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Close concepts: the increased heart, big heart, increase in heart, a miokardiya
Cardiomegaly — the standard term for designation of the increased heart. Increased can be one or all four cameras of heart. To define what of cameras of heart is increased, not always easily, special researches for this purpose can be required. At healthy faces the sizes and a configuration of heart vary depending on the constitution, geometry of a thorax, asymmetry of an arrangement of heart in a thorax, breath phases during research and a method of an assessment of the sizes of heart. The small sizes of heart are not always a norm indicator as well as "the increased heart" in itself does not mean existence of diseases of a myocardium or defeat of valves of heart. As upper limits of the sizes of heart are strictly not defined, the diagnosis of a cardiomegaly is more subjective, than is considered to be.
The cardiomegaly is found at physical inspection or is more often at a thorax X-ray analysis. Usually increase in heart is found only after expansion of cavities. The expressed hypertrophy of ventricles without expansion of cavities can mask under the guise of normal heart. Increase in thickness of a wall of a left ventricle from 10 to 20 mm can indicate a considerable hypertrophy, however one excess centimeter can be imperceptible at physical inspection or a X-ray analysis of a thorax.
As soon as increase in the sizes of heart or any of its cameras is found, the doctor has to define the reason and estimate physiological effects of this increase. Thus, the diagnosis of a cardiomegaly causes the necessity of systematic research of cardiovascular system.
In this chapter it is not given full differential diagnosis of a cardiomegaly. The majority of states which can lead to increase in heart are listed in table.
Usually it is easier to find a cardiomegaly in subacute or chronic, than in initial or acute stages of a disease. At primary detection of increase in heart presence of symptoms and symptoms of clinical cardiac pathology is not obligatory. However over time most of patients with an explicit cardiomegaly has accessory clinical signs of a heart disease.
Anamnesis of a cardiomegaly
In details collected anamnesis can not always give help in a cardiomegaly reason explanation. Very often, when increase in cameras of heart is found out at a routine X-ray analysis or, what is more rare, on an ECG, the patient completely has no disease symptoms. Even careful poll can not always furnish the clue to the correct diagnosis.
Symptomatology of cardiovascular diseases
Often heart disease symptoms are found in patients with a cardiomegaly. As the majority of cases of a kardnomegaliya at adults is connected with increase in the left or right ventricle, when collecting the anamnesis it is necessary to concentrate attention on identification of signs of dysfunction of ventricles of heart or congestive heart failure which can be not diagnosed before. At poll it is necessary to pay special attention to an asthma at rest or at an exercise stress. Such symptoms as an orthopnea, a paroxysmal night asthma or night asthma, can not draw attention of the patient. Patients quite often adapt to chronic heart diseases, without noticing essential changes of health. Easy fatigue or the decrease in portability of exercise stresses which does not have the visible reason can be the important signs indicating heart pathology.
The orthopnea or asthma can be manifestations of the isolated left ventricular failure, is more rare — a paroxysmal night asthma. Insufficiency right or both ventricles of heart leads to system venous hypertensia. Therefore, the patient should be interrogated carefully about emergence of puffiness of anklebones or shins, especially at the end of the day. In more expressed cases periodic or permanent increase in a stomach owing to a hepatomegalia or ascites can be noted. Patients usually do not notice protrusion of jugular veins until there is their considerable expansion or insufficiency of the three-leaved valve. Heartbeat usually are a nonspecific symptom which directly does not belong to increase in heart.
Thorax pains. In spite of the fact that the cardiomegaly is not characteristic display of coronary heart disease, is clear that existence in the anamnesis of a myocardial infarction or passing symptoms in the form of stable or unstable stenocardia has to pay attention of the clinical physician to existence of the atherosclerosis of coronary arteries which is the most widespread cardial pathology at adults. Therefore, ischemic heartaches are an important symptom. Stenocardia in itself does not cause increase in heart, however the previous myocardial infarction leading to fibrosis of a cardiac muscle can lead to a hypertrophy and dilatation of heart; patients with the expressed dysfunction of a left ventricle usually have a cardiomegaly of various degree of manifestation though the expressed disturbances of the movement of a wall of a left ventricle and considerable decrease in fraction of exile can sometimes occur at the patient with a coronary disease having a normal silhouette of heart. At patients with aneurism of a left ventricle as a result of the postponed myocardial infarction the cardiomegaly which is quite often shown in the form of characteristic protrusion on a radiological shadow of heart is the rule.
