Acute infective endocarditis. Attention! Infectious endocarditis. Which doctors should you contact if you have infectious endocarditis?

Inflammatory processes in the cardiovascular system are among the most dangerous, as they disrupt the functioning of the entire body. In the article you will learn about a disease that affects the valve and tissues of the heart - endocarditis. Below we will also discuss the main forms of the disease and treatment of infective endocarditis.

With infective endocarditis, the inflammatory process occurs in the endocardium. During it, the tissue and valves of the heart are affected, and in other structures (septum, chord, ventricles) disorders occur less frequently. Infective endocarditis is also called bacterial endocarditis.

The disease is considered severe and is assessed as a pathology with a high mortality rate. Without proper treatment, the patient's death cannot be avoided. For the development of the disease, the presence of risk factors, which can be congenital or acquired, is necessary. There are also special groups of people in whom the likelihood of such infection increases significantly, for example, drug addicts.

Treatment is carried out comprehensively using laboratory methods that make it possible to identify the causative agents of endocarditis, as well as using instrumental methods, where structural abnormalities of organs become noticeable.

The disease is usually severe and requires hospitalization of patients. Associated problems with the respiratory system, kidneys and blood vessels are often observed.

Endocarditis is a condition in which the cardiac structures are affected by a microbial infection, which negatively affects the condition of the blood vessels, and is also accompanied by bacteremia. Endocarditis leads to destructive changes in organs and the appearance of embolic and thrombotic pathologies.

The incidence rate has increased over the past few years. Experts attribute this to an active lifestyle, a careless attitude towards one’s health, the spread of pathologies of the cardiovascular system and increased antibiotic resistance.

Risk factors

Doctors identify several factors, the presence of which significantly increases the likelihood of infective endocarditis.

These include:

• Presence of heart valve defects. The etiology is not important - the structural disorder can be either acquired or congenital. Often, patients with infective endocarditis experience mitral valve prolapse, septal defect and other pathologies.
• Inflammatory process on the endocardium, which was observed previously and was not completely eliminated
• Congenital narrowing of the aortic lumen
• Immunosuppressive therapy
• Presence of cardiac prostheses
• Pathologies of the heart muscle, in which its functional abilities are reduced
• Severe illnesses and addictions also increase the likelihood of developing infective endocarditis - AIDS, drug addiction, long-term intensive care

Classification and forms

To prescribe the correct treatment for infective endocarditis, it is necessary to determine the causative agent, understand the degree of damage to the organ, the severity of the course, the presence of concomitant pathologies and other indicators. To do this, the disease is classified into several categories.

According to anatomical features:

• Primary - new damage to previously unaffected cardiac structures
• Secondary - infection occurs on structures that are already pathologically modified
• Prosthetic – infection occurs on artificial valves

According to the clinical picture:

• Active endocarditis - easily diagnosed and contributes to the appearance of clinical symptoms
• Inactive - the disease is hidden, signs of inflammation may not be detected in laboratory tests

According to the presence of complications:

• Cardiac complications
• Complications that manifest themselves in other organs - lungs, peripheral vessels, brain and others

There are also several forms of the disease.

Acute

No more than 2 months pass from the onset of the disease to pronounced clinical manifestations. Pathology often develops as complications of sepsis, trauma or surgical interventions in the cardiovascular system. Clinical symptoms in this form are quite pronounced; the pathogen is highly pathogenic and threatens the patient’s life.

Subacute

More than 2 months pass from the onset of the disease to the characteristic clinical picture. The symptoms are not as intense as in the acute form. Subacute endocarditis is often a consequence of an untreated acute form or an underlying cardiac disease.

Protracted

Endocarditis becomes almost chronic - inflammation and infection affect a fairly large area of ​​the heart. Treatment in this case takes a long time, and the result is achieved with difficulty, since it is quite difficult to defeat the pathogen.

This form occurs when the patient has an irresponsible attitude towards his health, in which he does not consult a doctor for a long time or does not complete the prescribed treatment regimen. This is also possible with long-term immunosuppressive therapy.

Symptoms

Typically, symptoms begin to appear 2 weeks after the microbe is activated in the endocardium. The range of clinical manifestations is quite wide - from erased signs to acute intoxication.

First, symptoms appear that are characteristic of any infectious process:

• fever and chills
• sweating
• weakness and fatigue
• pain in muscles and joints
• weight loss

Additional signs are:

• tachycardia
• warm dry skin
• enlarged spleen
• trophic disorders - dermatological peeling, hair fragility, vasculitis

When the pathology passes into the subacute stage, multiple organ failure occurs in the body, due to which symptoms can manifest themselves in disruption of the functioning of various organ systems.

The entry of bacterial toxins into the blood is manifested by weakness, shortness of breath, sudden weight loss, and fever. Disturbances in the gastrointestinal tract lead to anemia and sallow skin color. Damage to the vascular system leads to hemorrhages on the skin, oral cavity, and conjunctiva of the eyes. The capillaries become so brittle that they can be damaged even by minor injuries to the skin.

Endocarditis can be distinguished from respiratory infectious diseases by the presence of lesions on the heart. The patient develops functional murmurs, myocarditis and heart failure are detected. Instrumental studies reveal valve defects.

A long course, starting from the subacute form, leads to impaired blood circulation, which negatively affects the functioning of other organs due to insufficient supply of nutrients and oxygen. Embolism of cerebral vessels, blood clots in the spleen, inflammation in the kidneys and liver may occur.

The spread of a bacterial pathogen through the circulatory system often leads to the settling of the pathogen in the muscles and blood vessels, which is why polyarthritis develops. Other external manifestations of the disease may be impaired consciousness, cerebral complications, suffocation, and cyanosis.

Specific symptoms during a long course of the disease are changes in the shape of the phalanges of the fingers and nails. The first ones take on the appearance of drumsticks, and the nails become rounded.

Causes

The disease is polyetiological. Activation of infection in the connective tissue that lines the cavity and valves of the heart leads to an inflammatory and infectious process. More than 120 microorganisms can act as pathogens.

The main place among them is occupied by:

• staphylococci
• streptococci
• enterococci
• hemophilus influenzae infection
• Eicherichia
• Shigella
• candida
• aspergillus
• Klebsiella and others

In the largest number of patients, Staphylococcus aureus is isolated as the causative agent. In a healthy person, the internal tissues of the heart are immune to the action of bacterial flora and cannot serve as a substrate for their colonization.

Two main mechanisms can contribute to the appearance of infection:

• mechanical damage to connective tissue in the presence of electrodes and catheters in the heart
• entry into the body of highly virulent strains that have strong adhesive properties

Diffuse connective tissue diseases

Connective tissue diseases are accompanied by an inflammatory process and the response of the body's immune system. As a result, immune complexes enter the endocardium and the typical stages of fighting inflammation develop - the production of tissue factor, the deposition of fibrin and platelets. Changes in the structure of the endocardium and the appearance of tissue heterogeneity facilitate the adhesion of bacterial pathogens when they enter the systemic circulation by any means.

Injuries

Mechanical damage to cardiac tissue leads to a corresponding reaction of the immune system and transport of extracellular matrix proteins to the area of ​​damage. Tissue healing is accompanied by heterogeneity of connective tissue and an increased likelihood of infection.

Allergic reaction

The presence of a strong allergic reaction contributes to the release of a large amount of biologically active substances into the systemic bloodstream. Inflammatory mediators damage the vascular endothelium, as well as heart tissue. Over time, a hemodynamic disorder occurs and an inflammatory process develops on the endocardium.

Non-infectious endocarditis reduces the protective properties of the inner layer of the heart and creates favorable conditions for bacterial colonization. The body's response to inflammation results in the formation of fibrin-platelet patches, which are more susceptible to pathogens than the original endocardial tissue. Eosinophilic endocarditis is often isolated as a separate form of the disease, but it has not yet been fully studied.

