Postmyocardial cardiosclerosis (PC) is a pathological condition that is the outcome of myocarditis (inflammation of the heart muscle) and is characterized by the replacement of normally functioning myocardial tissue with connective tissue (fibrosis). The main symptoms include signs of congestive heart failure (CHF) and cardiac arrhythmias.
Description of the disease
Distinguish between diffuse (widespread) and focal PC (when small areas of the myocardium are affected or the process captures the entire thickness of the heart muscle). Pathology occurs in a third of all patients who have survived myocarditis.
There is no such diagnosis in the International Classification of Diseases (ICD). Therefore, cardiosclerosis that developed after inflammation is coded I51.4 (myocarditis, unspecified).
Changes in the heart muscle
Morphological signs in the heart muscle are represented by residual effects after a resolved inflammatory process. It contains a large number of connective tissue fibers (fibrosis), dead myocardial cells, a slight accumulation of lymphocytes and macrophages.
Symptoms and Signs
The severity of clinical manifestations directly depends on the degree of proliferation of connective tissue in the myocardium and the percentage of damaged cardiomyocytes. As a result of a decrease in the number of functioning cells, the ability of the heart muscle to pump blood is disrupted, which leads to its stagnation in the large or small circle of blood circulation. If the left side of the heart is affected, there is congestion in the lungs, which causes shortness of breath (difficulty breathing), which increases with exertion.
The lack of air at night is especially characteristic, due to the horizontal position of the body. The patient is forced to take the "orthopnea" posture (sitting on the bed, leaning widely on it with his hands).
With the defeat of the right heart, blood stagnation occurs in the systemic circulation. There is a cold snap and a feeling of chilliness in the arms and legs, heaviness and aching pain in the right hypochondrium, edema mainly up to the lower third of the legs.
Due to disturbances in the rhythm of the heart, attacks of dizziness, lightheadedness, darkening in the eyes appear. With more pronounced arrhythmias, a person may lose consciousness.
Causes
Myocarditis, and, consequently, this type of cardiosclerosis develops due to the following reasons.
- Coxsackie viruses, ECHO, herpes simplex viruses, influenza, Epstein-Barr viruses, cytomegalovirus.
- Bacteria: staphylococci, streptococci, enterococci, mycobacterium tuberculosis, less often - chlamydia, mycoplasma, rickettsia, borrelia, diphtheroids.
- Parasites and fungi: Toxoplasma, Trichinella, Echinococcus, Candida, Aspergillus.
- Taking medications. Inflammation in the heart muscle can be caused by both the direct toxic effect of medications and an indirect allergic reaction. These drugs include antibiotics, anti-TB drugs, antidepressants, and antineoplastic immunosuppressants (cytostatics).
- Autoimmune pathologies: acute rheumatic fever, systemic lupus erythematosus, systemic scleroderma, ankylosing spondylitis (ankylosing spondylitis).
The mechanism of development of pathology
The pathogenesis (development mechanism) of cardiosclerosis is as follows: after the resolution of acute inflammatory processes in the myocardium, the so-called fibroblast growth factors are released from the destroyed cells. They stimulate the production of collagen, the main protein in connective tissue.
Its large amounts form fibers that gradually replace the normally functioning parts of the heart muscle. As a result, the pumping work of the myocardium worsens, and various rhythm disturbances also occur.
However, this scenario is not always the case. Most people recover from myocarditis completely without significant residual effects. Why some patients develop cardiosclerosis, while others do not, still remains a mystery. This can depend on the extent of cellular damage, the state of the immune system, and many other factors.
Diagnostics: how to suspect and determine
From personal practical experience, I can say that the main thing is to know how the disease developed. A thorough survey allows you to establish the fact of myocarditis. It may be indicated by the appearance of pain in the heart, palpitations, shortness of breath, and constant weakness.
Also, a general examination (physical examination) of the patient plays an important role. In these patients, I usually pay attention to lip color (it may be bluish), swollen veins in the neck, thickening of the terminal phalanges of the fingers (the so-called drumstick symptom) and an enlarged liver.
Auscultation of the heart and lungs takes a special place. The patient can hear noises, deafness of tones, irregular rhythm, moist rales in the lower parts of the lungs. In severe and neglected cases, when there is a pronounced circulatory failure, an auscultatory phenomenon appears - "gallop rhythm", characterized by the appearance of a third tone between two physiological ones.
After questioning and general examination of the patient, I make a preliminary diagnosis. To confirm or exclude it, you need to undergo an additional examination, including the following.
- General and biochemical blood tests - they do not give enough data to diagnose cardiosclerosis itself, but sometimes they reveal abnormalities that could cause the development of myocarditis.
