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


==Overview==
==Overview==
'''Myocarditis''' is [[inflammation]] of the [[myocardium]], the muscular part of the [[heart]]. It may present with [[chest pain]], rapid signs of [[heart failure]], or [[sudden death]].
Myocarditis is defined as  [[inflammation]] of the [[myocardium]].  It may present with [[chest pain]], [[ST segment elevation]], elevated biomarkers of [[myonecrosis]], [[heart failure]], and/ or [[sudden death]]. [[Myocarditis]] can be classified clinicopathologically into fulminant myocarditis, acute myocarditis, chronic active myocarditis, and chronic persistent myocarditis. During either an infection or a [[hypersensitivity reaction]], the inflammatory response may cause [[myonecrosis]] either directly or indirectly as part of an [[autoimmune]] reaction. Life-threatening causes of myocarditis include [[carbon monoxide poisoning]] and [[Dengue fever]].  Common causes of myocarditis include infections, [[Lyme disease]], and medications.  Idiopathic myocarditis is the most common  type of myocarditis and is often suspected to be secondary to a [[viral]] infection. Myocarditis must be distinguished from [[pericarditis]] and the life threatening condition of [[ST elevation myocardial infarction]]. In young adults, up to 20% of all cases of [[sudden death]] are due to myocarditis. Myocarditis is slightly more frequent among males than females. 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 [[left bundle branch block]], [[q waves]], [[AV block]], [[syncope]] and a [[left ventricular ejection fraction]] < 40% are associated with [[sudden death]] and [[cardiac transplantation]]. The physical examination in patients with myocarditis may reveal [[tachycardia]], a [[cardiac gallop]], [[mitral regurgitation]] due to [[left ventricular dilation]], and [[pedal edema]] suggestive of [[cardiac failure]]. A [[pericardial friction rub]] may be noted in presence of concomitant [[pericarditis]], a condition sometimes referred to as [[myopericarditis]].


==Pathophysiology==
==Historical Perspective==
During an infection or hypersensitive reaction, the immune system produces inflammatory cells that release chemicals to fight the infection. These inflammatory cells enter the myocardium (heart muscle) where the infection resides. However, the chemicals produced by an immune response can damage the heart muscle ([[myocardium]]). As a result, the heart can become damaged,  enlarged, and weak. This damage to the [[myocardium]] leads to symptoms of [[heart failure]].
Myocarditis was first discovered by Jean Baptiste Senac, a French [[physician]], in 1794. The term myocarditis was introduced by German  [[physician]] Joseph Friedrich Sobernheim in 1837. In 1980s, the [[World Health Organization]] and the International Society and Federation of Cardiology were the first to [[differentiate]] between myocarditis and other [[cardiomyopathies]]. The [[Dallas criteria]] was published in 1986 as a [[Guideline (medical)|guideline]] for [[classification]] of myocarditis.


==Epidemiology and Demographics==
==Classification==
In developed countries, myocarditis is generally due to [[viral infections]] such as [[coxsackie B]], [[enterovirus]],[[adenovirus]], [[parvovirus B19]], [[hepatitis C]], and [[herpes virus]] 6. In developing countries, myocarditis is generally due to [[HIV]] and [[rheumatic heart disease]].
Myocarditis can be [[Classification|classified]] based on the [[Causes|causative]], [[histological]], and clinicopathological [[criteria]]. [[Causes|Causative]] [[criteria]] include three main groups, as well as [[infectious]], [[Immune-mediated disease|immune-mediated,]] and [[toxic]] myocarditis. Based on the type of [[Infiltration (medical)|infiltrating]] [[Cells (biology)|cells]] myocarditis divided in [[lymphocytic]], [[eosinophilic]], [[polymorphic]], [[giant cell]] myocarditis, and [[cardiac sarcoidosis]]. [[Acute]], [[fulminant]], [[chronic]] active, and [[Chronic (medicine)|chronic]] persistent are subtypes of clinicopathopogical [[classification]].


