MYOCARDITIS

DJOKO SOEMANTRI

INTRODUCTION

MYOCARDITIS

IS AN UNCOMMON DISEASE OF THE HEART CHARACTERIZED BY INFLAMMATION AND SUBSEQUENT

MYOCARDIAL DESTRUCTION
ACUTE
OFTEN
NON
SPECIFIC

OVERT
UNLESS

CHF
DEVELOPS

:
THE AVERAGE AGE OF PATIENTS WITH MYOCARDITIS IS 42, THE MALE TO FEMALE RATIO IS 1.5 : 1

CAUSES OF MYOCARDITIS
ENTEROVIRUSES
1

VIRUSES ARE THE MOST IMPORTANT INFECTIOUS AGENT

HIV

HAS BEEN SHOWN TO DIRECTLY

ATTACK THE MYOCARDIUM

2
BACTERIA, CHLAMYDIA, RICKETSSIA, FUNGI AND PROTOZOAN
ALONG WITH TOXIN & SYSTEMIC ILLNESS

CHAGAS DISEASE
3

THE MOST COMMON CAUSE OF MYOCARDITIS &

CARDIOMYOPATHY IN CENTRAL AND SOUTH AMERICA

HYPERSENSITIVITY
PENICILLIN, AMPICILLIN, HCT, METHYLDOPA, SULFONAMIDE

DIRECT CYTOTOXIC EFFECT ON MYOCYTE

LITHIUM, DOXORUBICIN, COCAINE, NUMEROUS CATHECOLAMINE & ACETOMINOPHEN

CAUSES OF MYOCARDITIS

ENVIROMENTAL TOXIN
LEAD, ARSENIC, CARBONMONOSIDE

SYSTEMIC DISEASE
SARCOIDOSIS, CONNECTIVE TISSUE DISORDER, SLE, GIANT CELL ARTERITIS

PAT I E N T P R E S E N TAT I O N
ACUTE

FULMINANT

OFTEN NON SPECIFIC

CONGESTIVE
HEART FAILURE
DEVELOPS

FATIGUE AND MILD

DYSPNEA

60% OF PATIENTS WITH

ANTECEDENT VIRAL SYNDROME
FEVER, FATIGUE, MYALGIA &
MALAISE

TYPICAL TIME
INTERVAL
BETWEEN VIRAL
ILLNESS & CARDIAC
INVOLVEMENT IS 2
WEEKS

ORTOPNEA,
SHORTNESS OF
BREATH
35 % OF PATIENTS
WITH CHEST PAIN
PALPITATIONS

SYNCOPE

MAY SIGNAL THE

DEVELOPMENT OF AV
BLOCK OR MALIGNANT
DYSRYTHMIAS
SUDDEN CARDIAC DEATH

PEDIATRIC (ESPECIALLY INFANTS) WILL PRESENTS WITH NON-SPECIFIC SYMPTOMPS. NEONATAL MYOCARDITIS SHOULD BE CONSIDERED
IN ANY INFANT WITH VIRAL-LIKE ILLNESS WHO DEVELOPS COMPROMISE OF CARDIAC FUNCTION.

P H Y S I C A L E X A M I N AT I O N

MILD CASE

NON-TOXIC APPEARANCE & SIMPLY APPEAR TO HAVE VIRAL SYNDROME

TACHYPNEA &
TACHYCARDIA

SEVERE CASE

OFTEN OUT OF PROPORTION TO FEVER

HYPOTENSION
CARDIOGENIC SHOCK

POOR PROGNOSIS

S3 & GALLOP
MURMUR OF MITRAL &
TRICUSPID
REGURGITATION

MAY BE PRESENT DUE TO

VENTRICULAR DILATION

FRICTION RUB

MAY BE PRESENT IF THERE IS AN

ASSOCIATED PERICARDITIS

PERICARDIAL EFFUSION
TAMPONADE

PE IS COMMON, BUT SIGNS OF

TAMPONADE IS RARE

PAT I E N T A S S E S M E N T
LABORATORY

CARDIAC ENZIM

SEDIMENTATION RATE) 60%

OF CASES
() IN MINORITY
PATIENT ONLY
SPECIFIC IF THEY
ARE
DEMONSTRATE
CHARACTERISTIC
ECG PATTERN
SLOW ELEVATION & FALL OVER A
PERIOD OF DAYS CONTRAST TO
THE MORE ABRUPT RISE IN AMI