Intoxication

Intoxication endocarditis develops as a secondary non-infectious lesion. In the absence of proper treatment, it leads to changes in the structure of the endocardium and the susceptibility of tissues to the adhesion of pathogens. Intoxication endocarditis is not an independent disease, but is a consequence of other pathologies.

Infection

Infection entering the endocardial cavity contributes to the appearance of primary infective endocarditis. In this case, as a rule, a person has provoking factors that increase the ability of pathogens to attach to connective tissue.

In the clinical picture, typical symptoms of sepsis are observed, leukocytosis occurs in the blood and ESR increases. The causative agents of infective endocarditis are exogenous bacteria and toxins that have entered the systemic circulation and reached the main organ.

Possible complications

Violation of the structure of the heart leads to disruption of its functioning, and the development of pathogenic microflora contributes to the spread of bacteria through the bloodstream throughout the body. Due to this, complications of infective endocarditis can manifest themselves in almost all organ systems.

Main complications of the disease:

• Heart failure. It occurs due to the destruction of the heart valves, which leads to their inability to function properly. The inflammatory-infectious process eventually spreads to deeper layers of tissue (myocardium), and also causes destruction of the aortic valve cusp.
• Neurological complications. The cause is embolism of cerebral vessels, which leads to disruption of tissue trophism and insufficient oxygen supply to them. In the future, patients may experience ischemic or hemorrhagic stroke, meningitis, and toxic damage to the meninges. In some cases, poor circulation leads to the appearance of aneurysms, the rupture of which reduces the likelihood of a favorable outcome for the patient.
• Kidney failure. Occurs when toxins enter the urinary system, which destroy its tissue. It may also develop due to the toxic effects of antibiotics or contrast agents used for diagnosis.
• Rheumatic diseases. Systemic spread of infection leads to damage to the musculoskeletal system.
• Pathologies of the spleen.
• Pathologies of the respiratory system - pneumonia, pulmonary hypertension, abscess.

Which doctor should I contact?

If primary symptoms of illness appear, the patient can consult a therapist. The doctor will send him for additional examinations, and after the results - to a more specialized specialist. Infective endocarditis is treated by a cardiologist and, if necessary, a cardiac surgeon.

Diagnostics

Diagnosis of the disease is carried out comprehensively. After making a preliminary diagnosis, the doctor refers the patient for additional studies. Diagnosis begins with collecting anamnesis and evaluating complaints. It should be taken into account that the clinical picture appears approximately 2 weeks after infection.

The patient can talk about the general manifestations of intoxication, as well as the subjective sensations that appear due to heart failure. The specialist may notice peripheral manifestations - petechiae, spots, nodules, joint changes.

During a physical examination, the doctor reveals pallor of the skin, loss of body weight, and changes in the phalanges of the fingers. During the consultation, a specialist can conduct a test, the results of which reveal the degree of capillary fragility. Percussion of the heart allows you to identify the localization of the lesion, and auscultation - the presence of organ dysfunction.

After consulting a specialist, the patient must undergo laboratory tests. Blood tests usually reveal leukocytosis, anemia and elevated ESR. Bacteriological blood culture is also carried out to identify the pathogen.

Some patients experience an increase in rheumatoid factor. If the urinary system is affected, protein and signs of inflammation may be found in the urine. Instrumental diagnostics make it possible to make a definitive diagnosis. The cardiogram plays a key role, but can be supplemented by MRI and other methods.

The patient may also be prescribed Doppler ultrasound to assess the condition of the blood vessels and circulatory system. Infective endocarditis is often accompanied by thromboembolic complications. With the timely detection of such pathology, it is possible to prevent a heart attack of the affected organs in time.

Treatment

The basic principles of treatment of infective endocarditis are as follows:

• The patient must be hospitalized even if the disease is suspected or there is only a preliminary diagnosis
• Antibacterial therapy involves the use of antimicrobial drugs in maximum doses. Treatment time for the disease is usually several weeks
• Treatment must be supplemented with detoxification agents, vitamins, and protein compounds.
• The blood must be tested to identify the pathogen and select the correct drug for treatment. However, antibiotic therapy is usually started before culture results are available.

Drug therapy

Pending the results of bacterial culture, the patient is prescribed vancomycin plus third-generation cephalosparins. After identifying a specific pathogen and determining its sensitivity to drugs, therapy can be adjusted. The duration is at least 4 weeks, during which the main drugs are administered intravenously. Self-treatment for infective endocarditis is strictly unacceptable, since the patient must be hospitalized in a hospital.

Surgery

Indications for surgical treatment are:

• presence of heart failure
• manifestation of uncontrolled infection
• persistence of fever during antibiotic therapy
• identification of a multidrug-resistant pathogen or fungal etiology of endocarditis
• embolism prevention

Endocarditis is considered cured if the patient's stable condition and normal laboratory values ​​remain for 2 months after discontinuation of antibiotics.

Forecast

Lack of treatment or incorrect prescription of antibiotics leads to the death of the patient. Proper treatment and full recovery after completion of therapy provides a 70% chance of survival over the next five years. The remaining percentage remains, since health problems can be caused by complications of endocarditis.

The following factors increase the likelihood of an unfavorable outcome:

• elderly patient
• the presence of diabetes mellitus and severe concomitant pathologies - kidney disease, lung disease, heart failure
• the appearance of complications of endocarditis
• complex pathogen strains
• prosthetic valve endocarditis
• large size growing season

Prevention

Prevention consists of preventing infection, maintaining oral hygiene, timely treatment of congenital heart defects, and eliminating drug addiction. In some cases, cardiologists may prescribe antibiotic prophylaxis for certain groups of patients.

Conclusion

Infective endocarditis is a dangerous disease that requires urgent hospital treatment. The first symptoms are nonspecific and can be regarded by the patient as a common respiratory disease. It is recommended to be attentive to your health, not to self-medicate, and to consult a doctor if your health worsens and your body temperature rises. Only timely treatment will help avoid serious complications and save the patient’s life.

Video: Infective endocarditis - inflammation of the inner lining of the heart

Cardiologist

Higher education:

Cardiologist

Kabardino-Balkarian State University named after. HM. Berbekova, Faculty of Medicine (KBSU)

Level of education – Specialist

Additional education:

"Cardiology"

State educational institution "Institute for Advanced Medical Studies" of the Ministry of Health and Social Development of Chuvashia

The list of cardiac diseases includes infective endocarditis. It is dangerous due to possible complications (myocarditis, damage to the kidneys, lungs, liver, central nervous system). If this pathology develops, patients must be hospitalized.

Development of endocarditis in children and adults

The endocardium is the inner layer of the heart that lines the cavities of the atria and ventricles. It also forms the heart valves, which take part in the unidirectional movement of blood. Infectious endocarditis is an inflammatory disease of the inner lining of infectious origin. This is not a type of heart pathology transmitted from one person to another. The causative agents can be a variety of microorganisms (bacteria, viruses).

The incidence rate in the world ranges from 3 to 10 cases per 100,000 people. The progression of endocarditis leads to destruction of the valves and disruption of their functioning. The consequence of all this is the development of their insufficiency. The aortic and mitral valves are most often involved in the process. The first is located between the left ventricle and the aorta, and the second is located between the left parts of the heart.

The main purpose of the valve apparatus is to prevent the backflow of blood. This eliminates overload of the ventricles and atria. In recent years, the number of patients with infectious myocarditis has increased. The reasons are immunodeficiency, frequent heart surgeries and the use of invasive treatment methods.

The disease can occur in a relapsing form. This pathology has a high mortality rate. Almost every third patient dies without proper medical care. In 2015, this cardiac pathology was detected mainly in the young population aged 20 to 50 years. The disease often develops in drug addicts and people with reduced immunity. Less commonly, inflammation of the endocardium is observed in childhood.

What is endocarditis?

The classification of infective endocarditis is not known to everyone. It is divided according to the following characteristics:

• reason for occurrence;
• clinical and morphological form;
• the nature of the flow;
• localization.

