Myocarditis: Difference between revisions

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{{Adult top}} [[myocarditis (peds)]]
==Background==
==Background==
*Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes  
*Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes  


==Causes===
===Causes===
*Infectious agents
*Infectious agents
**[[Enterovirus]] (Coxsackie B) and [[adenovirus]] most common
**[[Enterovirus]] (Coxsackie B) and [[adenovirus]] most common
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**[[CMV]]
**[[CMV]]
**[[Toxoplasma]]
**[[Toxoplasma]]
**[[Chagas]] (most common cause worldwide
**[[Chagas]] (most common cause worldwide)
**[[Trichinosis]]
**[[Trichinosis]]
**[[Diphtheria]]
**[[Diphtheria]]
**[[Lyme disease]]
**[[Lyme disease]]
**[[COVID-19]]<ref>[https://link.springer.com/article/10.1007/s11739-021-02635-w Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w]</ref>
*Drugs
*Drugs
**[[Doxorubicin]]
**[[Doxorubicin]]
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*[[Chest pain]]  
*[[Chest pain]]  
*Pericardial friction rub
*Pericardial friction rub
*Flu like syndrome
*[[Flu-like symptoms]]
**Fever, fatigue, myalgia, nausea and vomiting
**[[Fever]], [[fatigue]], [[myalgia]], [[nausea and vomiting]]
**Tachycardia (out of proportion to fever)
**[[Tachycardia]] (out of proportion to fever)
**Tachypnea
**[[Tachypnea]]
*New onset [[congestive heart failure]]
*New onset [[congestive heart failure]]
*Pediatric patients:
*Pediatric patients:
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**Ronchi
**Ronchi
*Infants may have fulminant syndrome
*Infants may have fulminant syndrome
**Fever
**[[Fever]]
**Cyanosis
**Cyanosis
**Respiratory distress
**[[Shortness of breath (peds)|Respiratory distress]]
**Tachycardia
**[[Tachycardia]]
**Heart failure
**[[Heart failure]]
**Ventricular dysrhythmias  
**[[Ventricular dysrhythmias]]


*Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids
*Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids
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==Evaluation==
==Evaluation==
*[[ECG]]
*[[ECG]]
**Sinus tachycardia
**Sinus [[tachycardia]]
**Low voltages
**[[low voltage ECG|Low voltages]]
**[[Prolonged QTc]]
**[[Prolonged QTc]]
**AV block
**[[AV block]]
**ST elevations (Usually >1 vessel distribution)  
**[[ST elevation]]s (Usually >1 vessel distribution)  
*Elevated troponin  
*Elevated [[troponin]]
*Echocardiogram
*[[Echocardiography]]
**Decreased LVEF
**Decreased LVEF
**Global hypokinesis
**Global hypokinesis
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==Management==
==Management==
*Acute phase
*Acute phase
**Antiviral agents (Pleconaril/[[Ribavirin]]) may be effective  
**Antiviral agents (Pleconaril/[[Ribavirin]]) may be effective
**COVID-related: limited/conflicting evidence regarding efficacy of high-dose [[steroids]] and/or [[IVIG]] <ref>[https://link.springer.com/article/10.1007/s11739-021-02635-w Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w]</ref>
*Subacute phase
*Subacute phase
**Studies have not shown efficacy of immunosupressants
**Studies have not shown efficacy of immunosupressants
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*Chronic phase
*Chronic phase
**Treatment for CHF symptoms
**Treatment for CHF symptoms
**Ventricular Assist Devices (VAD)
**Ventricular Assist Devices ([[LVAD|VAD]])
**Cardiac transplant
**Cardiac transplant


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*If [[CHF]] is present, admit to monitored bed
*If [[CHF]] is present, admit to monitored bed
*If hemodynamically unstable, admit to ICU
*If hemodynamically unstable, admit to ICU
==Prognosis==
*Fulminant myocarditis has best prognosis  
*Fulminant myocarditis has best prognosis  
*Mortality: 20% 1 yr/ 50% 5 yr  
*Mortality: 20% 1 yr/ 50% 5 yr  
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==Complications==
==Complications==
*Ventricular dysrhythmias  
*[[Ventricular dysrhythmias]]
*LV anneurysm
*[[LV aneurysm]]
*[[CHF]]
*[[CHF]]


Latest revision as of 19:56, 24 February 2021

This page is for adult patients. For pediatric patients, see: myocarditis (peds)

Background

  • Inflammatory (dilated) cardiomyopathy caused by necrosis of myocytes

Causes

Phases

  • Acute
    • Viral cytotoxicity and focal necrosis
  • Subacute
    • Host's humoral/immune response leading to further cell injury
  • Chronic
    • Diffuse myocardial fibrosis and cardiac dysfunction

Clinical Features

  • Consider this diagnosis in the septic-appearing patient who gets WORSE after receiving IV fluids

Differential Diagnosis

Consider other causes of CHF

Chest pain

Critical

Emergent

Nonemergent

Evaluation

Management

  • Acute phase
    • Antiviral agents (Pleconaril/Ribavirin) may be effective
    • COVID-related: limited/conflicting evidence regarding efficacy of high-dose steroids and/or IVIG [2]
  • Subacute phase
    • Studies have not shown efficacy of immunosupressants
    • Pediatric patients may receive high-dose IVIG
  • Chronic phase
    • Treatment for CHF symptoms
    • Ventricular Assist Devices (VAD)
    • Cardiac transplant

Disposition

  • If CHF is present, admit to monitored bed
  • If hemodynamically unstable, admit to ICU

Prognosis

  • Fulminant myocarditis has best prognosis
  • Mortality: 20% 1 yr/ 50% 5 yr
  • Children with 70% survival rate at 5 yrs

Complications

See Also

References

  1. ↑ Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w
  2. ↑ Mele D, Flamigni F, Rapezzi C, Ferrari R. Myocarditis in COVID-19 patients: current problems. Internal and Emergency Medicine. 2021. doi:10.1007/s11739-021-02635-w
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