==Natural History, Complications & Prognosis==
==Pathophysiology==
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]].
During either an infection or a [[hypersensitivity reaction]], the inflammatory response may cause [[myonecrosis]] either directly or indirectly as part of an [[autoimmune]] reaction.


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>.
==Causes==
Life-threatening causes of myocarditis include [[carbon monoxide poisoning]] and [[Dengue fever]].  Common causes of myocarditis include infections such as [[Lyme disease]] and medications.  Idiopathic myocarditis is the most common  type of myocarditis and is often suspected to be secondary to a [[viral]] infection.


==Clinicopathological classification<ref name="pmid1960305">{{cite journal| author=Lieberman EB, Hutchins GM, Herskowitz A, Rose NR, Baughman KL| title=Clinicopathologic description of myocarditis. | journal=J Am Coll Cardiol | year= 1991 | volume= 18 | issue= 7 | pages= 1617-26 | pmid=1960305 | doi= | pmc= | url= }} </ref>==
==Differentiating Myocarditis from other Diseases==
Myocarditis must be distinguished from [[pericarditis]] and the life threatening condition of [[ST elevation myocardial infarction]].
==Risk factors==
There are no established [[risk factors]] for myocarditis.


*'''Fulminant myocarditis''' - Fulminant myocarditis occurs following a viral prodrome.  Fulminant myocarditis presents as acute severe cardiovascular compromise with ventricular dysfunction. The prognosis is good if the patient survives the acute illness<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>.  On [[endomyocardial biopsy]], there are multiple focci of inflammation.
==Screening==
There is insufficient [[evidence]] to recommend routine [[screening]] for myocarditis.


*'''Acute myocarditis''' - Acute myocarditis presents with a less distinct onset of the illness.  When the patient does present, there is already a decline in left ventricular dysfunction. Acute myocarditis may progress to [[dilated cardiomyopathy]].
==Epidemiology and Demographics==


*'''Chronic active myocarditis''' Chronic active myocarditis has a less distinct onset of the illness. There are clinical and histologic relapses and the development of ventricular dysfunction. Histologically, chronic inflammatory changes with mild to moderate fibrosis may be present.
The [[incidence]] of myocarditis is approximately 10 to 20 per 100,000 [[patients]] worldwide. It commonly affects younger individuals. Yong [[males]] are slightly more commonly affected by myocarditis than [[females]]. There is no [[racial]] predilection to myocarditis. [[Viral infections]] especially [[coxsackie B]] and [[enterovirus]] are the most common cause of myocarditis in [[Developed country|developed countries]]. While, In South America, [[Chagas' disease]] (caused by ''[[Trypanosoma cruzi]]'') is the main cause of myocarditis.  


*'''Chronic persistent myocarditis''' - Chronic persistent myocarditis has a less distinct onset ff the illness. Histologically it is characterized by persistent infiltration and myocyte necrosis.  Despite the presence of symptoms, ventricular dysfunction is absent.
==Natural History, Complications and Prognosis==
 
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]].
==Symptoms==
The symptoms and the intensity of symptoms associated with myocarditis are variable.  Myocarditis may be associated with no symptoms. If symptoms are present,they may be similar to the flu.  Patients may present with [[chest pain]] as a result of the inflammatory process involving the myocardium or with symptoms of [[congestive heart failure]]. Patients may complain of [[palpitations]], a [[racing heart]] or [[syncope]]. In fulminant myocarditis, patients present with the abrupt onset of [[flu]]-like symptoms and the abrupt onset of [[heart failure]] symptoms. In chronic and acute myocarditis, the onset of symptoms may be more insidious. Symptoms may include:
*[[Palpitations]]
*[[Chest pain]]
*[[Fatigue]]
*[[Fever]] and other signs of infection including [[headache]], muscle aches, [[sore throat]], [[diarrhea]], or rashes
*Joint pain or swelling
*[[Pedal edema]]
*[[Shortness of breath]]
*[[Fainting]], often related to irregular heart rhythms
*[[Low urine output]]


