stenosis. Signs of the overload of the left atrium are presented in Figure 5. An increase in the left atrium (see Fig. 5) is characterized by: Since the lengthening of the P may be due not only to the increase in the left atrium, but also in the in-service blockade, then the presence of a pronounced negative phase of the R teeth in the V 1 is more important when evaluating overload (hypertrophy) of the left atrium. At the same time, the severity of the negative phase of the R teeth of the V 1 depends on the heart rate and on the general characteristics of the voltage of the teeth. Electrocardiographic signs of overload (hypertrophy) of the right atrium form a complex of signs, called R-Pulmonale, since it develops at pulmonary pathology, as well as in chronic pulmonary heart. However, children are infrequent in children. Therefore, the main reasons for increasing the right atrium are congenital defects of the heart, for example an anomaly of the three-grated valve of Ebstin, as well as primary changes in pulmonary artery - primary pulmonary hypertension. Signs of increasing right atrium are presented in Figure 6. An increase in the right atrium (see Fig. 6) is characterized by: Figure 6, in addition to the signs of the overload of the right atrium, there are also signs of the overload of the right ventricle. Since the ECG norm reflects the activity of only the left ventricle, the electrocardiographic signs of the overload of the left ventricle are emphasized (exaggerated) norm. Where, in the norm, the High Teeth R (in Deletion V 4, the position of which coincides with the left limit of the heart), it becomes even higher; Where is the deep teeth of the S (in all the V 2), it becomes even deeper. There are many volost criteria for overloading (hypetrophy) of the left ventricle - more than 30. The most famous refers to the Sokolowa-Lion index: the sum of the amplitudes of the teeth R in the brass V 5 or V 6 (where more) and s in the assignment V 1 or V 2 ( Where more) more than 35 mm. However, the amplitude of the teeth in breasts is affected by the floor, the age and constitution of the patient. So, the increase in the voltage of the teeth can be observed in thin young people. Therefore, the secondary changes in the final part of the ventricular complex are of great importance: the displacement of the S-T interval and T. T. as a sign of the relative deficit of coronary blood flow, it is possible to deepen the q teeth in the leads V 5, V 6. But at the same time, the q should not exceed more than 1/4 of its R and 4 mm in depth, since this feature indicates primary coronary pathology. The prevailing dilatation of the left ventricle has the following signs: R in V 6 is larger than R in v 5, more than R in V 4 and more than 25 mm; a sudden transition from deep teeth S to the high teeth R in breasts; Displacement of the transition zone to the left (to v 4) (Fig. 7). Signs of the prevailing hypertrophy of myocardial myocardium left ventricle is depression (offset below the isolated) S-T segment in [V 6, perhaps, possibly in V 5 (Fig. 8). Electrocardiographic signs of overload (hypertrophy) of the right ventricle appear when its mass increases by 2-3 times. The most reliable sign of hypertrophy of the right ventricle - the QR complex in the assignment V 1. Additional features are secondary changes in the form of a shift of the ST segment and changing the teeth of T. for some pathological conditions, in particular during the defect of the interpreservation partition, the hypertrophy of the right ventricle is also demonstrated by the incomplete blockade of the right leg of the Gis beam in the form of RSR in the assignment V 1 (Fig. 9) . In conclusion, it should be noted that the standard electrocardiogram is very important for adequate diagnosis subject to several rules. This, firstly, the shooting of an electrocardiogram with the change of body position, which allows primary to differentiate organic and inorganic damage to the heart. Secondly, this is the choice of the optimal shooting speed - in children 50 mm / s. Finally, an electrocardiogram analysis should be carried out, taking into account the individual characteristics of the child, including its constitution. For literature, please contact the editor. In the weekend of the article "Lush", No. 8 2004, you should read: A. E. Kudryavtsev, Candidate of Medical Sciences, Associate Professor, In the article I. Yu. Fofanova "Some questions of pathogenesis of intrauterine infections", No. 10.2004. On page 33 in the 2nd column from left to right to read: "In the II trimester (after clarifying the diagnosis), the use