19. apical impulse is displaced to the left and down, strengthened, broadened, medium or high amplitude, resistant;

19. the borders of the heart are expanded to the left, the aortic configuration;

20. emphasis of II tone on the aorta, weakening of I tone at the apex;

21. Blood pressure above 140 / 90mm RT. st .;

22. on ECG signs of left ventricular hypertrophy

19. Echocardiography confirms the anatomical and hemodynamic changes associated with an increase in blood pressure;

17. fundus: hypertensive retinal angiopathy (narrowing of arteries, dilatation of veins).

Pic 3.4 The borders of the heart are extended to the left, the aortic configuration

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V.Kh. Vasilenko (1935).

Stage I: initial or hidden.

It appears only during physical exertion, there are no stagnant phenomena ..

1. signs of fatigue (shortness of breath, sweating, finger tremors, cyanosis of the tip of the nose and lips);

2. slow recovery of the patient's initial state (more than 10 minutes after exercise);

3. with percussion of the heart, its increase is detected;

4. with palpation of the pulse and auscultation of the heart, tachycardia, cardiac arrhythmias, the presence of noise are determined;

5. increased fatigue during physical exertion.

Stage II: severe or prolonged.

Circulatory failure, not only during exercise, but also at rest.

1. a persistent decrease in stroke and minute blood volume;

2. an increase in the volume of circulating blood;

3. increased venous pressure, venous congestion in both circles of blood circulation, a change in water-salt metabolism;

Period IIA: stagnation mainly in the small or large circle

1. shortness of breath;

2. acrocyanosis;

3. transient, not very pronounced swelling of the legs and feet;

4. the size of the heart is increased, tachycardia is observed, sometimes arrhythmia;

5. a slight increase in the liver. On palpation in the right hypochondrium, the liver is painful, protrudes from under the costal margin by 2-3 cm;

6. single wet rales in the lower parts of the lungs;

7. in X-ray photographs - strengthening of the pulmonary pattern and roots of a lung of a stagnant nature.

Period IIB: congestion in both circles of blood circulation;

1. shortness of breath at rest (patients occupy a sitting position);

2. significant acrocyanosis;

3. massive swelling of the legs and feet;

4. the development of atrial fibrillation, often a tachyarrhythmic form; heart sounds are deaf, heart sizes are increased;

5. the liver is large, dense with a rounded or pointed edge, painful on palpation, protrudes from the costal margin by 6-10 cm;

6. ascites;

7. moist rales in the lower parts of the lungs and compaction of the roots of the lungs;

8. less commonly, hydrothorax and hydropericardium;

9. oliguria, high density of urine;

10. significant congestion in the organs;

11. severe hemodynamic disturbances;

Stage III: final or dystrophic

1. all the signs of period II B

2. exhaustion of patients (cardiac cachexia);

3. the skin is pale, flabby, pigmentation and trophic changes in the skin and subcutaneous tissue of the legs, significant acrocyanosis;

4. anasarca;

5. significant changes and metabolic disorders, hemodynamics;

6. dense edema (ascites, hydrothorax, hydropericardium);

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7. an increase in heart size - cardiomegaly;

7. heart sounds are weakened or deaf, the heart rate is often incorrect - tachycardia, atrial fibrillation;

7. cardiac fibrosis of the liver (the liver is dense, enlarged, the edge is pointed, slightly painful, protrudes from the hypochondrium by 8-10 cm;

7. nephroangiosclerosis;

8. severe dysfunction of the endocrine system and c.n.s;

7. patients occupy a forced position (sedentary or half-sitting) due to severe shortness of breath at rest.

8. Arterial hypotension syndrome

Lowering blood pressure in arteries - systolic below 100 mm Hg. Art., diastolic - below 60 mm RT. Art. Distinguish between physiological and pathological arterial hypotension. A decrease in blood pressure can be observed in individuals of asthenic type, especially in an upright position (orthostatic hypotension). How a pathological symptom can be observed with shock and collapse, as a manifestation of heart or vascular insufficiency - with infectious diseases, intoxications, some lesions of the central nervous system, anemia. SYMPTOMS:

• weakness, lethargy;

• dizziness, fainting;

• headaches, tinnitus;

• visual impairment;

• sometimes, cold sweat;

• blood pressure below 100/60 mm Hg

• pallor;

• palpitations, tachycardia;

• pulse of low voltage, filling.

9. Heart failure syndrome

FORMS:

1. acute left ventricular (left atrial);

2. acute right ventricular;

3. chronic left ventricular (left atrial);

4. chronic right ventricular;

5. total, chronic, stagnant.

CAUSES: 1) diseases that cause dystrophy, necrosis, sclerosis, inflammation and myocardial hypertrophy: heart defects, hypertension, myocarditis, thyrotoxicosis, coronary heart disease, cardiomyopathy, myocardial dystrophy, etc. 2) diseases affecting the heart from the outside: diseases of the lungs, pleura, pericardium, etc.

BASIC SYMPTOMS the severity of all manifestations depends on the severity of heart failure:

1. shortness of breath, often inspiratory. Sometimes as an equivalent - cough, hemoptysis;

2. tachycardia;

3. swelling, decreased urine output;

4. acrocyanosis, cyanosis.

With left ventricular and left atrial (with mitral stenosis) heart failure - congestion is noted in the pulmonary circulation (inspiratory dyspnea, cough, hemoptysis, moist rales, in the lower parts of the lungs, and sometimes over the entire surface of the lungs, pink foamy sputum, orthopedic. manifestations - cardiac asthma, alveolar pulmonary edema.

