Myocarditis natural history, complications and prognosis: Difference between revisions

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{{Myocarditis}}
{{Myocarditis}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' [[Varun Kumar]], M.B.B.S.
{{CMG}} {{AE}} [[Varun Kumar]] M.B.B.S., {{Maliha}}{{Homa}}


==Overview==
==Overview==
Myocarditis is usually self limiting and is associated with a good prognosis especially if it is secondary to a [[viral infection]]. Patients rarely develop [[cardiac failure]], [[pulmonary edema]], [[arrhythmias]] or [[cardiogenic shock]]. In some instances, myocarditis may be associated with [[sudden death]].  Patients with fulminant myocarditis have a good long term prognosis if they survive the acute phase of the disease <ref name="pmid10706898">{{cite journal| author=McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM et al.| title=Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. | journal=N Engl J Med | year= 2000 | volume= 342 | issue= 10 | pages= 690-5 | pmid=10706898 | doi=10.1056/NEJM200003093421003 | pmc= | url= }} </ref> .  The prognosis of fulminant myocarditis is better than that of either acute myocarditis or [[giant cell myocarditis]].
Myocarditis is usually self limiting and is associated with a good [[prognosis]] especially if it is [[secondary]] to a [[viral infection]]. [[Patients]] [[Rare|rarely]] [[Development|develop]] [[cardiac failure]], [[pulmonary edema]], [[arrhythmias]], or [[cardiogenic shock]]. In some instances, myocarditis may be associated with [[sudden death]].  Patients with fulminant myocarditis have a good long term [[prognosis]] if they survive the [[acute]] phase of the [[disease]]. The [[prognosis]] of fulminant myocarditis is better than that of either [[acute]] myocarditis or [[giant cell myocarditis]]. The presence of [[syncope]], [[pulmonary hypertension]], [[Ventricular dysfunction|biventricular dysfunction]], [[left bundle branch block]], [[q waves]], [[AV block]], and a [[left ventricular ejection fraction]] < 40% are associated with [[sudden death]] and [[cardiac transplantation]]. [[Complications]] of myocarditis include [[chronic]] [[dilated cardiomyopathy]], [[heart block]], [[congestive heart failure]], [[pericarditis]], [[ventricular dysfunction]], [[arrythmia]]s, and [[sudden cardiac death]].


The presence of [[left bundle branch block]], [[q waves]], [[AV block]], [[syncope]] and a [[left ventricular ejection fraction]] < 40% are associated with [[sudden death]] and [[cardiac transplantation]]<ref name="pmid1194054">{{cite journal| author=Scartazzini R, Schneider P, Bickel H| title=[New beta-lactam antibiotics. Functionalisation of the cephem 3-position with sulfur or nitrogen bearing substituents (author's transl)]. | journal=Helv Chim Acta | year= 1975 | volume= 58 | issue= 8 | pages= 2437-50 | pmid=1194054 | doi=10.1002/hlca.19750580824 | pmc= | url= }} </ref>.
==Natural History==


==Natural History and Complications==
* The [[Course (medicine)|course]] of [[viral]] myocarditis is usually [[benign]] and the majority of cases of [[Coxsackie B]] [[virus]] [[infection]] are [[subclinical]].
The course of viral myocarditis is usually benign and the majority of cases of [[Coxsackie B]] virus infection are subclinical.
* [[Patients]] [[Presenting symptom|presenting]] with mild [[ventricular dysfunction]] [[secondary]] to [[viral myocarditis]] typically improve within weeks to months and [[Rare|rarely]] progress to severe [[ventricular dysfunction]], [[heart block]], [[arrhythmias]], or even [[sudden cardiac death]].
* Among [[patients]] who [[Presenting symptom|present]] with more advanced [[left ventricular dysfunction]]; 50% of [[patients]] [[Development|develop]] [[Chronic (medicine)|chronic]] [[ventricular dysfunction]] and 25% have spontaneous improvement in [[ventricular function]] while the remaining 25% progress to [[transplantation]] or death.<ref name="pmid16476862">{{cite journal| author=Magnani JW, Dec GW| title=Myocarditis: current trends in diagnosis and treatment. | journal=Circulation | year= 2006 | volume= 113 | issue= 6 | pages= 876-90 | pmid=16476862 | doi=10.1161/CIRCULATIONAHA.105.584532 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16476862  }} </ref><ref name="pmid436050">{{cite journal| author=Wentworth P, Jentz LA, Croal AE| title=Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. | journal=Can Med Assoc J | year= 1979 | volume= 120 | issue= 6 | pages= 676-80, 706 | pmid=436050 | doi= | pmc=PMC1819176 | url= }} </ref><ref name="pmid3730208">{{cite journal| author=Hosenpud JD, McAnulty JH, Niles NR| title=Unexpected myocardial disease in patients with life threatening arrhythmias. | journal=Br Heart J | year= 1986 | volume= 56 | issue= 1 | pages= 55-61 | pmid=3730208 | doi= | pmc=PMC1277385 | url= }} </ref>