of antibacterial therapy is shown, taking into account the sensitivity of antibiotics (penicillin row or macrolides). The purpose of amoxiclava, Augmentina, Ranclava, Aithitroces, Summen during pregnancy is possible only when the estimated benefit for the mother exceeds the potential risk to the fetus or child. Despite the fact that in experimental studies of teratogenic action of these drugs was not detected, their uses during pregnancy should be avoided. " E. V. Murashko, Candidate of Medical Sciences, Associate Professor RGMU, Moscow The likelihood that the doctor diagnoses the patient with a pulmonary heart depends on how much it realizes that the disease that exists in a patient may entail the pulmonary hypertension. The correct diagnosis is usually placed in the presence of refrigerant circuit in the vessels of the pulmonary circulation, for example, with multiple embolism in the pulmonary trunk. The diagnosis of pulmonary heart is not so obvious in obstructive diseases of the respiratory tract due to the fact that the clinical manifestations of chronic bronchitis and bronchiolites may be less pronounced, and the clinical indices of pulmonary hypertension are not very reliable. Of course, the first attack of pulmonary hypertension and the pulmonary heart, developed secondly due to the presence of chronic bronchitis, can be diagnosed only retrospectively, that is, after the development of the obvious episode of the right-hand deficiency. Diagnostics can be particularly difficult if the systemic venous stagnation and peripheral edema develops secretly, within days or weeks, and not suddenly, as it happens with sharp bronchopal infections. Recently, a lot of attention is paid to the problem of the gradual development of the pulmonary heart and the right-hand deficiency in patients with alveolar hypoventilation, which is one of the manifestations of apnea syndrome in a dream, and not the result of the disease itself. The presence of a pulmonary heart is especially important to establish in elderly patients when the likelihood of sclerotic changes in the heart is high, especially if for many years they are worried about cough with a wet branch (chronic bronchitis) and there are obvious clinical manifestations of destroying failure. The determination of the gas composition of blood is most informative if necessary, to determine which of the ventricles (right or left) is the root cause of heart disease, since pronounced arterial hypoxemia, hyperkapinia and acidosis are rarely found in the lack of a left heart, unless simultaneously develop the lung edema. Additional confirmations of the diagnosis of the pulmonary heart give X-ray and ECG signs of increasing the right ventricle. Sometimes, if the pulmonary heart is suspected, the catheterization of the right heart departments is required. In the case of this study, it is revealed, as a rule, hypertension in the pulmonary trunk, normal pressure in the left atrium (pressure of the pulmonary trunk) and the classical hemodynamic signs of the deficiencies of the right ventricle. The increase in the right ventricle is characterized by the presence of a heartfold along the left border of the sternum and the IV of the heart tone arising in the hypertrophic ventricle. About the concomitant pulmonary hypertension is assumed in cases where the heart pusher is detected in the second left intercostal age near the sternum, the unusually loud 2nd component II of the heart tone in the same region and sometimes in the presence of noise of lack of valve of the pulmonary trunk. With the development of the deficiency of the right ventricle, the additional tone of the heart often accompanies, which causes the occurrence of the rhythm of the rhythm of the right ventricle. The hydrotorax rarely occurs even after the appearance of explicit right-minded failure. Permanent arrhythmias, such as flickering or fluttering atrial, are also rare, but transient arrhythmias usually arise in the case of severe hypoxia when the respiratory alkalosis appears caused by mechanical hyperventilation. The diagnostic value of electrocardiography at a pulmonary heart depends on the severity of changes in lungs and ventilation disorders (Table 191-3). This is the most valuable in vascular diseases of the lungs or damage to the interstitial tissue (especially in cases where they are not accompanied by the exacerbation of respiratory diseases), or with alveolar hypoventilation in normal lungs. On the contrary, at a pulmonary heart, developed secondly due to chronic bronchitis and emphysema, an increase in the light and episodic nature of pulmonary