Depending on the main cause of inflammation, primary and secondary endocarditis is distinguished. They have a fundamental difference between themselves. In the primary form of endocarditis, inflammation develops against the background of acute infectious conditions (sepsis, septicemia, septicopyemia). In this case, the valves were not initially changed. Secondary endocarditis is a complication of another pathology. The disease can occur in acute, subacute and protracted forms.

In the first case, the symptoms bother the person for no more than 2 months. The most common cause is sepsis. It's very difficult. Subacute endocarditis lasts more than 2 months. If complaints and signs of damage to the lining of the heart persist for a long time, then such endocarditis is called protracted. Inflammation may be limited only to the valve leaflets or extend beyond them. There are 3 clinical forms of the disease:

• infectious-allergic;
• infectious-toxic;
• dystrophic.

The toxic type of endocarditis has the following symptoms:

• leads to the formation of microbial growths;
• leads to transient bacteremia;
• accompanied by damage to other organs.

In case of progression of the pathological process, a dystrophic form of inflammation develops. With it, irreversible changes are observed. The infectious-allergic form of endocarditis differs in that it leads to nephritis, hepatitis and other complications. There is another classification, which is based on the activity of the inflammatory process. It allows you to judge the patient's condition. According to it, a distinction is made between healed and active endocarditis.

Etiological factors

Only a doctor knows the etiology of infective endocarditis. The following causes of damage to the lining of the heart and valves by microbes are distinguished:

• congenital heart defects;
• violation of hemodynamics (blood circulation);
• acquired vices;
• secondary immunodeficiency due to HIV infection, drug addiction, alcoholism, smoking, diabetes;
• surgical interventions;
• septic conditions;
• bacteremia;
• valve prolapse;
• valve replacement;
• rheumatism;
• atherosclerosis;
• introduction of a pacemaker.

Secondary infective endocarditis develops mainly against the background of congenital heart defects and rheumatism. Hemodynamic disturbances lead to damage to the valve apparatus and damage to the endocardium. This disease causes the development of heart failure and vasculitis. The pathogenesis of infective endocarditis is based on the adhesion (sticking) of microbes to the endocardium and valves.

This most often occurs in drug addicts, alcoholics and the elderly. Risk factors include the use of drugs that suppress the immune system. The most common causative agents of endocarditis are staphylococci, streptococci, enterococci and fungi. In total, more than 120 types of microbes are known that can cause this cardiac pathology.

The health prognosis largely depends on this. The highest mortality rates are observed with infection with epidermal and streptococcus aureus. Fungal endocarditis accounts for up to 7% of all cases of the disease. The highest activity of the inflammatory process is observed against the background of infection caused by anaerobic microflora.

A new stage in the development of medicine led to the emergence of diseases caused by a person’s stay in a hospital. Nosocomial endocarditis is often detected. It develops within 48 hours after a person is admitted to the hospital. Endocarditis not associated with hospitalization can occur at home. This is facilitated by hemodialysis, intravenous administration of drugs, and caring for a sick person. Separately, repeated endocarditis is identified, which develops some time after the primary inflammation.

Clinical manifestations of endocarditis

In infective endocarditis, symptoms are determined by the following factors:

• the age of the person;
• duration of illness;
• types of pathogen;
• concomitant pathology;
• cause of inflammation.

The most pronounced form of endocarditis is caused by pathogenic strains of staphylococcus. The following symptoms are observed with this disease:

• fever;
• chills;
• flushes of sweat;
• pallor of the skin and visible mucous membranes;
• gray skin tone;
• minor hemorrhages on the skin;
• chest pain;
• lack of appetite;
• weight loss;
• weakness.

Manifestations of intoxication are the most constant diagnostic sign. It is caused by the presence of microbes and their toxins in the blood. The temperature in patients may be low-grade or hectic. A common manifestation of endocarditis is shortness of breath. It is caused by heart failure. The small blood vessels of patients become fragile.

This manifests itself as multiple hemorrhages (petechiae). They appear in the area of ​​the collarbones, eyelids, nails, and oral mucosa. A specific symptom of endocarditis is Roth spots. They are hemorrhages in the retina of the eye. Similar changes are detected during an ophthalmological examination.

Subacute infective endocarditis often presents with the sign of drumsticks and watch glasses. In patients, the phalanges of the fingers thicken. Osler's nodes often appear on the skin. This is a sign of septic endocarditis. A distinctive feature of the disease is the development of complications in the early period.

Complications and consequences of endocarditis

Presentations on infective endocarditis by famous doctors always indicate possible complications of this disease. This pathology can lead to the following consequences:

• kidney damage such as glomerulonephritis;
• hepatitis;
• cerebral embolism;
• pulmonary embolism;
• splenic infarction;
• septic shock;
• respiratory distress syndrome;
• heart pathologies;
• stroke;
• paresis;
• paralysis;
• brain abscess;
• aneurysm;
• vasculitis;
• thrombosis;
• thrombophlebitis.

With endocarditis, the infection spreads throughout the body, leading to dysfunction of all vital organs. The kidneys are very often affected. The process primarily involves the glomerular apparatus, which is responsible for filtering blood plasma. Glomerulonephritis develops. It is manifested by decreased diuresis, high blood pressure and edema syndrome.

In 2015, many people died from kidney disease. Complications of infective endocarditis include blood thickening and blood clots. The latter can cause inflammation of blood vessels and their blockage. With pulmonary embolism, there is a high probability of developing a pulmonary infarction. This is a dangerous condition caused by an acute lack of oxygen.

A heart attack is manifested by chest pain, shortness of breath, and difficulty breathing. If a blood clot breaks off and blocks cerebral vessels, an ischemic stroke may develop. It manifests itself as a disorder of consciousness, impaired speech and motor function, weakness in the legs and arms, and dizziness. Neurological complications include meningitis, limb paresis, and brain abscess. If treatment for infective endocarditis is not carried out, then secondary arterial hypertension may develop.

If a doctor has a presentation on endocarditis, he knows that the heart itself suffers against the background of this disease. In the absence of proper treatment, there is a risk of developing defects (insufficiency of the mitral and aortic valves), myocarditis and inflammation of the pericardial sac. The most dangerous consequences of endocarditis include septic shock and acute respiratory failure. With delayed treatment of respiratory distress syndrome, mortality reaches 70%.

How to identify endocarditis

Diagnosis and treatment are carried out by a doctor. To identify endocarditis in a patient, a number of studies need to be performed:

• clinical blood and urine analysis;
• biochemical research;
• tonometry;
• physical examination (percussion and auscultation);
• blood clotting test;
• immunological research;
• blood culture;
• plain radiography;
• echocardiography;
• heart murmur examination;
• spiral computed tomography;

You may need to consult several specialists at once (cardiologist, pulmonologist, therapist, ophthalmologist). If infective endocarditis is suspected, diagnosis necessarily includes an ultrasound of the heart. This is the main and most informative method for assessing the condition of the heart chambers and valves. Echography can be simple or transesophageal. In the latter case, the sensor is inserted through the esophagus.

During the ultrasound, the following changes are revealed:

• vegetation (accumulation of microbes along with blood clots);
• small purulent cavities in the valve area;
• valve insufficiency.

To identify the pathogen, a polymerase chain reaction can be performed. Diagnosis of infective endocarditis includes questioning, examination, measuring blood pressure and pulse, listening to the lungs and heart. During auscultation, signs of valve insufficiency are often revealed. Pathological murmurs and weak heart sounds are heard. When the liver and kidneys are damaged, the biochemical parameters of the blood change dramatically.

Treatment of patients with endocarditis

Once the diagnosis is made, treatment begins. The main documents that the doctor takes into account when prescribing medications are the medical history and outpatient card. If endocarditis is detected, hospitalization is indicated. Therapy is combined. The following treatment is carried out:

• symptomatic;
• etiotropic;
• pathogenetic;
• radical (surgical).

