–едакци€ портала
17 окт€бр€ 2013, 20:50 531 +3

ћиокардит 

√руппа заболеваний: болезни сердца и сосудов
—межные болезни: инфаркт миокарда, ишемическа€ болезнь сердца
¬рачи в каталоге: кардиолог, кардиотерапевт
ѕораженный орган: сердце
 

‘акторы риска

  • Ѕеременность;
  • Ќаследственную предрасположенность;
  • »ммунодефицитные состо€ни€.

ќписание

ћиокардит — это очаговое или диффузное воспаление сердечной мышцы (миокарда), в результате которого нарушаютс€ его основные функции: возбудимость, проводимость и сократимость.

—татистика миокардита:

  • „астота возникновени€ заболевани€   составл€ет  4-11% от всех патологий сердечно-сосудистой системы. ƒействительную встречаемость легких форм болезни  трудно определить, потому что  многие случаи протекают без €рко-выраженной клинической картины. 
  • —тоит отметить, что миокардитом заболевают чаше люди молодого возраста (от 30 до 40 лет). 
  • «аболеваемость у женщин несколько выше, чем у мужчин, но у мужчин чаще встречаютс€ более т€желые формы. 
  • ” людей, умерших от внезапной сердечной смерти в молодом возрасте, признаки воспалени€ миокарда колеблютс€ от 8,6 до 12%. 
  • „астота прижизненной постановки диагноза миокардита находитс€ в довольно широких пределах (0,02-40%).

¬ насто€щее врем€ большинство случаев воспалени€ миокарда благополучно излечиваетс€, практически без морфологических и физиологических последствий дл€ организма. Ѕлагодар€ высокотехнологичным методам диагностики т€жЄлые, со смертельным исходом, формы болезни развиваютс€ достаточно редко. “ем не менее, крайне важно правильно и во врем€ оценить первичные симптомы патологии, прин€ть своевременное и адекватное лечение, чтобы не допустить формировани€ р€да сопутствующих заболеваний сердечно-сосудистой системы. 

 лассификаци€

—уществует весьма сложна€ классификаци€ миокардита по различным критери€м.

1.  лассификаци€ миокардитов по течению:
  • острый миокардит;
  • подострый миокардит;
  • хронический миокардит.

2. ћиокардит бывает:

  • с установленной причиной;
  • неуточненный (идеопатический).

3.  лассификаци€ миокардита по причине:

  • ревматический миокардит;
  • инфекционный миокардит;
  • аллергический миокардит;
  • токсический миокардит;
  • миокардит при травмах, ожогах;
  • идиопатический миокардит (то есть невы€сненной природы) миокардит јбрамова-‘идлера.
4.  лассификаци€ миокардита по распространенности воспалительного процесса:
  • ќчаговый (изолированный) миокардит. ќчаг повреждени€ кардиомиоцитов и воспалительной клеточной инфильтрации располагаетс€ преимущественно в одной из стенок левого желудочка. ¬ зависимости от его расположени€ и размера могут возникать различные клинические про€влени€, такие как нарушени€ ритма и проводимости, изменени€ сегмента S“ на Ё √ в нескольких отведени€х, могут по€вл€тьс€ участки гипокинезии, акинезии и дискинезии, вы€вл€емые при Ёхо √.
  • ƒиффузный миокардит. ¬ патологический процесс вовлечен весь миокард левого желудочка, что приводит к существенному нарушению его сократимости, уменьшению ‘¬, сердечного индекса и увеличению  ƒƒ и  ƒќ и, как следствие, к развитию сердечной недостаточности.
5.  лассификаци€ миокардита по степени т€жести:
  • легка€ форма миокардита;
  • среднет€жела€ (умеренна€) форма миокардита;
  • т€жела€ форма миокардита.
Ќередкий исход подострого миокардита  развитие миокардиофиброза.
ћиокардиофиброз  это процесс замещени€ здоровой мышцы клетками, которые не могут сокращатьс€ и плохо провод€т импульс. ≈сли воспалительный процесс протекает длительно, а миокардиофиброз не развиваетс€, то такой миокардит называетс€ хроническим.

6.  линические варианты миокардита допускают про€влени€ иных нарушений работы сердца, таких как аритмии, кардиалги€ (боль в сердце) и т.д.

7. —ердечна€ недостаточность и миокардит (0-III стади€).

