Myocarditis medical therapy: Difference between revisions
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__NOTOC__ | __NOTOC__ | ||
{{Myocarditis}} | {{Myocarditis}} | ||
{{CMG}} | {{CMG}} {{AE}} [[Varun Kumar|Varun Kumar, M.B.B.S.]]; {{Maliha}}{{Homa}} | ||
==Overview== | ==Overview== | ||
[[Symptomatic]] [[Therapy|treatment]] is the mainstay of [[therapy]] for [[patients]] with [[viral myocarditis]]. Supportive [[therapy]] includes [[diuretic]]s and [[inotrope]]s for [[left ventricular failure]]. [[ACE inhibitor]] [[therapy]] may aid in left [[ventricular remodeling]]. Among patients with [[fulminant myocarditis]], placement of either an [[intra-aortic balloon pump]] or a [[left ventricular assist device]] may be necessary as bridge to [[recovery]]. Administration of [[antimicrobial]] [[therapy]] is recommended for [[bacterial myocarditis]]. [[Immunosuppressive therapy]] may be effective in the management of [[giant cell myocarditis]], [[autoimmune myocarditis]], and [[eosinophilic myocarditis]]. In [[patients]] with [[arrythmias]], [[Therapy|treatment]] should be initiated only if [[arrhythmias]] are [[symptomatic]] or sustained. [[Myocarditis]] [[patients]] presenting with [[Electrical conduction system of the heart|conduction]] abnormalities, particularly [[Mobitz II|Mobitz type II]] and [[complete heart block]] require temporary [[pacemaker]] usually during the [[acute]] phase. | |||
==Medical Therapy== | ==Medical Therapy== | ||
===Lymphocytic Myocarditis=== | ===Lymphocytic/Viral Myocarditis=== | ||
* | * The mainstay of [[therapy]] for [[viral myocarditis]] is supportive care and [[standard]] management of [[CHF]].<ref name="pmid2855719">{{cite journal| author=Kishimoto C, Crumpacker CS, Abelmann WH| title=Prevention of murine coxsackie B3 viral myocarditis and associated lymphoid organ atrophy with recombinant human leucocyte interferon alpha A/D. | journal=Cardiovasc Res | year= 1988 | volume= 22 | issue= 10 | pages= 732-8 | pmid=2855719 | doi= | pmc= | url= }} </ref><ref name="pmid9529271">{{cite journal| author=Yamamoto N, Shibamori M, Ogura M, Seko Y, Kikuchi M| title=Effects of intranasal administration of recombinant murine interferon-gamma on murine acute myocarditis caused by encephalomyocarditis virus. | journal=Circulation | year= 1998 | volume= 97 | issue= 10 | pages= 1017-23 | pmid=9529271 | doi= | pmc= | url= }} </ref><ref name="pmid2775346">{{cite journal| author=Ray CG, Icenogle TB, Minnich LL, Copeland JG, Grogan TM| title=The use of intravenous ribavirin to treat influenza virus-associated acute myocarditis. | journal=J Infect Dis | year= 1989 | volume= 159 | issue= 5 | pages= 829-36 | pmid=2775346 | doi= | pmc= | url= }} </ref><ref name="pmid12771005">{{cite journal| author=Kühl U, Pauschinger M, Schwimmbeck PL, Seeberg B, Lober C, Noutsias M et al.| title=Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. | journal=Circulation | year= 2003 | volume= 107 | issue= 22 | pages= 2793-8 | pmid=12771005 | doi=10.1161/01.CIR.0000072766.67150.51 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12771005 }} </ref><ref name="pmid11435335">{{cite journal| author=Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, Glanowska G, Wilczewski P, Niklewski T et al.| title=Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. | journal=Circulation | year= 2001 | volume= 104 | issue= 1 | pages= 39-45 | pmid=11435335 | doi= | pmc= | url= }} </ref><ref name="pmid7596370">{{cite journal| author=Mason JW, O'Connell JB, Herskowitz A, Rose NR, McManus BM, Billingham ME et al.| title=A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. | journal=N Engl J Med | year= 1995 | volume= 333 | issue= 5 | pages= 269-75 | pmid=7596370 | doi=10.1056/NEJM199508033330501 | pmc= | url= }} </ref><ref name="pmid11435335">{{cite journal| author=Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, Glanowska G, Wilczewski P, Niklewski T et al.| title=Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. | journal=Circulation | year= 2001 | volume= 104 | issue= 1 | pages= 39-45 | pmid=11435335 | doi= | pmc= | url= }} </ref><ref name="pmid19556262">{{cite journal| author=Frustaci A, Russo MA, Chimenti C| title=Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. | journal=Eur Heart J | year= 2009 | volume= 30 | issue= 16 | pages= 1995-2002 | pmid=19556262 | doi=10.1093/eurheartj/ehp249 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19556262 }} </ref> <ref name="pmid20610207"></ref><ref name="pmid11342473">{{cite journal| author=McNamara DM, Holubkov R, Starling RC, Dec GW, Loh E, Torre-Amione G et al.| title=Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. | journal=Circulation | year= 2001 | volume= 103 | issue= 18 | pages= 2254-9 | pmid=11342473 | doi= | pmc= | url= }} </ref><ref name="pmid12381097">{{cite journal| author=Shioji K, Matsuura Y, Iwase T, Kitaguchi S, Nakamura H, Yodoi J et al.| title=Successful immunoglobulin treatment for fulminant myocarditis and serial analysis of serum thioredoxin: a case report. | journal=Circ J | year= 2002 | volume= 66 | issue= 10 | pages= 977-80 | pmid=12381097 | doi= | pmc= | url= }} </ref><ref name="pmid9856608">{{cite journal| author=Takeda Y, Yasuda S, Miyazaki S, Daikoku S, Nakatani S, Nonogi H| title=High-dose immunoglobulin G therapy for fulminant myocarditis. | journal=Jpn Circ J | year= 1998 | volume= 62 | issue= 11 | pages= 871-2 | pmid=9856608 | doi= | pmc= | url= }} </ref><ref name="pmid9184576">{{cite journal| author=McNamara DM, Rosenblum WD, Janosko KM, Trost MK, Villaneuva FS, Demetris AJ et al.| title=Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. | journal=Circulation | year= 1997 | volume= 95 | issue= 11 | pages= 2476-8 | pmid=9184576 | doi= | pmc= | url= }} </ref><ref name="pmid15301907">{{cite journal| author=Kim HS, Sohn S, Park JY, Seo JW| title=Fulminant myocarditis successfully treated with high-dose immunoglobulin. | journal=Int J Cardiol | year= 2004 | volume= 96 | issue= 3 | pages= 485-6 | pmid=15301907 | doi=10.1016/j.ijcard.2003.05.037 | pmc= |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15301907 }} </ref><ref name="pmid8281654">{{cite journal| author=Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL, Takahashi M et al.| title=Gamma-globulin treatment of acute myocarditis in the pediatric population. | journal=Circulation | year= 1994 | volume= 89 | issue= 1 | pages= 252-7 | pmid=8281654 | doi= | pmc= | url= }} </ref><ref name="pmid14583071">{{cite journal| author=Meune C, Spaulding C, Mahé I, Lebon P, Bergmann JF| title=Risks versus benefits of NSAIDs including aspirin in myocarditis: a review of the evidence from animal studies. | journal=Drug Saf | year= 2003 | volume= 26 | issue= 13 | pages= 975-81 | pmid=14583071 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14583071 }} </ref><ref name="pmid18221804">{{cite journal| author=Imazio M, Trinchero R| title=Myopericarditis: Etiology, management, and prognosis. | journal=Int J Cardiol | year= 2008 | volume= 127 | issue= 1 | pages= 17-26 | pmid=18221804 | doi=10.1016/j.ijcard.2007.10.053 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18221804 }} </ref><ref name="pmid1695914">{{cite journal| author=Khatib R, Reyes MP, Smith F, Khatib G, Rezkalla S| title=Enhancement of coxsackievirus B4 virulence by indomethacin. | journal=J Lab Clin Med | year= 1990 | volume= 116 | issue= 1 | pages= 116-20 | pmid=1695914 | doi= | pmc= | url= }} </ref><ref name="pmid2420912">{{cite journal| author=Rezkalla S, Khatib G, Khatib R| title=Coxsackievirus B3 murine myocarditis: deleterious effects of nonsteroidal anti-inflammatory agents. | journal=J Lab Clin Med | year= 1986 | volume= 107 | issue= 4 | pages= 393-5 | pmid=2420912 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=2420912 }} </ref> | ||