Patients presenting with mild [[ventricular dysfunction]] secondary to viral myocarditis typically improve within weeks to months and rarely progress to severe [[ventricular dysfunction]], [[heart block]], [[arrhythmias]] or even [[sudden cardiac death]]<ref name="pmid436050">{{cite journal| author=Wentworth P, Jentz LA, Croal AE| title=Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. | journal=Can Med Assoc J | year= 1979 | volume= 120 | issue= 6 | pages= 676-80, 706 | pmid=436050 | doi= | pmc=PMC1819176 | url= }} </ref><ref name="pmid3730208">{{cite journal| author=Hosenpud JD, McAnulty JH, Niles NR| title=Unexpected myocardial disease in patients with life threatening arrhythmias. | journal=Br Heart J | year= 1986 | volume= 56 | issue= 1 | pages= 55-61 | pmid=3730208 | doi= | pmc=PMC1277385 | url= }} </ref>.
==Complications==
*[[Complications]] of myocarditis include:<ref name="pmid16476862">{{cite journal| author=Magnani JW, Dec GW| title=Myocarditis: current trends in diagnosis and treatment. | journal=Circulation | year= 2006 | volume= 113 | issue= 6 | pages= 876-90 | pmid=16476862 | doi=10.1161/CIRCULATIONAHA.105.584532 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16476862  }} </ref><ref name="pmid436050">{{cite journal| author=Wentworth P, Jentz LA, Croal AE| title=Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. | journal=Can Med Assoc J | year= 1979 | volume= 120 | issue= 6 | pages= 676-80, 706 | pmid=436050 | doi= | pmc=PMC1819176 | url= }} </ref><ref name="pmid3730208">{{cite journal| author=Hosenpud JD, McAnulty JH, Niles NR| title=Unexpected myocardial disease in patients with life threatening arrhythmias. | journal=Br Heart J | year= 1986 | volume= 56 | issue= 1 | pages= 55-61 | pmid=3730208 | doi= | pmc=PMC1277385 | url= }} </ref>
**[[Chronic]] [[dilated cardiomyopathy]]
**[[Heart block]]
**[[Congestive heart failure]]
**[[Pericarditis]]
**[[Ventricular dysfunction]]
**[[Arrythmia]]s
**[[Sudden cardiac death]]


==Prognosis==
==Prognosis==


===Endomyocardial Biopsy===
===Endomyocardial Biopsy===
[[Endomyocardial biopsy]] remains the gold standard diagnostic tool in patients with myocarditis.  An [[endomyocardial biopsy]] is usually obtained in patients presenting with advanced [[heart failure]] or [[arrhythmias]].  Endomyocardial biopsy can shed light on the prognosis by ascertaining the underlying cause and the histopathologic severity of the disease.
====Fas and Fas ligand====
[[Fas]] and [[Fas ligand]] are associated with [[apoptotic]] death of myocytes and thus causing cardiac dysfunction. A study evaluating the role of gene expression for predicting myocardial recovery in recent-onset cardiomyopathy, reported that patients in the highest tertile of Fas expression had minimal improvement at six months when compared with the intermediate and lowest tertiles<ref name="pmid16168288">{{cite journal| author=Sheppard R, Bedi M, Kubota T, Semigran MJ, Dec W, Holubkov R et al.| title=Myocardial expression of fas and recovery of left ventricular function in patients with recent-onset cardiomyopathy. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 6 | pages= 1036-42 | pmid=16168288 | doi=10.1016/j.jacc.2005.05.067 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168288  }} </ref>.
====Antimyosin Autoantibodies====
Antimyosin autoantibodies are associated with left ventricular systolic dysfunction and diastolic stiffness in patients with chronic myocarditis<ref name="pmid10636253">{{cite journal| author=Lauer B, Schannwell M, Kühl U, Strauer BE, Schultheiss HP| title=Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis. | journal=J Am Coll Cardiol | year= 2000 | volume= 35 | issue= 1 | pages= 11-8 | pmid=10636253 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10636253  }} </ref>.