==Diagnosis==
==Diagnosis==
===Physical examination===
===History and Symptoms===
Myocarditis should be suspected in a [[patient]] with [[acute]] [[decompensation]] of [[Cardiac function curve|cardiac function]] who is at low risk of [[ischemic heart disease]]. A [[History and Physical examination|history]] of a recent (within the preceding 2-4 weeks) [[viral]] [[illness]] is often elicited in a large [[number]] of [[patients]] with myocarditis. [[Cardiac]] specific [[symptoms]] may become apparent usually in the [[subacute]] [[virus]]-clearing [[Phase (matter)|phase]]. In myocarditis due to [[drug hypersensitivity]], [[patients]] may give a [[History and Physical examination|history]] of ingesting an offending [[drug]]. In [[fulminant]] myocarditis, [[patients]] present with the abrupt onset of [[flu]]-like [[symptoms]] and the abrupt onset of [[heart failure]] [[symptoms]]. In [[chronic]] and [[acute]] myocarditis, the onset of [[symptoms]] may be more insidious.  Common [[symptoms]] of myocarditis include [[chest pain]], [[pedal edema]], [[palpitation]]s, [[fever]], and [[joint pain]]s.


Physical examination in patients with myocarditis may reveal [[tachycardia]], a [[cardiac gallop]], [[mitral regurgitation]] and [[pulmonary edema]] suggestive of [[cardiac failure]]. A [[pericardial friction rub]] may be noted in presence of concomitant [[pericarditis]], a condition sometimes referred to as [[myopericarditis]].
===Physical Examination===
There are no specific findings for myocarditis. [[Patients]] with myocarditis usually show [[signs]] of [[cardiac dysfunction]] and underlying [[diseases]]. The [[physical examination]] in [[patients]] with myocarditis may reveal [[tachycardia]], a [[cardiac gallop]], [[mitral regurgitation]] due to [[left ventricular dilation]], and [[pedal edema]] suggestive of [[cardiac failure]]. A [[pericardial friction rub]] may be noted in presence of concomitant [[pericarditis]], a condition sometimes referred to as [[myopericarditis]].


===Electrocardiographic Findings===
===Laboratory Findings===
[[Laboratory|Laboratory findings]] consistent with the [[diagnosis]] of myocarditis include [[Elevation|elevated]] [[Marker|markers]] of [[myonecrosis]], [[inflammatory]] [[Marker|markers]], and other [[biomarkers]]. [[Marker|Markers]] of [[myonecrosis]] include [[creatine kinase]] ([[CK-MB]]), [[Troponin|cardiac troponin]] I ([[cTnI]]) or T ([[cTnT]]), [[lactate dehydrogenase]] ([[LDH]]), [[alanine transaminase]] ([[ALT]]), and [[aspartate transaminase]] ([[AST]]).  [[Elevation|Elevated]] levels of [[C-reactive protein]] and [[erythrocyte sedimentation rate]] ([[ESR]]), and [[leukocytosis]] are suggestive of myocarditis. [[Serologic]] [[Marker|markers]] such as [[Fas]], [[Fas ligand]], [[interleukin-10]] or antimyosin [[autoantibodies]] are of [[prognostic]] value in myocarditis.  Other [[Autoantibodies|auto-antibodies]] such as [[ANA]] and [[rheumatoid factor]] may also be detected.


