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, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC