MYOCARDITIS

Layers of the Heart Muscle

 Inflammatory Disorders of the Heart
• Endocarditis
• Pericarditis
• Myocarditis
 Myocarditis is an inflammatory
disease of the myocardium
caused by different infectious and
noninfectious triggers
Acute Viral Myocarditis
Viruses That Have Been Shown to
Cause Myocarditis

• Common • Less Common

– Coxsackievirus A – Adenovirus family
– Coxsackievirus B – Arbovirus
– Echovirus – Epstein-Barr virus
– Human immunodeficiency – Herpes simplex virus type 1
virus – Human cytomegalovirus
– Influenza – Measles virus
– Respiratory syncytial virus
– Rubella virus
– Varicella-zoster virus
Endomyocardial biopsy in acute myocarditis:
Arrow shows a collection of lymphocytes infiltrating the cardiac
muscle in response to a viral infection..
The arrowhead shows an area of cardiac muscle damage induced by
the virus directly or to the cytotoxic immune response to the viral infection.
New England Journal of Medicine 343:1391 2000
 PATHOPHYSIOLOGY OF MYOCARDITIS
THE DOMINO EFFECT
Viral Infection

Inflammation and Injury

Decreased Myocardial Contractility

Scarring Heart Enlarges: LVEDV

LAP
Dysrhythmias Cardiac Output

Pulm.
Sympathetic Tone edema

CHF
 Diagnosis
Myocarditis is a challenging diagnosis due to
the heterogeneity of clinical presentations.

Clinical presentation
Myocarditis presents in many different ways, ranging from
mild symptoms of chest pain and palpitations associated
with transient ECG changes to life-threatening cardiogenic
shock and ventricular arrhythmia
 Signs and symptoms
• Chest pain (often described as "stabbing" in character).
• CHF(leading to edema,breathlessness and hepatic congestion).
• Palpitations (due to arrhythmias).
• Sudden death (in young adults, myocarditis causes up to 20% of all
cases of sudden death).
• Fever (especially when infectious)
• Since myocarditis is often due to a viral illness, many patients give a
history of symptoms consistent with a recent viral infection,
including fever, diarrhea, joint pains, and easy fatigueability.
• Myocarditis is often associated with pericarditis, and many patients
present with signs and symptoms that suggest concurrent
myocarditis and pericarditis.
 Diagnostic Tests

• ECG- Non-specific T-wave abnormalities

• CK-MB and Troponin may be elevated
• Chest X-Ray- Variable (Normal to Cardiomegaly)
• Echocardiogram
• Cardiovascular Magnetic Resonace
• A safe and sensitive noninvasive diagnostic test to confirm the
diagnosis is not available
• Endomyocardial biopsy- there are risks and not used for every
case but is definitive for myocarditis
 Biomarkers
Inflammatory markers
ESR and CRP levels are often raised in myocarditis, but they do not
confirm the diagnosis and are often increased in acute pericarditis

While cardiac troponins are more sensitive of

myocyte injury in patients with clinically suspected
myocarditis than creatine kinase levels, they are non-
specific and when normal do not exclude myocarditis.
ECG in Myocarditis
ECG changes can be variable and include

•Sinus tachycardia
•QRS / QT prolongation
•Diffuse T wave inversion
•Ventricular arrhythmias
•AV conduction defects
•With inflammation of the adjacent pericardium, ECG features of pericarditiscan
also been seen ( myopericarditis

NB. The
most common abnormality seen in myocarditis is sinus tachycardia with
non-specific ST segment and T wave changes
 Myocarditis mimicking acute
myocardial infarction:

Occasionally, a pseudo infarct pattern and

ischemic changes are seen.
ST segment elevation is commonly seen, but ST
segment depression, T wave inversion, poor R
wave progression,and Q waves have also been
described
Chest Radiograph
 Echocardiography
•Echocardiography helps to rule out non-inflammatory
cardiac disease such as valve disease and to monitor
changes in cardiac chamber size, wall thickness, ventricular
function, and pericardial effusions.