Common [[electrocardiogram|ECG]] findings in myocarditis include<ref name="pmid11070105">{{cite journal| author=Feldman AM, McNamara D| title=Myocarditis. | journal=N Engl J Med | year= 2000 | volume= 343 | issue= 19 | pages= 1388-98 | pmid=11070105 | doi=10.1056/NEJM200011093431908 | pmc= | url= }} </ref>:
===Electrocardiogram===
* [[Sinus tachycardia]]
The presence of [[ST segment elevation]] in patients with [[myocarditis]] can mimic [[pericarditis]] and [[myocardial infarction]]. [[Arrhythmias]] and [[heart block]] may also be observed in myocarditis [[patients]].  Myocarditis can be distinguished from [[pericarditis]] by the presence of [[PR depression]] in the [[patient]] with [[pericarditis]].
* Diffuse [[T wave]] inversions
* [[ST segment]] elevation may also be present


[[ST segment elevation]] may also be seen in [[pericarditis]]. [[PR]] depression is also present, however, in patients with [[pericarditis]].
===Endomyocardial Biopsy===
[[Endomyocardial biopsy]] remains the gold standard test to evaluate for the presence of and to subclassify the type of myocarditis.  A small tissue sample of the [[endocardium]] and [[myocardium]] is obtained via right sided cardiac catheterization. The sample is then evaluated by a pathologist using [[immunochemistry]] and special staining techniques as necessary.  Histopathological features include abundant [[edema]] in the myocardial [[interstitium]] and an inflammatory infiltrate which is rich in [[lymphocyte]]s and [[macrophage]]s.  Focal destruction of [[myocytes]] as a result of the inflammatory process results in [[left ventricular dysfunction]].  [[Endomyocardial biopsy]] is recommended when the results would identify an underlying disease that is amenable to therapy. Routine performance of [[endomyocardial biopsy]] is not recommended in all patients with myocarditis.
===Chest X Ray===
Findings on [[Chest X-ray|chest x-ray]] suggestive of myocarditis include [[cardiomegaly]], [[Cephalization on chest x-ray|cephalization]] of the [[pulmonary vessels]] and, [[Kerley B lines|Kerley B-lines]] in presence of [[heart failure]]  [[pericardial]] thickening in presence of [[pericarditis]], [[pulmonary edema]], and [[pleural effusion]].


===Echocardiography===
===Echocardiography===
[[Echocardiography]] in patients with [[myocarditis]] allows for serial assessment of left ventricular dysfunction. <ref name="pmid10898439">{{cite journal| author=Felker GM, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Baughman KL et al.| title=Echocardiographic findings in fulminant and acute myocarditis. | journal=J Am Coll Cardiol | year= 2000 | volume= 36 | issue= 1 | pages= 227-32 | pmid=10898439 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10898439  }} </ref>.
[[Echocardiography]] in patients with [[myocarditis]] allows for serial assessment of left ventricular dysfunction and can be used to distinguish fulminant (non-dilated [[hypocontractile left ventricle]] with thick [[interventricular septum]]) from acute myocarditis (dilated [[hypocontractile left ventricle]] with normal [[interventricular septum]]). Echocardiography may be helpful in the diagnosis of myocarditis. Findings on an echocardiography suggestive of myocarditis include wall [[Motion (physics)|motion]] [[abnormalities]], [[Systolic dysfunction|systolic]] and [[diastolic dysfunction]], changes in [[image]] texture, [[pericardial effusion]], and functional [[regurgitation]] through the [[Atrioventricular valves|AV valves]].


===Endomyocardial Biopsy===
===CT scan===
[[Cardiac]] [[CT scan]] may be helpful in the [[diagnosis]] of myocarditis. [[Cardiac]] [[CT scan]] can be used in [[diagnosis]] of [[acute myocarditis]] ( [[Epicardium|subepicardial]] late [[iodine]] enhancement), [[Exclusion criteria|exclusion]] of [[Acute coronary syndromes|acute coronary syndrome]] by [[CT angiography]], and alternative [[diagnostic]] tool in [[patients]] with [[CMR]] [[contraindications]].


