Septic Endocarditis – Heart Treatment

The endocardium, which is inflamed with endocarditis, is several layers of cells:

  1. the innermost layer consists of endothelial cells. They are similar to those that form the mucous membranes of all internal organs, and are identical to the cells that line the blood vessels from the inside. Endotheliocytes lie on the basement membrane, which gives them signals to grow and divide;
  2. subendothelial layer. It is built of connective tissue rich in poorly differentiated cells;
  3. muscle-elastic layer. It consists of muscle fibers that are “packed” into the connective tissue. The layer is an analog of the middle layer of blood vessels;
  4. outer connective tissue layer. It consists of connective tissue and is identical to the outer membrane of the vessels.

The endocardium lines the inside of the heart wall, forms folds – valve flaps, as well as tendon chords attached to them and papillary muscles that pull the chords. It is this shell of the heart that separates the blood and the internal structure of the heart. Therefore, in the absence of inflammation, it is designed so that there is no significant friction of blood on the heart walls, and blood clots are not deposited here. This is achieved by the fact that the surface of the endothelium is covered with a layer of glycocalyx, which has special, atrombogenic properties.

The endocardium of the heart valves from the atria is more dense. This is ensured by a large number of collagen fibers in the muscular-elastic layer of the membrane. From the ventricles, the muscle-elastic layer is 4-6 times thinner, almost does not contain muscle fibers. The valves between the cardiac cavities and the vessels (pulmonary trunk, aorta) are thinner than the atrioventricular.

The nutrition of the deepest, bordering the myocardium, endocardium comes from the vessels that make up its structure. The remaining departments receive oxygen and the necessary substances directly from the blood, which is located in the cardiac cavities.

Directly under the endocardium is the heart muscle – myocardium. He is responsible not only for contractions of the heart, but also for the correct rhythm of these contractions: “paths” of cells are laid in the myocardium, some of which produce, and others transmit further electrical impulses, obliging the necessary parts of the heart to contract.

When enough microbes (bacteria or fungi) enter the bloodstream, they naturally end up inside the heart cavities. If human immunity is sufficiently weakened, then microorganisms settle on the endocardium (especially on the valves between the left atrium and ventricle, as well as at the entrance from the left ventricle to the aorta) and cause inflammation there.

Thrombotic masses can come off at any moment and with a blood stream enter the arteries that feed the internal organs. So a stroke, a heart attack of the spleen, intestines, lungs and other organs can develop.

Due to the increase in the mass of the valve with blood clots and scar tissue, it ceases to perform its function normally – to prevent the reverse flow of blood. Because of this, a condition called “chronic heart failure” develops.

Microorganisms that have settled on valves, chords, or the surface of the papillary muscles can cause the formation of endothelial ulcers (ulcerative endocarditis). If this leads to the development of a “hole” in the valve or the separation of the chord, the heart “loses control” over its own processes. Thus, acute heart failure develops, proceeding according to one of the scenarios: either pulmonary edema, shortness of breath and a feeling of lack of air, or a sharp decrease in pressure, increased heart rate, a panic state with a possible loss of consciousness.

The presence of bacteria or fungi in the blood causes the activation of immunity, as a result of which antibodies are formed against these microorganisms, the complement system (several immune proteins) is activated. Microbial antigens are combined with antibodies and complement proteins, but they are not destroyed (as should be normal), but are deposited around the vessels of many organs: kidneys, myocardium, joints, individual vessels. This causes an inflammatory-allergic reaction, resulting in the development of glomerulonephritis, arthritis, myocarditis or vasculitis.

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Causes and pathogenesis of endocarditis

Septic endocarditis is an inflammation of the inner layer of the lining of the heart during sepsis. A characteristic sign of pathological anatomy in such a case is ulceration of the valves of the organ. The diagnosis is complicated by the fact that it develops mainly in unhealthy people with a reduced immune response of the body. Often, septic endocarditis affects patients with rheumatic diseases, which in turn have defective valve structures of the heart. Patients with congenital malformations of this organ are also at risk of pathology.

Subject to septic endocarditis and patients of advanced age. As a rule, they already have dilatation of the left chambers of the heart, in which the mitral and aortic valves are affected.

But inflammation of the right parts of the myocardium is characteristic of injecting drug addicts and patients with intravascular catheters.

The picture of septic endocarditis depends on the agent by which it was caused. Fungus and gram-negative microflora become the cause of the disease very rarely, and if there are exceptions, then only for drug addicts and people who have undergone heart valve replacement. In addition to the above reasons, the disease is caused by ordinary or green streptococcus, less often white, Staphylococcus aureus, Enterococcus.

The disease is difficult to recognize. Often, the final diagnosis is made with an obvious picture of the pathology, when the symptoms of heart failure are manifested.

Classification according to the course of the disease:

  • Acute – lasts more than a crescent;
  • subacute septic endocarditis – with a course of up to three months;
  • chronic, which can last for years.

According to the clinical and morphological form, the disease is divided into primary (obsolete name – Chernogubov’s disease) and secondary. The first type occurs in about thirty percent of the total number of patients with unchanged valves. The second is dianostatic in the vast majority of patients with rheumatic heart disease. Occasionally, the secondary variant is diagnosed in people with congenital malformations, as well as atherosclerotic, syphilitic lesions.

The causative agents of infectious endocarditis are gram-positive and gram-negative bacteria (strepto- and staphylococci, enterococci, Escherichia coli and Pseudomonas aeruginosa, Proteus), less commonly, fungi, rickettsia, chlamydia, viruses.

Transient bacteremia is noted both for various infections (sinusitis, sinusitis, cystitis, urethritis, etc.), and after a large number of diagnostic and therapeutic procedures, during which the epithelium is colonized by a variety of microbes. An important role in the development of infectious endocarditis is played by a decrease in immunity due to concomitant diseases, advanced age, immunosuppressant therapy, etc.

Causes of subacute septic endocarditis

Before the widespread use of antibiotics, endocarditis was most often caused by streptococci. Nowadays, the main causative agents of endocarditis are staphylococci, fungi, Pseudomonas aeruginosa. The most severe course is endocarditis of fungal origin.

Patients often become infected with streptococcus within 2 months after prosthetic heart valves and people with congenital and acquired heart defects. But the infection can affect the endocardium and a completely healthy person – with severe stress, reduced immunity, because in the blood of every person there are many microorganisms that can take hold on any organs, even on the heart valves.

