Rheumatic carditis
Rheumatic carditis is the most significant manifestation of rheumatic fever, which allows you to determine the severity of the underlying disease and the tactics of managing the patient. Cardiac rheumatic heart disease may be the only isolated sign of rheumatism or enter the clinical symptom complex, simultaneously with other manifestations of the underlying pathology.
The classical form of rheumatic carditis implies the defeat of all layers of the heart wall from the endocardium to the pericardium, but with timely diagnostics and a specific therapy scheme initiated, it is possible to stop the spread of the inflammatory process and limit changes in the structure of the heart wall.
Causes of rheumatic carditis
The main trigger mechanism in the development of the classic form of rheumatic carditis as a manifestation of rheumatism is acute streptococcal infection located in the mucosa of the upper respiratory tract, as evidenced by the findings of numerous randomized studies. Thus, in 80% of the examined patients with rheumatic carditis, high titres of antistreptococcal antibodies of various serotypes are found.
The pathogenetic mechanism of rheumatic heart disease has not been adequately studied, but among cardiologists and immunologists, it is believed that the basis for the formation of the inflammatory process in the layers of the cardiac wall is massive passive or active toxic effects of infectious agents on heart tissue at the cellular level. In addition, as a result of the destruction of most of the streptococci, a large number of exoenzymes that produce direct tissue damage to the heart are produced.
It should be taken into account that with the return form of rheumatic carditis there may be no signs of an anti-streptococcal immune response, therefore the role of other etiopathogenetic factors in the occurrence of rheumatic carditis, for example, of a viral nature, is not excluded.
The so-called "hereditary predisposition" is of great importance in the development of rheumatic carditis, since not all patients who have experienced streptococcal infection even in severe form, eventually suffer from rheumatic heart disease. The predisposition to the development of rheumatic carditis is based on the theory of an individual hyperimmune reaction of the organism in response to the intake of streptococcal antigens, which is of a genetic nature. On the topic of finding a defective gene responsible for the development of hypersensitivity to streptococcal infection, a large number of studies have been carried out, which so far have no positive result.
Symptoms and signs of rheumatic carditis
The development of the clinical symptom complex and the intensity of certain manifestations of rheumatic heart disease depend on the localization of the inflammatory process and its prevalence. The most active symptoms are acute rheumatic carditis, in which the primary lesion of the endocardium occurs and the rapid dynamics of the increase in clinical manifestations, which may be specific and obshchematic.
Rheumatic carditis with isolated endocardial lesion is of short duration and does not differ in the activity of clinical manifestations. Patients with this form of heart disease do not present active complaints and do not feel a significant disorder of their own health, rheumatic cardiac endocarditis can be classified as a "random finding" during routine preventive medical examination. An experienced expert in the field of karyology may suspect that the patient has rheumatic cardiac endocarditis on the basis of objective examination data( a mild diastolic type of noise in the projection of the apex of the heart, as well as coarse systolic murmur at the auscultation points of the aorta and the apex of the heart).
With the further spread of the inflammatory process, a clinical picture of myocarditis with focal lesion is formed, which is characterized by the appearance of unpleasant sensations in the heart area that are not related to physical activity and are of a transient nature. In some situations, the first manifestation of rheumatic myocarditis is the disruption of cardiac rhythm. In the case of a limited lesion of the myocardial layer, the patient never develops cardiodynamic disorders.
Only with diffuse endomyocarditis of rheumatic origin is formed a typical clinical picture, which consists in the appearance of pronounced dyspnea, a feeling of cardiac disruption, the appearance of dry cough during an active physical activity. With prolonged flow, the patient has attacks of cardiac asthma and pulmonary edema. At the primary examination of a patient with a severe course of rheumatic carditis, all signs of congestive heart failure are found( the characteristic position of the patient in the orthopnea posture, cyanosis of the skin in the distal parts of the limbs, generalized edematous syndrome, increased heart rate with signs of arrhythmia).