*The [[Heart Failure]] Society of America recommends against the routine use of [[immunosuppressive agents]] in [[Therapy|treatment]] of [[myocarditis]]. | |||
* | *[[Animal studies]] have demonstrated better [[Outcome|outcomes]] in [[viral myocarditis]] with the use of [[antiviral]] agents and [[interferon]] early in the course of [[infection]] prior to [[inoculation]]. The use of [[Antiviral Therapy|antiviral therapy]] may be limited since [[patients]] with [[viral myocarditis]] are usually not seen in the early stages. However, it may be used in [[acute]], [[fulminant myocarditis]] and in institutional [[outbreaks]]. In a series, 6 months of [[Interferon-beta|beta interferon]] in [[patients]] with myocarditis [[secondary]] to [[enterovirus]] or [[adenovirus]] [[infection]] resulted in the elimination of [[viral]] [[genomes]] in all [[patients]] and improvement of [[LV function]] in 68% of the [[patients]]. | ||
*[[ | *[[Immunotherapy]] was thought to be a [[Therapy|treatment]] option for [[myocarditis]] as they suppress the activity of [[Immunological|immunologic]] agents mediating [[myocardial inflammation]]. There is no significant change in [[mortality]] rate with [[immunotherapy]]. However, improvement in [[LV function]] is seen in [[patients]] with [[chronic inflammatory]] [[Dilated cardiomyopathy|dilated cardiomyopathy.]] | ||
*[[ | *[[Intravenous immunoglobulin]] ([[IVIG]]) is known to have both [[antiviral]] and [[Immunology|immunologic]] properties. Therefore, it can be used in both [[viral]] and [[autoimmune]] types of myocarditis. | ||
* Temporary [[pacemaker]] [[insertion]] is [[Indication (medicine)|indicated]] in [[patients]] with [[symptomatic]] [[bradycardia]] and/or [[heart block]] during the acute phase of [[myocarditis]]. | |||
*[[ICD]] [[implantation]] is not [[Indication (medicine)|indicated]] during the [[Acute (medicine)|acute]] phase of [[myocarditis]]. | |||
*[[Antiarrhythmic therapy]] can be useful in [[patients]] with [[symptomatic]] [[Non-sustained ventricular tachycardia|NSVT]] or [[sustained VT]] during the [[acute]] phase of [[myocarditis]]. | |||
===Giant Cell Myocarditis=== | ===Giant Cell Myocarditis=== | ||
[[Giant cell myocarditis]] is a rare form of myocarditis and is generally associated with a poor prognosis | *[[Giant cell myocarditis]] is a [[rare]] form of myocarditis and is generally associated with a poor [[prognosis]]. In a non-[[randomized]] series, 22 [[patients]] with [[giant cell myocarditis]] who were treated with [[corticosteroid]]s and [[cyclosporine]]/[[azathioprine]], [[Survival rate|survived]] for an [[average]] of 12.3 months. In contrast, those [[patients]] who were not treated with [[immunosuppressant]]s survived for an average of 3 months. Use of [[immunosuppressive therapy]] was further strengthened by a [[prospective]], [[Multicenter trial|multicenter]] [[observational study]] which reported an improved [[Survival rate|survival]] of 6 years among [[patients]] receiving high dose [[steroid]]s and [[cyclosporine]] with or without [[muromonab-CD3]]. Of the 11 [[patients]] studied, two [[patients]] underwent [[cardiac transplantation]] early in the course of the study and one [[patient]] died. The [[Study design|study]] also reported that [[withdrawal]] of [[immunosuppression]] was associated with a [[Recurrence plot|recurrence]] of [[giant cell myocarditis]] in some [[patients]] which in some cases was [[fatal]]. [[Immunosuppressive therapy]] directed at [[T-cells]] may be beneficial as [[T-cell]]s mediate [[myocardial inflammation]].<ref name="pmid10593350">{{cite journal| author=Menghini VV, Savcenko V, Olson LJ, Tazelaar HD, Dec GW, Kao A et al.| title=Combined immunosuppression for the treatment of idiopathic giant cell myocarditis. | journal=Mayo Clin Proc | year= 1999 | volume= 74 | issue= 12 | pages= 1221-6 | pmid=10593350 | doi= | pmc= | url= }} </ref><ref name="pmid9197214">{{cite journal| author=Cooper LT, Berry GJ, Shabetai R| title=Idiopathic giant-cell myocarditis--natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators. | journal=N Engl J Med | year= 1997 | volume= 336 | issue= 26 | pages= 1860-6 | pmid=9197214 | doi=10.1056/NEJM199706263362603 | pmc= | url= }} </ref><ref name="pmid19026310">{{cite journal| author=Cooper LT, Hare JM, Tazelaar HD, Edwards WD, Starling RC, Deng MC et al.| title=Usefulness of immunosuppression for giant cell myocarditis. | journal=Am J Cardiol | year= 2008 | volume= 102 | issue= 11 | pages= 1535-9 | pmid=19026310 | doi=10.1016/j.amjcard.2008.07.041 | pmc=PMC2613862 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19026310 }} </ref> | ||
[[Cardiac transplantation]] is sometimes required to treat refractory [[giant cell myocarditis]]. However, the condition can recur in post-transplant patients. Recurrence of biopsy proven giant cell myocarditis between 3 weeks to 9 years was observed in 9 of 34 [[cardiac transplant]] patients | *[[Cardiac transplantation]] is sometimes required to treat [[refractory]] [[giant cell myocarditis]]. However, the condition can recur in post-[[Transplantation|transplant]] [[patients]]. [[Recurrence plot|Recurrence]] of [[biopsy]] proven [[giant cell myocarditis]] between 3 weeks to 9 years was observed in 9 of 34 [[cardiac transplant]] [[patients]]. | ||
===Eosinophilic Myocarditis=== | ===Eosinophilic Myocarditis=== | ||
Eosinophilic myocarditis | |||
* [[Eosinophilic myocarditis]] can occur [[secondary]] to [[hypersensitivity]] to [[drugs]], [[helminthiasis|parasitic infestation]], or [[hypereosinophilic syndrome]]. The [[eosinophils]] which [[Infiltration (medical)|infiltrate]] the [[myocardium]], [[degenerate]] leading to [[extracellular]] release of [[Eosinophil granulocyte|eosinophil granules]] which can contribute to death of [[myocytes]]. Usage of [[immunosuppressant]]s such as high dose [[steroids]] (after excluding [[infections]]) and removal of offending [[drug]] (in [[drug]] induced [[hypersensitivity]]) is known to be beneficial in treatment of [[eosinophilic myocarditis]]. [[Immunosuppressive therapy]] may be tapered gradually after one year if normal [[Cardiac function curve|cardiac function]] and [[cardiac enzymes]] levels are restored.<ref name="pmid16186853">{{cite journal| author=Cooper LT, Zehr KJ| title=Biventricular assist device placement and immunosuppression as therapy for necrotizing eosinophilic myocarditis. | journal=Nat Clin Pract Cardiovasc Med | year= 2005 | volume= 2 | issue= 10 | pages= 544-8 | pmid=16186853 | doi=10.1038/ncpcardio0322 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16186853 }} </ref><ref name="pmid15343520">{{cite journal| author=Corradi D, Vaglio A, Maestri R, Legname V, Leonardi G, Bartoloni G et al.| title=Eosinophilic myocarditis in a patient with idiopathic hypereosinophilic syndrome: insights into mechanisms of myocardial cell death. | journal=Hum Pathol | year= 2004 | volume= 35 | issue= 9 | pages= 1160-3 | pmid=15343520 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15343520 }} </ref> | |||