There are factors that significantly affect the likelihood of endocarditis:

  • congenital heart defects, especially heart valves;
  • prosthetic (artificial) heart valves;
  • previously endocarditis;
  • transplantation of the heart or pacemaker;
  • hypertrophic cardiomyopathy;
  • injecting drugs;
  • hemodialysis procedure;
  • AIDS.

If the patient belongs to a risk group, he is obliged to warn about this during various medical, dental procedures and other procedures associated with the risk of infection (tattoos). In this case, perhaps antibiotics should be used as a prophylaxis – this can be done only as directed by the doctor.

A variety of factors can provoke infectious endocarditis. Their recognition guarantees a positive effect from the treatment. The main causes of the inflammatory process in the endocardium are:

  • ailment of connective tissue of a diffuse nature;
  • trauma;
  • allergies
  • chemical poisoning;
  • infection.

The disease is described by Tsangov (1884), Lukin (1903) and only later by foreign authors.

Etiology and pathogenesis. Subacute septic endocarditis — a protracted, lingering chronioseptic process with localization of the infectious focus on valves disfigured by an old rheumatic, syphilitic, congenital, traumatic defect, or not previously changed. The causative agent — non-hemolytic Streptococcus viridans, a common inhabitant of the oral cavity and pharynx — is found on the AND valves in the blood of patients;

however, it is usually not possible to clinically establish a relationship with tonsillitis. The disease is characterized by a kind of reaction on the part of the body, proceeding, as a rule, without purulent metastases, with a violation of the bone marrow and the reticulo-endothelial apparatus. In recent decades, attention has been paid to the independence and relative frequency of this form of endocarditis.

Organic valvular heart disease is the main predisposing condition for sedimentation on the valves of septic infection, just as in the classical experiments of Vysokovich preliminary mechanical damage to the valves proved to be a necessary condition for obtaining experimental endocarditis with the introduction of bacteria into the blood.

Subacute septic endocarditis develops on the soil:

  1. most often rheumatic defects of the aortic and mitral valves, usually with a relatively mildly affected myocardium in the stage of compensation, without atrial fibrillation;
  2. congenital heart defects, especially non-closure of the interventricular septum, Botallus duct, pulmonary artery stenosis, congenital aortic valve anomaly;
  3. rarely because of syphilitic aortic insufficiency and even less so on sclerotic aortic valve disease;
  4. as an exception due to traumatic heart defects, which are generally extremely rare. Subacute septic endocarditis may also develop on previously unchanged valves (Chernogubov).

Rheumatic defects numerically significantly prevail among other organic valvular defects, therefore, it is natural that rheumatism is most often found in the history of patients with subacute septic endocarditis. Some authors (Strazhesko) recognize a closer connection between subacute septic endocarditis and rheumatism, believing that both diseases are based on the changing response of the body to infection with the same low-virulent streptococcus.

However, heart defects of a different etiology in no less than a percentage of cases are complicated by subacute septic endocarditis. The relationship of congenital heart defects with subsequent inflammatory endocarditis was established already 100 years ago, and the same relationship with traumatic defects was discovered more than 50 years ago. The main pathogenetic mechanisms of the development of subacute septic endocarditis, as well as other forms of endocarditis, are not well understood.

It is impossible to imagine that the pathological process boils down to the settling of bacteria in certain places of slow or perverted blood flow (with heart defects) or to the engraftment of various microbes due to violation of the blood supply conditions of the “vicious” valves themselves. The leading value is, one must think, of the particular reactivity of the valvular apparatus (or parietal endocardium) as a result of a neuroallergic or neurodystrophic effect, which, only under very specific conditions that are difficult to reproduce in an experiment, causes a complex inflammatory process that progresses for a long time towards the development of a pronounced clinical and anatomical endocardial disease .

It is characteristic that the development of especially typical protracted forms of endocarditis is more often observed with less virulent pathogens that do not cause suppuration in the organs, just as recurrent vascular lesions are often observed with a weakened infection. Development of endocarditis of the heart valves following inflammatory lesions of the arteries, which is observed in rare cases subacute septic arteritis of the Botallic duct with its non-closure or with arteriovenous aneurysm, possibly contributing to intravascular cardiac reflex exposure, and not just the mechanical transfer of the infectious onset.

Pathologically, an ulcerative, destructive process predominates, sometimes with perforation of the valves; sometimes warty growths are found, often with damage to the parietal endocardium. In the thickness of warty-ulcerative changes, bacterial masses are already found in large numbers even with a small increase in the microscope.

Embolic processes in various organs are characteristic, however purulent fusion in them is observed only as an exception; usually find focal embolic, and often diffuse nephritis, splenic megalia with multiple heart attacks, etc. Constant participation in the spleen process with a possible increase in its function can contribute to anemia, leukopenia, thrombopenia by inhibiting bone marrow function.

Depending on the initial state of the inner cardiac membrane, infectious endocarditis of the heart is primary and secondary. Both of them are caused by such microorganisms:

  • bacteria: green (is the main cause of subacute endocarditis) and pneumonic streptococci, Staphylococcus aureus and enterococcus (cause an acute inflammatory process), E. coli, tuberculosis mycobacterium, treponema pallidum (with syphilis), brucella, some gram-negative bacteria and anaerobes;
  • mushrooms, usually Candida. Such microflora usually appears when a person has been treated with antibiotics for a long time, or he has had a venous catheter for a long time (in the treatment of any diseases);
  • some viruses;
  • some of the simplest.

Only primary endocarditis is one that occurs on normal, healthy valves, and secondary on valves affected by rheumatism or prolapse, on artificial valves and those near which there is a pacemaker. Recently, the incidence of primary endocarditis has begun to increase. She reached 41-55%.

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Endocarditis Epidemiology

The incidence of IE is recorded in all countries of the world and ranges from 16 to 59 cases per 1000 people, in Russia – 000 per 46,3 people per year and is steadily increasing. Men get sick 1000-000 times more often than women. The most frequent endocardial damage occurs at the age of about 1.5 years, ¼ of all cases are recorded in the age group of 3 years and older.

The increase in the incidence of IE is due to a significant increase in the number of cardiac surgeries, surgical interventions and post-injection abscesses. It is believed that the likelihood of septic endocarditis in people who use non-sterile syringes (for example, with drug addiction) is 30 times higher than in healthy people.

The clinical picture of acute septic endocarditis

The general condition of patients is severe. Often there is adynamia, prostration, hectic fever, sweats, septic diarrhea, etc.