hypertension and overloading of the right ventricle, the diagnostic signs of the right ventricular hypertrophy are rare. And even if the increase in the right ventricle due to chronic bronchitis and emphysema is quite pronounced, as it happens during exacerbations during the infection of the upper respiratory tract, ECG signs may be inconclusive as a result of rotation and heart offset, increase the distance between the electrodes and the surface of the heart, the predominance of dilatation over hypertrophy with increasing heart. Thus, a reliable diagnosis of increasing right ventricle can be put in 30% of patients with chronic bronchitis and emphysens, in which the right ventricle hypertrophy is detected with autopsy, while such a diagnosis can be easily and reliably installed in a significant majority of patients with a pulmonary heart. Pathology of lungs other than chronic bronchitis and emphysema. Having in mind, it is more reliable criteria for hypertrophy of the right ventricle in a patient with chronic bronchitis and emphysens, the following are presented: S 1 Q 3 -typ, deviation of the electrical axis of the heart of more than 110 °, S 1. S 2. S 3 -typ, R / S ratio in V6 assignment<1,0. Сочетание этих признаков увеличивает их диагностическую ценность. Table191-3. ECG signs of chronic pulmonary heart
1. Chronic obstructive lung diseases (probable, but not diagnostic signs of increasing the right ventricle) a) "P-Pulmonale" (in leads II, III, AVF) b) deviation of the heart axis to the right more than 110 ° C) R / S ratio in V6< 1. г) rSR в правых грудных отведениях д) блокада правой ножки пучка Гиса (частичная или полная) 2. Diseases of pulmonary vessels or interstitial lung tissue; General alveolar hypoventilation (diagnostic signs of increasing right ventricular) a) classical features in V1 or V3R (dominant R or R with inverted T. Teeth in right-wing infants) b) is often combined with the likely criteria indicated above Among the probable criteria is difficult to distinguish those that reflect the increase in the right ventricle (hypertrophy and dilatation) on the anatomical changes and changes in the electrical axis of the heart caused by an increase in light airiness. Accordingly, the probable criteria as a supporting circumstance are more useful than diagnostic. X-ray has a large diagnostic value in suspected an increase in the right ventricle or to confirm such a state than to identify it. Suspicions arise in cases where the patient has signs of the previously predisposing disease of the lungs associated with large central pulmonary arteries and a trimmed peripheral arterial network, that is, the signs of pulmonary hypertension. A series of radiological studies has a large diagnostic value than a single definition of heart sizes, especially in obstructive respiratory diseases, when significant changes in heart dimensions may occur during periods between exacerbations of acute respiratory failure and remission. In recent years, echocardiography, based on registration of the motion of the pulmonary trunk, began to use pulmonary hypertension. This technique is quite complicated, but it is gaining popularity. Page 4 of 5 IN clinical analysis of blood
In patients with chronic pulmonary heart, in most cases is detected erythrocytosis, Increase hematokrit and content hemoglobin What is very characteristic of chronic arterial hypoxemia. In severe cases, polycythemia is developing with an increase in the content of platelet and leukocytes erythrocytes. The decrease in ESP is often associated with an increase in blood viscosity, which is also naturally observed in many patients suffering respiratory failure The described changes in blood tests are naturally not direct evidence of the presence of a pulmonary heart, but they usually indicate the severity of pulmonary arterial hypoxemia - the main level of the pathogenesis of the chronic pulmonary heart Electrocardiography
With an electrocardiographic study, signs of hypertrophy of the right ventricle and PP are detected in patients with chronic pulmonary heart. The earliest ECG changes are the appearance in leads II, III, AVF (sometimes in v1) high-amplitudes (more than 2.5 mm) with a pointed peak of teeth (
P.
—
pulmonale
)
Moreover, their duration does not exceed 0.10 s. The ECG signs of the right ventricle hypertrophy be revealed somewhat later. Depending on the level of pressure in the pulmonary artery of the magnitude of the muscular mass of the right ventricle and the severity of the accompanying emphysema of the lungs in patients with a pulmonary heart, three types of ECG changes can be revealed: rSr.