===Autoimmune Myocarditis=== | ===Autoimmune Myocarditis=== | ||
[[ | |||
* Myocarditis can [[Development|develop]] in [[autoimmune diseases]] such as [[celiac disease]] and [[sarcoidosis]]. Treatment with [[gluten-free diet]] and [[immunosuppressants]] in [[celiac disease]] improves [[Cardiac function curve|cardiac function]]. [[Corticosteroids]] are found to be beneficial in [[patients]] with [[sarcoidosis]] related myocarditis, particularly during initial stages of the [[disease]] before [[development]] of extensive [[fibrosis]] of [[myocardium]].<ref name="pmid19081391">{{cite journal| author=Kim JS, Judson MA, Donnino R, Gold M, Cooper LT, Prystowsky EN et al.| title=Cardiac sarcoidosis. | journal=Am Heart J | year= 2009 | volume= 157 | issue= 1 | pages= 9-21 | pmid=19081391 | doi=10.1016/j.ahj.2008.09.009 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19081391 }} </ref><ref name="pmid12045166">{{cite journal| author=Frustaci A, Cuoco L, Chimenti C, Pieroni M, Fioravanti G, Gentiloni N et al.| title=Celiac disease associated with autoimmune myocarditis. | journal=Circulation | year= 2002 | volume= 105 | issue= 22 | pages= 2611-8 | pmid=12045166 | doi= | pmc= | url= }} </ref> | |||
==Treatment of Heart Failure== | ==Treatment of Heart Failure== | ||
''For more information on heart failure treatment, click [[Congestive heart failure#Treatment|here]]'' | * As [[heart failure]] in [[patients]] with myocarditis has poor [[prognosis]], it is important to [[Prevention|prevent]] progression or worsening of [[cardiac dysfunction]]. These [[patients]] should be treated with [[low sodium]] intake, [[diuretics]] and [[ACE inhibitors]]. Few [[animal studies]] report that [[mortality rate]] is high with [[digoxin]] in comparison to [[beta blocker]] in [[viral myocarditis]]. Studies have also demonstrated that [[Usage analysis|usage]] of [[carvedilol]] during [[recovery]] phase decreases [[expression]] of several histochemicals and subsequently [[myocardial inflammation]] and there by improving [[Survival analysis|survival]]. The [[beta-blockers]] should however be avoided in the [[Acute (medicine)|acutely]] [[Decompensated heart failure|decompensating phase]] of [[illness]]. If [[heart failure]] or [[cardiogenic shock]] does not respond to [[medical]] [[therapy]], [[circulatory]] support with an [[intraaortic balloon pump]] should be considered which could be used in [[fulminant myocarditis]] as a bridge to spontaneous [[recovery]]. [[Implantation]] of [[ICD]] in severe [[heart failure]] should be deferred for several months to allow sufficient time for [[recovery]] of [[ventricular function]]. Following the initial [[circulatory]] [[Stabilization (medicine)|stabilization]], further [[Therapy|treatment]] of [[cardiac dysfunction]] should follow current ACC/[[AHA]] recommendations. [[Anticoagulation]] may be considered in [[patients]] with severe/[[chronic heart failure]] as they are at risk for developing [[thromboembolic]] [[complications]].<ref name="pmid19324966">{{cite journal| author=Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG et al.| title=2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. | journal=Circulation | year= 2009 | volume= 119 | issue= 14 | pages= e391-479 | pmid=19324966 | doi=10.1161/CIRCULATIONAHA.109.192065 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19324966 }} </ref><ref name="pmid16442915">{{cite journal| author=Magnani JW, Danik HJ, Dec GW, DiSalvo TG| title=Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors. | journal=Am Heart J | year= 2006 | volume= 151 | issue= 2 | pages= 463-70 | pmid=16442915 | doi=10.1016/j.ahj.2005.03.037 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16442915 }} </ref><ref name="pmid1674900">{{cite journal| author=Tominaga M, Matsumori A, Okada I, Yamada T, Kawai C| title=Beta-blocker treatment of dilated cardiomyopathy. Beneficial effect of carteolol in mice. | journal=Circulation | year= 1991 | volume= 83 | issue= 6 | pages= 2021-8 | pmid=1674900 | doi= | pmc= | url= }} </ref><ref name="pmid10614837">{{cite journal| author=Matsumori A, Igata H, Ono K, Iwasaki A, Miyamoto T, Nishio R et al.| title=High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity. | journal=Jpn Circ J | year= 1999 | volume= 63 | issue= 12 | pages= 934-40 | pmid=10614837 | doi= | pmc= | url= }} </ref><ref name="pmid15923319">{{cite journal| author=Wang JF, Meissner A, Malek S, Chen Y, Ke Q, Zhang J et al.| title=Propranolol ameliorates and epinephrine exacerbates progression of acute and chronic viral myocarditis. | journal=Am J Physiol Heart Circ Physiol | year= 2005 | volume= 289 | issue= 4 | pages= H1577-83 | pmid=15923319 | doi=10.1152/ajpheart.00258.2005 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15923319 }} </ref><ref name="pmid2000764">{{cite journal| author=Rockman HA, Adamson RM, Dembitsky WP, Bonar JW, Jaski BE| title=Acute fulminant myocarditis: long-term follow-up after circulatory support with left ventricular assist device. | journal=Am Heart J | year= 1991 | volume= 121 | issue= 3 Pt 1 | pages= 922-6 | pmid=2000764 | doi= | pmc= | url= }} </ref><ref name="pmid10226900">{{cite journal| author=Chen JM, Spanier TB, Gonzalez JJ, Marelli D, Flannery MA, Tector KA et al.| title=Improved survival in patients with acute myocarditis using external pulsatile mechanical ventricular assistance. | journal=J Heart Lung Transplant | year= 1999 | volume= 18 | issue= 4 | pages= 351-7 | pmid=10226900 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10226900 }} </ref> | ||
* ''For more information on heart failure treatment, click [[Congestive heart failure#Treatment|here]].'' | |||
==Treatment of Arrhythmia== | ==Treatment of Arrhythmia== | ||
[[Supraventricular tachycardia]](SVT) can aggravate heart failure. Symptomatic and sustained SVT should be immediately converted electrically. While, patients with recurrent sustained SVT should be treated with [[antiarrhythmic]]s and rate controlling agents. Implantation of [[ICD]] should be considered in patients with recurrent ventricular arrhythmia refractory to medical therapy. Myocarditis patients presenting with conduction abnormalities, particularly [[Mobitz II|Mobitz type II]] and [[complete heart block]] require temporary pacemaker usually during the acute phase. Implantation of | * [[Arrhythmias]] or [[Conduction disorders|conduction]] abnormalities can occur in [[patients]] with [[myocarditis]]. Treatment should be initiated only if [[arrhythmias]] are [[symptomatic]] or sustained. Caution should be observed while using [[antiarrhythmic]]s as majority of these agents have negative [[inotropic]] property which may worsen [[heart failure]]. Regular [[Monitoring competence|monitoring]] with [[ECG]] is important as it enables early [[Detection and Diagnosis in Adulthood|detection]] and treatment of [[asymptomatic]] yet life threatening [[arrhythmias]]. | ||