ѕричины

 ак видно из классификации при миокардите причина может быть определена, а может остатьс€ неуточненной. ¬се возбудители заболевани€ можно объединить в группы. ¬оспаление сердечной мышцы развиваетс€ в результате различных инфекций, воздействи€ токсинов, лекарственных препаратов или иммунологических и аллергических реакций, привод€щих к повреждению кардиомиоцитов и развитию сердечной дисфункции.

»нфекционные и инфекционно-токсические причины миокардита:

  • вирусы (аденовирусы, вирусы  оксаки ¬, гриппа, инфекционного гепатита, иммунодефицита человека-1, парагриппа, ECHO, коримононуклеоза, цитомегаловирусы и др.);
  • бактерии (дифтери€, микобактерии, микоплазмы, стрептококки, менингококки, стафилококки, гонококки, легионеллы, клостридии и др,);
  • грибы (аспергиллез, актиномикоз, кандидоз, кокцидомикоз, криптококкоз, гистоплазмоз);
  • риккетсии (сыпной тиф, лихорадка Q и др.);
  • спирохетозы (лентоспироз, сифилис, болезнь Ћайма);
  • протозойные инфекции (трипаносомоз или болезнь Ўагаса, токсоплазмоз, амебиаз);
  • паразиты (шистосомоз, вызванный личинкой гельминта, синдром «блуждающей личинки», эхинококкоз).

јллергические причины миокардита:

  • лекарственные препараты (сульфонамиды, цефалоспорины, дитоксин, добутамин, трициклические антидепрессанты и др.);
  • сывороточна€ болезнь;
  • остра€ реакци€ организма на некоторые вакцины;
  • трансплантаци€ органов и тканей.

»ммунологические причины миокардита:

  • системные заболевани€ соединительной ткани (ревматизм);

“оксические причины миокардита:

  • наркотики (особенно кокаин);
  • алкоголь;
  • воздействии ионизирующей радиации;
  • регул€рное воздействие токсических веществ и газов.

ƒругие заболевани€ и состо€ни€:

  • ожоги;
  • болезнь  авасаки;
  • лучевое лечение. 

 ак развиваетс€ болезнь

—уществует несколько механизмов, вызывающих развитие воспалени€ и повреждени€ сердечной мышцы:

  • Ќепосредственное действие инфекционных агентов, способных внедр€тьс€ внутрь кардиомиоцита (вирусы, трипаносомы, риккетсии) или локализоватьс€ в интерстициальной ткани, формиру€ небольшие абсцессы (гнойники). 
  • ѕовреждение кардиомионитов токсинами, выдел€емыми возбудителем в кровь при системной инфекции или непосредственно в сердце. Ётот механизм повреждени€ наиболее характерен дл€ дифтерийного миокардита, но может развиватьс€ при инфекционно-токсическом шоке.
  • –азвитие коронариита и эндотелиальной дисфункции сосудов сердца с последующим коропарогенным повреждением сердечной мышцы (риккетсии).
  • Ќеспепифическое повреждение клеток миокарда в результате аутоиммунных заболеваний (системна€ красна€ волчанка, системна€ склеродерми€, ревматоидный артрит, сывороточна€ болезнь), при которых сердце оказываетс€ одним из органов-мишеней генерализованного процесса.
  • —пецифическое повреждение кардиомиоцитов факторами гуморального и клеточного иммунитета, которые активируютс€ при внедрении возбудители или реактивируютс€ в результате длительно персистирующей первичной инфекции.

Ќаибольшее распространение получила гипотеза аутоиммунного повреждени€, согласно которой вирусна€ инфекци€ на стадии активной репликации вируса запускает иммунопатологические реакции с участием клеток (лимфоцитов —D8+): аутоантител к различным компонентам кардиомиоцитов (миозину), ниток и по в (»Ћ-1, 2, 6, ‘Ќќ-а), что приводит к поражению кардиомиоцитов.  роме того, локальное выделение цитокинов, оксида азота может вли€ть на активность “-клеток и поддерживать аутоиммунный процесс. ѕоказано, что цитокины могут обратимо снижать сократимость миокарда, не вызыва€ гибели клеток. “акже считаетс€, что вирусна€ –Ќ , обнаруживаема€ в кардиомиоцитах, может служить антигеном, поддерживающим иммунные реакции.

