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MYOCARDITIS
Dr. M. A. SOFI
MD; FRCP (London); FRCPEdin; FRCSEdin
Myocarditis
Myocarditis is an inflammatory disease of the
myocardium with a wide range of clinical
presentations, from subtle to devastating.
Clinical features of myocarditis:
Myocarditis should be suspected in patients with or
without cardiac signs and symptoms, who present
with:
 Rise in cardiac biomarker levels
 Change in electrocardiogram suggestive of
acute myocardial injury
 Arrhythmia
 Abnormalities of ventricular systolic function
Signs and symptoms
Manifests in an otherwise healthy person with rapidly progressive
(and often fatal) heart failure and arrhythmia.
• Chest pain: Mild
symptoms of chest pain
(in concurrent
pericarditis), fever,
sweats, chills, dyspnea.
• Mimic myocardial
ischemia and/or MI
symptomatically and
on the ECG particularly
in younger patients
• Recent history (≤1-2 wk)
of flulike symptoms of
fevers, arthralgias, and
malaise or pharyngitis,
tonsillitis, or upper
respiratory tract
infection in viral
myocarditis
Signs and symptoms
Manifests in an otherwise healthy person with rapidly progressive
(and often fatal) heart failure and arrhythmia.
• Palpitations: Number
of arrhythmias may be
seen.
• Sudden cardiac
death: due to
underlying ventricular
arrhythmias or
atrioventricular block
(especially in giant cell
myocarditis)
• Heart failure: Many
cases of postviral or
lymphocytic
myocarditis present
with heart failure and
dilated
cardiomyopathy.
• Rapidly evolving diffuse,
severe myocarditis can
result in acute
myocardial failure and
cardiogenic shock.
Clinical features of myocarditis
Excessive fatigue or exercise
intolerance
Partial or complete heart block,
new-onset bundle branch block
Chest pain
New onset or worsening heart
failure
Unexplained sinus tachycardia
Acute pericarditis
S3, S4, or summation gallop
Cardiogenic shock
Abnormal electrocardiogram
Sudden cardiac death
New cardiomegaly on chest x-ray Hepatomegaly
Atrial or ventricular arrhythmia
Diagnostic evaluation: The diagnostic evaluation of patients
with suspected myocarditis should include:
• History/physical
examination
• Electrocardiogram (ECG)
• Cardiac biomarkers
• Chest radiograph.
• Brain natriuretic peptide .
• An echocardiogram.
• Cardiovascular magnetic
resonance (CMR) imaging
may provide supportive
evidence of myocarditis.
• In selected patients cardiac
catheterization may aid
determination of
hemodynamic status.
• Coronary angiography in
selected patients with
clinical findings of acute
coronary syndrome.
• Potential indications for
endomyocardial biopsy
(EMB)
Diagnostic work up
Testing
Laboratory studies of
myocarditis may include:
• CBC
• ESR/C-reactive protein
• Rheumatologic
screening
• Cardiac enzyme
(creatine kinase or cardiac
troponins)
• Serum viral antibody
titers
• Viral genome testing in
endomyocardial biopsy
• Electrocardiography
Imaging studies
• Echocardiography: To
exclude causes of heart
failure ( amyloidosis or
valvular or congenital)
• Antimyosin scintigraphy:
To identify myocardial
inflammation
• Cardiac angiography: To
rule out IHD
• Gadolinium-enhanced
MRI: To assess extent of
inflammation and cellular
edema; nonspecific
Sequential chest radiographs in myocarditis
PA view sequential chest radiographs in a young man with
acute myocarditis (left). Cardiomegaly and pulmonary
congestion are apparent. Three months later, the lungs have
cleared but the patient has developed dilated cardiomyopathy
with persistent cardiomegaly.
Cardiovascular magnetic resonance images of coxsackievirus-induced
myocarditis
Cardiovascular magnetic
resonance images of a 58year-old woman with
coxsackievirus-induced
myocarditis and
ventricular tachycardia.
Late gadolinium
enhancement is seen in a
basal to mid anterior and
anterolateral distribution
(arrows). Note the
epicardial to transmural
distribution of the
enhancement, which is
more consistent with
myocarditis than
myocardial infarction.
Causes:
Drugs:
• Ethanol,
• Anthracyclines
• Chemotherapy
• Antipsychotics, e.g.
clozapine,
• Mephedrone
Physical agents
• Electric shock
• Hyperpyrexia, and radiation
Heavy metals
• (copper or iron)
Toxins: (arsenic, toxic shock
syndrome, carbon
monoxide, or snake venom)
Immunologic:
• Acetazolamide
• Heart Transplant Rejection
• Autoantigens :
– Scleroderma
– Systemic lupus
erythematosus
– Sarcoidosis
– Churg-Strauss syndrome
– Wegener's
granulomatosis,
– Kawasaki disease
Diagnosis: The diagnosis of myocarditis is usually presumptive.
Because many cases are not clinically obvious, a high degree of
suspicion is required.
• Acute rheumatic fever:
Myocarditis usually present
Usually associated signs,
with acute heart failure
such as chorea, erythema
and, in those with
marginatum, polyarthralgia.
pericarditis, with
• Hypersensitive/eosinophi
pericardial friction rub.
lic myocarditis: Pruritic
Specific findings in special
maculopapular rash and
cases are:
history of using drug
• Sarcoid myocarditis:
• Peripartum
Lymphadenopathy, also
cardiomyopathy - Heart
with arrhythmias, sarcoid
failure developing in the last
involvement in other
month of pregnancy or
organs (up to 70%)
within 5 months following
delivery
Procedures
• Endomyocardial biopsy is the standard tool
for diagnosing myocarditis.
• Routine endomyocardial biopsy for
diagnosis of myocarditis rarely is helpful
clinically.
• Histologic diagnosis seldom has an impact
on therapeutic strategies, unless giant cell
myocarditis is suspected
Management
• In improving cardiac
hemodynamics in heart
failure, as well as
providing supportive
therapy, with the hope of
prolonging survival.
• Vasodilators :
• Nitroglycerin
• Sodium
nitroprusside.
• ACEI (Enalapril)
• Diuretics (Furosemide)
• Anticoagulation may be
advisable as a preventive
measure
• Antiarrhythmics can be
used cautiously, although
most antiarrhythmic drugs
have negative inotropic
effects that may aggravate
heart failure
• Inotropic drugs
(dobutamine, milrinone)
may be necessary for severe
decompensation,they are
highly arrhythmogenic
Surgical option
Supportive care in patients Surgical intervention in
with myocarditis includes: myocarditis may include:
• Temporary transvenous
• Hemodynamic and
pacing for complete
cardiac monitoring
heart block
• Administration of
• Cardiac transplantation
supplemental oxygen
• Extreme cases:
• Fluid management
Nonpharmacotherapy


Ventricular assist device
or percutaneous
circulatory support
left ventricular assistive
devices (LVADs) and
extracorporeal
membrane oxygenation