* [[Supraventricular tachycardia]] ([[SVT]]) can aggravate [[heart failure]]. [[Symptomatic]] and sustained [[SVT]] should be immediately converted electrically. While, [[patients]] with recurrent sustained [[SVT]] should be treated with [[antiarrhythmic]]s and [[Heart rate|rate]] controlling agents. [[Implantation]] of [[ICD]] should be considered in [[patients]] with recurrent [[Ventricular arrhythmias|ventricular arrhythmia]] refractory to [[medical]] [[therapy]]. [[Myocarditis]] [[patients]] presenting with [[Electrical conduction system of the heart|conduction]] abnormalities, particularly [[Mobitz II|Mobitz type II]] and [[complete heart block]] require temporary [[pacemaker]] usually during the [[acute]] phase. [[Implantation]] of [[permanent pacemaker]] or [[ICD]] may be necessary in few [[patients]].<ref name="pmid19357408">{{cite journal| author=Cooper LT| title=Myocarditis. | journal=N Engl J Med | year= 2009 | volume= 360 | issue= 15 | pages= 1526-38 | pmid=19357408 | doi=10.1056/NEJMra0800028 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19357408 }} </ref> | |||
==2006 ACC/AHA/ESC Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis<ref name="pmid16949478">{{cite journal| author=European Heart Rhythm Association. Heart Rhythm Society. Zipes DP, Camm AJ, Borggrefe M, Buxton AE et al.| title=ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 5 | pages= e247-346 | pmid=16949478 | doi=10.1016/j.jacc.2006.07.010 | pmc= | | ==2006 ACC/AHA/ESC Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis<ref name="pmid16949478">{{cite journal| author=European Heart Rhythm Association. Heart Rhythm Society. Zipes DP, Camm AJ, Borggrefe M, Buxton AE et al.| title=ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). | journal=J Am Coll Cardiol | year= 2006 | volume= 48 | issue= 5 | pages= e247-346 | pmid=16949478 | doi=10.1016/j.jacc.2006.07.010 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16949478 }} </ref>== | ||
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| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]] | | colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]] | ||
|- | |- | ||
| bgcolor="LightGreen"| <nowiki> | | bgcolor="LightGreen"| <nowiki></nowiki> '''1.''' Temporary [[pacemaker]] [[insertion]] is [[Indication (medicine)|indicated]] in [[patients]] with [[symptomatic]] [[bradycardia]] and/or [[heart block]] during the [[Acute (medicine)|acute]] phase of [[myocarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki></nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"| <nowiki> | | bgcolor="LightGreen"| <nowiki></nowiki> '''2.''' [[Acute]] [[aortic regurgitation]] associated with [[Ventricular tachycardia|VT]] should be treated [[Surgery|surgically]] unless otherwise [[contraindicated]].''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])<nowiki></nowiki> | ||
|- | |- | ||
| bgcolor="LightGreen"| <nowiki> | | bgcolor="LightGreen"| <nowiki></nowiki> '''3.''' [[Endocarditis|Acute endocarditis]] [[Complication (medicine)|complicated]] by [[aortic]] or annular [[abscess]] and [[AV block]] should be treated [[Surgery|surgically]] unless otherwise [[contraindicated]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki></nowiki> | ||
|} | |} | ||
| Line 55: | Line 61: | ||
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]] | |colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class III]] | ||
|- | |- | ||
|bgcolor="LightCoral"|<nowiki> | |bgcolor="LightCoral"|<nowiki></nowiki>'''1.'''[[ICD]] [[implantation]] is not [[Indication (medicine)|indicated]] during the [[Acute (medicine)|acute]] phase of [[myocarditis]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki></nowiki> | ||
|} | |} | ||
| Line 62: | Line 68: | ||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]] | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki> | |bgcolor="LemonChiffon"|<nowiki></nowiki>'''1.''' [[ICD]] [[implantation]] can be beneficial in [[patients]] with life-threatening [[ventricular arrhythmias]] who are ''not'' in the [[acute]] phase of [[myocarditis]], as [[Indication (medicine)|indicated]] in the ACC/[[AHA]]/NASPE 2002 [[Guideline (medical)|guideline]] update for [[implantation]] of [[cardiac]] [[Pacemaker|pacemakers]] and [[antiarrhythmic]] devices who are receiving [[Chronic (medical)|chronic]] optimal [[Therapy|medical therapy]], and who have reasonable [[expectation]] of [[Survival rate|survival]] with a good functional status for more than 1 year. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])<ref name="pmid12379588">{{cite journal| author=Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA et al.| title=ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines). | journal=Circulation | year= 2002 | volume= 106 | issue= 16 | pages= 2145-61 | pmid=12379588 | doi= | pmc= | url= }} </ref><nowiki></nowiki>'' | ||
|- | |- | ||
|bgcolor="LemonChiffon"|<nowiki> | |bgcolor="LemonChiffon"|<nowiki></nowiki> '''2.''' [[Antiarrhythmic therapy]] can be useful in [[patients]] with [[symptomatic]] [[Non-sustained ventricular tachycardia|NSVT]] or [[sustained VT]] during the [[Acute (medicine)|acute]] phase of myocarditis. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki></nowiki> | ||
|} | |||
==2013 ESC Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis<ref name="PrioriBlomström-Lundqvist2015">{{cite journal|last1=Priori|first1=Silvia G.|last2=Blomström-Lundqvist|first2=Carina|last3=Mazzanti|first3=Andrea|last4=Blom|first4=Nico|last5=Borggrefe|first5=Martin|last6=Camm|first6=John|last7=Elliott|first7=Perry Mark|last8=Fitzsimons|first8=Donna|last9=Hatala|first9=Robert|last10=Hindricks|first10=Gerhard|last11=Kirchhof|first11=Paulus|last12=Kjeldsen|first12=Keld|last13=Kuck|first13=Karl-Heinz|last14=Hernandez-Madrid|first14=Antonio|last15=Nikolaou|first15=Nikolaos|last16=Norekvål|first16=Tone M.|last17=Spaulding|first17=Christian|last18=Van Veldhuisen|first18=Dirk J.|title=2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death|journal=European Heart Journal|volume=36|issue=41|year=2015|pages=2793–2867|issn=0195-668X|doi=10.1093/eurheartj/ehv316}}</ref>== | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class I]] | |||
|- | |||
| bgcolor="LightGreen"| <nowiki></nowiki> '''1.''' It is recommended that [[patients]] with a life-threatening presentation of [[Sustained ventricular tachycardia|sustained ventricular tachyarrhythmias]] in the context of clinically suspected myocarditis are referred to specialized centers with the ability to perform [[hemodynamic]] monitoring, [[cardiac catheterization]] and [[endomyocardial biopsy]] and to use mechanical [[cardio]]-[[pulmonary]] assist devices and specialized [[arrhythmia]] [[Therapy|therapies]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="CaforioPankuweit2013">{{cite journal|last1=Caforio|first1=A. L. P.|last2=Pankuweit|first2=S.|last3=Arbustini|first3=E.|last4=Basso|first4=C.|last5=Gimeno-Blanes|first5=J.|last6=Felix|first6=S. B.|last7=Fu|first7=M.|last8=Helio|first8=T.|last9=Heymans|first9=S.|last10=Jahns|first10=R.|last11=Klingel|first11=K.|last12=Linhart|first12=A.|last13=Maisch|first13=B.|last14=McKenna|first14=W.|last15=Mogensen|first15=J.|last16=Pinto|first16=Y. M.|last17=Ristic|first17=A.|last18=Schultheiss|first18=H.-P.|last19=Seggewiss|first19=H.|last20=Tavazzi|first20=L.|last21=Thiene|first21=G.|last22=Yilmaz|first22=A.|last23=Charron|first23=P.|last24=Elliott|first24=P. M.|title=Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases|journal=European Heart Journal|volume=34|issue=33|year=2013|pages=2636–2648|issn=0195-668X|doi=10.1093/eurheartj/eht210}}</ref><ref>{{Cite journal | |||