There are various recommendations, but systemic antimicrobial drugs are always prescribed for this disease. Most often these are antibiotics. The type of bacteria is preliminarily determined. If streptococci are detected, antibiotic therapy is carried out for 4 weeks. There are no breaks. If staphylococci are isolated, treatment of infective endocarditis may take up to one and a half months.

The longest treatment requires inflammation caused by anaerobic microflora. It is recommended to use modern broad-spectrum antibiotics. They must be administered intravenously or intramuscularly. The most effective are penicillins (Benzylpenicillin, Phenoxymethylpenicillin, Ampicillin, Amoxiclav). Penicillins are often combined with aminoglycosides.

Antibacterial treatment is stopped when the temperature normalizes, the results of microbiological tests are negative, and blood and urine parameters are normalized. Treatment recommendations are known to every doctor. Antistaphylococcal globulin is administered according to indications. For infective endocarditis, symptomatic therapy is carried out.

The following groups of drugs can be used:

• diuretics;
• painkillers (NSAIDs and analgesics);
• ACE inhibitors;
• nitrates;
• cardiac glycosides.

Treatment recommendations include antiplatelet agents and anticoagulants. This reduces the likelihood of developing thrombosis and vascular embolism. Any good lecture or presentation on the topic of endocarditis states that massive fluid resuscitation is required to eliminate the symptoms of intoxication.

Severe fever is an indication for prescribing antipyretic drugs. When the heart is damaged, medications are often prescribed to reduce the load on the organ. Treatment recommendations include the use of systemic glucocorticoids (Prednisolone). For infective endocarditis, treatment involves plasmapheresis.

Radical treatment methods and prognosis

A good presentation or lecture on endocarditis will tell you that in severe cases, drug treatment alone is not always enough. Surgery is required if complications develop. Surgical treatment can be planned, emergency or delayed. In the first case, assistance is provided within the first 24 hours. Emergency surgery is performed within several days. Often radical treatment is delayed.

Preliminary antibiotic therapy is carried out. Urgent surgery is indicated for heart failure, prolonged, recurring fever and ineffective medications. Treatment recommendations often include surgery to prevent embolism. This is possible with large vegetations and a high risk of blood clots. Very often, intervention is performed to replace the valves with artificial ones.

Endocarditis is one of the most dangerous cardiovascular diseases, so the prognosis for it is not always favorable. In case of acute inflammation without treatment, a person dies after 1-1.5 months from complications. In old age the prognosis is worse. In 10-15% of cases, acute endocarditis becomes chronic with periodic exacerbations.

How to prevent the development of endocarditis

There is no specific prevention of infective endocarditis. Transmission of infection from sick to healthy does not occur, so contact with other people does not play a role in the development of this pathology. Any presentation on the topic of endocarditis includes prevention. To avoid damage to the endocardium and valves, you must adhere to the following recommendations:

• promptly treat infectious diseases (pyelonephritis, pneumonia, caries, sinusitis, tonsillitis);
• avoid hypothermia;
• move more;
• give up alcohol and cigarettes;
• exercise;
• treat heart diseases;
• exclude all kinds of operations;
• Healthy food;
• prevent hypothermia;
• Avoid contact with people with flu or sore throat;
• increase immunity;
• give up drugs.

Very often the heart is affected due to sepsis. To avoid it, you need to sanitize foci of infection and consult a doctor at the slightest complaint. If there is a risk of infection spreading, a short course of antibiotic therapy may be given as a preventive measure. Thus, endocarditis is a dangerous cardiac pathology. When the first symptoms appear, you should contact a cardiologist or therapist.

Today, carditis is increasingly coming to the fore among diseases of the cardiovascular system - the main cause of death in the adult population.

They are especially dangerous due to the development of life-threatening complications for the patient, therefore their diagnosis and treatment are one of the main areas of fundamental medical science in the field of cardiology.

One of these types of heart problems is endocarditis - what kind of disease is this? The pathology is an infectious-inflammatory disease of the heart of an acute or chronic nature, in which the main target of pathogenic microorganisms is the inner lining (endocardium) of the atria and ventricles, as well as the valve apparatus.

Statistics

The disease is common in all countries of the world and in different climate zones. The incidence ranges from 3.1 to 11.6 per 100,000 inhabitants. Men suffer from endocarditis 2–3 times more often than women.

Recently, in developed countries there has been a clear “aging” of this pathology. If previously the average age of patients with endocarditis was 35 years, now it is 50. The risk of developing the disease in early childhood is also higher, especially in the presence of congenital heart defects.

The mortality rate for this disease varies from 15 to 45%.

Kinds

The division into types of disease is made on the basis of the reasons that caused it. Conventionally, they are divided into two large groups: aseptic and bacterial inflammation.

The first group includes rheumatic, Libman-Sachs and Leffler. The second is diagnosed much more often; it includes a bacterial or septic and infectious process.

Etiology: causes and risk factors

Among the predisposing factors for the development of endocarditis are:

• hidden foci of dormant infection of various locations: tonsillitis, carious teeth;
• congenital and acquired heart defects, hereditary anomalies of its development;
• primary and secondary immunodeficiency;
• stress, sluggish chronic diseases that weaken the body’s defenses;
• addiction;
• elderly age.

An increase in the number of episodes of inflammation of the inner lining of the heart in older people is associated with a history of diseases that predispose to endocardial damage: calcification, involutive processes in the immune system, deterioration of rheological blood parameters, an increase in the frequency of operations and therapeutic and diagnostic procedures.

Learn more about this disease from the video:

Classification

According to the nature of the flow

Here they highlight:

• primary: occurs on healthy heart valves;
• secondary: develops on pathologically altered structures of the heart and blood vessels during rheumatism, congenital and acquired defects, syphilis, after surgery for valve replacement, etc.

According to the clinical course there are:

• spicy: lasts up to 2 months. The reason is staphylococcal origin, trauma and therapeutic and diagnostic manipulations in the field of the cardiovascular system.

  With this form of inflammation, infectious and toxic manifestations rapidly increase, as well as valve vegetation and thrombus formation, and purulent metastases to various organs are not uncommon;

• subacute: lasts more than 2 months. Develops with inadequate treatment of acute endocarditis;
• chronic relapsing: more than 6 months. Formed with deep damage to the myocardium or dysfunction of the valve apparatus. It is more common in newborns and infants with hereditary heart defects, drug addicts and people who have undergone surgical interventions.

Check out the ECG signs of left atrial hypertrophy - detailed information is waiting for you.

Stages

There are three stages of the pathogenesis of endocarditis: infectious-toxic, immunoinflammatory and dystrophic.

By localization

According to the localization of endocarditis, they are distinguished:

• left-sided inflammation of the native (natural) valve;
• left-sided endocarditis of the prosthetic valve, which is divided into early (less than a year after installation) and late (more than a year has passed since the operation);
• right-sided endocarditis;
• associated with devices such as a pacemaker.

In addition, valvular, parietal and chordal pathologies are distinguished.

When a disease develops on the valve apparatus, only the leaflets may be involved in the process (valvulitis), which is more common in the rheumatic process. Whereas it covers all parts of the valve: leaflets, valve ring, chords and papillary muscles.

The main signs of right atrial hypertrophy are described in detail in. Find out all the details!

Treatment

Conservative

Antibiotic therapy is prescribed in a hospital setting after accurate identification of the microorganism strain.Preference in the treatment of endocarditis is given to broad-spectrum antibiotics. For fungal infections, Amphotericin B and Flucytosine are prescribed for a long time.

To maintain the functioning of the heart muscle and eliminate symptoms such as shortness of breath, high blood pressure and tachycardia, edema, ACE inhibitors, beta-blockers, aldosterone receptor antagonists, diuretics, and cardiotonics are used.

Hemolytics that thin the blood are also in demand, especially in the postoperative period to prevent thrombosis. Plasmapheresis, ultraviolet irradiation of autologous blood, and intravenous laser irradiation of blood are prescribed as detoxification measures and for immunomodulation.