Complaints of a heartbeat, pain in the heart are few and do not usually attract the attention of a doctor to this organ. The study finds signs of heart disease, if there was one before, and with a previously healthy heart, only doubtful signs of damage to it. An unsharp systolic murmur is heard at the apex or on the aorta, or a weak diastolic murmur on the aorta, which is usually mistaken for anemic or muscular murmur, so frequent in severe infections in general.

The expressed galloping pulse, characteristic of the formed aortic defect, is also usually not observed. Significant expansion of the heart, as well as obvious signs of its insufficiency, is usually not observed. Sharp tachycardia, arrhythmia, and especially variability of noise are more characteristic. The spleen is felt indistinctly due to its soft consistency and the general serious condition of the patients, although at the autopsy they naturally reveal its increase.

An infectious agent is constantly easily seeded from the blood; sharp neutrophilic leukocytosis and anemia are also found.

Flow. Acute septic endocarditis begins gradually, lasts a few weeks, less often drags out to 2-3 months. A longer course or development of endocarditis is possible only after months with a milder course of sepsis, for example, with chronic meningococcal sepsis. The forecast is serious. Before the introduction of penicillin, all cases ended in death.

Diagnosis. You should think about this disease in severe septic courses of acute infections in surgical and gynecological patients and evaluate even minor signs of the heart, embolic events, and kidney damage in this direction. Progressive metastasis of the infection involving the meninges and serous membranes, with phlebitis with persistent positive blood culture is very suspicious of endocarditis.

Causes of endocarditis and its classification

A. The course of the disease

  • acute – from a few days to 2 weeks;
  • subacute infectious endocarditis;
  • chronic relapsing course.

B. The nature of the defeat of the valvular apparatus

  • primary infective endocarditis (Montenegrin form) that occurs on unchanged heart valves;
  • secondary endocarditis – develops against the background of the existing pathology of heart valves or large vessels (including in patients with artificial valves).

B. According to the etiological factor

  • streptococcal,
  • staphylococcal,
  • enterococcal,
  • viral,
  • others

When making a diagnosis take into account: diagnostic status – ECG with a typical picture; process activity – active, persistent or repeated; pathogenesis – IE of own valves; IE prosthetic valve, IE in drug addicts. Localization of IE: with damage to the aortic or mitral valve of the tricuspid valve, with damage to the pulmonary valve; with parietal localization of vegetation.

Symptoms and signs

In general, the symptoms of an infectious lesion are fever, chills, weakness, anorexia, sweating, arthralgia. In the elderly or in patients with renal failure, fever may be absent. The disease is characterized by the presence of heart murmurs, anemia, hematuria, splenomegaly, petechiae of the skin and mucous membranes, sometimes emboli. Acute heart failure, aneurysms may develop.

Most often (approximately 85% of patients), a fever is observed and heart murmurs are heard.

In addition, there are classic signs of septic endocarditis are found. These or those signs are observed on average in 50% of patients:

  • hemorrhage;
  • subcutaneous nodules near fingertips;
  • painless spots on the palms and soles;
  • painful seals of the fingertips (Osler nodules).

The following signs of the disease are found in approximately 40% of patients:

  • microabscesses
  • intracerebral hemorrhage.

The following symptoms are less commonly observed:

  • neck tension
  • paralysis,
  • rave,
  • sweating (especially at night)
  • shortness of breath,
  • pallor of the skin
  • arrhythmia.

Symptoms of early subacute endocarditis, as a rule, are weakly expressed non-specifically – they include the following:

  • body temperature of about 37,5 degrees, observed in 85% of patients;
  • anorexia and weight loss;
  • flu-like sensations in the body;
  • possible vomiting after taking write and abdominal pain.

The clinical picture is primarily associated with the infectious nature of the disease and embolic processes in the presence of an old heart disease and a kind of intoxication.

Prolonged fever of an indefinite type is one of the most important signs of the disease. Often there are febrile waves lasting 1–2–3 weeks, or one-, two-day temperature jumps up to 39–40 °, provoked by various moments, or long-term subfebrile condition. Typically, there is significant variability in the febrile reaction and the temperature can be almost normal for weeks and months. Long-term fever most often leads the patient to the doctor.

The general appearance of the patient is characteristic: pale skin with a special dirty shade of “coffee with milk”, although rarely seldom expressed; “Drum fingers” as a manifestation of a kind of intoxication, pathogenetically not entirely clear. Patients complain of weakness, decreased appetite; as a rule, severe intoxication is absent, delusional state, headaches, tongue is not taxed.

Pain phenomena due to embolism in various organs (into the spleen, kidneys, limbs, etc.) often represent the patient’s main complaint. On the part of the heart, there are signs of an old defect — rheumatic, congenital, or syphilitic, usually compensated, without severe rhythm disturbances. Often heard diastolic murmur on the aorta or mitral melody at the apex.

With the development of the process, unchanged (usually aortic) valves reveal a fresh defect (acute) due to septic lesion of the valves, which, however, for a long time does not give obvious local signs. The heart usually does not appear to be significantly enlarged; complaints are not primarily of a cardiac nature.

The examination reveals an enlarged spleen, sometimes to the extent of significant splenomegaly, simultaneously with an increase in the liver of the nature of an infectious rather than congestive liver. The contours of the spleen are easily determined by palpation, with the exception of periods of fresh spleen infarcts, causing sharp pain with a return to the region of the left shoulder joint, muscle protection from the side of the abdominal press, restriction of respiratory mobility of the lung on the left, sometimes the noise of friction of the peritoneum (perisplenitis) when listening to the area of ​​the lower ribs on the left or the spleen itself below the costal margin.

Similar embolic manifestations from other organs cause complaints primarily of pain or are detected with a thorough examination of the patient. So, kidney embolism often gives acute paroxysmal or dull lower back pain, sometimes with the release of bloody urine, soreness when tapping the kidney area behind (a positive symptom of Pasternatsky);

embolisms in the extremities cause petechiae, sometimes painful points or nodules on the fingers, especially on the terminal phalanges or on the elevations of the palm (thenar and hypo-thenar) in the form of red stripes, spots, sometimes with a white central point – a bridge to block blood vessels, which, along with with drum fingers, represents changes characteristic of the disease from the extremities.

