LECTURE No. 1. Diseases of the cardiovascular system. Rheumatism

Rheumatism (Sokolsky-Buyo disease) is a systemic inflammatory disease of the connective tissue with a predominant localization of the process in the cardiovascular system, which develops in persons predisposed to it (as a rule, these are young people) due to an acute infection with group A β-hemolytic streptococcus .

This definition of the disease was given in 1989 by V. A. Nasonov. It reflects all the characteristic features of the disease:

1) predominant damage to the cardiovascular system;

2) the role of pathological heredity;

3) the significance of streptococcal infection.

The essence of the disease lies in the defeat of all membranes of the heart, but mainly the myocardium and endocardium with the occurrence of deformation of the valvular apparatus - heart disease and the subsequent development of heart failure.

The defeat of other organs and systems in rheumatism is of secondary importance and does not determine its severity and subsequent prognosis.

Etiology. Group A beta-hemolytic streptococci cause damage to the upper respiratory tract. That is why the onset of rheumatism, as a rule, is preceded by a sore throat, an exacerbation of chronic tonsillitis, and an increased amount of streptococcal antigen and anti-streptococcal antibodies (ASL-O, ASG, ASA, antideoxyribonuclease B (anti-DNase B)) are detected in the blood of the sick.

Such a connection with a previous streptococcal infection is especially pronounced in the acute course of rheumatism, accompanied by polyarthritis.

In the development of rheumatism, age and social factors (adverse living conditions, malnutrition) play a role, and genetic predisposition also matters (rheumatism is a polygenically inherited disease, the existence of "rheumatic" families is well known), which consists in a hyperimmune response to streptococcus antigens, the propensity of patients to autoimmune and immunocomplex processes.

Pathogenesis. With rheumatism, a complex and diverse immune response occurs (immediate and delayed hypersensitivity reactions) to numerous streptococcal antigens. When an infection enters the body, anti-streptococcal antibodies are produced and immune complexes are formed (streptococcal antigens + antibodies to them + complement), which circulate in the blood and settle in the microcirculatory bed. Streptococcal toxins and enzymes also have a damaging effect on the myocardium and connective tissue.

Due to a genetically determined defect in the immune system, streptococcal antigens and immune complexes are not completely and quickly eliminated from the body of patients. The tissues of such patients have an increased tendency to fix these immune complexes. Cross-reacting antibodies also play a role here, which, being formed on streptococcal antigens, are able to react with tissue, including cardiac, antigens of the body. In response, inflammation develops on an immune basis (according to the type of immediate hypersensitivity), while the factors that implement the inflammatory process are lysosomal enzymes of neutrophils that phagocytize immune complexes and are destroyed at the same time. This inflammatory process is localized in the connective tissue, predominantly of the cardiovascular system, and changes the antigenic properties of it and the myocardium. As a result, autoimmune processes develop according to the type of delayed-type hypersensitivity, and lymphocytes reacting with cardiac tissue are found in the blood of patients. These cells are of great importance in the origin of organ lesions (mainly the heart).

In the connective tissue with rheumatism, phase changes occur: mucoid swelling - fibrinoid changes - fibrinoid necrosis. The morphological expression of immune disorders are cellular reactions - infiltration by lymphocytes and plasmocytes, the formation of rheumatic, or Ashoff-Talalayevsky, granuloma. The pathological process ends with sclerosis.

Another morphological substrate of heart damage in rheumatic heart disease is a nonspecific inflammatory reaction similar to that in the joints and serous membranes: swelling of the intermuscular connective tissue, fibrin sweating, infiltration by neutrophils and lymphocytes.

The disease flows in waves, aggravated under the influence of infection or nonspecific factors (hypothermia, physical stress, stress, etc.), which is associated with the autoimmune nature of the pathological process.

When the heart is affected, the inflammatory process can spread to all the membranes of the heart (pancarditis) or in isolation to each of the membranes. Morphological changes in rheumatism are found primarily in the myocardium, so it is myocarditis in the early stages that determines the clinical picture. Inflammatory changes in the endocardium (valvulitis, verrucous endocarditis), damage to the tendon filaments and fibrous ring are clinically detected 6-8 weeks after the attack of rheumatism. The mitral valve is most commonly affected, followed by the aortic and tricuspid valves. The pulmonary valve in rheumatism is almost never affected.