‘-
mun.
Published as moderate hypertrophy of the right ventricle When his mass approaches the mass of LV myocardium or somewhat less (Fig. 1): RV1 + S V5,6\u003e 10 5 mm, transition zone to the left to leads V5, V6 and appearance in leads V5, V5 complex QRS type RS) III, AVF, VL, V2, qR
—
mun.
Received as severe hypertrophy of the right ventricle When his mass is somewhat larger than the mass of myocardial lz. For this type of ECG-change characteristic (Fig. 2): RV1 + S V5, 6\u003e 10 5 mm, transition zone to the left to leads V5, Vb and appearance in leads V5, V6, QRS complex type RS), keeping (VI) more than 0.03 s, III, AVF, V1, V2, Thus, the main differences between these two types of ECG changes in hypertrophy of the right ventricle are in the form of the QRS complex in the V1 assignment. S.
—
mun.
ECG changes are often observed in patients with severe emified lungs and a chronic pulmonary heart when the hypertrophied heart sharply shifts the stop predominantly due to emphysema. At the same time, the ventricular depolarization vector is projected into negative parts of the axes of breasts and leads from the limbs (signs of the head of the heart around the transverse axis of the stopper) This explains the essential features of the changes in the QRS V complex of these patients (Fig. 3): gate of the heart around the transverse axis of the top for the hollow) arrow (displacement of the transition zone to the left to leads V5, V6I appearance in leads V5, V6 complex QRS type RS) Fig.1. ECG patient with chronic pulmonary heart Fig.2 ECG patient with chronic pulmonary heart (rSr. ‘-
mun. Hypertrophy of the right ventricle) ( qR —
mun. Hypertrophy of the right ventricle) Fig. 3. ECG patient with chronic pulmonary heart (P-Pulmonale and S- type of hypertrophy of the right ventricle) It should be noted that with all three types of ECG-change, the diagnosis of PJ hypertrophy is indirectly confirmed by the presence of signs of hypertrophy of PP P. —
pulmonale ),
Defaped in leads II, III and AVF. X-ray study
X-ray study allows you to clarify the character lung damage as well as identify several important radiographic signs indicating increasing the size of the right ventricle and presence pulmonary hypertension: in a straight projection (expansion of II arc left heart circuit) from detection of vascular drawing on the periphery pulmonary fields due to narrowing small pulmonary arteries Echocardiographic study in patients with chronic pulmonary heart is carried out with the aim — objective confirmation of the presence of hypertrophy of the right ventricle (with the thickness of the front wall of the right ventricle exceeding 5 mm) and pp. (The norm of PP and LPs are about the same dimensions, the dilatation of PP leads to the dominance of its image.) — estimates of the systolic function of the right ventricle. E. This assessment is based primarily on identifying signs of dilatation - with dilatation, the diastolic size of the right ventricle from parasherial access along the short axis of the heart usually exceeds 30 mm. The reduction of right ventricle is most often estimated visually - by the nature and amplitude of the movement of the front wall of the right ventricle and MZhP. For example, the volumetric overload of the right ventricle in patients with a decompensated pulmonary heart is characterized not only by the expansion of its cavity, but also enhanced with the pulsation of its walls and paradoxical movements of the MZP: during the systole MZHP begged to the cavity of the right ventricle, and during diastole - towards LV. Systolic dysfunction of the right ventricle can be estimated according to the degree of collaboration of the lower hollow vano time. Normally, at the height of deep breath, the collaboration of the lower hollow vein is approximately 50%. Insufficient falling on inhale indicates PA increase of pressure in PP and in the venous bed of a large circle of blood circulation. - Pressure definitions in the pulmonary artery. The diagnosis of pulmonary hypertension is necessary to assess the severity of the flow and forecast of the chronic pulmonary heart. For this purpose, the Doppler Study of the Blood flow form in the endurance the path of the right ventricle And at the mouth of the pulmonary artery valve. Under normal pressure in the pulmonary artery, the form of blood flow approaches the dome-shaped and symmetric, and at pulmonary hypertension becomes a triangular or duplek. quantitation systolic pressure in the pulmonary artery (SDL) is possible when using a constant-wave