• Global ventricular dysfunction, regional wall motion

abnormalities,and diastolic dysfunction with preserved EF
may occur in myocarditis.

• Histologically proven myocarditis may resemble dilated,

hypertrophic, and restrictive cardiomyopathy and can
mimic ischaemic heart disease.
Echocardiogram

Echocardiogram
markedly dilated heart
with ejection fraction
of 15 %, mural
thrombus was present
 Echocardiographic Findings in
Fulminant and Acute Myocarditis

Fulminant myocarditis

Acute myocarditis

Fulminant myocarditis often presents with a non-dilated, thickened, and

hypocontractile left ventricle as the intense inflammatory response results in
interstitial oedema and loss of ventricular contractility
 Fulminant myocarditis

Acute myocarditis

Fulminant myocarditis is characterized by more

extensive and diffuse lympocytic infiltration and
myocyte necrosis than acute myocarditis
The diagnosis of myocarditis made based on
clinical,laboratory, ECG, and echo findings is
not always easy.

Endomyocardial biopsy

The gold standard in diagnosis of

myocarditis is still the EMB.
Endomyocardial Biopsy
RV - EMB : THE TECHNIQUE (jugular approach)
MRI is emerging as an important tool
for the diagnosis and follow-up of
patients with acute myocarditis
 When is a heart attack
not a heart attack?

Viral myocarditis may have various

clinical presentations, sometimes
mimicking acute myocardial
infarction or ischaemia.
Disproportionate thickening, increased
Diffuse ST-segment elevation in precordial and
echogenicity, and dyskinesis of the
limb leads. Hyperacute T waves are seen
inferolateral wall relative to the septum;
in leads V2 and V3
findings are consistent with tissue edema.
(A) asymmetric thickening
consistent with extensive
myocardial oedema in the
inferior and inferolateral
segments of the left ventricle.
(B) extensive enhancement of
mid-wall and epicardium with
sparing of the subendocardium.
MRI can also play a role in discriminating myocarditis from
myocardial infarction, which can help in the evaluation of acute
chest pain.
In myocarditis the infiltrates are characteristically located in the
mid-wall and tend to spare the sub-endocardium,whereas in
infarction, the sub-endocardium is involved first.
 Treatment
Acute myocarditis resolves in about 50% of cases in the
first 2–4 weeks, but about 25% will develop persistent
cardiac dysfunction and 12–25% may acutely deteriorate
and either die or progress to end-stage DCM with a need
for heart transplantation.

The core principles of treatment in myocarditis are

optimal care of arrhythmia and of heart failure
 Treatment
* Patients with LV dysfunction or symptomatic HF
should follow current HF therapy guidelines,
including diuretics and ACE inhibitors or ARBs

*Beta-blockers can be used cautiously in the acute

setting.

*Digoxin should be avoided in patients suffering

from acute HF induced by viral myocarditis
 Diet and Lifestyle
• Restrict salt intake to 2-3g of sodium per day
• Exercise especially during the acute phase of virus
myocarditis enhances viral replication rate, enhances
immune mechanisms and increases inflammatory
lesions and necrosis.
Resumption of physical activity can take place within
2 months of the acute disease.
 Investigational treatment options.

Because mechanism-based therapy of myocarditis is not

proven, different approaches have been investigated in
clinical studies in recent years.

More than 20 treatment trials have been reported,

using immunosuppressive, immunomodulating, or
antiinflammatory agents as well as immunoadsorption
therapy
 Conclusions
Acute myocarditis presents multiple
challenges in diagnosis and treatment.
 Clinical Presentation of Myocarditis
Acute Viral Myocarditis

No Symptoms Dysrhythmias/
Heart Failure Conduction
Disorders

Chronic Dilated
Cardiomyopathy Complete Recovery
Sudden Death

Have a high clinical suspicion, if we don’t think of it, we won’t dx