Surgical

The need for surgical treatment arises in case of complications Surgical intervention involves mechanical excision of the altered valve with implantation of an artificial one in its place with additional sanitation of the inflammation site with broad-spectrum antibiotics.

Pathological areas can also be treated with low-frequency ultrasound.

Special symptoms in children

In childhood, this pathology is very rare. Most often in children it develops acutely and is characterized by the following symptoms:

• acute intoxication of the body, manifested by weakness, headache, joint pain;
• inflammatory process in the endocardium;
• Blood clots appear on the affected endocardium, which contribute to the development of thromboembolism.

The course of childhood endocarditis does not differ from the development process in adults, but the symptoms increase rapidly, in addition, the treatment of the pathology also does not differ much. The destructive process affects all internal organs, especially the urinary system. Any infectious disease is a risk factor that needs to be treated immediately.

Course of the disease in HIV-infected people

Nonbacterial thrombotic endocarditis most often develops in HIV-infected patients(marantic). It occurs in 3-5% of virus carriers and in almost all AIDS patients. Typically, this form of pathology develops asymptomatically and less commonly causes thromboembolism. Anticoagulants are used for treatment to prevent the formation of blood clots. Therapy is carried out aimed at eliminating damage to the valve apparatus.

Infectious endocarditis (IE, bacterial endocarditis) is a severe inflammatory disease of the heart valves with an unfavorable prognosis and the formation of persistent complications affecting…

Endocarditis is an inflammatory process localized in the inner lining of the heart, most often in the valve region. A feature of the disease is that only connective tissue is affected: the myocardium and pericardium (the lining of the organ) are not affected. With rapid progression and lack of adequate therapy, the disease can provoke destruction of the heart valves.

The endocardium is the inner cardiac membrane that lines the cavities and valves of the pumping organ and forms the valves of the latter. Infectious endocarditis most often develops on the affected tissue or in the presence of a focus of infection and reduced immunity of the body. In a healthy state, due to its structure, the internal lining is insensitive to pathogenic microorganisms.

The structure of the endocardium

The heart consists of three successively located layers: epithelial, internal (endocardium), muscular (myocardium) and external (epicardium), which is a petal of the serous membrane of the organ (pericardium).

The structure of endothelial cells, which are in direct contact with blood in the cavities and valves, is identical to the vascular endothelium and similar to the mucous membranes of the visceral organs. These cells are located on a basement membrane that controls their proliferation (division). The surface of the layer in contact with the blood is covered with an atrombogenic substance - glycocalyx, which reduces the friction of the fluid against the walls of the heart and prevents the formation of blood clots.

The next layer, the subendothelial layer, consists of connective tissue. Its cells are poorly differentiated, which allows them to divide quickly if necessary.

The muscular-elastic layer of the endocardium is built from muscle fibers clothed in connective tissue. The outer, deepest layer consists entirely of connective tissue cells. These two layers are similar in structure to the middle and outer lining of blood vessels.

Pathogenesis of endocarditis

Due to the vessels lying deep in the pumping muscle, only the deep layers of the endocardium are fed. The outer layers of the epithelium receive all the necessary substances from the blood passing through the cavities and valves of the heart. Accordingly, the presence of infectious agents in the pericardial zone and the body as a whole can provoke an inflammatory process.

In rheumatic and other non-infectious connective tissue diseases, the inner wall of the heart swells and thickens. Small blood clots can settle on it, interfering with the flow of blood through the valves or then migrating into the coronary vessels.

The process can also develop by the reverse mechanism. When the endothelium is damaged or heart defects occur, platelets adhere to the site of microtrauma, forming an initially sterile clot. Infectious agents migrate into the finished thrombus, turning it into vegetation (a lump of various blood cells, damaged endocardium and microorganisms).

Thus, infective endocarditis occurs when several conditions are present:

• microtrauma of adjacent vessels and the endocardium itself;
• low immunity;

• disruptions in hemodynamics (abnormally high blood viscosity);
• the presence of pathogenic agents directly in the layer of the heart wall or blood.

The resulting thrombus thickens, taking on a polyp-like or warty shape (polypous and warty endocarditis, respectively). The soft tissue of a blood clot can be destroyed, and individual parts can spread throughout the vessels, causing thromboembolism and infarction of internal organs. At the site of damage, an area of ​​tissue necrosis forms, which provokes deformation of the heart valve (ulcerative endocarditis).

Reasons for the development of the disease

The main cause of infectious inflammation of the inner lining of the heart is the penetration of pathogenic microorganisms. The disease can develop primarily, but this form is less common than the secondary one, due to the low susceptibility of healthy endothelial tissue to pathogens.

Secondary endocarditis occurs on the valves in the presence of heart defects or systemic diseases (rheumatism, lupus). There are also allergic, intoxication, post-traumatic, fibroplastic and thromboendocarditis. Overgrowth of connective tissue or valve prolapse leads to blood stagnation and hemodynamic disturbances. This increases the likelihood of injury to the membrane and the formation of blood clots.

Causative agents of infectious endocarditis

Depending on the type of infectious agent, endocarditis occurs:

• bacterial (microbial);
• fungal (most often candidiasis - caused by the Candida fungus);
• viral;
• caused by protozoa.

Pathogenic microflora can enter the internal lining in several ways:

• Through damage to the skin or mucous membrane with subsequent infection in a person with low immunity or prostheses in the heart area (artificial valve or pacemaker).
• For invasive diagnostic procedures and surgical interventions (catheterization of vessels for administration of a contrast agent, endoscopy, cystoscopy, surgical termination of pregnancy, tooth extraction).
• From the bloodstream in the presence of a large focus of infection (with bacterial diseases of the lungs, kidneys, maxillary sinuses, gastrointestinal tract, musculoskeletal system, abscesses, gangrene) with reduced immunity, the presence of a prosthesis or valve disease.
• Through injection of drugs with non-compliance with sterility (typically damage to the tricuspid valve).
• During heart surgery, including installation of vascular, valve prostheses and pacemaker.

Risk factors for developing the disease

Factors that increase the likelihood of inflammation in the endocardium include:

• Congenital and acquired abnormalities of the valve structure, the presence of septal defects between the ventricles, narrowing of the aorta.
• The patient has a cardiac or vascular prosthesis or a pacemaker.
• Previously suffered endocarditis of the infectious type.

• Treatment with immunosuppressants after tissue transplantation or with regular blood transfusions.
• Long-term wearing of catheters in peripheral vessels.
• Immunodeficiency of various etiologies (including AIDS).
• Long-term use of antibacterial drugs (increases the risk of fungal growth in a weakened body).
• Structural changes and functional disorders of the myocardium (hypertrophy, inflammation).
• Kidney pathologies (glomerulonephritis), hemodialysis.
• Systemic connective tissue diseases, including genetic ones (Marfan syndrome).
• Hypertension, coronary heart disease.

Children and the elderly are also at risk. Patients over 55 years of age, on average, have reduced immunity and the presence of cardiovascular diseases, which require drug therapy and surgery. If protocols are not followed, infection may occur during or immediately after the intervention. If a child has heart defects, the likelihood of developing the disease increases several times.

In adult patients, the incidence of endocarditis is approximately 6-15 clinical cases per 100,000 inhabitants.

There are several classifications of the disease: according to the duration of the course, localization of the lesion, the causative agent, the presence of concomitant diagnoses, and the circumstances of infection. The wording may also indicate the activity of the inflammatory process.

According to the criterion of duration and intensity, the following types of endocarditis are distinguished:

• acute (lasts no more than 2 months);
• subacute

Chronic course is rare with infectious etiology (more typical for rheumatic disease). Doctors use a single ICD code for acute and subacute endocarditis - I33.0. If necessary, indicate the pathogen using the additional code B95-98 (streptococci and staphylococci, other bacteria, viruses, other infectious agents).