—имптомы

—имптомы миокардита не имеют специфических черт, но в большинстве, случаев можно проследить хронологическую св€зь заболевани€ сердца с инфекцией или другими этиологическими факторами, способными привести к развитию токсических или аллергических повреждений миокарда. «аболевание чаще всего развиваетс€ через несколько дней (реже — несколько недель) после перенесенной вирусной инфекции и в р€де случаев протекает бессимптомно.

¬ остальных случа€х пациенты испытывают различные непри€тные про€влени€ миокардита. ќсновные жалобы: боли в сердце, отдышка, усиленное сердцебиение или перебои в работе сердца, а также отеки. –ассмотрим каждый симптом подробней.

Ѕоли в области сердца бывают часто (60% случаев), они обычно локализованы в области верхушки сердца, могут распростран€тьс€ на всю прекардиальную область сердца, нос€т колющий или дав€щий характер, обычно продолжительные, не св€заны с физической нагрузкой и не купируютс€ приемом нитратов. “акой характер болей может быть св€зан с вовлечением в патологический процесс перикарда (миоперикардит), однако возможны и редкие случаи стенокардии, например при текущем вирусном коронариите и вазоспазме.

ќдышка €вл€етс€ вторым по частоте (47,3%) симптомом текущего миокардита. ќна св€зана с развивающейс€ левожелудочковой недостаточностью, может возникать только при интенсивной физической нагрузке (при легкой форме миокардита) или даже в покое (при среднет€желой и т€желой формах). ќдышка может усиливатьс€ в горизонтальном положении тела за счет увеличени€ преднагрузки па сердце. —ерьезный признак миокардита — внезапное по€вление симптомов застойной сердечной недостаточности у молодого пациента без клинических признаков »Ѕ—.

—ердцебиение (47,3%) св€зано с уменьшением сердечного выброса и рефлекторным увеличением активности симпатоадреналовой системы.

ѕеребои в работе сердца, головокружени€ и обмороки возникают у 38% больных и обусловлены различными нарушени€ми ритма и проводимости (атриовентрикул€рные блокады II степени, экстрасистоли€) фибрилл€ци€ предсердий и др.), определ€емыми локализацией очага некроза, воспалени€ и степенью его распространенности. ∆изнеугрожающа€ желудочкова€ аритми€ и йодна€ атриовентрикул€рна€ блокада характерны дл€ т€желого диффузного миокардита и могут привести к внезапной остановке кровообращени€.

ќтеки на ногах, боли в правом подреберье и другие про€влени€ недостаточности кровообращени€ по большому кругу чаще развиваютс€ при хроническом течении миокардита.

ѕри наличии тех или иных симптомов, можно определить течение миокардита.  лассификаци€ миокардитов по характеру течени€ предполагает три типа:
  • ќстрый миокардит. ’арактеризуетс€ острым началом, повышением температуры тела, выраженными клиническими про€влени€ми, изменени€ми в лабораторных данных, свидетельствующими о протекающем воспалительном процессе, повышение уровн€ кардиоспецифических маркеров повреждени€. ƒл€ вирусного миокардита характерна виреми€. √истологическа€ картина указывает на некроз кардиомиоцитов.
  • ѕодострый миокардит. ’арактеризуетс€ менее €ркой клинической картиной, умеренными отклонени€ми лабораторных данных. Ќаблюдаетс€ увеличение специфических антител в диагностическом титре. ѕроисходит активаци€ “- и ¬-лимфоцитов. √истологическа€ картина указывает на инфильтрацию миокарда мононуклеарными клетками.
  • ’ронический миокардит. ’арактеризуетс€ длительным течением с периодами обострени€ и ремиссии. ”станавливают высокий титр противокардиальных антител и других нарушений клеточного и гуморального иммунитета. √истологическа€ картина — фиброз и воспалительна€ инфильтраци€. ¬ исходе развиваетс€ поствоспалительна€ дилатационна€ кардиомиопати€.