====Persistence of the Viral Genome====
* An [[endomyocardial biopsy]] is usually obtained in [[patients]] presenting with advanced [[heart failure]] or [[arrhythmias]].  The [[endomyocardial biopsy]] can shed light on the [[prognosis]] by ascertaining the underlying [[cause]] and the [[histopathologic]] severity of the [[disease]].
Persistence of the viral genome in the myocardium is associated with worsening of left ventricular [[ejection fraction]]<ref name="pmid16172268">{{cite journal| author=Kühl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W et al.| title=Viral persistence in the myocardium is associated with progressive cardiac dysfunction. | journal=Circulation | year= 2005 | volume= 112 | issue= 13 | pages= 1965-70 | pmid=16172268 | doi=10.1161/CIRCULATIONAHA.105.548156 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16172268  }} </ref><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= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=19357408  }} </ref>.


====Giant Cell Myocarditis====
* The markers which can be associated with poor [[prognosis]] include:<ref name="pmid16168288">{{cite journal| author=Sheppard R, Bedi M, Kubota T, Semigran MJ, Dec W, Holubkov R et al.| title=Myocardial expression of fas and recovery of left ventricular function in patients with recent-onset cardiomyopathy. | journal=J Am Coll Cardiol | year= 2005 | volume= 46 | issue= 6 | pages= 1036-42 | pmid=16168288 | doi=10.1016/j.jacc.2005.05.067 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16168288  }} </ref><ref name="pmid10636253">{{cite journal| author=Lauer B, Schannwell M, Kühl U, Strauer BE, Schultheiss HP| title=Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis. | journal=J Am Coll Cardiol | year= 2000 | volume= 35 | issue= 1 | pages= 11-8 | pmid=10636253 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10636253}}</ref><ref name="pmid16172268">{{cite journal| author=Kühl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W et al.| title=Viral persistence in the myocardium is associated with progressive cardiac dysfunction. | journal=Circulation | year= 2005 | volume= 112 | issue= 13 | pages= 1965-70 | pmid=16172268 | doi=10.1161/CIRCULATIONAHA.105.548156 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16172268  }} </ref><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><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="pmid15364334">{{cite journal| author=Nishii M, Inomata T, Takehana H, Takeuchi I, Nakano H, Koitabashi T et al.| title=Serum levels of interleukin-10 on admission as a prognostic predictor of human fulminant myocarditis. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 6 | pages= 1292-7 | pmid=15364334 | doi=10.1016/j.jacc.2004.01.055 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15364334  }} </ref>
[[Giant cell myocarditis]] (GCM) is a rare type of myocarditis which usually occurs in relatively young and predominantly healthy adults. It is frequently associated with poor prognosis. In a series of 63 patients with idiopathic giant-cell myocarditis, death and cardiac transplantation accounted for 89% and the median survival was 5.5 months from the onset of symptoms. Of the 34 patients who underwent cardiac transplantation, 9 patients (26%) died during an average follow-up of 3.7 years and 5 died within 30 days post surgery<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>.  
**[[Fas]] and [[Fas ligand]] ([[cell death]] [[receptors]]) are associated with [[apoptotic]] death of [[myocytes]] and are a marker of [[cardiac dysfunction]].
**[[Myosin|Antimyosin]] [[autoantibodies]] are associated with [[left ventricular systolic dysfunction]] and [[diastolic stiffness]] in [[patients]] with [[Chronic (medical)|chronic]] [[myocarditis]].
** Persistence of the [[viral]] [[genome]] in the [[myocardium]] is associated with worsening of [[left ventricular]] [[ejection fraction]].
**[[Giant cell myocarditis]] (GCM) is a less common form of myocarditis which usually occurs in relatively young and [[healthy]] [[Adult|adults]]. It is associated with a poorer [[prognosis]].
** High levels of [[interleukin-10]] in fulminant myocarditis [[patients]] at admission may be [[Predictive medicine|predictive]] of subsequent [[development]] of [[cardiogenic shock]] (requiring [[Mechanical Ventilatory Support|mechanical cardiopulmonary support]] system) and [[mortality]].


===Prognostic Implications of EKG Changes===
===Prognostic Implications of EKG Changes===
Despite its worrisome appearance, [[ST segment elevation]] suggestive of [[myocardial infarction]] is usually self-limited with no overt sequelae<ref name="pmid1607543">{{cite journal| author=Dec GW, Waldman H, Southern J, Fallon JT, Hutter AM, Palacios I| title=Viral myocarditis mimicking acute myocardial infarction. | journal=J Am Coll Cardiol | year= 1992 | volume= 20 | issue= 1 | pages= 85-9 | pmid=1607543 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1607543  }} </ref>.


In contrast, the presence of either [[left bundle branch block]], [[q wave]]s suggestive of old infarct or high degree [[AV block]] are associated with a poor long term prognosis and are associated with the development of [[cardiac failure]] and [[cardiac transplantation]]<ref name="pmid10089938">{{cite journal| author=Nakashima H, Katayama T, Ishizaki M, Takeno M, Honda Y, Yano K| title=Q wave and non-Q wave myocarditis with special reference to clinical significance. | journal=Jpn Heart J | year= 1998 | volume= 39 | issue= 6 | pages= 763-74 | pmid=10089938 | doi= | pmc= | url= }} </ref>.
* Despite its worrisome [[appearance]], [[ST segment elevation]] suggestive of [[myocardial infarction]] is usually self-limited with no overt [[sequelae]].<ref name="pmid1607543">{{cite journal| author=Dec GW, Waldman H, Southern J, Fallon JT, Hutter AM, Palacios I| title=Viral myocarditis mimicking acute myocardial infarction. | journal=J Am Coll Cardiol | year= 1992 | volume= 20 | issue= 1 | pages= 85-9 | pmid=1607543 | doi= | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1607543  }} </ref><ref name="pmid10089938">{{cite journal| author=Nakashima H, Katayama T, Ishizaki M, Takeno M, Honda Y, Yano K| title=Q wave and non-Q wave myocarditis with special reference to clinical significance. | journal=Jpn Heart J | year= 1998 | volume= 39 | issue= 6 | pages= 763-74 | pmid=10089938 | doi= | pmc= | url= }} </ref>
* In contrast, the presence of either [[left bundle branch block]], [[q wave]]s suggestive of old [[infarct]] or high degree [[AV block]] is associated with a poor long term [[prognosis]], [[development]] of [[cardiac failure]] and the need for [[cardiac transplantation]].


===Clinical Predictors of Prognosis===
===Clinical Predictors of Prognosis===
The development of [[syncope]], [[bundle branch block]], [[ejection fraction]] <40% and [[pulmonary hypertension]] are known to be poor predictors of [[myocarditis]] and are associated with death or [[cardiac transplantation]].


====Prognosis Associated with Left Ventricular Dysfunction====
* The [[clinical]] manifestations which can associated with poor [[prognosis]] (associated with death or [[cardiac transplantation]]) include: <ref>{{Cite journal
The prognosis in patients with new onset [[heart failure]] depends on the degree of ventricular dysfunction<ref name="pmid16476862">{{cite journal| author=Magnani JW, Dec GW| title=Myocarditis: current trends in diagnosis and treatment. | journal=Circulation | year= 2006 | volume= 113 | issue= 6 | pages= 876-90 | pmid=16476862 | doi=10.1161/CIRCULATIONAHA.105.584532 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16476862  }} </ref>. The majority of myocarditis patients recover well with treatment. However, approximately 25% of patients develop chronic ventricular dysfunction and 25% of patients will continue to deteriorate<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= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16442915  }} </ref>
| author = [[Alida L. P. Caforio]], [[Fiorella Calabrese]], [[Annalisa Angelini]], [[Francesco Tona]], [[Annalisa Vinci]], [[Stefania Bottaro]], [[Angelo Ramondo]], [[Elisa Carturan]], [[Sabino Iliceto]], [[Gaetano Thiene]] & [[Luciano Daliento]]
| title = A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis
| journal = [[European heart journal]]
| volume = 28
| issue = 11
| pages = 1326–1333
| year = 2007
| month = June
| doi = 10.1093/eurheartj/ehm076
| pmid = 17493945
}}</ref><ref>{{Cite journal
| author = [[Thomas P. Cappola]], [[G. Michael Felker]], [[W. H. Linda Kao]], [[Joshua M. Hare]], [[Kenneth L. Baughman]] & [[Edward K. Kasper]]
| title = Pulmonary hypertension and risk of death in cardiomyopathy: patients with myocarditis are at higher risk
| journal = [[Circulation]]
| volume = 105
| issue = 14
| pages = 1663–1668
| year = 2002
| month = April
| doi = 10.1161/01.cir.0000013771.30198.82
| pmid = 11940544
}}</ref>
**[[Syncope]]
**[[Bundle branch block]]
**[[Ejection fraction]] <40%
**[[Pulmonary hypertension]]
**[[Ventricular dysfunction|Biventricular dysfunction]]