- Electrocardiography. On the ECG, nonspecific changes are noted: an elevation of the ST segment and a negative T wave. Often, violations of the rhythm and conduction of the heart in the form of supraventricular and ventricular extrasystoles, atrial fibrillation and atrial flutter, atrioventricular blocks and blocks of the bundle of His bundle are observed.
- Chest x-ray - may detect enlarged heart borders and signs of pulmonary congestion.
- Echocardiography (ultrasound of the heart, ECHO-KG) - allows you to see the thickening of the walls of the myocardium, dilatation (expansion) of the atria and ventricles, zones of impaired muscle contractility.
- Endomyocardial biopsy - according to modern recommendations, the diagnosis of cardiosclerosis is established by histological examination of the myocardium. However, due to the technical complexity, I rarely prescribe this procedure to my patients.
Treatment and methods
The need for hospitalization depends on the severity of the patient's condition. In most cases, outpatient treatment is sufficient. The use of antiviral, antibacterial, antifungal drugs is pointless, since at the time of the formation of cardiosclerosis, the pathogen had already left the body.
The first stage of treatment is to limit physical activity. Professional sports are strictly contraindicated. Aerobic exercise and exercise therapy are allowed. I explain to my patients that they should follow a diet low in salt, consuming no more than 2-3 grams per day. This is necessary to prevent stagnation of fluid in the body.
The treatment is based on drug therapy. To slow the progression of heart failure, I use drugs of the following pharmacological groups - ACE inhibitors (Perindopril, Ramipril), beta-blockers (Bisoprolol, Nebivalol) and mineralocorticoid receptor antagonists (Spironolactone).In case of severe congestion, I prescribe diuretics - loop diuretics (Furosemide, Torasemide).
Treatment methods for arrhythmias are determined by their type, severity and accompanying symptoms. With atrial fibrillation and flutter, blood clots form in the cavities of the heart, which can migrate and clog a vessel in an organ, such as the brain, thereby causing an ischemic stroke. Therefore, to prevent thrombus formation, I use anticoagulants ("Warfarin", "Dabigatran", "Apixaban", "Ksarelto").
If arrhythmias are accompanied by symptoms such as dizziness and lightheadedness, it is worth considering the option of taking medications that normalize the heart rate - Procainamide, Propafenone, Sotalol. With resistance to drug therapy, surgery is performed - radiofrequency ablation. With severe atrioventricular blockade, the installation of a pacemaker is indicated.
Complications: what causes death and in what cases
Adverse consequences are observed in diffuse forms of cardiosclerosis. These include acute heart failure, including pulmonary edema and cardiogenic shock (a sharp decrease in the pumping function of the heart).
In severe rhythm disturbances, sudden cardiac death may occur due to ventricular fibrillation and asystole (complete cardiac arrest). These conditions are very often fatal. They occur in about 5-10% of cases of postmyocarditis cardiosclerosis.
Doctor's advice
If you feel that your legs are swollen, especially in the evenings, if you are worried about shortness of breath, which worsens in the supine position or at night, you have paroxysmal dizziness, darkening in the eyes and even fainting, be sure to consult a doctor for a full cardiac examination and treatment.
Clinical case
A 49-year-old man came to see me complaining of weakness, increased fatigue, difficulty breathing, and frequent attacks of dizziness. He lost consciousness last night, which was the reason for the visit to the doctor. During the survey, it turned out that six months ago, after a cold, the patient developed chest pains, which the patient did not attach much importance to. On auscultation, a weak, irregular heartbeat was noted with a frequency of 42 beats per minute. The ECG revealed a complete atrioventricular block, the frequency of ventricular contractions was 35-47 per minute.
Echo-KG showed a thickening of the myocardial walls, zones of hypokinesis (reduced contractility) and a small ejection fraction (45%). I suspected postmyocardial cardiosclerosis. At the medical council, it was decided to conduct an endomyocardial biopsy. The obtained histological specimen revealed myocardial fibrosis and degenerative cell changes.
The final diagnosis was: “Myocarditis, unspecified. Complications: CHF II FC according to NYHA, complete AV block. The patient was prescribed drugs for the treatment of heart failure and a permanent pacemaker was implanted. After the operation, the patient feels satisfactory, dizziness and shortness of breath no longer bother.
Conclusion
Myocarditis cardiosclerosis is a consequence of myocarditis. It is caused by pathological proliferation of connective tissue in the heart muscle after resolved inflammation processes. The disease develops in one third of patients with myocarditis. The diagnosis is made on the basis of symptoms, survey data, physical examination and the results of instrumental research methods (ECG, Echo-KG).
As a treatment, drugs are used that slow the progression of heart failure, anticoagulants and antiarrhythmics. Severe patients undergo radiofrequency ablation and a pacemaker. Death from postmyocardial cardiosclerosis occurs in 5-10% of cases. Acute heart failure and fatal arrhythmias are the immediate causes.
