- Clinical science
Myocarditis is an inflammatory disease of the myocardium that most often affects young patients, causing approx. 10% of sudden deaths in young adults. The disease is commonly caused by viral infections (e.g., parvovirus B19, coxsackie virus) or acute rheumatic fever, but may also manifest in patients with systemic conditions such as systemic lupus erythematosus or vasculitic syndromes. Adult patients are commonly asymptomatic or present with nonspecific symptoms, including fever, fatigue, and weakness. Some patients also experience cardiac signs that vary in severity from chest pain and arrhythmias to heart failure or sudden cardiac death. Infants and children typically have a more severe presentation. Inflammation may also spread and lead to concurrent pericarditis. Myocarditis should be suspected in patients with a history of flulike symptoms and new evidence of ECG abnormalities, such as sinus tachycardia or concave ST-segment elevations. Further diagnostic tests may show elevated cardiac enzymes and cardiac enlargement in chest x-rays. If diagnosis is uncertain, an additional myocardial biopsy may also be indicated. Initial management of myocarditis involves supportive measures and treatment of any underlying diseases (e.g., antibiotic therapy). Cardiac symptoms usually require additional medication, including amiodarone for arrhythmias or beta blockers for congestive heart failure. Whereas most adults with viral myocarditis make a full recovery, there is a small risk of the condition progressing to dilated cardiomyopathy. The prognosis is especially poor for infants and small children.
- The exact incidence is unknown.
- ∼ 1–5% of viral infections are estimated to have cardiac involvement.
- Often occurs in young patients (average age: ∼ 40 years)
- In ∼ 10% of sudden deaths in young adults, myocarditis is diagnosed in the post-mortem examination.
Epidemiological data refers to the US, unless otherwise specified.
- Fungal ( , )
- Protozoan (, caused by Trypanosoma cruzi, is a common pathogen in South America)
- Parasitic (, )
- (e.g., systemic lupus erythematosus)
- Vasculitis syndromes (e.g., Kawasaki disease)
- Toxic myocarditis
- Often asymptomatic, but may range from acute, fulminant cases to chronically active or persistent myocarditis
- Preceding (1–2 weeks) flulike symptoms (fever, arthralgia, myalgia, upper respiratory tract infections) → indicates possible viral cause
- In infants and young children: poor feeding, irritability, respiratory distress, and failure to thrive
- Fatigue, weakness, dyspnea, nausea, vomiting
- : often sinus tachycardia; , ventricular extrasystoles with palpitations or syncope, heart block with bradyarrhythmia
- Chest pain: indicates pericardial involvement (perimyocarditis)
- Acute decompensated with : See and .
- in fulminant cases
- Auscultation findings
The clinical manifestation of myocarditis is very heterogenous and nonspecific, ranging from asymptomatic courses to fulminant cardiac decompensation!
Patients suspected of myocarditis should have an ECG and laboratory tests conducted to support the diagnosis. Ultimately, if the diagnosis is unclear, a biopsy may be indicated to help determine treatment.
ECG/24-hour Holter monitoring
- Sinus tachycardia
- Arrhythmias: atrial or ventricular ectopic beats, complex ventricular arrhythmia, atrial tachycardia
- Repolarization abnormalities
- Heart block: , complete heart block, AV block
- Rule out myocardial infarction: loss of R wave and pathological Q wave specific to myocardial infarction, not found in myocarditis
- Pericardial effusion: low voltage (low R-wave with poor progression)
- (CK, CK-MB, troponin T)
- ↑ ESR (and CRP)
- Virus serology
- Autoantibodies: antimyolemmal IgM antibodies (AMLA), antisarcolemmal IgM antibodies (ASA)
- Chest x-ray and CT: cardiac enlargement, pulmonary congestion, pleural effusions
- Findings often unremarkable
- Ventricles: dilation, diffuse hypokinesia, reduced ejection fraction, impaired contractility, regional wall motion abnormalities
- Pericardial effusion: localized or circumferential fluid surrounding the ventricles
- Exclusion of other possible etiologies of heart failure (e.g., heart defects)
- Diagnosis and follow-ups
- Evidence of inflammatory edema
- Detection of changes in ventricular size and shape, wall motion abnormalities
- Via cardiac catheterization of the left heart and MRI-supported biopsy
- Procedure (see “
- The biopsy site is identified prior to catheterization via cardiac MRI.
- Not a routine procedure due to the risk of severe complications (perforation, arrhythmias)
- Inpatient surveillance (cardiac monitoring, oxygen administration, management of fluid status)
- Rest; avoid physical activity
- Analgesic drugs if required
- Causative treatment
- Treatment of complications
- Progression to (∼ 15% of cases)
- Concurrent pericaridits (perimyocarditis) that may lead to (associated with large pericardial effusions)
- Heart failure or sudden cardiac death: probably due to ventricular tachycardia or fibrillation
- Acute and/or persistent arrhythmias
- Atrioventricular block
We list the most important complications. The selection is not exhaustive.
- Viral myocarditis: : Most adults make a full recovery; however, progression to dilated cardiomyopathy may occur.
- Markers of poor prognosis