 лассификаци€ миокардита по степени т€жести основана на двух основных критери€х, изменении размеров сердца и степени выраженности сердечной недостаточности:

  • Ћегка€ форма миокардита. Ќе происходит изменени€ размеров и сократительной способности сердца, главным образом левого желудочка. ƒанна€ форма миокардита протекает с формированием субъективных симптомов, по€вл€ющихс€ вскоре (через 2—3 нед) после перенесенной инфекции; обща€ слабость, незначительна€ одышка, возникающа€ при выполнении физических нагрузок, различные болевые ощущени€ в области сердца, сердцебиение и перебои.
  • —реднет€жела€ форма. ѕротекает с кардиомегалией, но без признаков сердечной недостаточности в состо€нии поко€. Ёта форма включает диффузные миокардиты и миоперикардиты, заканчивающиес€ чаще полным выздоровлением с нормализацией размеров сердца, однако в остром периоде дл€ нее характерны более выраженные объективные и субъективные про€влени€.
  • “€жела€ форма. ’арактеризуетс€ кардиомегалией и выраженными признаками сердечной недостаточности (острой или хронической). ¬ редких случа€х т€жела€ форма миокардита может про€вл€тьс€ кардиогенным шоком или т€желыми нарушени€ми ритма и проводимости с синдромом ћорганьи-јдамса-—токса.

ƒиагностика

ƒл€ диагностики миокардита необходимо уточнить хронологическую св€зь указанных симптомов с перенесенной инфекцией, а также от€гошенность семейного анамнеза по случа€м внезапной сердечной смерти или развити€ сердечной недостаточности у родственников в молодом возрасте. ћетоды диагностики: консультаци€ врача-кардиолога, диагностические и лабораторные исследовани€.

¬ процессе сбора анамнеза необходимо вы€снить и уточнить у больного следующие моменты:

  • ѕредшествовало ли насто€щему состо€нию простудное заболевание, были ли отмечены у больного повышение температуры тела, лихорадка, слабость, суставна€ или мышечна€ боль, сыпь на коже. ѕериод между перенесенной инфекцией верхних дыхательных путей или желудочно-кишечного тракта составл€ет около 2—3 нед.
  • Ѕеспоко€т ли пациента боли в области сердца или в грудной клетке посто€нного колющего или дав€щего характера, усиливающиес€ при физической нагрузке, не проход€щие после приема нитроглицерина.
  • ≈сть ли жалобы, указывающие на разнившуюс€ или развивающуюс€ сердечно-сосудистую недостаточность (утомл€емость, одышка, ночные приступы удушь€) различной степени т€жести, сердцебиение, синкопальные состо€ни€.

‘изикальное исследование

ѕри миокардитах отмечают тахикардию, гипотензию и лихорадку. —ели миокардит протекает в среднет€желой или т€желой форме с формированием сердечной недостаточности, то возможны акроцианоз, набухание вен шеи в покое или при незначительной физической нагрузке, периферические отеки, хрипы и крепитаци€ в легких.

—ледует также помнить, что при более детальном физикальном обследовании можно обнаружить клинические признаки инфекционного или системного заболевани€ (лихорадка, кожна€ сыпь, лимфаденопати€ и др.), послужившего причиной развити€ миокардита.

ѕри пальпации области сердца можно обнаружить ослабление верхушечного толчка, а также его смещение кнаружи от левой срединно-ключичной линии при кардиомегалии.

ѕри перкуссии (постукивании) у больных со среднет€желой и т€желой формами миокардита происходит смещение левой границы относительной тупости сердца влево. 

ѕри аускультации (выслушивании шумов) возможны снижение громкости I тона, акцент II тона на легочной артерии, а также ритм галопа, предиктор т€желого течени€ миокардита, в частности прогрессирующего снижени€ сократительной способности миокарда и систолической дисфункции.

ќбычно его по€вление предшествует развитию клинических признаков сердечной недостаточности. ѕри развитии миоперикардита выслушиваетс€ шум трени€ перикарда.

ѕри миокардитах обычно развиваетс€ тахикарди€, котора€ не соответствует степени повышени€ температуры тела («токсические ножницы»), а также не исчезает во сне, что служит значимым дифференциально-диагностическим признаком. “ахикарди€ может возникать как при физической нагрузке, так и в покое. –едко встречаютс€ брадикарди€ и снижение пульсового давлени€.

Ћабораторна€ диагностика миокардита

¬ клиническом анализе крови могут отмечатьс€ незначительный лейкоцитоз со сдвигом влево и увеличение —ќЁ. ƒиагностическа€ ценность этой реакции может уменьшатьс€ при развитии застойной сердечной недостаточности и гепатите. ѕовышение уровн€ эозинофилов характерно дл€ паразитарных заболеваний и может нарастать по мере выздоровлени€ от миокардита.