doppler study of three-cuspal regurgitation, and diastolic Pressures - in assessing the maximum rate of diastolic regurgitation of blood from the pulmonary artery in the right of the ventricle stomach. The catheterization of the right heart departments is the main method of direct pressure measurement in the pulmonary artery. The study is carried out in specialized clinics using the "floating" catheter Svan-Ganz. The catheter is introduced through the inner jugular, outer jugular, connective or femoral vein in the right atria, then into the right ventricle and the pulmonary artery, measuring the pressure in these heart chambers. When the catheter is located in one of the branches of the pulmonary artery, the canister, located at the end of the catheter, is inflated. Short-term vessel occlusion allows you to measure the pressure of the occlusion of the pulmonary artery (the pressure of the jellection - DZL), which approximately corresponds to the pressure in the pulmonary veins, LP and the finite-diastolic pressure in the LV. When the catheterization of the cavities of the heart and the pulmonary artery, the patients with chronic pulmonary heart identify reliable signs of pulmonary hypertension - the pressure values \u200b\u200bin the pulmonary artery is more than 25 mm Hg. Art. Alive or more than 35 mm Hg. Art. With load .
It remains normal or even lowered the pressure of the sludge of the pulmonary artery (ZLL) - not more than 10-12 mm RT. Art. Recall that for patients with left-deceased deficiency or vices of the heart, accompanied by venous stagnation of blood in the lungs, the increased pressure in the pulmonary artery is combined with an increase in the ZLLE to 15-18 mm RT. Art. and higher. Research Function Function
As was shown above, the basis of the occurrence of pulmonary hypertension and the formation of a chronic pulmonary heart in most cases is a violation of the function of external respiration, leading to the development of alveolar hypoxia and pulmonary arterial hypoxemia. Therefore, the severity of the flow, the forecast and the outcomes of the chronic pulmonary heart, as well as the choice of the most effective methods of treating this disease are largely determined by the nature and severity of violations of the lung function. In connection with this main tasks IS. functions of external respiratory function (FVD) In patients with a pulmonary heart are: These tasks are solved with a number of instrumental and laboratory research methods: spirometry, spirographs, pneumatic phones, tests for the diffusion capacity of the lungs, etc. To identify specific complaints is impossible, since they do not exist. Complaints of patients during this period are determined by the underlying disease, as well as by one or another degree of respiratory failure. You can reveal a straight clinical sign of hypertrophy of the right ventricle - reinforced pulsation, determined in the precodal region (in the fourth intercostride to the left of the sternum). However, with a pronounced emphysema, when the heart is pushed from the anterior thoracic wall with emphysematoous enhanced lungs, detect the specified feature is rare. At the same time, with emphysema of the lungs, the epigastric pulsation caused by the strengthened operation of the right ventricle may also be observed in the absence of its hypertrophy as a result of a low standing of the diaphragm and the omission of the top of the heart. Auscultative data specific to compensated drugs does not exist. However, the assumption about the presence of pulmonary hypertension becomes more likely when identifying an accent or splitting II. Tone above the pulmonary artery. At a high degree of pulmonary hypertension, the diastolic noise of the sin-style can be listened. A sign of a compensated LAN is also considered loud i tone over the right three-stranded valve compared to the first tone above the top of the heart. The meaning of these auscultational features relative, as they may be absent in patients with severe emphysema lungs. III stage of diagnostic search. Decisive for the diagnosis of compensated LS is III The stage of diagnostic search, allowing to identify hypertrophy of the right heads of the heart. The value of various instrumental diagnostic methods is not the same. External respiratory functions
Reflect the type of respiratory disorder (obstructive, restrictive, mixed) and the degree of respiratory failure. However, they cannot be used to differentiate compensated LS and respiratory failure. Radiological methods
