Internal illnesses. Myocarditis (lecture notes)

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Internal illnesses. Myocarditis (lecture notes)

Lecture notes, cheat sheets

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LECTURE № 4. Myocarditis

Myocarditis is an inflammatory disease of the heart muscle of an infectious, allergic or toxic-allergic nature.

Etiology. The main factors in the development of the disease are bacterial infections, purulent-septic diseases (pneumonia, cholangitis, tuberculosis, sepsis), viral infections (Coxsackie viruses, influenza, ECHO), allergic factors, intoxications (thyrotoxicosis, uremia, alcohol).

Pathogenesis. Myocardial damage leads to the development of dystrophic-necrobiotic changes in muscle cells. The activity of cells in the inflammatory infiltrate increases due to hydrolases: acid phosphatase, β-glucuronidase, aminopeptidase. During a viral infection, viruses replicate in the myocardium. Against this background, the nucleic acid metabolism of cardiomyocytes is disrupted, collagen synthesis increases with the development of fibrous tissue.

Clinic. The main clinical variants are: pain (not accompanied by heart failure, recovery after 1-2 months), arrhythmic (with severe myocardial damage), circulatory failure (severe diffuse myocardial damage in combination with rhythm and conduction disorders), mixed (pain with arrhythmic , arrhythmic with circulatory failure, etc.), Abramov-Fiedler (severe idiopathic myocarditis).

The disease begins during the period of convalescence or 1-2 weeks after recovery from infection. An inexplicable low-grade fever appears, rarely - fever, weakness, malaise, sweating. There are cardialgias: from non-intense short stabbing pains to severe angina pectoris pains, a feeling of palpitations, interruptions in the work of the heart, shortness of breath. Objectively noted tachycardia, low filling of the pulse, in severe cases - altered pulse. In severe cases, the size of the heart increases, blood pressure is normal or reduced. The heart sounds are muffled, splitting of the I tone is possible, the appearance of additional III and IV tones, the "gallop rhythm", a muscular systolic murmur appears above the apex of the heart, there may be a pericardial rub.

With Abramov-Fiedler's myocarditis, increasing symptoms of progressive heart failure, thromboembolism of the kidneys, lungs, and spleen suddenly appear.

Additional diagnostic study. A general blood test is performed to determine the presence of leukocytosis and an increase in ESR. Biochemical studies are being carried out which indicate dysproteinemia, an increase in the content of α- and β-globulins, an increase in the level of sialic acids, the appearance of C-reactive protein, an increase in the activity of AST and CPK (in severe forms), a virological study, an immunological study (a decrease in the activity of the nonspecific component of the immune system). response, increase in the content of IgA, IgJ, IgM, CEC, appearance of anticardiac antibodies).

Scintigraphy is performed with Ga67, while radioactive gallium accumulates in inflammatory infiltrates.

An ECG study reveals the following changes: ST segment displacement, T wave changes - flat, biphasic, negative, (expansion of the QRST complex, decrease in voltage; there may be atrioventricular blockade, blockade of the legs of the His bundle; atrial, ventricular tachycardia; with Abramov's myocarditis- Fiedler changes may be similar to myocardial infarction.

Echocardiography is not very specific. Hypo- and dyskinesia of the myocardium, accumulation of a small amount of fluid in the pericardium, an increase in the left ventricle and left atrium are revealed, with Abramov-Fiedler's myocarditis, dilatation of the cavities, to a lesser extent, myocardial hypertrophy.

Complications. Complications of the disease include arrhythmias, circulatory failure, angina pectoris, myocardial cardiosclerosis, thromboembolism.

Differential diagnostics. Should be carried out with neurocirculatory dystonia, coronary heart disease, thyrotoxic myocardial dystrophy, primary rheumatic heart disease.

Treatment. In treatment, the appointment of bed rest is mandatory (for 1-2 months, depending on the severity of the condition). Conducted etiotropic therapy, which is effective in infectious myocarditis, and in viral myocarditis is ineffective.

NSAIDs are prescribed: salicylates, pyrozolone derivatives (butadione, reopyrin), indolacetic acid (indomethacin, metindol), phenylpropionic acid (brufen, naproxen, phenylacetic acid (voltaren).

In the treatment of effective immunosuppressants, which include corticosteroids, rarely cytotoxic drugs. Treatment with prednisolone is carried out for 1,5-12 months with an initial dose of 30-60 mg / day.

Symptomatic therapy is also carried out with cardiac glycosides, antiarrhythmic drugs, diuretics, and metabolic agents.

Flow. It can be acute, abortive, recurrent, latent, chronic.

Forecast. With most myocarditis, the prognosis is favorable, and with Abramov-Fiedler myocarditis, it is serious.

Prevention. The primary measures to prevent the disease include prevention, timely treatment and sanitation of foci of infections, after acute infections - limiting physical activity. Measures of secondary prevention is dispensary dynamic monitoring of ill persons.

Author: Myshkina A.A.

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