OTHERS

() ESR (ERYTROCYTE

() LEUKOCYTOSIS 25%
OF CASES

BLOOD CULTURE

MYCOPLASMA CULTURES
MONOSPOT

() CRP

ASO

HEPATITIS PANEL

CMV SEROLOGY
NOT TYPICALLY HELPFUL IN
SECURING THE DIAGNOSIS IN
EMERGENCY DEPARTEMENT

PAT I E N T A S S E S M E N T

CHEST X-RAY (CXR)

OFTEN NORMAL
CARDIAC
SILHOUETTE

CARDIOMEGALY

MAY REVEAL A WIDE VARIETY

OF ABNORMALITES

PLEURAL EFFUSION
ENGORGED
PULMONARY VEINS
INTERSTITIAL
PULMONARY EDEMA

IN YOUNGER PEOPLE
PRESENCE OF
INFILTRAT BILATERAL
LEADS TO
MISDIAGNOSIS
PNEUMONIA

ELECTROCARDIOGRAM (ECG)

THE MOST COMMON ABNORMALITY IS

SINUS TACHYCARDIA

CARDIAC DYSRHYTHMIAS
PAC, PVC, SVT, AF, ATRIAL FLUTTER, AV
BLOCK

TAVB

(TOTAL AV BLOCK)

SYNCOPE or SUDDEN
CARDIAC DEATH (SCD)

PAT I E N T A S S E S M E N T

ECHOCARDIOGRAM
IMPAIRMENT LV SYSTOLIC &
DIASTOLIC
IMPAIRMENT EF

MYOCARDIAL BIOPSY

ENDOMYOCARDIAL BIOPSY
DIAGNOSTIC PROCEDURE OF CHOICE

PERICARDIAL EFFUSION RARE

LV THROMBUS 15% OF CASES

NUCLEAR MEDICINE
STUDY
SENSITIVITY & SPECIFICITY 83%
NEGATIVE PREDICTIVE VALUE OF 95 %

ACTIVE MYOCARDITIS
INFLAMMATORY INFILTRATE OF
THE MYOCARDIUM WITH
NECROSIS & DEGENERATION
OF ADJACENT MYOCYTES NOT
TYPICAL OF ISCHEMIA
SIGNIFICANT SAMPLING ERROR
LEADING TO ONLY 30% PATIENT WITH
POSITIVE BIOPSIES IN WHICH DISEASE
SUSPECTED

PAT I E N T M A N A G E M E N T

MILD
MILD SYMPTOMS & NO SIGNS
OF CARDIAC FAILURE & NO
DYSSRHYTMIAS

MAY BE TREATED OUTPATIENTS

LOW SODIUM DIET

SEVERE

RESTRICT ACTIVITY

IABP

LIFE SAVING

ANTICOAGULATION

REDUCE THE RISK OF

THROMBOEMBOLIZATI
ON IN PATIENTS WITH
DILATED VENTRICLES

DIGOXIN

LV DYSFUNCTION

VASODILATOR
ACE I

LUNG EDEMA

CLASS OF DRUGS HAS BEEN SHOWN TO

BENEFICIAL IN THE TREATMENT OF AGENTS

DIURETIC

IN GENERAL, SYMPATHOMIMETIC & BETA BLOCKER DRUGS SHOULD BE AVOIDED

PAT I E N T M A N A G E M E N T
IMMUNOSUPPRESIVE
THERAPY
GLUCOCORTICOID, OTHER
IMMUNOSUPPRESIVE DRUGS & NSAID

POTENTIAL TO WORSEN THE ACUTE PHASE

OF VIRAL MYOCARDITIS

LITTLE USE IN THE EMERGENCY

DEPARTEMENT

ANTIVIRAL THERAPY
PLECONARIL

ADMISSION

BOARD SPECTRUM
ANTIVIRAL DRUG

BED REST

HAS BEEN SHOWN PROMISING RESULT

AGAINTS ENTEROVIRUSES

VIRAL MYOCARDITIS IS TYPICALLY A MILD

DISEASE & RESPON WELL TO BED REST

ICCU
FOR SEVERE HF, SYNCOPE, HEART BLOCK & OTHER DYSRHYTHMIAS