Chronic rheumatic heart disease (CHRD) is a disease characterized by damage to the heart valves in the form of post-inflammatory marginal fibrosis of valvular cusps or heart disease (insufficiency and / or stenosis) formed after acute rheumatic fever.
Rheumatic heart defects are formed as the outcome of rheumatic heart disease. Isolated defects predominate: mitral insufficiency, aortic valve insufficiency, mitral stenosis, combined aortic and mitral valve defect.
Rheumatic heart disease (rheumatic carditis) is not an independent disease, but a leading component of acute rheumatic fever (ARF), which determines the severity of the patient’s condition. Damage to the heart can occur both in isolation and together with other manifestations of rheumatism (joint pain, rash, subcutaneous nodules, hyperkinesis).
In clinical cardiology, rheumatic heart disease is divided into primary (debut attack) and return (subsequent attacks); accompanied by the formation of valvular defect or proceeding without damage to the valves. With rheumatic heart disease, various parts of the heart are affected. According to the degree of involvement in the inflammatory process of the heart walls, there are:
- Endocarditis. Infectious endocarditis occurs in almost 100% of cases, that is, it is an essential component of rheumatic heart disease. It can be combined with valvulitis – inflammation of the valves.
- Myocarditis With inflammation of the heart muscle, the size of the heart increases and its contractile function deteriorates. In general, it is myocarditis that determines the severity of the disease. For rheumatic heart disease, the most typical combination of inflammation of the valves and the heart muscle is endomyocarditis.
- Pericarditis. Inflammation of the heart bag (pericarditis) is quite rare – in 2-3% of cases. Involvement of all the walls of the heart (pancarditis) also occurs infrequently.
There are special clinical criteria for determining the severity of rheumatic heart disease: organic heart murmur, enlargement of the heart (cardiomegaly), signs of heart failure (severe shortness of breath, cyanosis, swelling of the lower extremities, enlargement of the liver, enlargement of the neck veins, wheezing in the lungs), noise pericardial friction or signs of pericardial effusion. Given these criteria, in the course of rheumatic heart disease there are three degrees of severity:
- Easy. It is diagnosed in the presence of only organic noise.
- Medium. It is determined in the presence of organic noise and cardiomegaly.
- Heavy. It is exposed in the presence of noise, cardiomegaly, circulatory failure and pericardial effusion.
During the diagnosis, the severity of the disease is determined according to the established classification. Types of rheumatic heart disease are divided by phase, severity, and the spread of affected foci.
According to the medical classification, there are 3 phases of rheumatic carditis:
- Phase 1 (mild) – mild symptoms
- 2 phase (medium) – moderate symptoms
- 3 phase (severe) – pronounced symptoms, the last degree of the disease
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Rheumatism of the heart can occur in several forms:
- Acute – the rapid development of the disease with the presence of pronounced symptoms. In this case, the patient needs urgent medical care.
- Subacute – the period of development of the disease is about six months, the intensity of the manifestations is low.
- Protracted – the disease lasts from six months or more. In the beginning, the signs are pronounced, but, over time, the manifestations weaken.
- Recurrent – the disease passes into this form after several stages of remission. Frequent attacks and rapid progression are observed.
- Latent – a latent course of the disease without any signs. As a rule, the disease is detected at the last stage, when a heart defect is already present.
Depending on the area of damage, the following forms of rheumatism of the heart are distinguished:
- Endocarditis is an inflammation of the inner lining of an organ. Often leads to the development of valve defects, and, as a result – to heart disease. Symptoms are extremely blurred. The disease can be suspected by severe sweating, fever, the appearance of noise in the upper region of the heart and aorta.
- Local – pathological changes affect the muscle middle layer of the heart, which is called the myocardium. It is accompanied by chest pain, palpitations, general weakness and increased fatigue. The disease is indicated by changes in the cardiogram and general blood count.
- Diffuse – a severe form, which is accompanied by severe shortness of breath, pallor, palpitations, weakness. Systematically, the patient falls into a fainting or fainting state, stagnation in the liver and lungs occurs, the nature of the tones changes when listening.
- Endomyocarditis is an inflammatory process that affects the endocardium and myocardium.
- Pericarditis is an inflammation of the outer membranes of an organ. This form is rare, difficult to diagnose. It is manifested by pain and noise in the heart, the appearance of shortness of breath, dizziness and weakness.
- Pancarditis is an inflammation of the 3 membranes, is quite difficult.
- Recurrent rheumatic heart disease – has a protracted course, is difficult to diagnose. Manifestations are similar to myocarditis and endocarditis. The first symptoms occur after the development of heart disease.
How to recognize
Symptoms of rheumatic heart disease in each case depend on the area of damage and the severity of the disease.