When examining the skin, petechiae are found, due to the fragility of the vessels, and in other parts of the body, and in the conjunctival sac, especially on the lower eyelid, petechiae due to hemorrhage, embolism and vasculitis (Lukin’s symptom). On the part of the joints, light arthralgic phenomena were noted, on the part of the bones, especially the sternum, soreness when added.

Laboratory studies reveal characteristic data. First of all, in the urine, as usual with septic processes, changes characteristic of focal nephritis are found: erythrocytes in the sediment, an insignificant amount of protein with normal specific gravity of urine, undisturbed renal function and normal blood pressure (with aortic defects, there is, of course, high systolic and low diastolic pressure).

There is severe anemia in the blood with a drop in hemoglobin content of up to 40-30%, leukopenia (about 4 leukocytes), thrombopenin with thrombopenic phenomena: sharply prolonged bleeding time, the appearance of petechiae after applying a tourniquet to the shoulder. Among erythrocytes there may be nuclear forms, among leukocytes, monocytes and histiocytes as an indicator of the peculiar reaction of the reticuloendothelial system to septic infection.

Blood serum with a high content is also peculiar, which is invisible due to the same irritation of the reticuloendothelial system, globulins, in particular, eiglobulins, why the serum coagulates and becomes cloudy when formalin is added (positive formol reaction).

The most direct evidence of the septic nature of the disease is a positive blood culture, which is obtained by observing the appropriate methodology during periods of higher temperature and generally more activity of the process.

Symptoms and signs of subacute septic endocarditis

The clinical manifestations of IE are diverse. In acute endocarditis of streptococcal and staffilococcal etiology, symptoms such as a sudden marked increase in body temperature, severe chills, signs of acute failure of the affected valves and heart failure are noted. Acute endocarditis is considered as a complication of general sepsis.

The disease lasts up to 6 weeks from the onset of the disease, characterized by rapid destruction and perforation of valve flaps, multiple thromboembolism, and progressive heart failure. In case of untimely surgical intervention, IE quite quickly leads to death.

Subacute infectious endocarditis often develops at the age of 35-55 years and older. Symptoms usually appear 1-2 weeks after bacteremia.

Initially, symptoms of intoxication are observed: fever, chills, weakness, night sweats, increased fatigue, weight loss, arthralgia, myalgia. The disease can occur in the form of “repeated acute respiratory infections” with short courses of antibiotic treatment.

With prolonged severe course of the disease in some patients, the following characteristic symptoms are revealed:

  • The symptom of Janeway (spots or rashes of Janeway) is one of the extracardiac manifestations of infectious endocarditis: an immuno-inflammatory reaction in the form of red spots (ecchymoses) up to 1-4 mm in size on the soles and palms.
  • Osler’s nodules – also a symptom of septic endocarditis – are red painful seals (nodules) in the subcutaneous tissue or skin.
  • Petechial rashes with septic endocarditis are often found on the mucous membranes of the mouth, conjunctiva and folds of the eyelids – a symptom of Lukin-Libman.
  • The symptom of “drumsticks” and “watch glasses” is a thickening of the distal phalanges of the fingers and the appearance of a convex shape of the nails.
  • Roth spots – hemorrhages on the fundus having an intact center – not a pathognomonic symptom.
  • In patients with infectious endocarditis, a pinch symptom (Hecht symptom) or a tourniquet symptom (Konchalovsky-Rumpel-Leede symptom) are usually positive: hemorrhages appear in this zone when fingers compress the skin folds or pull the limb with a tourniquet.

Perhaps the development of glomerulonephritis, arthritis, myocarditis, thromboembolic complications.

There are variants of the course of infectious endocarditis without fever, with the defeat of any one organ – nephropathy, anemia.

The presence of endocarditis should be suspected with a newly appearing noise over the region of the heart, embolism of the cerebral and renal arteries; septicemia, glomerulonephritis and suspected renal infarction; fever with prosthetic heart valves; first developed ventricular arrhythmias; typical manifestations on the skin;

Signs and symptoms of endocarditis depend on its type (infectious, rheumatic, syphilitic, tuberculous) and are dictated by the course of the disease. So, if acute endocarditis has developed, then the symptoms will be as follows:

  • high body temperature (up to 39,5 ° C);
  • during the rise, the person’s temperature beats a strong chill;
  • copious perspiration;
  • pain in all joints and muscles;
  • retardation;
  • headache;
  • the skin becomes grayish with slight yellowness, sometimes red spots appear on it;
  • reddish painful nodules appear on the fingers;
  • conjunctival hemorrhages are noted.

Subacute infectious endocarditis occurs with the following symptoms:

  • increased body temperature – up to 38,5 ° C;
  • chills;
  • sleep disturbance;
  • weight loss;
  • skin color becomes “coffee with milk”;
  • red rash on the body;
  • small painful nodules appear under the skin,

but the main difference from the acute process is that this symptomatology is observed for 2 months or more.

For the chronic process, the same symptoms are characteristic (only the temperature is usually up to 38 ° C) for six months or more. During this time, a person loses weight greatly, the fingers of his hands take the form of drum sticks (extended in the area of ​​the nail phalanges), and the nails themselves become dull and become convex (resemble watch glasses).

When a heart defect forms, shortness of breath appears: at first during physical exertion, then at rest, pain behind the sternum, the heart beats more often (up to 110 beats per minute and more often) regardless of temperature.

If glomerulonephritis or kidney infarction develops, swelling on the face appears, urination is impaired (usually the urine becomes smaller), urine changes color to reddish, lower back pain appears.

If, against the background of the main signs, severe pain develops in the left hypochondrium, this indicates that one of the branches of the arteries supplying the spleen is clogged, and part or all of this organ dies.

With the development of pulmonary embolism, there is a sharp feeling of lack of air, pain behind the sternum. Against this background, impaired consciousness quickly grows, and the skin (especially on the face) acquires a purple hue.

Symptoms of infectious endocarditis develop in three stages:

  1. Infectious-toxic: bacteria enter the bloodstream, “land” on the valves, begin to multiply there, forming growths – vegetation.
  2. Infectious-allergic: due to activation of the immune system, internal organs are affected: myocardium, liver, spleen, kidneys.
  3. Dystrophic. At this stage, complications develop both on the part of the internal organs and on the side of the myocardium (parts of the heart muscle die in 92% of cases of prolonged inflammation of the endocardium).
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Infectious endocarditis in children develops as an acute process and is very similar to SARS. The difference is that with ARVI, the complexion should not change to yellowish, and heart pain should not be noted.

