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. WHO/ISFC definition specifies diagnosis by established histological (Dallas criteria), immunological, and immuno-histochemical criteria though many patients with clinical manifestations of myocarditis do not undergo endomyocardial biopsy so a definitive diagnosis is not established. 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 Myocarditis usually 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 infarction both symptomatically and on the electrocardiogram, 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. 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 .  An echocardiogram to evaluate regional and global ventricular function. Cardiovascular magnetic resonance (CMR) imaging may provide supportive evidence of myocarditis. In selected patients with suspected myocarditis, cardiac catheterization may aid determination of hemodynamic status. Coronary angiography is indicated in selected patients with clinical findings suggestive of acute coronary syndrome. Potential indications for endomyocardial biopsy (EMB) and other testing are reviewed.

Diagnostic work up Testing Laboratory studies use to evaluate suspected 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 other causes of heart failure ( amyloidosis or valvular or congenital causes) 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: A large number of causes of myocarditis have been identified, but often a cause cannot be found. Worldwide, however, the most common cause is Chagas' disease Drugs: Ethanol, Anthracyclines chemotherapy, and 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 amitriptyline Heart Transplant Rejection Autoantigens (scleroderma, systemic lupus erythematosus, sarcoidosis, systemic vasculitis such as Churg-Strauss syndrome, and Wegener's granulomatosis, Kawasaki disease)

Infection Viral (adenovirus, parvovirus B19, coxsackie virus, HIV, enterovirus, rubella virus, polio virus, cytomegalovirus, human herpesvirus 6 and possibly hepatitis C) Bacterial (Brucella, Corynebacterium diphtheriae, gonococcus, Haemophilus influenzae, Actinomyces, Tropheryma whipplei, Vibrio cholerae, Borrelia burgdorferi, leptospirosis, and Rickettsia) Fungal (Aspergillus) Parasitic (ascaris, Echinococcus granulosus, Paragonimus westermani, schistosoma, Taenia solium, Trichinella spiralis, visceral larva migrans, and Wuchereria bancrofti) Protozoan (Trypanosoma cruzi causing Chagas diseasea nd Toxoplasma gondii Bacterial myocarditis is rare in patients without immunodeficiency.

Diagnosis: The diagnosis of myocarditis is usually presumptive Diagnosis: The diagnosis of myocarditis is 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, subcutaneous nodules 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%)

Diuretics (Furosemide) 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

Nonpharmacotherapy Surgical option Surgical intervention in Supportive care in patients with myocarditis includes the following: Hemodynamic and cardiac monitoring Administration of supplemental oxygen Fluid management Surgical option Surgical intervention in myocarditis may include the following: Temporary transvenous pacing for complete heart block Cardiac transplantation Extreme cases: Ventricular assist device or percutaneous circulatory support left ventricular assistive devices (LVADs) and extracorporeal membrane oxygenation

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