In cases of the acute pericardis proceeding with accumulation of liquid in a pericardium cavity "cardiomegaly" of weak or moderate degree sometimes is found. At some types of a chronic pericardis the exudate in a cavity of a pericardium can lead to significant increase in a shadow of heart. The pericardium tamponade, a rare, but dangerous syndrome, can arise in a number of cases, including an injury, uraemia and collagenoses. Usually, though not always, there is thorax pain. Heart increases slightly. Pain of Yari a pericardis has a pleural origin and quite often can change intensity at change of position of a body, amplify when swallowing and pass at body tilts forward.
History of the previous diseases
Patients with suspicion or the established cardiomegaly should be interrogated carefully concerning existence in the anamnesis of noise in heart or acute rheumatic attack. Rheumatism meets infrequently, however many remember that when they were children or teenagers, they found noise in heart in them. Existence in the anamnesis of arterial hypertension, even non-constant, can be important; the hypertrophy of a left ventricle develops at many patients with is long the existing insignificant arterial hypertension. Fremingemsky research showed that arterial hypertension is the most frequent reason of congestive heart failure among adult population. Usually the cardiomegaly with expansion of a cavity of a left ventricle precedes symptoms of the expressed heart failure within several months or years.
Existence of a diabetes mellitus or disturbance of tolerance to glucose can be important. It is proved that it is long the existing diabetes can lead to dysfunction of a myocardium and a diabetic cardiomyopathy. Frequency of congestive heart failure at elderly patients with diabetes, especially at women, is quite high. Besides, patients with diabetes have the increased predisposition to a coronary disease, and at mature age they have clinical signs of coronary heart disease. It is necessary to remember that among patients with diabetes the frequency of the "latent" myocardial infarction is high; electrocardiographic symptoms of a transmural heart attack can be noted at absence in the anamnesis of pains in a thorax or the diagnosed stenocardia. The combination of diabetes and arterial hypertension which very often leads to increase in heart is especially adverse.
When collecting the general anamnesis it is necessary to pay special attention to cases of the postponed viral infections or heavy flu concerning which the patient asked for medical care. In many cases the so-called idiopathic cardiomyopathy is result of the postponed earlier viral myocarditis. Patients with subacute or acute viral myocarditis can have the accompanying symptoms: severe cough, fever, indisposition and general weakness.
Alcoholic injury of a muscle of heart is the important potential reason of a cardiomegaly. At the persons consuming a large amount of alcohol during 10 or more than flying, sometimes develops an alcoholic cardiomyopathy of which existence of a cardiomegaly is characteristic. Alcohol should be considered as a possible etiological factor of a cardiomegaly at all drinking even if symptoms and symptoms of congestive heart failure are absent. Key factor is consumption of a large amount of ethanol for many years. Cirrhosis is not always found in such patients.
The patients accepting gidrolazin or novokainamid have a risk of emergence of a medicinal syndrome of a system lupus erythematosus at which the cardiomegaly can develop as a result of a vypotny pericardis. Sometimes autoimmune myocarditis happens result of reception of Methyldopa. Treatment of malignant new growths adriamycin or other compounds of anthracycline is important in diagnosis of a cardiomegaly; these drugs at their accumulation in an organism make toxic impact, dependent on a dose, on a myocardium; in these cases the cardiomegaly can develop even before emergence of symptoms of congestive heart failure.
At patients with an asymptomatic cardiomegaly is most likely the cardiomyopathy or increase in a left ventricle are connected with arterial hypertension. If cardiomegalies accompany clinical symptoms, then information relating to possible displays of congestive heart failure is most important. It is obvious that the data of the anamnesis indicating coronary heart disease are also important directed by the diagnosis.
The first eight from the listed below questions concern the possible reasons of a cardiomegaly; the others help with an assessment of function of cardiovascular system.
1. Whether found in you sometime noise in heart or rheumatism?
2. Whether you ever increased arterial pressure?
3. Whether you take alcohol? In what quantity?
4. Whether you had recently viral infection or flu which gave complications on lungs?
5. Whether you were recently pregnant? At young women with a cardiomegaly the anamnesis of pregnancy is of great importance, such symptoms as fast fatigue and an asthma at the end of the third trimester or after permission of pregnancy during which not diagnosed cardiomegaly could develop are especially important.
6. Whether you were ill or any of your relatives a diabetes mellitus?
7. Whether you had heart attacks or thorax pains?
8. You what medicines you accept now could not remember or accepted recently?
9. Whether quickly you are tired?
10. Whether it became more difficult for you to perform a physical activity recently?
11. Whether you note emergence of an asthma in time or right after an exercise stress?
12. Whether more difficultly to you to breathe in a prone position, than sitting or standing?
13. Whether there is at you sometimes at night cough or goose breathing?
14. Whether you note puffiness of shins, especially at the end of the day?