| title = Guidelines for diagnosis and treatment of myocarditis (JCS 2009): digest version | |||
| journal = [[Circulation journal : official journal of the Japanese Circulation Society]] | |||
| volume = 75 | |||
| issue = 3 | |||
| pages = 734–743 | |||
| year = 2011 | |||
| month = | |||
| doi = 10.1253/circj.cj-88-0008 | |||
| pmid = 21304213 | |||
}}</ref><ref>{{Cite journal | |||
| author = [[Naoyoshi Aoyama]], [[Tohru Izumi]], [[Katsuhiko Hiramori]], [[Mitsuaki Isobe]], [[Masatoshi Kawana]], [[Michiaki Hiroe]], [[Hitoshi Hishida]], [[Yasushi Kitaura]] & [[Tsutomu Imaizumi]] | |||
| title = National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee) | |||
| journal = [[Circulation journal : official journal of the Japanese Circulation Society]] | |||
| volume = 66 | |||
| issue = 2 | |||
| pages = 133–144 | |||
| year = 2002 | |||
| month = February | |||
| doi = 10.1253/circj.66.133 | |||
| pmid = 11999637 | |||
}}</ref><ref name="LibermanAnderson2014">{{cite journal|last1=Liberman|first1=Leonardo|last2=Anderson|first2=Brett|last3=Silver|first3=Eric S.|last4=Singh|first4=Rakesh|last5=Richmond|first5=Marc E.|title=INCIDENCE AND CHARACTERISTICS OF ARRHYTHMIAS IN PEDIATRIC PATIENTS WITH MYOCARDITIS: A MULTICENTER STUDY|journal=Journal of the American College of Cardiology|volume=63|issue=12|year=2014|pages=A483|issn=07351097|doi=10.1016/S0735-1097(14)60483-6}}</ref><nowiki></nowiki> | |||
|- | |||
| bgcolor="LightGreen"| <nowiki></nowiki> '''2.''' [[Temporary cardiac pacing|Temporary pacemaker]] [[insertion]] is recommended in [[patients]] with [[bradycardia]] and/or [[heart block]] triggering VA during the [[acute]] phase of myocarditis/pancarditis.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])<ref name="CaforioPankuweit2013">{{cite journal|last1=Caforio|first1=A. L. P.|last2=Pankuweit|first2=S.|last3=Arbustini|first3=E.|last4=Basso|first4=C.|last5=Gimeno-Blanes|first5=J.|last6=Felix|first6=S. B.|last7=Fu|first7=M.|last8=Helio|first8=T.|last9=Heymans|first9=S.|last10=Jahns|first10=R.|last11=Klingel|first11=K.|last12=Linhart|first12=A.|last13=Maisch|first13=B.|last14=McKenna|first14=W.|last15=Mogensen|first15=J.|last16=Pinto|first16=Y. M.|last17=Ristic|first17=A.|last18=Schultheiss|first18=H.-P.|last19=Seggewiss|first19=H.|last20=Tavazzi|first20=L.|last21=Thiene|first21=G.|last22=Yilmaz|first22=A.|last23=Charron|first23=P.|last24=Elliott|first24=P. M.|title=Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases|journal=European Heart Journal|volume=34|issue=33|year=2013|pages=2636–2648|issn=0195-668X|doi=10.1093/eurheartj/eht210}}</ref><ref>{{Cite journal | |||
| title = Guidelines for diagnosis and treatment of myocarditis (JCS 2009): digest version | |||
| journal = [[Circulation journal : official journal of the Japanese Circulation Society]] | |||
| volume = 75 | |||
| issue = 3 | |||
| pages = 734–743 | |||
| year = 2011 | |||
| month = | |||
| doi = 10.1253/circj.cj-88-0008 | |||
| pmid = 21304213 | |||
}}</ref>''<nowiki></nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
|colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIa]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki>'''1.'''[[Anti-arrhythmic therapy]] should be considered in [[patients]] with [[symptomatic]] non-sustained or sustained [[Ventricular tachycardia|VT]] during the [[Acute (medicine)|acute]] phase of myocarditis.''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="CaforioPankuweit2013">{{cite journal|last1=Caforio|first1=A. L. P.|last2=Pankuweit|first2=S.|last3=Arbustini|first3=E.|last4=Basso|first4=C.|last5=Gimeno-Blanes|first5=J.|last6=Felix|first6=S. B.|last7=Fu|first7=M.|last8=Helio|first8=T.|last9=Heymans|first9=S.|last10=Jahns|first10=R.|last11=Klingel|first11=K.|last12=Linhart|first12=A.|last13=Maisch|first13=B.|last14=McKenna|first14=W.|last15=Mogensen|first15=J.|last16=Pinto|first16=Y. M.|last17=Ristic|first17=A.|last18=Schultheiss|first18=H.-P.|last19=Seggewiss|first19=H.|last20=Tavazzi|first20=L.|last21=Thiene|first21=G.|last22=Yilmaz|first22=A.|last23=Charron|first23=P.|last24=Elliott|first24=P. M.|title=Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases|journal=European Heart Journal|volume=34|issue=33|year=2013|pages=2636–2648|issn=0195-668X|doi=10.1093/eurheartj/eht210}}</ref><nowiki></nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki> '''2.''' The [[Implant (medicine)|implant]] of an [[ICD]] or [[pacemaker]] in [[patients]] with [[inflammatory]] [[heart]] [[diseases]] should be considered after [[resolution]] of the acute episode. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="CaforioPankuweit2013">{{cite journal|last1=Caforio|first1=A. L. P.|last2=Pankuweit|first2=S.|last3=Arbustini|first3=E.|last4=Basso|first4=C.|last5=Gimeno-Blanes|first5=J.|last6=Felix|first6=S. B.|last7=Fu|first7=M.|last8=Helio|first8=T.|last9=Heymans|first9=S.|last10=Jahns|first10=R.|last11=Klingel|first11=K.|last12=Linhart|first12=A.|last13=Maisch|first13=B.|last14=McKenna|first14=W.|last15=Mogensen|first15=J.|last16=Pinto|first16=Y. M.|last17=Ristic|first17=A.|last18=Schultheiss|first18=H.-P.|last19=Seggewiss|first19=H.|last20=Tavazzi|first20=L.|last21=Thiene|first21=G.|last22=Yilmaz|first22=A.|last23=Charron|first23=P.|last24=Elliott|first24=P. M.|title=Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases|journal=European Heart Journal|volume=34|issue=33|year=2013|pages=2636–2648|issn=0195-668X|doi=10.1093/eurheartj/eht210}}</ref><ref name="KindermannKindermann2008">{{cite journal|last1=Kindermann|first1=Ingrid|last2=Kindermann|first2=Michael|last3=Kandolf|first3=Reinhard|last4=Klingel|first4=Karin|last5=Bültmann|first5=Burkhard|last6=Müller|first6=Thomas|last7=Lindinger|first7=Angelika|last8=Böhm|first8=Michael|title=Predictors of Outcome in Patients With Suspected Myocarditis|journal=Circulation|volume=118|issue=6|year=2008|pages=639–648|issn=0009-7322|doi=10.1161/CIRCULATIONAHA.108.769489}}</ref><nowiki></nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki> '''3.''' In [[patients]] with [[hemodynamically]] compromising sustained [[Ventricular tachycardia|VT]] occurring after the [[resolution]] of [[acute]] episodes, an [[ICD]] [[implantation]] should be considered if the [[patient]] is expected to survive >1 year with good functional status. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<nowiki></nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki> '''4.''' A wearable [[Defibrillation|defibrillator]] should be considered for bridging until full [[recovery]] or [[ICD implantation]] in [[patients]] after [[inflammatory]] [[heart diseases]] with [[residual]] severe [[LV dysfunction]] and/or [[ventricular]] [[electrical]] [[instability]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="ProchnauSurber2009">{{cite journal|last1=Prochnau|first1=Dirk|last2=Surber|first2=Ralf|last3=Kuehnert|first3=Helmut|last4=Heinke|first4=Matthias|last5=Klein|first5=Helmut U.|last6=Figulla|first6=Hans R.|title=Successful use of a wearable cardioverter-defibrillator in myocarditis with normal ejection fraction|journal=Clinical Research in Cardiology|volume=99|issue=2|year=2009|pages=129–131|issn=1861-0684|doi=10.1007/s00392-009-0093-2}}</ref><ref name="Chung2014">{{cite journal|last1=Chung|first1=Mina K.|title=The Role of the Wearable Cardioverter Defibrillator in Clinical Practice|journal=Cardiology Clinics|volume=32|issue=2|year=2014|pages=253–270|issn=07338651|doi=10.1016/j.ccl.2013.11.002}}</ref><nowiki></nowiki> | |||