According to the location of the lesion, disease of the mitral, aortic, tricuspid valve and the valve at the junction with the pulmonary artery is distinguished. The last two become inflamed mainly in patients with injection drug addiction.

Pediatric endocarditis is further classified into congenital (intrauterine) and acquired.

Bacterial endocarditis

In most cases, inflammation of the inner lining of the heart is caused by bacteria of various types. The main causative agents of backendocarditis are:

• Viridans streptococci. According to statistics, these microbes are isolated during analysis in 40% of cases of the disease (according to some data - up to 80%).
• Enterococci. Penetration of pathogenic microorganisms into the blood and infection of the endocardium occurs during intestinal operations and low immunity. These bacteria account for up to 15% of cases of the disease.

• Staphylococcus aureus. It is a typical “hospital” infection that develops after a hospital stay. Staphylococcal bacterial endocarditis is characterized by a severe course and severe structural damage to the heart. Other types of strepto- and staphylococci provoke the disease in a milder form.
• Pneumococci. Cause inflammation of the endocardium as a complication of pulmonary infection.
• Gram-negative bacteria. The inner lining of the heart is rarely affected and only with a large focus of infection of a different location. The clinical picture is mixed and includes signs of pathology of several systems.
• Other infectious agents. The causative agents of the disease can also be rickettsia, chlamydia, and brucella. In some cases, due to diagnostic deficiencies, it is not possible to identify the bacterium. For example, microbes of the HASEK group are characterized by an affinity for the endocardium, but are rarely cultivated in laboratory nutrient media.

The combination of several infectious agents aggravates the course of the disease and worsens the patient's prognosis.

Septic endocarditis

Septic endocarditis is one of the names of an acute infectious process. It occurs when pathogens spread from the source of infection, after birth endometritis, or surgical termination of pregnancy. The disease is considered a complication of sepsis; the clinical picture is also characterized by signs of general infection:

• hyperthermia with sudden changes in temperature and chills;
• anemia;
• confusion;
• dry mouth;
• hemorrhagic rash;
• enlarged liver, sometimes – spleen.

First, polyps appear on the inner lining, then ulcers. When listening to the heart, noises characteristic of damage to the valve apparatus are heard.

Symptoms of the inflammatory process

Endocarditis is manifested by both general signs of the infectious process (hyperthermia, chills, sweating) and specific symptoms. A number of disorders indicate heart damage (tachycardia, rhythm disturbances, murmurs, shortness of breath, swelling).

Infective endocarditis: symptoms and causes of their manifestation

Symptom	Frequency and stage	What is the reason
Dyspnea	Under intense loads, in the later stages - at rest	Overgrowth of the valves, decrease in the volume of the heart cavities, hemodynamic disturbances
Dyspnea
Pale skin, cyanosis (blue discoloration around the lips and nose)	At any stage of the disease
Cardiopalmus	From the initial stages of the disease for all types of lesions	Fever due to the entry of toxins into the blood, in the later stages - compensation for a decrease in the capacity of the heart chambers
Dry skin, brittle hair	In case of chronic disease	Peripheral tissue nutritional disorders
Hemorrhagic rash	In most clinical cases	Inflammation and fragility of vascular walls
“Drum” fingers, nails in the form of “hour glasses”	In the later stages of the inflammatory process, most often in rheumatic endocarditis	Active proliferation of connective tissue cells between the nail bed and bone tissue during oxygen deficiency
Fever, chills	From the initial stage	Intoxication
Heartache	Under stress and strain	Impaired myocardial nutrition due to blockage of the coronary arteries by blood clots

If the condition is complicated by glomerulonephritis or blockage of the renal artery, in addition to the signs indicated in the table, swelling, pain in the lumbar region appear, the daily volume of urine decreases, and an admixture of blood appears in it. With thrombosis of the branches of the vessels of the spleen, severe pain occurs under the ribs on the left side. Blockage of the pulmonary artery is characterized by a change in complexion to bluish or purple, shortness of breath, chest pain, and loss of consciousness.

The intensity of symptoms is determined by the type of inflammatory process:

• In acute endocarditis, the temperature reaches 39-40 0 C, hyperthermia is accompanied by severe chills, profuse sweating, headache, joint and muscle pain, and hemorrhages in the whites of the eyes. The skin acquires a grayish, sometimes yellowish tint. Scarlet spots appear on its surface. Small red nodules are noted on the fingers and palms, painful when pressed.
• In the subacute process, the temperature does not exceed 38.5 0 C, insomnia, weight loss, and darkening of the skin are noted. Hemorrhagic rash and Osler's nodes are also prominent.

Diagnostics

Differential diagnosis of the disease is carried out with other heart diseases - in particular, rheumatic endocarditis - and includes anamnesis, laboratory and instrumental methods. To determine the location and extent of the lesion, the following is carried out:

If necessary (for example, suspected tumor or metastases), an MRI and CT scan of the heart is performed.

To select the most effective antibiotic, a bacteriological analysis is taken. If the result is negative, the analysis is repeated using the PCR method. During diagnosis, rheumatic tests, general urine and blood tests (ESR monitoring) are also recommended.

If the results of instrumental studies indicate infectious inflammation of the membrane, and laboratory parameters are normal, endocarditis is called PCR- or culture-negative.

Treatment of endocarditis

Treatment of infective endocarditis is complex and consists of several groups of drugs, the main of which are antibacterial. Dr. Komarovsky’s reference book indicates the following treatment regimens for various types of pathogens:

• Viridans streptococcus: “Benzylpenicillin” 250,000 IU per day per 1 kg of weight (up to 20*10 6 IU/day). Intravenous 1/6 dose every 4 hours.
• Staphylococcus aureus: “Oxallicin” 200 mg/day per 1 kg of weight according to a scheme similar to that described above. In acute cases, Gentamicin is additionally used, in case of intolerance to penicillins - Vancomycin, Imipenem, Linezolid.
• Enteroccoci: Ampicillin 300 mg per 1 kg of body weight per day. ¼ dose every 6 hours. When combined with Gentamicin - every 8 hours.

The duration of antibacterial therapy, according to the leaflet, is from 1 to 3 months. Efficiency is monitored by serum bactericidal titer and ESR.

Fungal endocarditis must be treated with Amikacin, Flucytosine, and in severe cases with Amphotericin B.

In addition to antibiotics, medications such as:

• antiplatelet agents (“Heparin”);
• hormones (glucocorticoids) to relieve inflammation;
• antimycotic drugs;
• proteolytic enzyme inhibitors;
• immunoglobulins, antistaphylococcal plasma;
• medications to prevent and treat complications of the disease.

If after 3-4 weeks the therapy does not show effectiveness, surgery is recommended to sanitize the organ cavities, and in severe cases, remove the damaged valves and install artificial ones. In the presence of an abscess, fistulas, large mobile growths or pseudoaneurysms, rupture and perforation of the valve walls, acute cardiac dysfunction, emergency surgical intervention is performed. The subsequent 7-14-day course of antibiotics helps to recover completely.

Complications

Possible dangerous consequences of infective endocarditis include:

Prevention

The development of inflammation of the inner lining of the heart can only be partially prevented - with the help of timely and complete treatment of infectious diseases of other etiologies.

Update: October 2018

Endocarditis is an inflammation that occurs in the inner lining of the heart - the endocardium. The disease does not always occur with obvious signs: it is characterized by mild malaise, an increase in temperature to low levels, and, less often, discomfort in the heart. At the same time, it is characterized by an unpredictable course: at any moment, inflammation of the endocardium can cause thromboembolism of the arteries of vital organs, acute heart failure, dangerous arrhythmias, and damage to internal organs. In addition, the disease can recur.

Typically, endocarditis occurs as a complication of inflammation of the tonsils, kidneys, lungs, myocardium and other diseases, and therefore is rarely diagnosed. But there is also an independent pathology - infective endocarditis. It develops when microorganisms enter the endocardium.