====Prognosis Associated with Fulminant Myocarditis vs Acute Myocarditis====
===Prognosis Associated with Left Ventricular Dysfunction===
In a small series of 15 patients with fulminant myocarditis, 14(93%) survived for 11 years without the need for [[cardiac transplantation]]. This suggests that patients with fulminant myocarditis have a good long term prognosis if they survive the acute phase of the disease<ref name="pmid10706898">{{cite journal| author=McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM et al.| title=Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. | journal=N Engl J Med | year= 2000 | volume= 342 | issue= 10 | pages= 690-5 | pmid=10706898 | doi=10.1056/NEJM200003093421003 | pmc= | url= }} </ref>. In the same series, 132 patients met the criteria for acute [[myocarditis]] and 60(45%) of these patients were alive at the end of 11 years without having received a [[cardiac transplant]].


===Prognostic Biomarkers===
* The [[prognosis]] in [[patients]] with new onset [[heart failure]] depends on the degree of [[ventricular dysfunction]].<ref name="pmid16476862">{{cite journal| author=Magnani JW, Dec GW| title=Myocarditis: current trends in diagnosis and treatment. | journal=Circulation | year= 2006 | volume= 113 | issue= 6 | pages= 876-90 | pmid=16476862 | doi=10.1161/CIRCULATIONAHA.105.584532 | pmc= | http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16476862  }} </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= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16442915 }} </ref>
High levels of '''[[interleukin-10]]''' in fulminant myocarditis patients at admission may be predictive of subsequent development of [[cardiogenic shock]] (requiring mechanical cardiopulmonary support system) and mortality<ref name="pmid15364334">{{cite journal| author=Nishii M, Inomata T, Takehana H, Takeuchi I, Nakano H, Koitabashi T et al.| title=Serum levels of interleukin-10 on admission as a prognostic predictor of human fulminant myocarditis. | journal=J Am Coll Cardiol | year= 2004 | volume= 44 | issue= 6 | pages= 1292-7 | pmid=15364334 | doi=10.1016/j.jacc.2004.01.055 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15364334 }} </ref>.
* The majority of myocarditis [[patients]] [[Recovery|recover]] well with [[Therapy|treatment]]. However, approximately 25% of [[patients]] [[Development|develop]] [[Chronic (medicine)|chronic]] [[ventricular dysfunction]] and 25% of [[patients]] will continue to deteriorate.
 
===Prognosis Associated with Fulminant Myocarditis vs Acute Myocarditis===
 
* In a small series of 15 [[patients]] with fulminant myocarditis, 14(93%) survived for 11 years without the need for [[cardiac transplantation]]. This suggests that [[patients]] with fulminant myocarditis have a good long term [[prognosis]] if they survive the [[acute]] phase of the [[disease]]. In the same series, 132 [[patients]] met the [[criteria]] for [[acute]] [[myocarditis]] and 60(45%) of these [[patients]] were alive at the end of 11 years without having received a [[cardiac transplant]].<ref name="pmid10706898">{{cite journal| author=McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM et al.| title=Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. | journal=N Engl J Med | year= 2000 | volume= 342 | issue= 10 | pages= 690-5 | pmid=10706898 | doi=10.1056/NEJM200003093421003 | pmc= | url= }} </ref>


==References==
==References==
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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

Myocarditis is usually self limiting and is associated with a good prognosis especially if it is secondary to a viral infection. Patients rarely develop cardiac failure, pulmonary edema, arrhythmias, or cardiogenic shock. In some instances, myocarditis may be associated with sudden death. Patients with fulminant myocarditis have a good long term prognosis if they survive the acute phase of the disease. The prognosis of fulminant myocarditis is better than that of either acute myocarditis or giant cell myocarditis. The presence of syncope, pulmonary hypertension, biventricular dysfunction, left bundle branch block, q waves, AV block, and a left ventricular ejection fraction < 40% are associated with sudden death and cardiac transplantation. Complications of myocarditis include chronic dilated cardiomyopathy, heart block, congestive heart failure, pericarditis, ventricular dysfunction, arrythmias, and sudden cardiac death.