Allowed to identify the early sign of the LS - empty of the mulmonary artery cone (better determined in the 1st oblique position) and the expansion of it. Then a moderate increase in the right ventricle may be marked. Electrocardiography
It is the most informative method of the diagnosis of the pulmonary heart. There are convincing "direct" signs of ECG hypertrophy of the right ventricle and right atrial, correlating with the degree of pulmonary hypertension. In the presence of two or more "direct" signs on the ECG, an LC is considered reliable. The identification of signs of hypertrophy of the right atrium is also of great importance: (P-Pulmonale) in II and III ,
AVF and in right breasts. Phonocardiography
can help in the graphic detection of high amplitude of the pulmonary component II. Tone, diastolic noise of the sinham-stylla - a sign of a high degree of pulmonary hypertension. Have significant importance hemody Research Techniques namics, According to the results of which one can judge the magnitude of the pressure in the pulmonary artery: In recent years, new instrumental methods have appeared, which are used for early diagnosis of the pulmonary heart to them pulsed dopplercardiography, magnetic resonance imaging and radionuclide valrenculography. The most reliable way to identify pulmonary hypertension is pressure measurement in the right ventricle and in the pulmonary artery with catheter (At rest in healthy people, the upper limit of normal systolic pressure in the pulmonary artery is 25-30 mm Hg. Art.) However, this method cannot be recommended as the main, since its use is possible only in a specialized hospital. Normal systolic pressure indicators in the pulmonary artery at rest do not exclude the diagnosis of drugs. It is known that already with minimal physical exertion, as well as in the exacerbation of the bronchopulmonary infection and the amplification of the bronchial obstruction, it begins to increase (above 30 mm Hg. Art.) Inadequately load. With a compensated LAN, venous pressure and blood flow rate remain within the normal range. Diagnosis of decompensated drugs, if there are undoubted signs of destroying failure, is simple. The initial stages of heart failure with drugs are difficult to diagnose difficult, since the early symptom of heart failure - shortness of breath - can not serve as a help in this case, since it exists in patients with CHNZL as a sign of respiratory failure long before the development of heart failure. At the same time, the analysis of the dynamics of complaints and major clinical symptoms allows you to detect initial signs of LS decompensation. At the stage of the diagnostic search The change in the character of shortness of breath is revealed: it becomes more constant, it depends less on the weather. The frequency of breathing increases, but the exhale is not extended (extended only with bronchial obstruction). After coughing, the intensity and duration of shortness of breath increase, it does not decrease after receiving broncho-dilators. Simultaneously increasing pulmonary failure, reaching III degrees (shortness of breath). Progresses fatigue and reduced workability, drowsiness and headaches appear (the result of hypoxia and hypercapnia). Patients may complain about pain in the heart of an indefinite nature. The origin of these pain is quite difficult and explained by a combination of a number of factors, including metabolic disorders in myocardium, hemodynamic overload of it at pulmonary hypertension, the insufficient development of collaterals in hypertrophied myocardium. Sometimes heart pains can be combined with severe choking, excitation, sharp common cyanosis, which is characteristic of hypertensive crises in the pulmonary artery system. The sudden pressure lift in the pulmonary artery is due to irritation of the baroreceptors of the right atrial, increased blood pressure in the right ventricle. Complaints of patients on swelling, heaviness in the right hypochondrium, an increase in the size of the abdomen with the corresponding (most often chronic) pulmonary history allows to suspect decompensated LS. At the stage of the diagnostic search It is revealed by the symptom of constantly swollen cervical veins, since after joining the pulmonary and heart failure, the cervical veins swell not only in exhalation, but also in breathe. Against the background of diffuse cyanosis (a sign of pulmonary failure), acricyanosis develops, fingers and brushes of hands get cold to the touch. There are pastosity of the heads, swelling of the lower