|} | |||
{|class="wikitable" | |||
|- | |||
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA Guidelines Classification Scheme#Classification of Recommendations|Class IIb]] | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki>'''1.''' [[ICD implantation]] may be considered earlier in [[patients]] with [[giant cell myocarditis]] or [[sarcoidosis]] who had [[hemodynamically]] compromising sustained [[VA]] or aborted [[cardiac arrest]], due to adverse [[prognosis]] of these [[conditions]], if [[Survival rate|survival]] >1 year with good functional status can be expected. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="KandolinLehtonen2013">{{cite journal|last1=Kandolin|first1=Riina|last2=Lehtonen|first2=Jukka|last3=Salmenkivi|first3=Kaisa|last4=Räisänen-Sokolowski|first4=Anne|last5=Lommi|first5=Jyri|last6=Kupari|first6=Markku|title=Diagnosis, Treatment, and Outcome of Giant-Cell Myocarditis in the Era of Combined Immunosuppression|journal=Circulation: Heart Failure|volume=6|issue=1|year=2013|pages=15–22|issn=1941-3289|doi=10.1161/CIRCHEARTFAILURE.112.969261}}</ref><nowiki></nowiki> | |||
|- | |||
|bgcolor="LemonChiffon"|<nowiki></nowiki> '''2.''' Demonstration of persistent [[myocardial]] [[inflammatory]] [[Infiltration (medical)|infiltrates]] by immunohistological [[evidence]] and/or [[abnormal]] localized [[fibrosis]] by [[CMR]] after [[acute myocarditis]] may be considered as an additional [[indicator]] of increased risk of [[SCD]] in [[inflammatory]] [[Heart diseases|heart disease]]. ''([[ACC AHA Guidelines Classification Scheme#Level of Evidence|Level of Evidence: C]])''<ref name="SchummGreulich2014">{{cite journal|last1=Schumm|first1=Julia|last2=Greulich|first2=Simon|last3=Wagner|first3=Anja|last4=Grün|first4=Stefan|last5=Ong|first5=Peter|last6=Bentz|first6=Kerstin|last7=Klingel|first7=Karin|last8=Kandolf|first8=Reinhard|last9=Bruder|first9=Oliver|last10=Schneider|first10=Steffen|last11=Sechtem|first11=Udo|last12=Mahrholdt|first12=Heiko|title=Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis|journal=Journal of Cardiovascular Magnetic Resonance|volume=16|issue=1|year=2014|pages=14|issn=1532-429X|doi=10.1186/1532-429X-16-14}}</ref><nowiki></nowiki> | |||
|} | |} | ||
==References== | ==References== | ||
{{reflist|2}} | {{reflist|2}} | ||
{{WH}} | |||
{{WS}} | |||
[[Category:Medicine]] | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category: | [[Category:Up-To-Date]] | ||
[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
[[Category: | [[Category:Intensive care medicine]] | ||
Latest revision as of 22:51, 29 July 2020
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Myocarditis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Myocarditis medical therapy On the Web |
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American Roentgen Ray Society Images of Myocarditis medical therapy |
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Risk calculators and risk factors for Myocarditis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Varun Kumar, M.B.B.S.; Maliha Shakil, M.D. [2] Homa Najafi, M.D.[3]
Overview
Symptomatic treatment is the mainstay of therapy for patients with viral myocarditis. Supportive therapy includes diuretics and inotropes for left ventricular failure. ACE inhibitor therapy may aid in left ventricular remodeling. Among patients with fulminant myocarditis, placement of either an intra-aortic balloon pump or a left ventricular assist device may be necessary as bridge to recovery. Administration of antimicrobial therapy is recommended for bacterial myocarditis. Immunosuppressive therapy may be effective in the management of giant cell myocarditis, autoimmune myocarditis, and eosinophilic myocarditis. In patients with arrythmias, treatment should be initiated only if arrhythmias are symptomatic or sustained. Myocarditis patients presenting with conduction abnormalities, particularly Mobitz type II and complete heart block require temporary pacemaker usually during the acute phase.
Medical Therapy
Lymphocytic/Viral Myocarditis
- The mainstay of therapy for viral myocarditis is supportive care and standard management of CHF.[1][2][3][4][5][6][5][7] [8][9][10][11][12][13][14][15][16][17][18]
- The Heart Failure Society of America recommends against the routine use of immunosuppressive agents in treatment of myocarditis.
- Animal studies have demonstrated better outcomes in viral myocarditis with the use of antiviral agents and interferon early in the course of infection prior to inoculation. The use of antiviral therapy may be limited since patients with viral myocarditis are usually not seen in the early stages. However, it may be used in acute, fulminant myocarditis and in institutional outbreaks. In a series, 6 months of beta interferon in patients with myocarditis secondary to enterovirus or adenovirus infection resulted in the elimination of viral genomes in all patients and improvement of LV function in 68% of the patients.
- Immunotherapy was thought to be a treatment option for myocarditis as they suppress the activity of immunologic agents mediating myocardial inflammation. There is no significant change in mortality rate with immunotherapy. However, improvement in LV function is seen in patients with chronic inflammatory dilated cardiomyopathy.
- Intravenous immunoglobulin (IVIG) is known to have both antiviral and immunologic properties. Therefore, it can be used in both viral and autoimmune types of myocarditis.
- Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis.
- ICD implantation is not indicated during the acute phase of myocarditis.
- Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis.
Giant Cell Myocarditis
- Giant cell myocarditis is a rare form of myocarditis and is generally associated with a poor prognosis. In a non-randomized series, 22 patients with giant cell myocarditis who were treated with corticosteroids and cyclosporine/azathioprine, survived for an average of 12.3 months. In contrast, those patients who were not treated with immunosuppressants survived for an average of 3 months. Use of immunosuppressive therapy was further strengthened by a prospective, multicenter observational study which reported an improved survival of 6 years among patients receiving high dose steroids and cyclosporine with or without muromonab-CD3. Of the 11 patients studied, two patients underwent cardiac transplantation early in the course of the study and one patient died. The study also reported that withdrawal of immunosuppression was associated with a recurrence of giant cell myocarditis in some patients which in some cases was fatal. Immunosuppressive therapy directed at T-cells may be beneficial as T-cells mediate myocardial inflammation.[19][20][21]
- Cardiac transplantation is sometimes required to treat refractory giant cell myocarditis. However, the condition can recur in post-transplant patients. Recurrence of biopsy proven giant cell myocarditis between 3 weeks to 9 years was observed in 9 of 34 cardiac transplant patients.