Rheumatism classification. Currently, the classification and nomenclature of rheumatism, approved in 1990 by the All-Union Scientific Society of Rheumatology, has been adopted, reflecting the phase of the process, the clinical and anatomical characteristics of damage to organs and systems, the nature of the course and the functional state of the cardiovascular system (see Table 1).

clinical picture. All manifestations of the disease can be divided into cardiac and extracardiac. The clinical picture of the disease can be described from these positions.

Stage I: the connection of the disease with the transferred infection is revealed. In typical cases, 1-2 weeks after a sore throat or acute respiratory illness, body temperature rises, sometimes up to 38-40 ° C, with fluctuations during the day within 1-2 ° C and strong sweat (usually without chills).

With repeated attacks of rheumatism, a recurrence of the disease often develops under the influence of non-specific factors (such as hypothermia, physical overload, surgery).

Table 1

Rheumatism classification

The most common manifestation of rheumatism is heart damage - rheumatic heart disease: simultaneous damage to the myocardium and endocardium. In adults, rheumatic heart disease is not severe. Patients complain of mild pain or discomfort in the region of the heart, slight shortness of breath during exercise, interruptions or palpitations are much less common. These symptoms are not specific to rheumatic heart disease and may be seen in other heart conditions. The nature of such complaints is specified at the subsequent stages of the diagnostic search.

Rheumocarditis in young patients, as a rule, is severe: from the very beginning of the disease, severe shortness of breath during exercise and at rest, constant pain in the heart, and palpitations are noted. There may be symptoms of circulatory failure in a large circle in the form of edema and heaviness in the right hypochondrium (due to an increase in the liver). All these symptoms point to severe diffuse myocarditis.

Pericarditis, as well as extracardiac manifestations of rheumatism, is rare. With the development of dry pericarditis, patients note only constant pain in the region of the heart. With exudative pericarditis, characterized by the accumulation of serous-fibrinous exudate in the heart sac, the pain disappears, as the inflamed pericardial layers are separated by the accumulating exudate.

Shortness of breath appears, which increases with the horizontal position of the patient. Due to the difficulty of blood flow to the right heart, congestion appears in a large circle (edema, heaviness in the right hypochondrium due to an increase in the liver).

The most characteristic of rheumatism is the defeat of the musculoskeletal system in the form of rheumatic polyarthritis. Patients note rapidly increasing pain in large joints (knee, elbow, shoulder, ankle, wrist), the impossibility of active movements, an increase in the volume of joints.

There is a rapid effect after the use of acetylsalicylic acid and other non-steroidal anti-inflammatory drugs with relief for several days, often several hours of all articular manifestations.

Rheumatic lesions of the kidneys are also extremely rare, detected only in the study of urine.

Lesions of the nervous system in rheumatism are rare, mainly in children. Complaints are similar to those of encephalitis, meningoencephalitis, cerebral vasculitis of a different etiology.

Only "small chorea" deserves attention, which occurs in children (more often girls) and is manifested by a combination of emotional lability and violent hyperkinesis of the trunk, limbs and mimic muscles.

Abdominal syndrome (peritonitis) occurs almost exclusively in children and adolescents with acute primary rheumatism. It is characterized by sudden onset, fever, and signs of dysphagia (diffuse or localized cramping pains, nausea, vomiting, retention or frequent stools occur).

At stage II of the diagnostic search, the detection of signs of heart damage is of little importance.

In primary rheumatic heart disease, the heart is usually not enlarged. Auscultation reveals a muffled I tone, sometimes the appearance of a III tone, a soft systolic murmur at the apex. This symptomatology is due to changes in the myocardium. However, an increase in the intensity, duration and persistence of the noise may indicate the formation of mitral valve insufficiency. It is possible to confidently judge the formation of the defect 6 months after the onset of the attack, while maintaining the above auscultatory picture.

In case of damage to the aortic valve, a proto-diastolic murmur at the Botkin point may be heard, and the sonority of the II tone may be preserved. Only many years later, after the formation of severe aortic valve insufficiency, weakening (or absence) of the II tone in the II intercostal space on the right joins this auscultatory sign.

In patients with polyarthritis, joint deformity is noted due to inflammation of the synovial membrane and periarticular tissues, pain on palpation of the joint. In the area of ​​the affected joints, rheumatic nodules may appear, which are located on the forearms and shins, above the bony prominences. These are small, dense, painless formations that disappear under the influence of treatment.