Ѕольшое значение имеет исследование титра антител к кардиотропным вирусам, четырехкратное увеличение которого имеет диагностическое значение.

Ёлектрокардиограмма или суточное мониторирование Ё √ по ’олтеру при миокардите

ћиокардиты могут вызывать следующие изменени€ на Ё √ (одно или несколько):

  • –азличные нарушени€ сердечного ритма, такие как синусова€ тахикарди€ или брадикарди€, фибрилл€ци€ предсердий, пароксизмальна€ суправентрикул€рна€ или желудочкова€ тахикарди€, эктопические ритмы. Ќаджелудочкова€ тахикарди€ особенно часто возникает при застойной сердечной недостаточности или перикардите;
  • Ќарушени€ проводимости электрическою импульса по провод€щей системе сердца, которые могут про€вл€тьс€ в виде атриовентрикул€рной блокады I-III степени, блокады левой или, реже, правой ножки пучка √иса. —уществует определенна€ коррел€ци€ между степенью нарушени€ проводимости и т€жестью течени€ миокардита. Ќередко возникает полна€ атриовентрикул€рна€ блокада, чаще всего обнаруживаема€ после первого эпизода потери сознани€. ћожет быть необходима установка временного кардиостимул€тора;
  • »зменени€ конечной части желудочкового комплекса с виде депрессии сегмента S“ и по€влени€ низкоамплитудного, сглаженного или отрицательного зубца как правило, определ€ющиес€ в грудных отведени€х, но возможны и в стандартных;
  • ѕсевдоинфарктные изменени€, в том числе отрицательный коронарный зубец “, подъем сегмента ST и образование патологического зубца что отражает поражение сердечной мышцы и снижение ее электрической активности.

»зменени€ на Ё √ могут быть кратковременными и стойкими. ќтсутствие патологических изменений на Ё √ не исключает диагноз миокардита.

Ёхокардиографи€ при миокардите

ѕри выполнении Ёхо √ у больных с малосимптомным или бессимптомным течением миокардита изменени€ могут отсутствовать или можно определить незначительное увеличение  —ќ и  ƒќ левого желудочка.

¬ т€желых случа€х миокардита, сопровождающихс€ снижением сократительной способности миокарда, происходит уменьшение ‘¬ и сердечного индекса. ќбнаруживают расширение полости левого желудочка, локальные нарушени€ сократимости в виде отдельных участков гипокинезии (иногда - глобальную гипокинезию) или акинезию.

ƒл€ острой стадии наиболее характерно увеличение толщины стенок сердца, обусловленное интерстициальным отеком. ¬озможна недостаточность митрального и трехстворчатого клапанов. ѕри миоперикардите отмечают сепарацию листков перикарда и небольшое количество жидкости. ¬ 15% случаев диагностируют пристеночные тромбы.

–ентгенологическа€ диагностика миокардита

” значительной части пациентов изменени€ при рентгенографии органов грудной клетки отсутствуют, а у другой части пациентов определ€ют в различной степени выраженную кардиомегалию (увеличение кардиоторакального индекса до 50% и более) и признаки венозного засто€ по малому кругу кровообращени€: усиление легочного рисунка, расширение корней легких, наличие выпота в плевральных синусах. ѕри развитии экссудативного перикардита сердце приобретает шаровидную форму.

—цинтиграфи€

—цинтиграфи€ миокарда с 67Gа — чувствительный метод диагностики активного воспалительного процесса в миокарде ƒл€ определени€ повреждени€ кардиомиоцитов у пациентов с необъ€снимой клинической картиной сердечной недостаточности можно применить сцинтиграфию с моноклональными антителами к миозину.

Ѕиопси€ миокарда

ѕо современным представлени€м, окончательный диагноз может быть установлен только после эндомиокардиальной биопсии, которую на насто€щий момент считают «золотым стандартом» диагностики.

ѕоказани€ к эндомиокардиальной биопсии:

  • развитие т€желых или угрожающих нарушений ритма, особенно прогрессирующей желудочковой тахикардии или полной блокады;
  • существенное снижение ‘¬ и наличие клинических признаков застойной сердечной недостаточности, несмотр€ па проводимое адекватное лечение;
  • исключение других поражений миокарда, требующих специфического лечени€ (гигантоклеточный миокардит, системна€ красна€ волчанка и другие ревматические болезни; впервые диагностированна€ кардиомиопати€ при подозрении на амилоидоз, саркоидоз, гемохроматоз).