Eosinophilic Myocarditis
- Eosinophilic myocarditis can occur secondary to hypersensitivity to drugs, parasitic infestation, or hypereosinophilic syndrome. The eosinophils which infiltrate the myocardium, degenerate leading to extracellular release of eosinophil granules which can contribute to death of myocytes. Usage of immunosuppressants such as high dose steroids (after excluding infections) and removal of offending drug (in drug induced hypersensitivity) is known to be beneficial in treatment of eosinophilic myocarditis. Immunosuppressive therapy may be tapered gradually after one year if normal cardiac function and cardiac enzymes levels are restored.[22][23]
Autoimmune Myocarditis
- Myocarditis can develop in autoimmune diseases such as celiac disease and sarcoidosis. Treatment with gluten-free diet and immunosuppressants in celiac disease improves cardiac function. Corticosteroids are found to be beneficial in patients with sarcoidosis related myocarditis, particularly during initial stages of the disease before development of extensive fibrosis of myocardium.[24][25]
Treatment of Heart Failure
- As heart failure in patients with myocarditis has poor prognosis, it is important to prevent progression or worsening of cardiac dysfunction. These patients should be treated with low sodium intake, diuretics and ACE inhibitors. Few animal studies report that mortality rate is high with digoxin in comparison to beta blocker in viral myocarditis. Studies have also demonstrated that usage of carvedilol during recovery phase decreases expression of several histochemicals and subsequently myocardial inflammation and there by improving survival. The beta-blockers should however be avoided in the acutely decompensating phase of illness. If heart failure or cardiogenic shock does not respond to medical therapy, circulatory support with an intraaortic balloon pump should be considered which could be used in fulminant myocarditis as a bridge to spontaneous recovery. Implantation of ICD in severe heart failure should be deferred for several months to allow sufficient time for recovery of ventricular function. Following the initial circulatory stabilization, further treatment of cardiac dysfunction should follow current ACC/AHA recommendations. Anticoagulation may be considered in patients with severe/chronic heart failure as they are at risk for developing thromboembolic complications.[26][27][28][29][30][31][32]
- For more information on heart failure treatment, click here.
Treatment of Arrhythmia
- Arrhythmias or conduction abnormalities can occur in patients with myocarditis. Treatment should be initiated only if arrhythmias are symptomatic or sustained. Caution should be observed while using antiarrhythmics as majority of these agents have negative inotropic property which may worsen heart failure. Regular monitoring with ECG is important as it enables early detection and treatment of asymptomatic yet life threatening arrhythmias.
- Supraventricular tachycardia (SVT) can aggravate heart failure. Symptomatic and sustained SVT should be immediately converted electrically. While, patients with recurrent sustained SVT should be treated with antiarrhythmics and rate controlling agents. Implantation of ICD should be considered in patients with recurrent ventricular arrhythmia refractory to medical therapy. Myocarditis patients presenting with conduction abnormalities, particularly Mobitz type II and complete heart block require temporary pacemaker usually during the acute phase. Implantation of permanent pacemaker or ICD may be necessary in few patients.[33]
2006 ACC/AHA/ESC Guidelines for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis[34]
| Class I |
| 1. Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis. (Level of Evidence: C) |
| 2. Acute aortic regurgitation associated with VT should be treated surgically unless otherwise contraindicated.(Level of Evidence: C) |
| 3. Acute endocarditis complicated by aortic or annular abscess and AV block should be treated surgically unless otherwise contraindicated. (Level of Evidence: C) |
| Class III |
| 1.ICD implantation is not indicated during the acute phase of myocarditis. (Level of Evidence: C) |
| Class IIa |
| 1. ICD implantation can be beneficial in patients with life-threatening ventricular arrhythmias who are not in the acute phase of myocarditis, as indicated in the ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmic devices who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: C)[35] |
| 2. Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis. (Level of Evidence: C) |
2013 ESC Guideline for Management of Patients with Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death - Myocarditis, Rheumatic Disease, and Endocarditis[36]
| Class I |
| 1. It is recommended that patients with a life-threatening presentation of sustained ventricular tachyarrhythmias in the context of clinically suspected myocarditis are referred to specialized centers with the ability to perform hemodynamic monitoring, cardiac catheterization and endomyocardial biopsy and to use mechanical cardio-pulmonary assist devices and specialized arrhythmia therapies. (Level of Evidence: C)[37][38][39][40] |
| 2. Temporary pacemaker insertion is recommended in patients with bradycardia and/or heart block triggering VA during the acute phase of myocarditis/pancarditis.(Level of Evidence: C)[37][41] |
| Class IIa |
| 1.Anti-arrhythmic therapy should be considered in patients with symptomatic non-sustained or sustained VT during the acute phase of myocarditis.(Level of Evidence: C)[37] |
| 2. The implant of an ICD or pacemaker in patients with inflammatory heart diseases should be considered after resolution of the acute episode. (Level of Evidence: C)[37][42] |
| 3. In patients with hemodynamically compromising sustained VT occurring after the resolution of acute episodes, an ICD implantation should be considered if the patient is expected to survive >1 year with good functional status. (Level of Evidence: C) |
| 4. A wearable defibrillator should be considered for bridging until full recovery or ICD implantation in patients after inflammatory heart diseases with residual severe LV dysfunction and/or ventricular electrical instability. (Level of Evidence: C)[43][44] |
| Class IIb |
| 1. ICD implantation may be considered earlier in patients with giant cell myocarditis or sarcoidosis who had hemodynamically compromising sustained VA or aborted cardiac arrest, due to adverse prognosis of these conditions, if survival >1 year with good functional status can be expected. (Level of Evidence: C)[45] |
| 2. Demonstration of persistent myocardial inflammatory infiltrates by immunohistological evidence and/or abnormal localized fibrosis by CMR after acute myocarditis may be considered as an additional indicator of increased risk of SCD in inflammatory heart disease. (Level of Evidence: C)[46] |
References
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|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ 5.0 5.1 Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, Glanowska G, Wilczewski P, Niklewski T; et al. (2001). "Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results". Circulation. 104 (1): 39–45. PMID 11435335.
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|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑
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|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Drucker NA, Colan SD, Lewis AB, Beiser AS, Wessel DL, Takahashi M; et al. (1994). "Gamma-globulin treatment of acute myocarditis in the pediatric population". Circulation. 89 (1): 252–7. PMID 8281654.
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|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Imazio M, Trinchero R (2008). "Myopericarditis: Etiology, management, and prognosis". Int J Cardiol. 127 (1): 17–26. doi:10.1016/j.ijcard.2007.10.053. PMID 18221804. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Khatib R, Reyes MP, Smith F, Khatib G, Rezkalla S (1990). "Enhancement of coxsackievirus B4 virulence by indomethacin". J Lab Clin Med. 116 (1): 116–20. PMID 1695914.
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|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Menghini VV, Savcenko V, Olson LJ, Tazelaar HD, Dec GW, Kao A; et al. (1999). "Combined immunosuppression for the treatment of idiopathic giant cell myocarditis". Mayo Clin Proc. 74 (12): 1221–6. PMID 10593350.
- ↑ Cooper LT, Berry GJ, Shabetai R (1997). "Idiopathic giant-cell myocarditis--natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators". N Engl J Med. 336 (26): 1860–6. doi:10.1056/NEJM199706263362603. PMID 9197214.
- ↑ Cooper LT, Hare JM, Tazelaar HD, Edwards WD, Starling RC, Deng MC; et al. (2008). "Usefulness of immunosuppression for giant cell myocarditis". Am J Cardiol. 102 (11): 1535–9. doi:10.1016/j.amjcard.2008.07.041. PMC 2613862. PMID 19026310.
- ↑ Cooper LT, Zehr KJ (2005). "Biventricular assist device placement and immunosuppression as therapy for necrotizing eosinophilic myocarditis". Nat Clin Pract Cardiovasc Med. 2 (10): 544–8. doi:10.1038/ncpcardio0322. PMID 16186853. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Corradi D, Vaglio A, Maestri R, Legname V, Leonardi G, Bartoloni G; et al. (2004). "Eosinophilic myocarditis in a patient with idiopathic hypereosinophilic syndrome: insights into mechanisms of myocardial cell death". Hum Pathol. 35 (9): 1160–3. PMID 15343520. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Kim JS, Judson MA, Donnino R, Gold M, Cooper LT, Prystowsky EN; et al. (2009). "Cardiac sarcoidosis". Am Heart J. 157 (1): 9–21. doi:10.1016/j.ahj.2008.09.009. PMID 19081391. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Frustaci A, Cuoco L, Chimenti C, Pieroni M, Fioravanti G, Gentiloni N; et al. (2002). "Celiac disease associated with autoimmune myocarditis". Circulation. 105 (22): 2611–8. PMID 12045166.
- ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Magnani JW, Danik HJ, Dec GW, DiSalvo TG (2006). "Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors". Am Heart J. 151 (2): 463–70. doi:10.1016/j.ahj.2005.03.037. PMID 16442915. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Tominaga M, Matsumori A, Okada I, Yamada T, Kawai C (1991). "Beta-blocker treatment of dilated cardiomyopathy. Beneficial effect of carteolol in mice". Circulation. 83 (6): 2021–8. PMID 1674900.
- ↑ Matsumori A, Igata H, Ono K, Iwasaki A, Miyamoto T, Nishio R; et al. (1999). "High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity". Jpn Circ J. 63 (12): 934–40. PMID 10614837.
- ↑ Wang JF, Meissner A, Malek S, Chen Y, Ke Q, Zhang J; et al. (2005). "Propranolol ameliorates and epinephrine exacerbates progression of acute and chronic viral myocarditis". Am J Physiol Heart Circ Physiol. 289 (4): H1577–83. doi:10.1152/ajpheart.00258.2005. PMID 15923319. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Rockman HA, Adamson RM, Dembitsky WP, Bonar JW, Jaski BE (1991). "Acute fulminant myocarditis: long-term follow-up after circulatory support with left ventricular assist device". Am Heart J. 121 (3 Pt 1): 922–6. PMID 2000764.
- ↑ Chen JM, Spanier TB, Gonzalez JJ, Marelli D, Flannery MA, Tector KA; et al. (1999). "Improved survival in patients with acute myocarditis using external pulsatile mechanical ventricular assistance". J Heart Lung Transplant. 18 (4): 351–7. PMID 10226900. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Cooper LT (2009). "Myocarditis". N Engl J Med. 360 (15): 1526–38. doi:10.1056/NEJMra0800028. PMID 19357408. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ European Heart Rhythm Association. Heart Rhythm Society. Zipes DP, Camm AJ, Borggrefe M, Buxton AE; et al. (2006). "ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)". J Am Coll Cardiol. 48 (5): e247–346. doi:10.1016/j.jacc.2006.07.010. PMID 16949478. Unknown parameter
|http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=ignored (help) - ↑ Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA; et al. (2002). "ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines)". Circulation. 106 (16): 2145–61. PMID 12379588.
- ↑ Priori, Silvia G.; Blomström-Lundqvist, Carina; Mazzanti, Andrea; Blom, Nico; Borggrefe, Martin; Camm, John; Elliott, Perry Mark; Fitzsimons, Donna; Hatala, Robert; Hindricks, Gerhard; Kirchhof, Paulus; Kjeldsen, Keld; Kuck, Karl-Heinz; Hernandez-Madrid, Antonio; Nikolaou, Nikolaos; Norekvål, Tone M.; Spaulding, Christian; Van Veldhuisen, Dirk J. (2015). "2015 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death". European Heart Journal. 36 (41): 2793–2867. doi:10.1093/eurheartj/ehv316. ISSN 0195-668X.
- ↑ 37.0 37.1 37.2 37.3 Caforio, A. L. P.; Pankuweit, S.; Arbustini, E.; Basso, C.; Gimeno-Blanes, J.; Felix, S. B.; Fu, M.; Helio, T.; Heymans, S.; Jahns, R.; Klingel, K.; Linhart, A.; Maisch, B.; McKenna, W.; Mogensen, J.; Pinto, Y. M.; Ristic, A.; Schultheiss, H.-P.; Seggewiss, H.; Tavazzi, L.; Thiene, G.; Yilmaz, A.; Charron, P.; Elliott, P. M. (2013). "Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases". European Heart Journal. 34 (33): 2636–2648. doi:10.1093/eurheartj/eht210. ISSN 0195-668X.
- ↑ "Guidelines for diagnosis and treatment of myocarditis (JCS 2009): digest version". Circulation journal : official journal of the Japanese Circulation Society. 75 (3): 734–743. 2011. doi:10.1253/circj.cj-88-0008. PMID 21304213.
- ↑ Naoyoshi Aoyama, Tohru Izumi, Katsuhiko Hiramori, Mitsuaki Isobe, Masatoshi Kawana, Michiaki Hiroe, Hitoshi Hishida, Yasushi Kitaura & Tsutomu Imaizumi (2002). "National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee)". Circulation journal : official journal of the Japanese Circulation Society. 66 (2): 133–144. doi:10.1253/circj.66.133. PMID 11999637. Unknown parameter
|month=ignored (help) - ↑ Liberman, Leonardo; Anderson, Brett; Silver, Eric S.; Singh, Rakesh; Richmond, Marc E. (2014). "INCIDENCE AND CHARACTERISTICS OF ARRHYTHMIAS IN PEDIATRIC PATIENTS WITH MYOCARDITIS: A MULTICENTER STUDY". Journal of the American College of Cardiology. 63 (12): A483. doi:10.1016/S0735-1097(14)60483-6. ISSN 0735-1097.
- ↑ "Guidelines for diagnosis and treatment of myocarditis (JCS 2009): digest version". Circulation journal : official journal of the Japanese Circulation Society. 75 (3): 734–743. 2011. doi:10.1253/circj.cj-88-0008. PMID 21304213.
- ↑ Kindermann, Ingrid; Kindermann, Michael; Kandolf, Reinhard; Klingel, Karin; Bültmann, Burkhard; Müller, Thomas; Lindinger, Angelika; Böhm, Michael (2008). "Predictors of Outcome in Patients With Suspected Myocarditis". Circulation. 118 (6): 639–648. doi:10.1161/CIRCULATIONAHA.108.769489. ISSN 0009-7322.
- ↑ Prochnau, Dirk; Surber, Ralf; Kuehnert, Helmut; Heinke, Matthias; Klein, Helmut U.; Figulla, Hans R. (2009). "Successful use of a wearable cardioverter-defibrillator in myocarditis with normal ejection fraction". Clinical Research in Cardiology. 99 (2): 129–131. doi:10.1007/s00392-009-0093-2. ISSN 1861-0684.
- ↑ Chung, Mina K. (2014). "The Role of the Wearable Cardioverter Defibrillator in Clinical Practice". Cardiology Clinics. 32 (2): 253–270. doi:10.1016/j.ccl.2013.11.002. ISSN 0733-8651.
- ↑ Kandolin, Riina; Lehtonen, Jukka; Salmenkivi, Kaisa; Räisänen-Sokolowski, Anne; Lommi, Jyri; Kupari, Markku (2013). "Diagnosis, Treatment, and Outcome of Giant-Cell Myocarditis in the Era of Combined Immunosuppression". Circulation: Heart Failure. 6 (1): 15–22. doi:10.1161/CIRCHEARTFAILURE.112.969261. ISSN 1941-3289.
- ↑ Schumm, Julia; Greulich, Simon; Wagner, Anja; Grün, Stefan; Ong, Peter; Bentz, Kerstin; Klingel, Karin; Kandolf, Reinhard; Bruder, Oliver; Schneider, Steffen; Sechtem, Udo; Mahrholdt, Heiko (2014). "Cardiovascular magnetic resonance risk stratification in patients with clinically suspected myocarditis". Journal of Cardiovascular Magnetic Resonance. 16 (1): 14. doi:10.1186/1532-429X-16-14. ISSN 1532-429X.