The main signs of rheumatism of the heart:
- fatigue and well-being
- reduced working capacity
- chest pain
- rapid pulse
- periodic arrhythmia
- excessive sweating
- in a lying position shortness of breath occurs
- manifestation of cough during exercise
- swelling of the legs
- the skin on the legs becomes cyanotic, or vice versa, a pale shade
- accumulation of fluid in the peritoneum, which is manifested by an increase in the spleen, liver, volume of the abdomen as a whole
- noise while listening
- expansion of the borders of the heart to the left
- rhythm disturbance according to the electrocardiogram
- wheezing in the lungs
- asthma attacks and lack of oxygen
- thromboembolism – a violation of blood coagulation, the development of blood clots
In the severe stage of rheumatic heart disease, the symptoms are pronounced, circulation is difficult. Characteristic noises are heard, heart failure may develop. The patient is in serious condition, there is a risk of death.
The most important pathogenetic role is played by M-protein, which has strong immunogenicity, i.e., the ability to elicit an immune response. This protein is part of the streptococcus membrane and has the same molecular structure as the membrane of cardiomyocytes (the phenomenon of molecular mimicry). Due to this phenomenon, a cross autoimmune reaction occurs in which T-lymphocytes along with bacteria attack their own heart cells. Streptococcus exoenzymes that have a direct damaging effect on connective tissue cells (streptolysin O, streptolysin S, hyaluronidase, streptokinase) also take part in the pathogenesis.
Pathomorphologically, rheumatic carditis occurs in 4 stages, each of which lasts 1-2 months: mucoid swelling, fibrinoid swelling, the formation of rheumatic granuloma, sclerosis. In the process of these stages, the main substance of the connective tissue is destroyed, foci of necrosis and rheumatic granulomas are formed. The outcome is sclerosis, i.e. scarring. The most detrimental effect of these processes is on the heart valves, which are deformed, which leads to the formation of heart defects. It is heart defects in the outcome of rheumatic inflammation that are an extremely urgent problem.
Symptoms in children
As a rule, in children rheumatic heart disease occurs against a background of an upper respiratory tract infection, which is accompanied by an increase in body temperature. Dyspnea and chest pain of low intensity are also observed. Soon, these symptoms disappear, but after a while they come back again. At the second stage of the disease, rheumatic fever occurs, accompanied by signs of:
- slight increase in temperature
- pain in the head and joints
- excessive sweating
Often rheumatic fever becomes the first serious symptom that indicates the development of rheumatic heart disease. Over the next three years after repeated fever, damage to the heart walls forms, with the further development of valve defect.
Characteristic symptoms of the disease in children:
- pain in the heart area of a pressing, burning, stitching nature
- heart rate
- swelling of the feet and lower extremities
In some cases, heart damage is asymptomatic. Over time, this pathology can lead to the development of heart disease in the child.
A frequent complication of rheumatism is the rapid destruction of heart valves. Pathological changes lead to narrowing of the openings between the chambers, as well as to valve insufficiency. As a result of these problems, blood clots occur that provoke dangerous diseases: thromboembolism, heart attack, stroke. During the progression of rheumatism, the functionality of the heart muscle deteriorates.
The main danger of rheumatic heart disease is the development of heart defects. The frequency of this phenomenon is 20-25%. With a prolonged course, heart defects lead to heart failure, increased pressure in the vessels of the pulmonary circulation, expansion of the cavities of the heart, the formation of blood clots in them and ischemic stroke.
Another complication is myocardiosclerosis, i.e., replacement of the heart muscle with scar tissue. In this case, various disturbances in the rhythm of the heart and a decrease in its contractile function develop. All these pathologies force the patient to resort to constant drug therapy, worsen quality and reduce his life expectancy.
The prognosis for rheumatic heart disease directly depends on the formation of heart disease. People with rheumatic disease have an increased risk of developing infectious endocarditis. He is shown antibiotic prophylaxis in various surgical procedures – dental procedures, operations on ENT organs, etc. Primary prophylaxis implies the correct and timely treatment of tonsillitis.
For this purpose, the same antibiotics are used as for the treatment of rheumatic heart disease. To prevent the recurrence of rheumatic heart disease, there is the so-called secondary prevention. It consists in the monthly intramuscular administration of antibiotics of the penicillin series of prolonged action (benzathine, benzylpenicillin). The duration of such prophylaxis depends on whether heart disease has formed after rheumatic heart disease or not.
If acute or chronic rheumatic heart disease was detected in a timely manner and qualified medical care was provided to the patient, the prognosis is favorable. In most cases, after proper therapy, the functionality of the heart and its departments is fully restored. There is a likelihood of developing heart disease, which will subsequently make itself felt unpleasant symptoms.
The possibility of death from heart failure caused by rheumatic heart disease is rather low. According to statistics, death occurs in only 0,1-0,5% of cases. In the presence of other cardiovascular pathologies, as well as with increasing age, the prognosis for the patient may worsen.
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