Ќесмотр€ па то что обычно при эндомиокардиальной биопсии провод€т забор от 4 до 6 проб, при тщательном посмертном анализе доказанных случаев миокардитов было установлено, что дл€ правильной диагностики миокардитов более чем в 80% случаев необходимо более 17 проб (биоптатов). ¬ клинической практике это нереально, и поэтому очевидно отсутствие чувствительности эндомиокардиальной биопсии. ≈ще одно существенное ограничение в гистопатологической диагностике — непосто€нство микроскопической картины миокардита.

—труктура диагноза миокардита

“ечение миокардита

–аспространенность
воспалительного процесса

Ётиологический фактор

—тепень т€жести

ќстрый 
ѕодострый ’роническии

ќчаговый
ƒиффузный

¬ирусный
Ѕактериальный
√рибковый
ѕаразитарный
јллергический
“оксический
Ќеуточиенный

Ћегка€ форма ”меренна€ форма “€жела€ форма

ѕосле этого указывают осложнени€ (если они есть), стадию недостаточности кровообращени€ по Ќ.ƒ. —тражеско и ¬.’. ¬асиленко и функциональный класс (‘  ) по Ќью-…оркской классификации (NYЌј).

ѕримеры:

  • ќстрый очаговый постгриппозный миокардит, легка€ форма. Ќаджелудочкова€ экстрасистоли€, Ќ 0. I ‘ .

ƒифференциальна€ диагностика

ƒл€ постановки диагноза «миокардит» необходимо исключить заболевани€, протекающие с вторичным поражением миокарда, а также первичные поражени€ сердца неустановленной причины, не св€занные с заболевани€ми других органов и систем (кардиомиопатии). ѕри дифференциальной диагностике неревматических миокардитов следует исключать как причину поражени€ сердечной мышцы эндокринные, метаболические, общие системные заболевани€.

Ќаибольшее практическое значение имеет дифференциальный диагноз миокардитов с:

  • инфарктом миокарда;
  • дилатационной кардиомиопатией,
  • ревматическими и неревматическими поражени€ми клапанов сердца;
  • поражением сердца при длительно существующей артериальной гипертензии;
  • хроническим экссудативным и конструктивным перикардитом.

” детей раннего возраста надо иметь в виду возможность развити€ врожденных нервно-мышечных заболеваний, эндокардиальноо фиброэластоза, гликогеноза, врожденных аномалий венечных артерий сердца, болезни  авасаки.

Ћечение

ќсновное внимание удел€етс€ комплексной терапии и лечению осложнений. ќсновные цели лечени€ больных миокардитом, на достижение которых оно должно быть направлено:

  • предотвращение формировани€ необратимой дидатации и камер сердца;
  • предотвращение развити€ хронической сердечной недостаточности;
  • предупреждение возникновени€ угрожающих жизни больного состо€ний (т€желые нарушени€ ритма и проводимости).

√оспитализации подлежат все пациенты с подозрением на миокардит. ¬ об€зательном экстренном пор€дке должны быть госпитализированы больные, у которых с помощью Ё √ обнаружили изменени€, характерные дл€ миокардита или напоминающие инфаркт миокарда, у которых в крови повышен уровень кардиоспепифических маркеров или/и развиваютс€ признаки сердечной недостаточности.

Ќемедикаментозное лечение миокардита

—ущественные немедикаментозные методы лечени€ миокардитов - постельный режим, соблюдение которого уменьшает частоту осложнений и продолжительность восстановительною периода, а также кислородотерапи€.

ƒлительность постельного режима определ€етс€ степенью т€жести миокардита. ѕри легкой форме миокардита он составл€ет 3—4 нед, до нормализации или стабилизации Ё √ в покое. ѕри среднет€желой форме на 2 нед назначают строгий постельный режим с его расширением в последующие 4 нед. ¬ случа€х, когда у больного развиваетс€ т€жела€ форма миокардита, показан строгий постельный режим в палате интенсивной терапии до компенсации недостаточности кровообращени€, с последующим его расширением в течение 4 нед. Ћечение т€желых форм миокардитов в остром периоде в палате интенсивной терапии обусловлено возможностью развити€ у больного острой сердечной недостаточности, кардиогенного шока, угрожающих нарушений ритма или внезапной сердечной смерти.

