Myocarditis
OVERVIEW
- inflammation of heart muscle -> lymphocytic and fibroblast infiltration + myocyte necrosis
CAUSES (HIGAAP)
- hypersensitivity
- infectious/infiltrative (haemochromatosis or amyloidosis)
- giant cell myocarditis
- autoimmune (SLE, polymyositis, scleroderma, sarcoid)
- active viral (Coxsackie B, HIV)
- post viral (lymphocytic) – (rheumatic fever)
ASSESSMENT
HISTORY
- chest pain
- fatigue
- SOB
- palpitations
- fever
- malaise
- arthralgias
EXAMINATION
- fever
- tachycardia
- S3 and S4
- pericardial rub
- signs of biventricular failure
- cardiogenic shock
INVESTIGATIONS
- leukocytosis
- eosinophilia
- elevated ESR
- elevated cardiac biomarkers
- elevated rheumatological markers
- ECG: sinus tachycardia, non-specific ST elevation, TW changes
- ECHO essential
- myocardial biopsy: diagnosis based on Dallas criteria
- enterovirus PCR/serology
- parvovirus B19 PCR/serology
- HHV6 PCR/serology
- echovirus PCR/serology
- coxsackie virus PCR/serology
- HIV
- HCV
- rheumatic fever: ASOT
- lupus screen
- coeliac disease screen
- anti-myosin antibodies
- anti beta-1 adrenoreceptor antibodies
- quantiferon gold for TB
MANAGEMENT
- most recover to normal LV function
- paradoxically the more fulminant -> the better the prognosis
- ACE-I
- beta-blockers
- aldosterone antagonists
- inotropes/vasopressors
- IABP or VAD’s should be considered
- immunosuppressive therapy (no trial data but consider in patients with documented lymphocytic myocarditis and are failing to respond to supportive treatment or in rheumatological conditions)
References and Links
LITFL
- Myocarditis – ECG Library
- Pericarditis – ECG Library
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Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.
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