If endocarditis is rheumatic, then it usually develops after a sore throat, glomerulonephritis, in which beta-hemolytic streptococcus was isolated (in the first case, from the surface of the tonsils, in the second from the urine). After the disease has subsided, over time, a person notes weakness, fatigue, malaise.

Diagnostics

World clinical practice has summarized and deduced the criteria that are used to diagnose septic endocarditis. They are divided into large and small. Big ones include blood tests, during which a culture of microbes that are responsible for the infection of the body is sown.

  • two positive blood cultures taken at least twelve hours apart;
  • three positive crops of three;
  • from four blood cultures and more – maximum positive;
  • proven endocardial damage;
  • characteristic symptoms of acute septic endocarditis on ultrasound of the cardiovascular system.
  • predisposition;
  • fever;
  • vascular changes;
  • a change in laboratory blood standards. The presence of anemia, a shift in the leukocyte formula, an increased erythrocyte sedimentation rate, the presence of a C-reactive protein, a decrease in platelets, etc.

The final diagnosis is made in the presence of the so-called pathological criteria:

  • the presence of positive blood culture;
  • the presence of an intravascular substrate;
  • myocardial abscesses.

All of the above positions should be confirmed histologically or by adding up the criteria: two large, or one large, plus three small or five small.

Suspicion of pathology is removed if, after taking antibiotics for four days, symptoms disappear or signs of infection with the same duration of therapy are absent in blood samples.

Young and middle-aged patients with suspected septendocarditis require careful differential diagnosis with rheumatic lesions, accompanied by fever. In older people, the diagnosis should be separated from cancer problems. With a pathomorphological study of patients with certain types of cancer, it is possible to detect thromboendocarditis, which did not manifest itself during human life.

Often this disease is mistaken for malaria. The diagnosis changes in favor of endocarditis if plasmodia is not detected. Blood in the urine and lower back pain are encouraged to think about urolithiasis (ICD). However, groin pain is symptomatic for this disease.

An inconspicuous debut (subfebrile condition, loss of strength, pain in the joints and head) allows us to differentiate bacterial endocarditis from rheumatism, and in case of aortic insufficiency, from visceral syphilis. In all these cases, tactics are decided by positive tests for microbial culture.

Diagnosis of the disease is based on clinical data and, with characteristic symptoms, is not difficult. The main methods for diagnosing the disease is a blood test for the bacterial flora and a general blood test, as well as an echo-cardiogram, with which it is possible to detect microbial colonies on heart valves.

Septic endocarditis is usually suspected in cases of fever of unknown origin and heart murmur. Although in some cases, with parietal endocarditis or damage to the right heart, noises may be absent. The classic signs of the disease – a change in the nature of the noise or the appearance of new ones – are found only in 15% of cases. The most reliable diagnostic method is blood culture on the bacterial flora. This test makes it possible to identify the pathogen in 95% of cases.

Before antibiotics appeared, in 90% of cases the disease was caused by green streptococcus, mainly in young people with rheumatic heart diseases. Currently, older people are sick, most often men with heart defects. Pathogens, in addition to vermin streptococcus, can be Staphylococcus aureus, diphtheria-like bacteria, enterococci, and other strains.

The disease is diagnosed on the basis of the presence of two main signs:

  1. pathogens typical of infective endocarditis are found in the patient’s blood cultures;
  2. on echocardiography, signs of endocardial damage are observed – mobile growths on the heart valves, purulent inflammation in the area of ​​the valve prosthesis;

In addition, there are secondary symptoms:

  • detection of substances in large arteries that are not normal there (embolism);
  • infectious pulmonary infarction;
  • intracranial hemorrhage;
  • immunological phenomena;
  • febrile fever and other manifestations of systemic infection.

Thus, the diagnosis of infectious endocarditis in the presence of two main criteria in combination with several secondary ones.

Anamnesis and physical examination. It is necessary to ask the patient about existing heart defects, previous surgical interventions on the heart valves during the last 2 months; rheumatic fever, history of endocarditis; infectious diseases in the last 3 months; pay attention to skin manifestations – pallor (signs of anemia), ecchymosis.

Ophthalmic manifestations are Roth spots (retinal hemorrhages with a white center, Lukin-Liebman spots (petechiae on the transitional fold of the conjunctiva); transient, more often one-sided blindness or visual field disturbance.

The most important sign of infectious endocarditis is the appearance or change in the nature of heart murmur as a result of damage to the heart valves.

In the formation of aortic defect, first systolic murmur at the left edge of the sternum and at the V point (Botkin-Erba point), as a result of stenosis of the aortic mouth due to vegetation on lunate valves, then signs of aortic insufficiency appear – tender protodiastolic murmur above the aorta and at V point aggravated by standing and lying on the left side. With the destruction of the valves, the intensity of diastolic noise increases, II tone on the aorta weakens.

Symptoms of central nervous system damage manifest as confusion, delirium, paresis and paralysis as a result of thromboembolism, meningoencephalitis.

In acute infectious endocarditis, signs of severe heart failure are revealed – bilateral wet rales, tachycardia, additional III cardiac tone, edema of the lower extremities.

In half of the patients, splenic or hepatomegaly, it is often possible to notice icteric sclera and mild yellowness of the skin; lymphadenopathy. Perhaps the development of thromboembolic heart attacks of various organs (lungs, myocardium, kidneys, spleen).

In 30-40% of cases, common myalgia and arthralgia are observed with the predominant involvement of the shoulder, knee and sometimes small joints of the hands and feet. Myositis, tendonitis and enthesopathies, septic mono- or oligoarthritis of various localization are rare.

general blood test for acute infectious endocarditis – normochromic normocytic anemia, with a shift of the leukocyte formula to the left, thrombocytopenia (20% of cases), accelerated ESR.

In the biochemical analysis of blood, dysproteinemia with an increase in the level of gamma globulins, an increase in the CRH of 35-50%.

Urinalysis: macro- and microscopic hematuria, proteinuria, with the development of streptococcal glomerulonephritis – red blood cells.

Blood culture is an objective confirmation of the infectious nature of endocarditis in identifying the pathogen, allows you to determine the sensitivity of the infectious agent to antibiotics.

In 5-31% of cases with IE, a negative result is possible. Serological techniques are effective for IE.

ECG – against the background of IE with myocarditis or myocardial abscess – impaired conduction, less often paroxysm of atrial tachycardia or atrial fibrillation.