Most often these are bacteria, which is why the disease was previously called “bacterial endocarditis”. Now that fungi have become more frequently detected in blood cultures, this name for the disease is considered obsolete. Infectious endocarditis is also called septic because here, as in sepsis, microorganisms are found in the blood, which should normally be sterile.

What is the endocardium and why is its inflammation dangerous?

The endocardium, which becomes inflamed during endocarditis, consists of several layers of cells:

The endocardium lines the inside of the heart wall, forms folds - valve flaps, as well as chordae tendineae attached to them and papillary muscles that pull on the chordae. It is this lining of the heart that is the separator between 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 the blood against the heart walls, and there is no deposition of blood clots 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 on the atrium side is denser. This is ensured by a large number of collagen fibers in the muscular-elastic layer of the membrane. On the side of the ventricles, the muscular-elastic layer is 4-6 times thinner and contains almost no muscle fibers. The valves between the cavities of the heart and the vessels (pulmonary trunk, aorta) are thinner than the atrioventricular valves. The endocardium covering them is thicker at the base of the valve, but any layering is no longer visible on the valves themselves. There are very few muscle fibers on the valves that close the entrance to the vessels.

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

Directly below the endocardium is the heart muscle - the myocardium. It is responsible not only for the contractions of the parts 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 blood, they naturally end up inside the cavities of the heart. If a person’s immunity is sufficiently weakened, then microorganisms settle on the endocardium (especially on the valves between the left atria and the ventricle, as well as at the entrance from the left ventricle to the aorta) and cause inflammation there. The inflamed endocardium grows and thrombotic masses are deposited on it. This form of the disease is called “warty endocarditis” and is more characteristic of the rheumatic process

Thrombotic masses can break off at any time and enter the arteries that feed the internal organs through the bloodstream. This is how a stroke, infarction of the spleen, intestines, lungs and other organs can develop.

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

Microorganisms deposited on the valves, chordae, 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 separation of the chord, the heart “loses control” of its own processes. This is how acute heart failure develops, occurring 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, panic state with possible loss of consciousness.

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

Statistics

In 2001, the incidence of infective endocarditis was reported as 38 cases per 100,000 population. It is now indicated that the incidence of this disease is lower - 6-15 per 100 thousand people. However, mortality remains high - 15-45% (on average - 30%), especially in older people.

Endocarditis most often affects people of working age - 20-50 years old, as well as children. The incidence of men and women is the same.

Causes of endocarditis and its classification

Depending on the initial state of the inner lining of the heart, infective endocarditis of the heart can be primary or secondary. Both of them are caused by the following microorganisms:

• bacteria: viridans (the main cause of subacute endocarditis) and pneumonic streptococci, Staphylococcus aureus and Enterococcus (cause an acute inflammatory process), Escherichia coli, Mycobacterium tuberculosis, Treponema pallidum (with syphilis), Brucella, some gram-negative and anaerobic bacteria;
• mushrooms, usually Candida. Such microflora usually appears when a person has been treated with antibiotics for a long time, or has had a venous catheter in place for a long time (in the treatment of any disease);
• some viruses;
• some protozoa.

Only primary endocarditis is one that occurs on normal, healthy valves, and secondary endocarditis occurs 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. It reached 41-55%.

Microorganisms enter the human blood in the following ways:

• through a wound of the skin or mucous membranes when it has become contaminated with microbes in a person with reduced immunity or with an installed artificial valve or pacemaker;
• when performing various invasive methods of examination and treatment: catheterization of peripheral veins to introduce contrast into them (for angiographic studies), endoscopic and open interventions, abortions, cystoscopy and even extraction (pulling out) of teeth when a foreign surface comes into contact with blood;
• from any source of bacterial or fungal inflammation (for example, from the lungs with pneumonia, abscess of the tonsils, gangrene of the extremities) - in conditions of reduced immunity, especially if it is combined with pathology of the valve apparatus;
• for any infection (microorganisms always enter the blood and pass through the heart): respiratory tract, maxillary sinuses, kidneys, joints, intestines, and so on, if a person has an artificial valve or pacemaker;
• when using injecting drugs (the endocardium of the right side of the heart is most often affected), when sterility is not maintained;
• during the installation of prostheses or implants, especially when it comes to the installation of artificial heart valves or a pacemaker;
• during any heart surgery.

There is a greater chance that the microbe will “stick” to the endocardium and cause an inflammatory process in it in older people, drug addicts, and people with immunodeficiency conditions, including those who have immunodeficiency as a result of cancer treatment. People who constantly drink alcohol are also more susceptible to developing endocarditis.

There are also local factors that contribute to the development of this disease. These are heart defects - congenital and acquired (especially ventricular septal defects and coarctation of the aorta), artificial valves. There is evidence that in the presence of valve pathology, any entry of a certain amount of bacteria into the blood (even with a tooth root cyst or sore throat) can cause infective endocarditis in 90% of cases.

If everything is fine with the heart valves, then if bacteria enter the blood, it is more likely that endocarditis will develop in older people with arterial hypertension, coronary artery disease, cardiomyopathies, and Marfan syndrome. There is a higher risk of developing endocarditis in a person who has already had this disease once, even if it did not leave visible, ultrasound-detectable marks on the inner lining of the heart.

If the disease occurs when a pathogen is detected in the blood and there is already damage to internal organs, this is septic endocarditis, which is also called infectious and bacterial. When it occurs as a complication of streptococcal lacunar or follicular inflammation of the tonsils, or glomerulonephritis caused by streptococcus, it is called rheumatic endocarditis. There are also tuberculous, syphilitic, traumatic and post-infarction inflammation of the myocardium.

Depending on the course, any endocarditis can be:

• acute: lasts about 2 months;
• subacute, which lasts 2-4 months, is usually a consequence of an untreated acute process;
• chronic (protracted), “lasting” for more than 4 months. This is a rare type of infective endocarditis, but a fairly common type of disease of rheumatic origin.

According to the damage to the valves, there are:

• mitral valve endocarditis;
• inflammation of the aortic valve;
• endocarditis of the tricuspid (tricuspid) valve;
• inflammation of the pulmonary valve.

The last 2 valves, located in the right side of the heart, become inflamed most often in injection drug addicts.

The diagnosis may also include the activity of the process. Endocarditis will be considered active if a person experiences an increase in temperature in combination with the isolation of microorganisms during blood culture or bacteriological examination of the valves (if heart surgery was performed). If the first episode of endocarditis is over, and no symptoms have been observed for a year or more, then the re-development of inflammation of the endocardium, with the release of another pathogen from the blood or valves, will be called “recurrent endocarditis”. If, despite treatment, symptoms of the disease persist for 2 months or more, and the same microbe is sown from the blood, this is called persistent endocarditis.

If endocarditis develops after heart surgery, it is divided into:

• early: occurs in the first year after the intervention. Means that the infection occurred nosocomially;
• late: developed when a year passed after the operation. Caused by community-acquired microflora.

The selection of antibacterial therapy and prognosis depend on the latter classification. So, if infection occurs with nosocomial microflora, in the first 72 hours of hospital stay, mortality can reach 40-56%.

Endocarditis in children has an additional classification. It is divided into:

1. congenital, which is formed in the prenatal period when the fetus is infected;
2. acquired, arising after childbirth: either due to the same reasons as in adults, or due to infection during childbirth or immediately after it.

In children over 2 years of age, most cases of endocarditis develop against the background of congenital or acquired heart disease.

Symptoms

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, the symptoms will be as follows:

• high body temperature (up to 39.5°C);
• during the ascent, a person’s temperature rises with severe chills;
• profuse sweating;
• pain in all joints and muscles;
• lethargy;
• headache;
• the skin becomes grayish with a slight yellowness, sometimes red spots appear on it;
• reddish painful nodules appear on the fingers;
• There are hemorrhages in the conjunctiva.