Endomyocardial [[biopsy]] remains the gold standard test to evaluate for the presence of and to subclassify the type of myocarditis.  A small tissue sample of the [[endocardium]] and [[myocardium]] is obtained via right sided cardiac catheterization. The sample is then evaluated by a pathologist and if necessary using [[immunochemistry]] and special staining techniques.  Histopathological features include abundant [[edema]] in the myocardial [[interstitium]] and an inflammatory infiltrate which is rich in [[lymphocyte]]s and [[macrophage]]s. Focal destruction of [[myocytes]] as a result of the inflammatory process explains the myocardial [[pump failure]].<ref name="pmid11070105">{{cite journal| author=Feldman AM, McNamara D| title=Myocarditis. | journal=N Engl J Med | year= 2000 | volume= 343 | issue= 19 | pages= 1388-98 | pmid=11070105 | doi=10.1056/NEJM200011093431908 | pmc= | url= }} </ref>
===MRI===
[[Cardiac]] [[MRI]] is indicated in [[patients]] with new or persisting [[symptoms]] of [[chest pain]] and [[congestive heart failure]], who have [[evidence]] of [[significant]] [[myocardial injury]], in the absence of or in whom there is a low suspicion of coronary [[Atherosclerosis|atherosclerosis.]] [[Cardiac MRI]] findings associated with [[myocarditis]] include [[myocardial inflammation]], [[myocardial edema]], [[capillary leak]], and [[reduced left ventricular function]]While the [[CMR]] pattern of [[gadolinium]] hyperenhancement in [[ST segment elevation myocardial infarction]] is transmural and extends from the [[endocardium]] to the [[epicardium]], the patchy, non-segmental hyperenhancement pattern in [[myocarditis]] in contrast involves the [[epicardium]] and spares the [[Endocardium|subendocardium]]. [[CMR]] has a [[sensitivity]] of 76%, [[specificity]] of 95.5%, and overall [[diagnostic]] [[accuracy]] of 85% when any-two of the following three sequences are used, focal and global T2 signal [[intensity]], [[myocardial]] global relative enhancement, and delayed [[gadolinium]] enhancement.


===Coronary Angiography===
===Other Imaging Findings===
[[Coronary angiography]] may be helpful in excluding either [[myocardial ischemia]] or [[MI|infarction]] as the cause of [[ST segment elevation]], elevated [[cardiac biomarkers]], or [[left ventricular dysfunction]].
[[Coronary angiography]] may be helpful in excluding either [[myocardial ischemia]] or [[MI|infarction]] as the cause of [[ST segment elevation]], elevated [[cardiac biomarkers]], or [[left ventricular dysfunction]]. [[Nuclear]] [[imaging]] may be useful in [[diagnosis]] of [[cardiac sarcoidosis]].  


===Cardiac Magnetic Resonance Imaging===
===Other Diagnostic Findings===
Myocardial inflammation associated with myocarditis appears as a high intensity signal with delayed gadolinium hyperenhancement on cardiac MRI (cMRI). <ref name="pmid15936612">{{cite journal| author=Abdel-Aty H, Boyé P, Zagrosek A, Wassmuth R, Kumar A, Messroghli D et al.| title=Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. | journal=J Am Coll Cardiol | year= 2005 | volume= 45 | issue= 11 | pages= 1815-22 | pmid=15936612 | doi=10.1016/j.jacc.2004.11.069 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15936612  }} </ref>.  While the cMRI pattern of [[gadolinium]] hyperenhancement in [[ST segment elevation myocardial infarction]] is transmural and extends from the endocardium to the epicardium, the patchy, non-segmental hyperenhancement pattern in [[myocarditis]] in contrast involves the epicardium and spares the subendocardium<ref>{{cite journal |author=Skouri HN, Dec GW, Friedrich MG, Cooper LT |title=Noninvasive imaging in myocarditis |journal=J. Am. Coll. Cardiol. |volume=48 |issue=10 |pages=2085-93 |year=2006 |pmid=17112998 |doi=10.1016/j.jacc.2006.08.017}}</ref>.


