Acute myocarditis Flashcards
Diagnosis of acute myocarditis
Myocarditis definition
Inflammation +/- myocardial necrosis
Causes
Infectious
Autoimmune
Toxic
MRI
Bcz myocardial edema (green) and in the other scar
Only MRI capacity of tissue characterisation
Echo
- no pathognomonic
MRI
Edema + scar pathognomonic aspect -> sub epicardial topography
The most commmon scenario - the pseudo-infarction presentation
24yobold man ,GI viral pro drone and then chest pain
Heart attack - like enzyme dynamics ( CKMB180 )
Occluded artery
Treated as ST elevation MI -> send angiography as soon as possible
Pericardial pain
In expiration
Irradiates to trapezius
Differential diagnosis
myocardial infarction to some -> transmural
Takotsubo cardiomyopathy -> stress induced cardiomyopathy in which we have reversable hypokinesia + inflammation of myocardial muscle but its secondary to stress
Paripartum cardiomyopathy
Arrhythmogenic cardiomyopathy
Specific imaging aspects
Sarcoidosis
Hypereosinophilic myocarditis -> sub endocardial scar ,high number of eosinophils in blood
Chagas myocarditis - inflammation,aneurysm image in LV
Evolution and prognostic
Clinical presentation
Acute :
- spontaneous remission in 50% of cases after 2-4 weeks
- 25% cases - persistent cardiac dysfunction
- 12-25% cases - unfavourable evolution => death or heart transplant
Fulminant evolution:
- Cardiogenic shock => reserved prognostic
- Recovery > 80%
- Uterior good prognostic on long term
Subacute/chronic =>Dilated cardiomyopathy and heart failure
Treatment In Acute myocarditis
NO ANTIINFLAMMATORY
Supportive - Rest , no effort Treatment of complications Cardiogenic shock Malignant arrhythmias + conduction disorders HF
Pathogenic
Immunomodulators
Immunosuppressive
Supportive treatment in acute myocarditis
Cardiogenic shock
1.Transfer in specialised units capable of :
Malignant arrhythmias + conduction disorders
Continuous EKG monitoring
Treatment of malignant arrhythmias
External electrical shock
Antiarrhythmic
HF - hemodynamically stable
Medical treatment Diuretics aCE inhibitors Beta blockers Anti aldosterone
NSAIDS harmful to myocarditis?
Yes
Pericarditis + myocarditis
NSAIDS
Only myocarditis
No NSAIDS
Acute myocarditis - Clinical presentation of acute coronary syndrome
- Prodrom : viral infection (respiratory or gastrointestinal) - 1 to 4 weeks before debut
- Chest pain - frequently severe and recurrent
- ECG : ST -T changes
- Imagistic : with/without contractile dysfunction
- Biologic changes : with /without enzymatic dinamic changes suggestive of myocardial necrosis
- Angiography : normal coronary arteries
Sarcoidosis
is a specific type of myocarditis
we should think about it when we see lymph nodes enlargement or mediastinal lymph nodes enlargement typical for sarcoidosis, scar
distributed everywhere in the ventricle
Hypereosinophilic myocarditis
subendocardial hyper enhanchement,subendocardial scar but this scar is diffused,its not located only in one coronary artery , high number of eosinophils in the peripheral blood
Chagas myocarditis
Aneurysmal formation in the LV
Gold standard
MRI
Symptoms/physical exam
the clinical presentation is broad
asymptomatic heart failure findings e.g., dyspnea on exertion, fatigability, and volume overload arrhythmia findings e.g., palpitations and lightheadedness chest pain fever
Complications
Dilated cardiomyopathy
Heart failure
Sudden cardiac death
Treatment in acute myocarditis
Supportive: Rest , no effort Treatment of complications: - Cardiogenic shock - Malignant arrhythmias and conduction disorders - Heart failure
Pathogenic
- Immunomodulator
- Immunosuppresive
Supportive treatment in acute myocarditis
Cardiogenic shock
Transfer in sprecialized units capable of :
- Invasive hemodynamic monitoring
- Cardiac catheterism
- Myocardial biopsy
Hemodynamic support -Vasopressor : A,NA -Mechanic: IV aasist device ECMO
Emergency heart transplant
Supportive treatment in acute myocarditis
Malignant arrhythmias and conduction disorders
- Continuous EKG monitoring
- Treatment of malignant arrhythmias
External electrical shock
Antiaarhythmic : Amiodarone
Treatment - bradycardia :
Temporary pacing
Supportive treatment in acute myocarditis
Heart failure - hemodynamically stable
Medical treatment Diuretics ACE inhibitors / angiotensin receptor blockers beta blockers antialdosteronic +/-
Contraindications
Physical effort
AINS !
Especially aspirine
Pathogenic treatment in acute myocarditis
Immunomodulator therapies
Antiviral therapies
- Vaccines
- Herpes : aciclovir , valaciclovir
- Entero/adeno viruses : interferon
IV imunoglobulines
Immuno-absorbtion
Myocarditis treatment
Acute phase
- Rest
- Supportive - complications treatment
Chronic phase
Heart failure treatment
Immunomodulary/immunosupression treatment:
- Extremely limited role
- Indication based on the result of the endomyocardial biopsy