ќграничение физических нагрузок лицам, перенесшим миокардит, показано до полного возвращени€ Ё √ к исходным показател€м.

¬ зависимости от выраженности клинической картины сердечной недостаточности больным назначают диету с ограничением поваренной соли и жидкости, всем пациентам рекомендуетс€ отказ от курени€ и алкогол€.

ћедикаментозное лечение миокардита

ћедикаментозное лечение миокардита должно быть направлено на устранение этиологического фактора (причины), воздействие на основное заболевание, коррекцию гемодинамических нарушений и иммунного статуса, профилактику и лечение нарушений сердечною ритма и проводимости, а также тромбоэмболических осложнений.

Ётиологическое лечение миокардита

¬ св€зи с тем что в подавл€ющем большинстве случаев основной этиологический фактор в развитии неревматических миокардитов - вирусна€ инфекци€, существует предположение в остром периоде вирусного миокардита использовать противовирусные препараты (поликлональные иммуноглобулины, интерферон-альфа, рибавирин и др.), однако этот подход требует дальнейшего изучени€.

ѕри развитии миокардитов на фоне бактериальных инфекций больным показаны антибактериальные средства (антибиотики). јнтибиотик назначает лечащий врач с учетом основного заболевани€.

Ќерекомендуют применение Ќѕ¬— при лечении неревматических миокардитов, так как нет убедительных доказательств их положительного вли€ни€ на исход заболевани€. √люкокортикоиды не рекомендуетс€ назначать дл€ лечени€ вирусных миокардитов на ранней стадии заболевани€. Ќазначение иммуносупрессоров (циклоспорин, азатиоприн) при миокардитах в насто€щее врем€ не рекомендуетс€, кроме случаев гигантоклеточного миокардита либо других аутоиммунных заболеваний (например, — ¬).

ѕри т€желых формах миокардитов с высокой лабораторной и клинической активностью целесообразно назначение гепаринов. ÷ели их назначени€ в подобных случа€х - профилактика тромбоэмболических осложнений, а также иммунодепреесивиое, противовоспалительное (за счет снижени€ активности лизосомальных ферментов) действие.

јнтиаритмические средства примен€ют у больных с тахиаритми€ми или желудочковыми нарушени€ми ритма (необходимо избегать препаратов с выраженным отрицательным инотропным эффектом).

Ѕольным со стойкими нарушени€ми проводимости, не поддающейс€ консервативному лечению, возможна имплантаци€ кардиовертера-дефибрилл€тора. ѕациентам с клинически значимыми брадиаритми€ми или блокадами проведени€ высоких степеней показана имплантаци€ временного кардиостимул€тора.

ѕрогноз

¬ отношении прогноза миокардита действительно правило «трех третей»: одна треть пациентов выздоравливает, у трети развиваетс€ стабильна€ левожелудочкова€ дисфункци€ и еще у одной трети состо€ние быстро ухудшаетс€ (происходит переход в ƒ ћѕ).

ѕрофилактика

ћиокардит может развитьс€ как про€вление или осложнение любого инфекционного заболевани€, в первую очередь вирусного, поэтому профилактика неревматических миокардитов сводитс€ главным образом к профилактике этих заболеваний.

ќна заключаетс€ в проведении профилактических прививок и вакцинаций в угрожаемых коллективах или группах населени€ против тех кардиотропных инфекционных агентов, к которым уже существуют вакцины (корь, краснуха, грипп, парагрипп, полиомиелит, дифтери€ и др.). “ем не менее поскольку при многих вирусных инфекци€х серопрофилактика отсутствует или недостаточно эффективна, то наиболее важными мерами профилактики развити€ миокардита служат на короткий срок после перенесенной респираторной инфекции ограничение профессиональных физических нагрузок или зан€тий спортом и тщательное электрокардиографическое обследование. ¬ы€вление лиц с бессимптомными формами миокардитов и своевременный контроль их физической активности может предупредить переход в более т€желую форму.

¬сем лицам, имеющим от€гощенный семейный анамнез по случа€м внезапной смерти или развити€ сердечной недостаточности в молодом возрасте среди родственников, необходимы врачебный осмотр и электрокардиографическое исследование не реже одного раза в год. ѕомимо этого, они должны избегать перегрузок, св€занных с работой или профессиональным спортом.

 
–едакци€ портала
17 окт€бр€ 2013, 20:50
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