===Laboratory Findings===
==Treatment==
Myocardial inflammation can be suspected on the basis of the clinical history along with elevations of<ref name="pmid11070105">{{cite journal| author=Feldman AM, McNamara D| title=Myocarditis. | journal=N Engl J Med | year= 2000 | volume= 343 | issue= 19 | pages= 1388-98 | pmid=11070105 | doi=10.1056/NEJM200011093431908 | pmc= | url= }} </ref>:
===Medical Therapy===
*Biomarkers of myocardial damage such as [[troponin]] or [[creatine kinase]]
[[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.
*Antibodies against viruses known to affect the [[myocardium]] and cause myocarditis
*[[Erythrocyte sedimentation rate|ESR]]
*[[C-reactive protein]]
*Auto antibodies such as [[ANA]] and [[rheumatoid factor]]


==Treatment==
===Surgery===
Insofar as most viral infections cannot be treated with directed therapy, symptomatic 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 after the inflammation has begun to resolve.  in patients with fulminant myocarditis, placement of an [[intra-aortic balloon pump]] or a [[left ventricular assist device]] may be necessary as bridge to recovery.
[[Cardiac transplantation]] is sometimes required to [[Therapy|treat]] [[refractory]] [[giant cell myocarditis]]. However, the [[condition]] can recur in post-[[transplant]] [[patients]].


According to 2010 HFSA guidelines<ref name="pmid20610207">{{cite journal| author=Heart Failure Society of America. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA et al.| title=HFSA 2010 Comprehensive Heart Failure Practice Guideline. | journal=J Card Fail | year= 2010 | volume= 16 | issue= 6 | pages= e1-194 | pmid=20610207 | doi=10.1016/j.cardfail.2010.04.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610207  }} </ref>, routine use of immunosuppressive therapies in management of myocarditis is not recommended ''(Strength of Evidence A)''. Immunotherapy is beneficial in [[giant cell myocarditis]]. Finally, [[cardiac transplantation]] can be performed in patients with severe myocarditis who fail to recover.
===Primary prevention===
There are no established measures for the [[primary prevention]] of all types of myocarditis. [[Vaccination]] against [[measles]], [[rubella]], [[mumps]], [[poliomyelitis]], and [[influenza]] could [[Prevention|prevent]] myocarditis [[secondary]] to these [[diseases]].


[[Bacterial infection]]s are treated with [[antibiotic]]s the selection of which is based upon the nature of the pathogen and its sensitivity to antibiotics.
===Secondary prevention===
Effective measures for the [[secondary prevention]] of myocarditis include, [[clinical]] evaluation, [[ECG]], and [[echocardiography]]. [[CMR]], [[cardiac]] [[CT scan]], [[Nuclear|nuclear assessment]] in [[patients]] that [[echocardiography]] is undiagnostic. [[Patients]] should udergo [[Cardiac function curve|cardiac function]] assessment at one and six months and yearly after that.


==References==
==References==
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Latest revision as of 16:09, 14 June 2020

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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 defined as inflammation of the myocardium. It may present with chest pain, ST segment elevation, elevated biomarkers of myonecrosis, heart failure, and/ or sudden death. Myocarditis can be classified clinicopathologically into fulminant myocarditis, acute myocarditis, chronic active myocarditis, and chronic persistent myocarditis. During either an infection or a hypersensitivity reaction, the inflammatory response may cause myonecrosis either directly or indirectly as part of an autoimmune reaction. Life-threatening causes of myocarditis include carbon monoxide poisoning and Dengue fever. Common causes of myocarditis include infections, Lyme disease, and medications. Idiopathic myocarditis is the most common type of myocarditis and is often suspected to be secondary to a viral infection. Myocarditis must be distinguished from pericarditis and the life threatening condition of ST elevation myocardial infarction. In young adults, up to 20% of all cases of sudden death are due to myocarditis. Myocarditis is slightly more frequent among males than females. 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 left bundle branch block, q waves, AV block, syncope and a left ventricular ejection fraction < 40% are associated with sudden death and cardiac transplantation. The physical examination in patients with myocarditis may reveal tachycardia, a cardiac gallop, mitral regurgitation due to left ventricular dilation, and pedal edema suggestive of cardiac failure. A pericardial friction rub may be noted in presence of concomitant pericarditis, a condition sometimes referred to as myopericarditis.