Natural History

Complications

Prognosis

Endomyocardial Biopsy

Prognostic Implications of EKG Changes

Clinical Predictors of Prognosis

Prognosis Associated with Left Ventricular Dysfunction

Prognosis Associated with Fulminant Myocarditis vs Acute Myocarditis

References

  1. ↑ 1.0 1.1 1.2 Magnani JW, Dec GW (2006). "Myocarditis: current trends in diagnosis and treatment". Circulation. 113 (6): 876–90. doi:10.1161/CIRCULATIONAHA.105.584532. PMID 16476862.
  2. ↑ 2.0 2.1 Wentworth P, Jentz LA, Croal AE (1979). "Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis". Can Med Assoc J. 120 (6): 676–80, 706. PMC 1819176. PMID 436050.
  3. ↑ 3.0 3.1 Hosenpud JD, McAnulty JH, Niles NR (1986). "Unexpected myocardial disease in patients with life threatening arrhythmias". Br Heart J. 56 (1): 55–61. PMC 1277385. PMID 3730208.
  4. ↑ Sheppard R, Bedi M, Kubota T, Semigran MJ, Dec W, Holubkov R; et al. (2005). "Myocardial expression of fas and recovery of left ventricular function in patients with recent-onset cardiomyopathy". J Am Coll Cardiol. 46 (6): 1036–42. doi:10.1016/j.jacc.2005.05.067. PMID 16168288. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  5. ↑ Lauer B, Schannwell M, Kühl U, Strauer BE, Schultheiss HP (2000). "Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis". J Am Coll Cardiol. 35 (1): 11–8. PMID 10636253. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  6. ↑ Kühl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W; et al. (2005). "Viral persistence in the myocardium is associated with progressive cardiac dysfunction". Circulation. 112 (13): 1965–70. doi:10.1161/CIRCULATIONAHA.105.548156. PMID 16172268. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  7. ↑ 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)
  8. ↑ 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.
  9. ↑ Nishii M, Inomata T, Takehana H, Takeuchi I, Nakano H, Koitabashi T; et al. (2004). "Serum levels of interleukin-10 on admission as a prognostic predictor of human fulminant myocarditis". J Am Coll Cardiol. 44 (6): 1292–7. doi:10.1016/j.jacc.2004.01.055. PMID 15364334. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  10. ↑ Dec GW, Waldman H, Southern J, Fallon JT, Hutter AM, Palacios I (1992). "Viral myocarditis mimicking acute myocardial infarction". J Am Coll Cardiol. 20 (1): 85–9. PMID 1607543. Unknown parameter |http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom= ignored (help)
  11. ↑ Nakashima H, Katayama T, Ishizaki M, Takeno M, Honda Y, Yano K (1998). "Q wave and non-Q wave myocarditis with special reference to clinical significance". Jpn Heart J. 39 (6): 763–74. PMID 10089938.
  12. ↑ Alida L. P. Caforio, Fiorella Calabrese, Annalisa Angelini, Francesco Tona, Annalisa Vinci, Stefania Bottaro, Angelo Ramondo, Elisa Carturan, Sabino Iliceto, Gaetano Thiene & Luciano Daliento (2007). "A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis". European heart journal. 28 (11): 1326–1333. doi:10.1093/eurheartj/ehm076. PMID 17493945. Unknown parameter |month= ignored (help)
  13. ↑ Thomas P. Cappola, G. Michael Felker, W. H. Linda Kao, Joshua M. Hare, Kenneth L. Baughman & Edward K. Kasper (2002). "Pulmonary hypertension and risk of death in cardiomyopathy: patients with myocarditis are at higher risk". Circulation. 105 (14): 1663–1668. doi:10.1161/01.cir.0000013771.30198.82. PMID 11940544. Unknown parameter |month= ignored (help)
  14. ↑ 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.
  15. ↑ McCarthy RE, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM; et al. (2000). "Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis". N Engl J Med. 342 (10): 690–5. doi:10.1056/NEJM200003093421003. PMID 10706898.

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