extremities. Permanent tachycardia appears, and at rest this symptom is more pronounced than when loading. A pronounced epigastric pulsation is determined, due to abbreviations of hypertrophied right ventricle. In the dilatation of the right ventricle, the relative insufficiency of the atrocadic valve may develop, which causes the appearance of systolic noise from the sword-shaped grudge process. As cardiac insufficiency develops, the tones of the heart become deaf. It is possible to increase blood pressure due to hypoxia. It should be remembered to increase the liver as an early manifestation of blood circulation deficiency. The liver can perform from under the edge of the rib arc in patients with emphysema and without signs of heart failure. With the development of heart failure in the initial stages, an increase of predominantly left lobe of the liver is revealed, palpation of its sensitive or painful. As the symptoms of decompensation are rapidly, a positive symptom of Blash is detected. Ascites and hydrotorax are rarely observed and, as a rule, with a combination of LANs with IBS or hypertensive disease II-III stage. III stage of diagnostic search It has less significance in the diagnosis of decompensated drugs. Radiological data
Allow a more pronounced increase in the right-hand heart departments and the pathology of the pulmonary artery: 1) strengthening the vascular pattern of lung roots with relatively "light peripherals"; 2) the expansion of the right downward branch of the pulmonary artery is the most important X-ray sign of pulmonary hypertension; 3) increased ripples in the center of the lungs and weakening it in the peripheral departments. On the ECG - Progression of symptoms of hypertrophy of the right ventricular and atrium, often blockade of the right leg of the atrocadic beam (Gis beam), rhythm disorders (extrasystoles). For study hemodynamics Pressure growth increases in the pulmonary artery (above 45 mm Hg. Artery), slowing the speed of blood flow, an increase in venous pressure. The latter in patients with HP testifies to the attachment of heart failure (this symptom is not early). IN blood tests Erythrocytosis (reaction to hypoxia) can be detected, increasing the hematocrit rate, an increase in blood viscosity, and therefore such patients may remain normal even with the activity of the inflammatory process in the lungs.Training video Definition of EOS (electrical axis of the heart) by ECG
We will be glad to your questions and reviews:
Rotate the heart with left ventricle ahead How to treat
ECG when cornering the heart around the longitudinal axis. Example of longitudinal heart turn
Electrocardiogram when turning the heart around the longitudinal axis
Conductive heart system and why is it important to determine the EOS?
Options for the position of the electrical axis of the heart in healthy people
When does the EOS position talk about heart disease?
Deviations eos left
EOS deviations to the right
What if the cardiogram found the EOS offset?
Video: EOS in the course "ECG for each"
Harvesters in electrocardiography
Technique registration of electrocardiogram
Normal electrocardiogram
Analysis of electrocardiogram
- determination of the source of excitation;
- counting the number of heartbreaks;
- assessment of the regularity of heart abbreviations;
- assessment of the function of conductivity.
- positions of the electrical axis of the heart in the frontal plane (turns around the axis of the axis, sagittal);
- Heart turns around the longitudinal axis;
- Heart turns around the transverse axis.
- analysis of the QRS complex;
- analysis of the RS-T segment;
- test analysis T;
- Analysis of the Q-T interval.Analysis of cardiac rhythm and conductivity
Determination of the position of the electrical axis of the heart
Analysis of the atrial teeth
Analysis of the ventricular complex QRST
Electro Cardiograph Signs of hypertrophy and overloading of the cavities of the heart
Signs of overviews atserval
Signs of overloads (hypertrophy) of ventricles
Editors apologize for typos
T. E. LUKOVA, Candidate of Medical Sciences, Associate Professor,
K. Alikeev, Candidate of Medical Sciences
CNII Epidemiology Ministry of Health of the Russian Federation, MoscowDifferential diagnosis
Diagnosis and examination - chronic pulmonary heart
Laboratory and instrumental diagnostics
Catheterization of the right heart and pulmonary artery
Compensated and decompensated pulmonary heart
Compensated pulmonary heart (LS)
Decompensated pulmonary heart
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