Historical Perspective

Myocarditis was first discovered by Jean Baptiste Senac, a French physician, in 1794. The term myocarditis was introduced by German physician Joseph Friedrich Sobernheim in 1837. In 1980s, the World Health Organization and the International Society and Federation of Cardiology were the first to differentiate between myocarditis and other cardiomyopathies. The Dallas criteria was published in 1986 as a guideline for classification of myocarditis.

Classification

Myocarditis can be classified based on the causative, histological, and clinicopathological criteria. Causative criteria include three main groups, as well as infectious, immune-mediated, and toxic myocarditis. Based on the type of infiltrating cells myocarditis divided in lymphocytic, eosinophilic, polymorphic, giant cell myocarditis, and cardiac sarcoidosis. Acute, fulminant, chronic active, and chronic persistent are subtypes of clinicopathopogical classification.

Pathophysiology

During either an infection or a hypersensitivity reaction, the inflammatory response may cause myonecrosis either directly or indirectly as part of an autoimmune reaction.

Causes

Life-threatening causes of myocarditis include carbon monoxide poisoning and Dengue fever. Common causes of myocarditis include infections such as Lyme disease and medications. Idiopathic myocarditis is the most common type of myocarditis and is often suspected to be secondary to a viral infection.

Differentiating Myocarditis from other Diseases

Myocarditis must be distinguished from pericarditis and the life threatening condition of ST elevation myocardial infarction.

Risk factors

There are no established risk factors for myocarditis.

Screening

There is insufficient evidence to recommend routine screening for myocarditis.

Epidemiology and Demographics

The incidence of myocarditis is approximately 10 to 20 per 100,000 patients worldwide. It commonly affects younger individuals. Yong males are slightly more commonly affected by myocarditis than females. There is no racial predilection to myocarditis. Viral infections especially coxsackie B and enterovirus are the most common cause of myocarditis in developed countries. While, In South America, Chagas' disease (caused by Trypanosoma cruzi) is the main cause of myocarditis.

Natural History, Complications and Prognosis

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.

Diagnosis

History and Symptoms

Myocarditis should be suspected in a patient with acute decompensation of cardiac function who is at low risk of ischemic heart disease. A history of a recent (within the preceding 2-4 weeks) viral illness is often elicited in a large number of patients with myocarditis. Cardiac specific symptoms may become apparent usually in the subacute virus-clearing phase. In myocarditis due to drug hypersensitivity, patients may give a history of ingesting an offending drug. In fulminant myocarditis, patients present with the abrupt onset of flu-like symptoms and the abrupt onset of heart failure symptoms. In chronic and acute myocarditis, the onset of symptoms may be more insidious. Common symptoms of myocarditis include chest pain, pedal edema, palpitations, fever, and joint pains.

Physical Examination

There are no specific findings for myocarditis. Patients with myocarditis usually show signs of cardiac dysfunction and underlying diseases. The physical examination in patients with myocarditis may reveal tachycardia, a cardiac gallop, mitral regurgitation due to left ventricular dilation, and pedal edema suggestive of cardiac failure. A pericardial friction rub may be noted in presence of concomitant pericarditis, a condition sometimes referred to as myopericarditis.

Laboratory Findings

Laboratory findings consistent with the diagnosis of myocarditis include elevated markers of myonecrosis, inflammatory markers, and other biomarkers. Markers of myonecrosis include creatine kinase (CK-MB), cardiac troponin I (cTnI) or T (cTnT), lactate dehydrogenase (LDH), alanine transaminase (ALT), and aspartate transaminase (AST). Elevated levels of C-reactive protein and erythrocyte sedimentation rate (ESR), and leukocytosis are suggestive of myocarditis. Serologic markers such as Fas, Fas ligand, interleukin-10 or antimyosin autoantibodies are of prognostic value in myocarditis. Other auto-antibodies such as ANA and rheumatoid factor may also be detected.