Erythema annulare (a sign almost pathognomonic for rheumatism) are pink ring-shaped elements, not itchy, located on the skin of the inner surface of the arms and legs, abdomen, neck and trunk. This symptom is extremely rare (in 1-2% of patients).

Rheumatic pneumonia and pleurisy have the same physical signs as similar diseases of banal etiology. In general, non-cardiac lesions are currently observed extremely rarely, in young people with an acute course of rheumatism (in the presence of high activity - III degree). They are unsharply expressed, quickly amenable to reverse development during antirheumatic therapy.

At the III stage of the diagnostic search, the data of laboratory and instrumental studies allow us to establish the activity of the pathological process and clarify the damage to the heart and other organs.

With an active rheumatic process, laboratory tests reveal nonspecific acute phase and altered immunological parameters.

Acute phase indicators: neutrophilia with a shift of the leukocyte blood formula to the left; an increase in the content of 2-globulins, followed by an increase in the level of - globulins; increase in fibrinogen content; the appearance of C-reactive protein; ESR increases. With regard to immunological parameters, the titers of anti-streptococcal antibodies increase (anti-hyaluronidase and antistreptokinase more than 1: 300, anti-O-streptolysin more than 1: 250).

The ECG sometimes reveals rhythm and conduction disturbances: transient atrioventricular blockade (more often I degree - prolongation of the P-Q interval, less often - II degree), extrasystole, atrioventricular rhythm. In a number of patients, a decrease in the amplitude of the T wave is recorded up to the appearance of negative teeth. These rhythm and conduction disturbances are unstable and quickly disappear in the course of antirheumatic therapy. If changes in the ECG are persistent and remain after the elimination of a rheumatic attack, then one should think about organic damage to the myocardium.

During phonocardiographic examination, auscultation data are specified: weakening of the XNUMXst tone, the appearance of the XNUMXrd tone, systolic murmur. In the case of the formation of a heart disease, changes appear on the PCG that correspond to the nature of the valvular lesion.

X-ray at the first attack of rheumatism, no changes are detected. Only with severe rheumatic heart disease in children and young people can an increase in the heart be detected due to dilatation of the left ventricle.

With the development of rheumatic heart disease against the background of an existing heart disease, the x-ray picture will correspond to a specific defect.

An echocardiographic study in primary rheumatic heart disease does not reveal any characteristic changes. Only in severe rheumatic heart disease with signs of heart failure on the echocardiogram show signs indicating a decrease in the contractile function of the myocardium and expansion of the heart cavities.

Diagnostics. Recognizing primary rheumatism is very difficult, since its most common manifestations, such as polyarthritis and heart damage, are nonspecific. Currently, the major and minor criteria for rheumatism of the American Heart Association are most widely used.

The combination of two major or one major and two minor criteria indicates a greater likelihood of rheumatism only in cases of previous streptococcal infection. With the gradual onset of rheumatism, the syndromic diagnosis proposed by A. I. Nesterov in 1973 (see Table 2) matters: clinical and epidemiological syndrome (connection with streptococcal infection); clinical and immunological syndrome (signs of incomplete convalescence, arthralgia, increased titers of antistreptococcal antibodies, as well as the detection of dysproteinemia and acute phase indicators); cardiovascular syndrome (detection of carditis, as well as extracardiac lesions) (see Table 3).

Table 2

Criteria for rheumatism

Table 3

Degrees of rheumatism

Differential diagnostics. Rheumatic polyarthritis must be differentiated from non-rheumatic ones (see Table 4).

Table 4

Rheumatic and non-rheumatic polyarthritis

The following diseases and symptoms are suspect in relation to rheumatism:

1) endocarditis;

2) myocarditis;

3) pericarditis;

4) heart defects;

5) rhythm and conduction disturbances;

6) acute and chronic heart failure;

7) prolonged subfebrile condition;

8) erythema nodosum;

9) annular erythema;

10) subcutaneous nodules;

11) acute allergic polyarthritis;

12) chorea.

None of the clinical syndromes listed above is specific to this disease. Only a combination of heart pathology with at least one extracardiac main symptom of rheumatism gives reason to suspect rheumatism.

Recognition of rheumatic heart disease itself is carried out on the basis of symptoms such as shortness of breath and palpitations, fatigue, pain in the region of the heart and heart rhythm disturbances, noises, sometimes a gallop rhythm and a weakening of the I tone. Of great importance in the diagnosis of rheumatic heart disease is the identification of pathology on the ECG. In rheumatism, it is caused by myocarditis, pericarditis and heart defects. Dynamic observation makes it possible to distinguish irreversible changes characteristic of hypertrophy of various parts of the heart in case of defects, from transient ones, indicating the current inflammatory process.