Echocardiography – is performed for all patients with suspected IE no later than 12 hours after the initial examination of the patient. Transesophageal echocardiography is more sensitive to vegetation than transthoracic echocardiography, but it is more invasive.

Chest X-ray – with infectious endocarditis of the right heart, multiple or “volatile” lung infiltrates are observed.

Diagnosis of endocarditis is based on data:

  1. listening to the heart: first, systolic murmur is determined, then – diastolic murmur;
  2. definitions of the borders of the heart: they expand to the left (when the valves are damaged in the left parts of the heart) or to the right (if vegetations are found in the right parts);
  3. ECG: if irritation occurs with the inflamed endocardium of the myocardial pathways, the cardiogram determines rhythm disturbance;
  4. Ultrasound of the heart (echocardioscopy): this is how vegetation (growth) on the valves and the thickening of the endocardium and myocardium are determined. Ultrasound with dopplerography can be used to judge the function of the heart and indirectly, pressure in the small circle;
  5. bacteriological blood tests (sowing it on various nutrient media);
  6. blood tests using the PCR method: this is how certain viruses and bacteria are determined;
  7. rheumatic tests: in order to distinguish infectious endocarditis from rheumatic;
  8. If necessary, a magnetic resonance or computed tomography of the chest with a targeted examination of the heart can be performed.

An accurate diagnosis of infectious endocarditis is made when there is a specific ultrasound picture of the heart, and in addition, the pathogen is determined in the blood. If all the symptoms indicate this disease, a microbe is determined in the blood, but there are no significant changes in echocardioscopy, the diagnosis is “in doubt”.

When the pathogen is not detected in the blood, but the ultrasound picture is not in doubt, the diagnosis is written as infectious endocarditis or “culture-negative” (that is, bacteriological culture did not reveal anything), or “PCR-negative” (if PCR was not isolated pathogen).

Patient treatment and observation

This disease is always treated in a hospital in compliance with the regimen of medication and diet. The physical activity of the patient is minimal.

With a certain septic endocarditis, massive antibiotic treatment is used. The drug is selected, given the sensitivity to it of the alleged infectious agent. Usually, a broad-spectrum medication from a number of penicillins, cephalosporins is indicated. Often they are combined with aminoglycosides. Antimycotic agents and NSAIDs may be prescribed.

For endocarditis with an unknown pathogen, combined antibiotics are used, for example, tetracycline, terramycin, erythromycin. Preparations are preferably changed every two to four weeks due to the development of microorganism resistance to them.

The effectiveness of treatment can be assessed by the following signs:

  • 48–72 hours after the start of therapy, the state of health improves, appetite, chills disappear;
  • at the end of the first week, body temperature decreases, petechiae, embolism disappears, hemoglobin increases, ESR decreases, the sterility of crops is fixed;
  • in the final of the third week – the transition to the norm of leukoformula, ESR, the state of the spleen;
  • at the end of treatment – the norm of ESR, proteinograms, hemoglobin. No new vasculitis and thromboembolism occur.

Sometimes surgical intervention cannot be avoided. As a rule, this occurs in cases where conservative therapy was unsuccessful.

Sanatorium treatment in an institution with a cardiological direction may be recommended. Mandatory is the follow-up of a patient who has had infectious endocarditis.

In terms of the prognosis, it is worth noting that patients without treatment received do not often recover. With early antibiotic therapy, approximately 70 percent of patients with infection of their own valve structure and 50 with damage to prosthetic structures overcome the disease.

In all cases of septic endocarditis or suspected diagnosis, hospitalization of the patient is required. After intensive inpatient treatment for 10-14 days, stabilization and the absence of a significant risk of complications (absence of fever, negative blood culture, absence of rhythm disturbances and embolism), treatment is continued on an outpatient basis.

Treatment for infectious endocarditis consists mainly of intensive antibiotic therapy. Also, first of all, the main disease is treated – rheumatism, sepsis, systemic lupus erythematosus. Antibacterial treatment should be carefully selected, that is, the selected antibiotic should correspond to the bacterial flora and begin as early as possible. Therapy can last from 3-6 weeks to 2 months, depending on the degree of damage and the type of infection.

Drugs, for their constant concentration in the blood, are administered intravenously. It is important to monitor the concentration of antibiotics in the plasma, which should be kept at a therapeutic level, but does not become toxic to the body. To do this, in each case, determine the minimum (before the introduction of the fourth dose) and maximum (half an hour or an hour after the fourth dose) concentration levels.

A laboratory study of the sensitivity of the pathogen to antibiotics is mandatory. A biochemical and general blood test is also regularly performed, the bactericidal activity of the serum is evaluated, and the activity of the kidneys is monitored.

With subacute septic endocarditis, therapy is carried out with high doses of benzylpenicillin sodium salt or semi-synthetic penicillins (oxacillin, methicillin). Antibiotic treatment, mainly parenteral, is continued until a perfect bacteriological and clinical recovery.

Infectious endocarditis is a dangerous disease that requires timely prevention. This is a warning of sepsis and infectious complications, especially with congenital and acquired heart defects.

As preventive measures for subacute septic endocarditis, the fight against rheumatism and other infections that cause organic heart valve defects should be mentioned. With already existing heart disease of any nature, patients should be especially protected from septic infection by, for example, prophylactic penicillin therapy during tooth extraction, tonsillectomy and similar interventions.

Treatment of subacute septic endocarditis consists of general measures and specific treatment. Patients need bed rest already in the early period of the disease, regardless of their sometimes good health, in clean air, a relaxed atmosphere, good nutrition, and protection from infection.

Penicillin, which is detrimental, as experience shows, on most of the strains of green streptococcus seeded from the blood of patients with subacute septic endocarditis, as well as penicillin together with streptomycin, is considered to be the most effective means at present. Penicillin treatment is carried out according to general rules in large doses of 500-000 units per day for 1-500 weeks in a row with the repetition of such courses several times after short breaks. It is especially important to begin treatment with penicillin in the very first months of the disease.

Additionally, agents are used that enhance the effect of penicillin and increase the body’s resistance, its immune forces, as well as symptomatic drugs. They try to increase the effect of penicillin on streptococci by creating special conditions that delay its excretion from the body and, consequently, increase its concentration in the blood, as well as by preventing blood clots on the affected valves that block the antibiotic’s access to microbes, or by artificially increasing the patient’s body temperature to increase penicillin action.