Electrocardiogram

The presence of ST segment elevation in patients with myocarditis can mimic pericarditis and myocardial infarction. Arrhythmias and heart block may also be observed in myocarditis patients. Myocarditis can be distinguished from pericarditis by the presence of PR depression in the patient with pericarditis.

Endomyocardial Biopsy

Endomyocardial biopsy remains the gold standard test to evaluate for the presence of and to subclassify the type of myocarditis. A small tissue sample of the endocardium and myocardium is obtained via right sided cardiac catheterization. The sample is then evaluated by a pathologist using immunochemistry and special staining techniques as necessary. Histopathological features include abundant edema in the myocardial interstitium and an inflammatory infiltrate which is rich in lymphocytes and macrophages. Focal destruction of myocytes as a result of the inflammatory process results in left ventricular dysfunction. Endomyocardial biopsy is recommended when the results would identify an underlying disease that is amenable to therapy. Routine performance of endomyocardial biopsy is not recommended in all patients with myocarditis.

Chest X Ray

Findings on chest x-ray suggestive of myocarditis include cardiomegaly, cephalization of the pulmonary vessels and, Kerley B-lines in presence of heart failure pericardial thickening in presence of pericarditis, pulmonary edema, and pleural effusion.

Echocardiography

Echocardiography in patients with myocarditis allows for serial assessment of left ventricular dysfunction and can be used to distinguish fulminant (non-dilated hypocontractile left ventricle with thick interventricular septum) from acute myocarditis (dilated hypocontractile left ventricle with normal interventricular septum). Echocardiography may be helpful in the diagnosis of myocarditis. Findings on an echocardiography suggestive of myocarditis include wall motion abnormalities, systolic and diastolic dysfunction, changes in image texture, pericardial effusion, and functional regurgitation through the AV valves.

CT scan

Cardiac CT scan may be helpful in the diagnosis of myocarditis. Cardiac CT scan can be used in diagnosis of acute myocarditis ( subepicardial late iodine enhancement), exclusion of acute coronary syndrome by CT angiography, and alternative diagnostic tool in patients with CMR contraindications.

MRI

Cardiac MRI is indicated in patients with new or persisting symptoms of chest pain and congestive heart failure, who have evidence of significant myocardial injury, in the absence of or in whom there is a low suspicion of coronary atherosclerosis. Cardiac MRI findings associated with myocarditis include myocardial inflammation, myocardial edema, capillary leak, and reduced left ventricular function. While the CMR pattern of gadolinium hyperenhancement in ST segment elevation myocardial infarction is transmural and extends from the endocardium to the epicardium, the patchy, non-segmental hyperenhancement pattern in myocarditis in contrast involves the epicardium and spares the subendocardium. CMR has a sensitivity of 76%, specificity of 95.5%, and overall diagnostic accuracy of 85% when any-two of the following three sequences are used, focal and global T2 signal intensity, myocardial global relative enhancement, and delayed gadolinium enhancement.

Other Imaging Findings

Coronary angiography may be helpful in excluding either myocardial ischemia or infarction as the cause of ST segment elevation, elevated cardiac biomarkers, or left ventricular dysfunction. Nuclear imaging may be useful in diagnosis of cardiac sarcoidosis.  

Other Diagnostic Findings

Treatment

Medical Therapy

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.

Surgery

Cardiac transplantation is sometimes required to treat refractory giant cell myocarditis. However, the condition can recur in post-transplant patients.

Primary prevention

There are no established measures for the primary prevention of all types of myocarditis. Vaccination against measles, rubella, mumps, poliomyelitis, and influenza could prevent myocarditis secondary to these diseases.

Secondary prevention

Effective measures for the secondary prevention of myocarditis include, clinical evaluation, ECG, and echocardiography. CMR, cardiac CT scan, nuclear assessment in patients that echocardiography is undiagnostic. Patients should udergo cardiac function assessment at one and six months and yearly after that.

References

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