Subacute infective endocarditis occurs with the following symptoms:

• elevated body temperature – up to 38.5°C;
• chills;
• worsening sleep;
• 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 these symptoms are observed for 2 months or more.

The chronic process is characterized by the same symptoms (only the temperature is usually up to 38°C) for six months or more. During this time, the person loses a lot of weight, his fingers take on the appearance of drumsticks (widened in the area of ​​the nail phalanges), and the nails themselves become dull and become convex (reminiscent of watch glasses). Hemorrhages may appear under the nails, and painful reddish nodules the size of a pea are always found on the fingers, toes, palms and soles.

When a heart defect develops, shortness of breath appears: first during physical activity, then at rest, pain in the chest, the heart beats faster (up to 110 beats per minute or more often) regardless of temperature.

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

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

With the development of pulmonary embolism, there is a sudden feeling of lack of air and pain in the chest. Against this background, impaired consciousness quickly increases, and the skin (especially on the face) acquires a purple tint.

Symptoms of infective endocarditis develop in three stages:

1. Infectious-toxic: bacteria enter the blood, “land” on the valves, and begin to multiply there, forming growths - vegetations.
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 from the internal organs and from the myocardium (sections of the heart muscle die in 92% of cases of prolonged inflammation of the endocardium).

Infectious endocarditis in children develops as an acute process and is very similar to ARVI. The difference is that with ARVI, the complexion should not change to yellowish, and there should be no pain in the heart.

If endocarditis is rheumatic, then it usually develops after a sore throat or glomerulonephritis, in which beta-hemolytic streptococcus was isolated (in the first case, from the surface of the tonsils, in the second, from urine). After the disease has subsided, after a while the person notices weakness, fatigue, and malaise. Again (after a sore throat or kidney inflammation), the temperature usually rises to 38°C, but can be higher. There are also unpleasant sensations in the heart area. Against this background, other signs of rheumatism may be observed: temporary enlargement and pain in large joints, which goes away on its own.

Complications

One of the most dangerous complications of endocarditis is embolism - separation of a section of an overgrown valve, a blood clot, or a blood clot with a section of the valve with the further “travel” of this particle through the arteries. The embolus (or thromboembolus) will stop where it exactly corresponds to the diameter of the artery.

If a particle breaks away in the left side of the heart, then embolization of the systemic vessels develops - one of the internal organs may be damaged: the intestines, spleen, kidneys. They develop a heart attack (that is, the death of the area).

If a thrombus 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, resulting in a pulmonary infarction.

The following complications may also occur due to endocarditis:

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

Diagnostics

Diagnosis of endocarditis is based on the following data:

1. listening to the heart: first the systolic murmur is determined, then the diastolic murmur;
2. determining the boundaries of the heart: they expand to the left (if 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 of the myocardial pathways by the inflamed endocardium occurs, the cardiogram determines the rhythm disturbance;
4. Ultrasound of the heart (echocardioscopy): this is how vegetations (growths) on the valves and thickening of the endocardium and myocardium are determined. Ultrasound with Doppler can be used to judge the function of the heart and, indirectly, the pressure in the pulmonary circle;
5. bacteriological examination of blood (inoculating it on various nutrient media);
6. blood tests using the PCR method: this is how some viruses and bacteria are determined;
7. rheumatic tests: in order to distinguish infective endocarditis from rheumatic;
8. If necessary, a magnetic resonance or computed tomography scan of the chest with a targeted examination of the heart can be performed.

An accurate diagnosis of infective endocarditis is made when there is a specific ultrasound picture of the heart, and the pathogen is determined in the blood. If all the symptoms indicate this disease, a microbe is detected in the blood, but there are no significant changes on echocardioscopy, the diagnosis is called into question.

When the pathogen is not detected in the blood, but the ultrasound picture is beyond doubt, the diagnosis states that infective endocarditis is either “culture-negative” (that is, bacteriological culture did not reveal anything), or “PCR-negative” (if it was not isolated by PCR). pathogen).

Treatment

Since the disease in question is characterized by unpredictability and unexpected development of complications, treatment of endocarditis should be carried out only in a hospital. It includes the mandatory intravenous administration of antibiotics according to the latest orders of the Ministry of Health. Usually these are broad-spectrum antibiotics, with a special focus against viridans streptococcus and Staphylococcus aureus (Vancomycin, Zyvox); A combination of 2-3 drugs is often used.

Before starting antibiotic treatment, three blood samples are taken from a peripheral vein to ensure sterility. Based on its results (they are obtained approximately on the 5th day), the antibacterial drug can be changed.

The course of antibiotics is from 4 to 12 weeks. Their cancellation is carried out only after the temperature and laboratory parameters have normalized and after three negative bacteriological cultures have been obtained against the background of a trial withdrawal of antibacterial drugs.

In addition to antibiotics, the following are prescribed:

• blood thinners (heparin);
• glucocorticoids;
• antifungal agents;
• proteolytic enzyme inhibitors;
• antistaphylococcal plasma or immunoglobulin;
• drugs necessary to treat one or another complication of endocarditis;

If drug treatment is ineffective within 3-4 weeks, then surgery is performed to remove foci of infection inside the heart and avoid the progression of heart failure and the development of thromboembolism. The intervention involves removing the affected valves and then installing their prostheses.

Surgical intervention can also be performed urgently (within 24 hours after diagnosis). This can be life-saving if you develop:

• acute heart failure,
• the valve walls came off,
• valve perforation occurred
• fistulas, abscesses or pseudoaneurysms of the valves have developed,
• during the first week of therapy, movable growths on the valves more than 10 mm in diameter appeared,

but the risk from such an operation is also extremely high.

After surgery, the person receives antibiotics for 7-15 days. He is in the hospital, on semi-bed rest.

After endocarditis, the motor regime expands, but physical activity remains prohibited. Diet - table No. 10 with restriction of salt, liquid, complete exclusion of alcohol, cocoa, chocolate, coffee, as well as spicy, fatty and smoked foods.

Forecast

Infective 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 powerful antibacterial therapy is started immediately. If a person develops endocarditis, has chronic heart disease or a suppressed immune system, life-threatening complications may develop.

The prognosis also worsens if:

• symptoms of the disease began to appear after admission to the hospital (where either invasive diagnostics or operations, including heart surgery) were performed - within the first 72 hours;
• if gram-negative flora, Staphylococcus aureus, antibiotic-insensitive Cochiella or Brucella, fungal flora are sown from the blood (from the valves).

With infective endocarditis affecting the right side of the heart, a better outcome can be expected.

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

Prevention

Prevention of endocarditis is as follows:

• you need to adhere to sufficient physical activity and follow the rules of a healthy diet in order to be examined and treated with invasive methods as little as possible;
• it is important to promptly sanitize foci of infection: treat diseased teeth, wash the lacunae of the tonsils in case of chronic tonsillitis, ensure the outflow of contents from the sinuses - in case of chronic sinusitis;
• if you still have to undergo treatment, you need to do it not at home or dubious offices, but in specialized clinics;
• If work or everyday life involves frequent trauma, you need to take care of maintaining sufficient immunity. To do this, it is important to eat right, move enough, maintain the hygiene of your skin and external mucous membranes;
• in case of injury, proper antiseptic treatment of the wound and, if necessary, a visit to the doctor is required;
• if, as a result of heart disease, heart surgery, installation of an artificial valve or pacemaker was necessary, after which blood thinning drugs were prescribed, you cannot stop taking them without permission;
• If the doctor prescribes antibiotics for any reason, you need to take them for as many days as prescribed. From the 5th day of taking antibacterial therapy, you need to ask your doctor about the need to prescribe antifungal drugs;
• It is important to administer antibiotic prophylaxis before starting any invasive treatment. So, if the operation is planned, it is better to start administering drugs 12-24 hours before it (especially if the intervention will be carried out on the oral cavity or intestines). If you had to resort to emergency surgery, the antibiotic should be administered as soon as possible after admission to the hospital.