However, anticoagulants and artificial fever are not indifferent for the patient and, being seemingly justified from a theoretical point of view, do not give undeniable and significant advantages over conventional therapy with penicillin alone. The administration of agents simultaneously with penicillin, even with a weaker coagulation-inhibiting action, such as salicylates, quinine, could be justified from the point of view that the coagulation of blood under the influence of penicillin itself is somewhat accelerated;

however, these provisions cannot yet be considered sufficiently firmly established. To increase the general resistance of the body, treatment with liver preparations, vitamins, as well as blood transfusion of 100-150 ml in the absence of contraindications in the form of heart failure or frequent embolism can be used. Of the medicines, pyramidone is also prescribed, which often definitely reduces the temperature, soothing — bromides, luminal, etc.

Detonic -   Increased hemoglobin red blood cells and hematocrit causes treatment

In order to sanitize various infectious foci, for example, in the oral cavity, nasopharynx, as well as to change abnormal conditions, blood circulation, surgical interventions — tonsillectomy, etc., ligation of the open botall duct, which reduces fever and leads to more successful blood sterilization and healing, should be used valve infections.

When sowing penicillin-resistant microbes from the blood, large doses of sulfonamide drugs (up to 100,0 or more per course), streptomycin and other antimicrobial agents are used, depending on the properties of the pathogen. Treatment with sulfonamides in ordinary cases of subacute septic endocarditis gives undoubtedly more modest results compared to penicillin, and one should bear in mind the possible side effects of these drugs.

Previously used antibacterial therapy — rivanol, flavacridine (tripaflavin, acriflavine), silver preparations, vaccination, immunotransfusion — is often poorly tolerated and, as it were, suppresses the body’s defenses. The altered reactivity of patients with subacute septic endocarditis is probably of great importance in the outcome of this chronioseptic process caused by a low-virulent pathogen, however, this reactivity usually fails to change significantly.

It should be limited to mildly acting disinfectants (urotropin, salitropin in a vein or per rectum) and especially recommend, as already mentioned, a restorative regimen (physical and mental rest, complete easily digestible food, multivitamin mixtures, light sedatives, liver preparations, etc. .).

Under the influence of early treatment with large doses of penicillin, fever decreases, severe organ damage does not develop, and recovery or at least prolonged remission occurs. If treatment is started already with the development of the full clinical picture or in the late period, it is also almost always possible to cause remission — improvement of well-being, decrease in temperature, often to normal, improvement of blood composition, reduction of embolism;

less often there is a significant reduction in the enlarged spleen, etc. Moreover, as mentioned above, and upon termination of the fever, heart and kidney insufficiency may increase, which nevertheless leads the patient to death; it should be remembered that even after prolonged remission or apparently complete recovery, a new exacerbation or a new disease of sepsis is possible, sometimes already caused by another pathogen.

Treatment boils down to good care, good nutrition, and an increase in the body’s overall resistance. It is necessary to prevent pressure sores, etc.

With surgical (wound) and obstetric sepsis, the elimination of the primary focus of infection is of great importance. Basically, treatment comes down to the persistent use of antibiotics and chemotherapeutic agents, respectively, of the suitability of the causative agent of this case of endocarditis to one or another drug, along with blood transfusion and other general measures of influence on the body.

Therapeutic activities

Treatment of infectious endocarditis includes a set of measures to eliminate the inflammatory process in the inner membrane of the human “motor”. Most often, antibacterial therapy and surgical intervention are involved in the process. If there is a formation of heart disease, then treatment should be aimed at correcting it. If infectious endocarditis is suspected, the patient should be hospitalized urgently.

When treating endocarditis with antibiotics, you need to discuss this issue with your doctor. Their purpose is taking into account the degree of sensitivity. The course of admission should be at least 4-6 weeks. As a rule, a specialist prescribes a complex of medications to a patient in order to achieve maximum effect. It could be:

  • Ampicillin-Sulbactam with Gentamicin;
  • Vancomycin and Ciprofloxacin.

In addition to antibiotic medications, treatment of infectious endocarditis involves medications that affect the immune system.

If there is a disease of a non-bacterial nature, then for the treatment of endocarditis, the specifics of the underlying ailment must be taken into account. When endocrine pathology is diagnosed, the patient must undergo hormone tests and be treated under the supervision of an endocrinologist. Endocarditis, which is the result of intoxication, can be treated by canceling the use of a certain type of toxin.

Operation

Surgical removal of the inflammatory process involves the removal of the affected area of ​​the heart valve with further prosthetics. If there is such an opportunity, then the patient undergoes plastic surgery to maintain their own valves. After the rehabilitation period, the patient should be under the supervision of doctors.

The course, clinical forms and complications of subacute septic endocarditis

In the absence of adequate antibacterial treatment, there is a likelihood of complications of infectious endocarditis, often ending with a fatal outcome. Among them, septic shock, acute heart failure, impaired functioning and functions of the whole organism.

Complications from the presented disease arise due to growths on the heart valves. They can disconnect and with the flow of blood affect other organs and systems. If they get stuck in a small vessel, this will cause an acute lack of blood supply, which will result in tissue death.

The onset of the disease is difficult to pinpoint. It begins gradually with general symptoms of weakness, decreased ability to work, which are often incorrectly interpreted by an inexperienced doctor as depending on overwork, exhaustion of the nervous system. Clinically, one can distinguish various types, variants of the course of the disease, depending on the virulence of the infectious onset or the prevailing clinical syndrome due to the primary lesion one or another body.

So, one can distinguish more malignant forms with high fever, with an abundance of embolism, which lead to death in the first months of the disease, as well as the so-called outpatient forms with an almost normal temperature. According to the leading clinical syndrome, types are distinguished: anemic, splenomegalic, hepatosplenomegalic, nephritic (in cases of kidney damage with diffuse nephritis with hypertension and azotemia, or in kidney damage with amyloid with anasarca, hypercholesterolemia, etc.

), cerebral, psychotic, etc. Of the peculiar and serious complications, it should be noted embolism of the arteries of the brain with hemiplegia, embolism of the retina, embolism of the lungs (from the right heart), embolism of the coronary arteries of the heart with myocardial infarction, the development of multiple aneurysms of various organs of embolic bacterial (“mycotic”) nature, for example, aneurysm a.

One of the most formidable complications of endocarditis is embolism – a detachment of a part of an overgrown valve, thrombus or thrombus with a part of the valve with a further “travel” of this particle through the arteries. The embolus (or thromboembolism) will stop where the diameter of the artery exactly matches it.

