Dr. M. A. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin MYOCARDITIS Dr. M. A. SOFI MD; FRCP (London); FRCPEdin; FRCSEdin

Myocarditis Myocarditis is an inflammatory disease of the myocardium with a wide range of clinical presentations, from subtle to devastating. Clinical features of myocarditis: Myocarditis should be suspected in patients with or without cardiac signs and symptoms, who present with: Rise in cardiac biomarker levels Change in electrocardiogram suggestive of acute myocardial injury Arrhythmia Abnormalities of ventricular systolic function 

Signs and symptoms Manifests in an otherwise healthy person with rapidly progressive (and often fatal) heart failure and arrhythmia. Chest pain: Mild symptoms of chest pain (in concurrent pericarditis), fever, sweats, chills, dyspnea. Mimic myocardial ischemia and/or MI symptomatically and on the ECG particularly in younger patients  Recent history (≤1-2 wk) of flulike symptoms of fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper respiratory tract infection in viral myocarditis

Palpitations: Number of arrhythmias may be seen. Signs and symptoms Manifests in an otherwise healthy person with rapidly progressive (and often fatal) heart failure and arrhythmia. Palpitations: Number of arrhythmias may be seen. Sudden cardiac death: due to underlying ventricular arrhythmias or atrioventricular block (especially in giant cell myocarditis) Heart failure: Many cases of postviral or lymphocytic myocarditis present with heart failure and dilated cardiomyopathy. Rapidly evolving diffuse, severe myocarditis can result in acute myocardial failure and cardiogenic shock.

Clinical features of myocarditis Excessive fatigue or exercise intolerance Partial or complete heart block, new-onset bundle branch block Chest pain New onset or worsening heart failure Unexplained sinus tachycardia Acute pericarditis S3, S4, or summation gallop Cardiogenic shock Abnormal electrocardiogram Sudden cardiac death New cardiomegaly on chest x-ray Hepatomegaly Atrial or ventricular arrhythmia

Diagnostic evaluation: The diagnostic evaluation of patients with suspected myocarditis should include: History/physical examination Electrocardiogram (ECG) Cardiac biomarkers Chest radiograph. Brain natriuretic peptide (BNP) An echocardiogram. Cardiovascular magnetic resonance (CMR) imaging may provide supportive evidence of myocarditis. In selected patients cardiac catheterization may aid determination of hemodynamic status. Coronary angiography in selected patients with clinical findings of acute coronary syndrome. Potential indications for endomyocardial biopsy (EMB)

Testing Laboratory studies of myocarditis may include: CBC Diagnostic work up Testing Laboratory studies of myocarditis may include: CBC ESR/C-reactive protein Rheumatologic screening Cardiac enzyme (creatine kinase or cardiac troponins) Serum viral antibody titers Viral genome testing in endomyocardial biopsy Electrocardiography Imaging studies Echocardiography: To exclude causes of heart failure ( amyloidosis or valvular or congenital) Antimyosin scintigraphy: To identify myocardial inflammation Cardiac angiography: To rule out IHD Gadolinium-enhanced MRI: To assess extent of inflammation and cellular edema; nonspecific

Sequential chest radiographs in myocarditis PA view sequential chest radiographs in a young man with acute myocarditis (left). Cardiomegaly and pulmonary congestion are apparent. Three months later, the lungs have cleared but the patient has developed dilated cardiomyopathy with persistent cardiomegaly.

Cardiovascular magnetic resonance images of coxsackievirus-induced myocarditis Cardiovascular magnetic resonance images of a 58-year-old woman with coxsackievirus-induced myocarditis and ventricular tachycardia. Late gadolinium enhancement is seen in a basal to mid anterior and anterolateral distribution (arrows). Note the epicardial to transmural distribution of the enhancement, which is more consistent with myocarditis than myocardial infarction.

Causes: Immunologic: Drugs: Ethanol, Anthracyclines Chemotherapy Antipsychotics, e.g. clozapine Mephedrone Physical agents Electric shock Hyperpyrexia, and radiation Heavy metals (copper or iron) Toxins: (arsenic, toxic shock syndrome, carbon monoxide, or snake venom) Immunologic: Acetazolamide Heart Transplant Rejection Autoantigens : Scleroderma Systemic lupus erythematosus Sarcoidosis Churg-Strauss syndrome Wegener's granulomatosis, Kawasaki disease

Diagnosis: Usually presumptive Diagnosis: Usually presumptive. Because many cases are not clinically obvious, a high degree of suspicion is required. Acute rheumatic fever: Usually associated signs, such as chorea, erythema marginatum, polyarthralgia. Hypersensitive/eosinophilic myocarditis: Pruritic maculopapular rash and history of using drug Peripartum cardiomyopathy - Heart failure developing in the last month of pregnancy or within 5 months following delivery Myocarditis usually present with acute heart failure and, in those with pericarditis, with pericardial friction rub. Specific findings in special cases are: Sarcoid myocarditis: Lymphadenopathy, also with arrhythmias, sarcoid involvement in other organs (up to 70%)

Procedures Endomyocardial biopsy is the standard tool for diagnosing myocarditis. Routine endomyocardial biopsy for diagnosis of myocarditis rarely is helpful clinically. Histologic diagnosis seldom has an impact on therapeutic strategies, unless giant cell myocarditis is suspected

Management In improving cardiac hemodynamics in heart failure, as well as providing supportive therapy, with the hope of prolonging survival. Vasodilators : Nitroglycerin Sodium nitroprusside. ACEI (Enalapril) Diuretics (Furosemide) Anticoagulation may be advisable as a preventive measure Antiarrhythmics can be used cautiously, although most antiarrhythmic drugs have negative inotropic effects that may aggravate heart failure Inotropic drugs (dobutamine, milrinone) may be necessary for severe decompensation, they are highly arrhythmogenic

Non-pharmacotherapy Surgical option Surgical intervention in Supportive care in patients with myocarditis includes: Hemodynamic and cardiac monitoring Administration of supplemental oxygen Fluid management Surgical option Surgical intervention in myocarditis may include: Temporary trans-venous pacing for complete heart block Cardiac transplantation Extreme cases: Ventricular assist device or percutaneous circulatory support Left ventricular assistive devices (LVADs) Extracorporeal membrane oxygenation

THANK YOU FOR YOUR ATTENTION