In connection with diffuse damage of the heart, there is a sharp expansion of the boundaries of cardiac dullness and muffled heart tones, against which background auscultation of coarse systolic murmur is noted in all auscultative points. Listening to heart tones can be complicated due to the presence of changes in the lungs in the form of a multitude of scattered wet rales of various calibres, which is a reflection of the growing interstitial pulmonary edema.
Rheumatic heart disease with pericardial changes takes place with the same clinical symptoms as pericarditis is not of an infectious nature and significantly aggravates the course of the underlying disease. An interesting fact is that patients with rheumatic pericarditis do not complain about pain syndrome, but more notice signs of an increase in manifestations of congestive cardiac and pulmonary insufficiency. A characteristic auscultatory criterion of pericarditis of rheumatic nature is the noise of friction of pericardium leaves lasting no more than two days with the subsequent attachment of exudative processes in the pericardial cavity.
Primary rheumatic carditis of any severity usually results in the formation of valvular heart disease, while recurrent rheumatic heart disease develops against the background of already formed defect.
Treatment of rheumatic carditis
When choosing the tactics of management and the method of treatment of a patient with rheumatic heart disease, the degree of activity of the inflammatory process, the severity of the heart wall lesion and the degree of cardihaemodynamic dysfunction should be taken into account. All cases of primary rheumatic heart disease are subject to inpatient treatment in the cardiorheumatology department, after which the patient is recommended to undergo a course of rehabilitation therapy in a cardiac health resort and undergo scheduled examination with a cardiologist on an outpatient basis.
Predicting factor in the appointment of a particular regimen of the patient's stay in the ward is the severity of the condition and the severity of hemodynamic disorders.
Drug treatment of rheumatic heart disease consists in the appointment of an adequate scheme of anti-inflammatory therapy, the drugs of choice are nonsteroidal anti-inflammatory drugs.
Primary rheumatic carditis in children is an indication for the appointment of acetylsalicylic acid in the initial average daily dose of 1.5 g or Brufen in a dose of 20 mg per kg of the child's weight. Treatment of the adult category of patients with mild and moderate severity of the rheumatic process is also recommended to begin with the use of Acetylsalicylic acid in an average daily dosage of 4 grams orally, and if there are side effects from its use, it should be replaced with Diclofenac at a daily dose of 100 mg.
Indications for the appointment of drugs of the group of glucocorticosteroids is the lack of positive results from the use of non-steroidal anti-inflammatory drugs, the presence of signs of congestive cardiopulmonary insufficiency with concomitant cardiac rhythm disturbance. In this situation, short-term courses of Prednisolone in a low dosage( 1 mg per 1 kg of the patient's weight orally) should be used to avoid the development of adverse reactions. Abolition of prednisolone should be accompanied by the addition of Diclofenac in order to consolidate the anti-inflammatory effect. Some cardiologists practice the use of hormone pul- terapia, but due to the lack of data on the effectiveness of this method of treatment, it can not be considered a classic option for treating rheumatic heart disease.
In the active phase of rheumatic carditis there can be no question of the use of surgical treatment, which is shown only after the formation of cardiac defect during the remission of rheumatism. Currently, cardiosurgical practice proves the effectiveness of conducting vulvoloplasty, as a means of eliminating cardiohemodynamic disorders.
The return type of rheumatic heart disease is subject to the same amount of drug therapy as primary heart failure with the addition of symptomatic drugs. In the presence of signs of congestive heart failure, it is advisable to use diuretic drugs( Lasix in a daily dose of 80 mg), cardiac glycosides( Digoxin at an average daily dose of 1 g), ACE inhibitors( Enap 5 mg in the morning).
As a preventive measure that prevents the occurrence of recurrence of rheumatic carditis, timely sanation of chronic foci of infection should be considered as a means of preventing the spread of streptococcal infection.