Right ventricular heart failure is a congestive phenomenon in a large circle of blood circulation: enlarged liver, swelling in the legs, ascites.The symptom of Kussmaul is an increase in swelling of the cervical veins on inspiration.

Positive symptom of Plesha - is characteristic of severe biventricular or right ventricular failure, is an indicator of venous stasis, high central venous pressure and volume overload. When the patient is calmly breathing for 10 s, the palm is pressed onto the enlarged liver, which causes an increase in central venous pressure by approximately 4-5 cm of water. Art. and increased swelling of the cervical veins. An abdominal-jugular test can be performed, with palm pressure being applied to the anterior abdominal wall in the umbilical region (the abdominal press should not be stressed). The result of the sample is evaluated in the same way as with the hepatic-jugular Plesha test.

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The severity of chronic heart failure is regulated by the classification of N.D. Strazhesko -

Table 3.1 Classification of CHF

CHF stages in Vasilenko-Strazhesko								Functional classes of heart failure
								NewYorkHeartAssociation
							(NYHA)
I st	The initial stage of the disease (heart						I fc	There are no restrictions on physical
	damage). Hemodynamics is not							activity, habitual physical activity is
	broken.	Latent		heart		failure		not accompanied by rapid fatigue, the
	Asymptomatic LV dysfunction.							appearance of shortness of breath or
								palpitations. The patient suffers an
								increased load, but it can be
								accompanied by shortness of breath
								and / or delayed recovery of strength.
IIА	Clinically expressed stage of the						II fc	A slight restriction of physical
st	disease (heart damage). Violation of							activity: at rest, there are no
	hemodynamics in one of the circles of							symptoms, habitual physical activity
	blood	circulation,				expressed		is accompanied by fatigue, shortness
	moderately.		Adaptive		remodeling of			of breath or palpitations.
	the heart and blood vessels.
IIБ	Severe stage of the disease. Marked						III fc	A noticeable limitation of physical
st	changes in hemodynamics in both							activity: at rest, there are no
	circles	of	blood		circulation.			symptoms, physical activity of lower
	Disadaptive remodeling of the heart							intensity compared with the usual
	and blood vessels.							loads is accompanied by the
								appearance of symptoms.
III st	The final stage of heart damage.						IV fc	The inability to perform any physical
	Marked changes in hemodynamics and							activity without the appearance of
	severe (irreversible) changes in target							discomfort: the symptoms of HF are
	organs (heart, lungs, blood vessels,							present at rest and intensify with
	brain, kidneys). The final stage of							minimal physical activity.
	organ remodeling.

10. Cardiomegaly syndrome

Cardiomegaly (KMG) is a significant increase in heart size due to its hypertrophy and dilatation or accumulation of metabolic products, or the development of neoplastic processes. Causes:

1. Coronary heart disease:

a) atherosclerotic cardiosclerosis;

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2. postinfarction cardiosclerosis;

3. aneurysm of the heart;

2. Heart defects:

1. acquired defects;

2. congenital malformations.

3. Arterial hypertension:

1. hypertension;

2. secondary hypertension.

4. Myocarditis.

5. Cardiomyopathies:

1. primary;

2. secondary.

6. The accumulation of fluid in the pericardial cavity, etc.

SYMPTOMS:

1. rhythm and conduction disturbance;

2. physical data: expansion of borders, muffling or deafness of tones, weakening of 1 tone at the apex, manifestation of the protodiastolic or presystolic rhythm of the golop (3 and 4 tones), noise of relative mitral and tricuspid insufficiency (Rivero-Carvallo noise), less often - diastolic noise of functional mitraloo stenosis (Flint) and diastolic murmur of relative pulmonary insufficiency (Graham-Steel).

Specific signs are determined by the disease that led to KMG:

Pic 3.6 Total heart enlargement (cardiomegaly)

11. Syndrome of fluid accumulation in the pericardium (hydropericardium) The reasons for the accumulation of exudate:

1. rheumatic heart disease

2. tuberculosis

3. acute leukemia

4. pleuropneumonia

5. renal failure (uremic pericarditis)

6. myocardial infarction

7. traumatic heart damage

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The reasons for the accumulation of transudate:

1. heart failure

Complaints: intense, persistent and increasing shortness of breath. The patient takes a sitting position with an inclination forward or knee ¾ elbow, pressing against the pillow. There are pains in the region of the heart, which intensify with breathing, coughing, body movements and are not stopped by nitroglycerin.

Examination: cyanosis, swelling of the face and neck (Stokes collar), swelling of the cervical veins, especially on inhalation due to compression of the superior vena cava by pericardial effusion, swelling on the legs, enlargement and pain of the liver, ascites. Swelling in the region of the heart and smoothness of the intercostal spaces.

With a large amount of effusion in the pericardial cavity, the patient occupies a sitting position with the body tilted forward, with his forehead resting on a pillow (Breitman symptom).

In rare cases, the patient is in the position of ―Muslim in prayer‖ (Girtz symptom - patients kneel and press their faces and shoulders to the pillow).

In some patients (especially often in men), it can be seen that the upper abdomen is not involved in breathing (Winter's symptom).

With percussion, there is a sudden transition from a clear sound over the lungs to a dull and ―hip‖ sound in the region of the heart (Auerbruger symptom).

Palpation: the apical impulse is weakened and displaced inwards from the left border of relative cardiac dullness.