Treatment. A positive effect in treatment, as well as prevention of the development of heart disease, is facilitated by early diagnosis and individual treatment, which is based on an assessment of the type of course, the activity of the pathological process, the severity of carditis, and the variant of valvular heart disease. The condition of the myocardium, other tissues and organs, the patient’s profession, etc. are important.

Thus, the whole complex of treatment of rheumatism consists of antimicrobial and anti-inflammatory therapy, measures that are aimed at restoring immunological homeostasis. It is recommended to use a rational balanced diet, focus on adaptation to physical activity, preparation for work, timely surgical treatment of patients with complex heart defects. All patients during the active phase of rheumatism are shown penicillin (1-200 IU for 000 doses per day, every 1 hours), which has a bactericidal effect on all types of A-streptococcus. The course of treatment is 500 weeks during the active phase of rheumatism, in the future, a transfer to the prolonged drug bicillin-000 (6 units) is required. With intolerance to penicillin, erythromycin 4 mg 2 times a day can be prescribed.

Drugs with anti-inflammatory effect, which are used in the modern treatment of the active phase of rheumatism, are glucocorticosteroids, salicylic, indole derivatives, derivatives of phenylacetic acid, etc.

Prednisolone is used at 20-30 mg per day (for 2 weeks, then the dose is reduced by 2,5-5 mg every 5-7 days, for a total of 1,5-2 months) for primary and recurrent with III and II degree activity of the process of rheumatic heart disease, with polyserositis and chorea, with the development of heart failure due to active carditis. In the latter case, triamcinolone at a dose of 12-16 mg per day is preferred, since it has little ability to disturb the electrolyte balance.

Corticoid agents affect water-salt metabolism, therefore, potassium chloride 3-4 g / day, panangin and others should be used in the treatment, with fluid retention - aldosterone antagonists (veroshpiron up to 6-8 tablets per day), diuretics (lasix 40 -80 mg / day, furosemide 40-80 mg / day, etc.), with euphoria - tranquilizers, etc.

Non-steroidal anti-inflammatory drugs are also widely used for rheumatism: average doses of acetylsalicylic acid are 3-4 g per day, less often 5 g per day or more. Indications for the use of salicylates:

1) minimal degree of activity, slight severity of carditis, mainly myocarditis;

2) long-term treatment of rheumatism, suspicion of a latent course;

3) prolonged treatment with a decrease in the activity of the course of the process and the cessation of the use of corticosteroids, as well as after completion of treatment in a hospital;

4) recurrent rheumatic heart disease occurring against the background of severe heart defects and circulatory failure, since salicylates are not able to retain fluid, prevent the formation of blood clots, and are stimulants of the respiratory center;

5) reducing the likelihood of exacerbation of rheumatism in the spring and autumn periods, as well as after suffering intercurrent infections (together with antibiotics).

Acetylsalicylic acid is used 1 g 3-4 times a day after meals for 1-3 months or more with normal tolerance and subject to control of side effects.

The successful use of indolacetic acid derivative - indomethacin in rheumatism for more than 20 years. It has a pronounced therapeutic effect: subjective symptoms of carditis (cardialgia, palpitations, shortness of breath) disappear by the 8-10th day of therapy, and objective signs - by the 14-16th day. The disappearance of polyarthritis and polyserositis occurs even faster.

In the treatment of rheumatism, a combination of three main stages is important: hospital - clinic - resort.

In the hospital, treatment is carried out with the drugs listed above. After reducing the activity of rheumatism and normalizing the patient's condition, they are transferred to stage II - treatment in a rheumatological sanatorium.

The main goal of this stage is the continuation of treatment with non-steroidal anti-inflammatory drugs, which are individually selected in the hospital, aminoquinoline derivatives, bicillin-5, rehabilitation.

Stage III includes dispensary observation and preventive treatment. This is the implementation of therapeutic measures aimed at the final elimination of the active course of the rheumatic process; conducting symptomatic treatment of circulatory disorders in patients with heart disease; resolving issues of rehabilitation, working capacity and employment; implementation of primary prevention of rheumatism and secondary prevention of recurrence of the disease.

Author: Mostovaya O.S.

>> Forward: Diseases of the cardiovascular system. Cardiomyopathy. Dilated cardiomyopathy

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