If the separation of the particle occurred in the left parts of the heart, embolization of the vessels of the big circle develops – one of the internal organs may suffer: intestines, spleen, kidneys. They develop a heart attack (that is, the death of the site).

If a blood clot or unstable (poorly fixed) vegetation is located in the right sections, the embolus blocks the vessels of the small circle, that is, the pulmonary artery, as a result of which pulmonary infarction develops.

Also, due to endocarditis, such complications can be observed:

  1. Acute congestive heart failure.
  2. The formation of heart disease.
  3. Myocarditis.
  4. Pericarditis.
  5. Chronic heart failure.
  6. Renal lesions: glomerulonephritis, nephrotic syndrome, renal failure.
  7. Lesions of the spleen: abscess, enlargement, rupture.
  8. Complications of the nervous system: stroke, meningitis, meningoencephalitis, brain abscess.
  9. Vascular lesions: inflammation, aneurysms, thrombophlebitis.

Prevention and treatment of subacute septic endocarditis

To prevent infectious endocarditis, simple hygiene rules should be followed:

  • Keep your teeth healthy.
  • Be as serious as possible about cosmetic procedures that can cause infection (tattoos, piercings).
  • Try to see a doctor immediately if you find any skin infection or have a non-healing wound.

Before agreeing to medical and dental procedures, discuss with your doctor the need to take antibiotics in advance that can prevent the development of an accidentally introduced infection. This is especially true for people who have already experienced endocarditis, having heart defects, artificial heart valves. Be sure to tell your doctor about your medical conditions.

If you do not want your body to pick up such a pathology, then you should know the main measures that can protect you from endocarditis. Prevention involves the following series of actions:

  1. When using drugs, it is urgently necessary to refuse them, since it is these people who are at greater risk of getting sick.
  2. Those who have artificial valves or chronic heart disease should always be under the supervision of a specialist.
  3. Constantly monitor the quality of processing of medical equipment and ask your doctor about the quality of sterilization.

Endocarditis can be affected by every person, both an adult and a child. The reason for this pathology lies in the defeat of the body by an infectious agent. The disease manifests itself with chills, fever and headaches. It is possible to cure this condition, but only under the condition of an integrated approach. If you delay with therapy, you can get a number of unpleasant and dangerous complications, which will subsequently be very difficult to treat.

Antibiotics should be prescribed to patients from high and medium risk groups: prosthetic heart valve, hemodialysis, complex congenital heart disease, surgical vascular conduits, history of infectious endocarditis, mitral valve prolapse, treatment with corticosteroid drugs and cytostatics, intravenous catheter infection, surgical interventions and post-injection. abscesses.

Prevention of endocarditis is as follows:

  • you must adhere to sufficient physical activity and follow the rules of a healthy diet so that as little as possible examined and treated with invasive methods;
  • it is important to sanitize foci of infection in a timely manner: to treat diseased teeth, rinse tonsil lacunae with chronic tonsillitis, ensure the outflow of contents from the sinuses – with chronic sinusitis;
  • if you still have to be treated, you need to do this not at home or in doubtful rooms, but in specialized clinics;
  • if work or life involves frequent injuries, care must be taken to maintain sufficient immunity. For this, it is important to eat right, just move, maintain the hygiene of your skin and external mucous membranes;
  • upon injury, proper antiseptic treatment of the wound and, if necessary, a visit to the doctor;
  • if, due to heart disease, a heart operation was required, the installation of an artificial valve or pacemaker, after which blood-thinning drugs were prescribed, it is impossible to voluntarily cancel their intake;
  • if the doctor prescribes antibiotics for some reason, you need to take them as many days as prescribed. From the 5th day of taking antibacterial therapy, you need to ask a doctor about the need to prescribe antifungal drugs;
  • it is important to take antibiotic prophylaxis before starting any invasive treatment. So, if the operation is planned, it is better to start administering the drugs 12-24 hours before it (especially if the intervention is performed on the organs of the oral cavity or intestines). If you had to resort to emergency surgery, you need to enter the antibiotic as soon as possible after admission to the hospital.

Forecast

Microbes, multiplying, can completely destroy the heart valve or its parts, which guarantees the development of heart failure. Also, infection or damaged areas of the valves can enter the brain with blood flow and cause cerebral infarction.

Healing without serious consequences requires early hospitalization with targeted treatment for the infection. The presence of heart disease in a patient also seriously worsens the prognosis of infectious endocarditis.

There is a likelihood of the disease becoming chronic with periodic exacerbations.

With the right choice of treatment and the absence of significant concomitant pathologies, the 5-year survival rate is 70%.

With timely antibiotic therapy, the prognosis is quite favorable. With fungal infective endocarditis, mortality reaches 80% or more. In case of chronic heart failure – mortality is more than 50% in the next 5 years.

Infectious endocarditis is a disease whose prognosis is conditionally unfavorable. In people without immune deficiency, defects and diseases of the heart and its valves, it is more favorable, especially if the disease is diagnosed early and emergency antibiotic therapy is started urgently. If a person becomes ill with endocarditis, having chronic heart disease or suppressed activity of the immune system, life-threatening complications can develop.

Also, the prognosis worsens if:

  • symptoms of the disease began to appear after admission to the hospital (where either an invasive diagnosis or surgery, including surgery on the heart) was performed – during the first 72 hours;
  • if gram-negative flora, Staphylococcus aureus, insensitive to Cochiella or Brucella antibiotics, fungal flora are sown from the blood (from the valves).

With infectious endocarditis with damage to the right heart, a better outcome can be expected.

Rheumatic endocarditis is more favorable for life: acute heart failure and thromboembolism are less characteristic for it. But heart disease with this pathology develops in the vast majority of cases.

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Svetlana Borszavich

General practitioner, cardiologist, with active work in therapy, gastroenterology, cardiology, rheumatology, immunology with allergology.
Fluent in general clinical methods for the diagnosis and treatment of heart disease, as well as electrocardiography, echocardiography, monitoring of cholera on an ECG and daily monitoring of blood pressure.
The treatment complex developed by the author significantly helps with cerebrovascular injuries and metabolic disorders in the brain and vascular diseases: hypertension and complications caused by diabetes.
The author is a member of the European Society of Therapists, a regular participant in scientific conferences and congresses in the field of cardiology and general medicine. She has repeatedly participated in a research program at a private university in Japan in the field of reconstructive medicine.

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