Myocarditis

Question 1

What is myocarditis

Answer 1

Inflammation of mycoardium

Question 2

What is the most common cause of myocarditis

Answer 2

Viral infections
eg enteroviruses especially coxsackie B
HHV 6
Parvovirus B-19
Influenza A
HIV

Question 3

Other infectious causes of myocarditis

Answer 3

Rheumatic fever - strep A
Trypanosoma cruzi (chagas disease)
Diptheria - worldwide most common

Question 4

Rare causes of myocarditis

Answer 4

Radiation, chemotherapy exacerbates (antrhacyclines eg doxorubicin, trastuzumab)
AI disorders - SLE, sarcoidossi, giant cell myocarditis, kawasaki dsease
Clozapine
Pembrolizumab

Question 5

Presenting sympotms of myocarditis

Answer 5

Chest pain
Systemic upset - fatigeu, fevers, lethargy, unwell
SOB
rEDUCED exercise tolerance
Palpitations
Tachycardia
Collpase eg cardiac syncope
Sudden death
Precedng viral infection
Signs of HF on exam
Pericardial rub if concurrent pericarditis, pansystolic murmur if functional mitral regurgitation

Question 6

Bedside testing for myocarditis

Answer 6

ECG
Resp viral screening - nasopharygneal aspirate
Urine dip for blood and protein

Question 7

ECG changes myocardtis

Answer 7

ST segment elevation/depression
T wave inversion
Atrial arrhyhtmias
Transient AV block

Question 8

Blood tests for myocarditis

Answer 8

FBC
ESR
CRP
Cardiac enzymes - CK, troponin
ANA
Rf
Serum ACE
dS-dna - SLE
Viral screening - coxsackievirus group B, human immunodeficiency virus (HIV), cytomegalovirus, Ebstein-Barr virus, hepatitis A, B, C

Question 9

Imaging for myocarditis

Answer 9

ECHO
Cardiac MRI - myocarditis or MI
Endomyocardial biopsy may be considered but only if not responding to treatment and unknown cause of acute HF

Question 10

What see on ECHO in myocarditis

Answer 10

Exclude other pathologues
Generalised or regional wall abnormalities
Ejection fraction
Pericardial effusion if present - cardiac tamponade
Fulminant vs acute myocarditis - LVS and septal thicness

Question 11

Pericardial chest pain

Answer 11

dull, central and relieved by sitting forwards.

Question 12

Pericarditis vs myocarditis

Answer 12

Myocarditis may also have pericarditis
Pericarditis can -> cardiac tamponade -> acute HF
Pericarditis DOESNT show raised cardiac enzymes and ECHO should be clear

Question 13

How is takutsobo cardiomyopathy different to myocarditis on ECHO

Answer 13

egional hypokinesis of the anteroapical and inferoapical myocardium identified on echocardiogram.

Question 14

Managemnet of myocarditis

Answer 14

O2 when required
Monitoring for and control of underlying arrhtyhmias
Fluid balance management
Treat underlying cause if any identified
Early escalation to specialist intensive care physicians
Organ support as required - early escalation if any signs cardiac shock

Question 15

Cardiac shock or symptomatic hypotenson in ymocarditis treatment

Answer 15

cardiac support -inotropes = dobutamine, vasopressors = milrinone or
mechanical support - ventricular assist device
ECMO - extracorperal membrane oxygenation considered in patients refractory to chemical or mechanical support with a view of heart transplanatation

Question 16

Which type of myocarditis are steroids shown to improve survival in

Answer 16

Giant cell myocarditis

Question 17

Recovery from myocarditis recommendations

Answer 17

Avoid strenous exercise
Usual HF managment incl ACEi, BB and aldosterone antagonists
Serial ECHOs to monitor

Question 18

Short term compplications of myocarditis

Answer 18

Cardiogenic shcok
Cardiac arrhythmias - regular ECGs and new symptoms exploration
Sudden death

Question 19

Medium to long term complications of myocarditis

Answer 19

Dilated cardiomyopathy - 20%
HF

Question 20

DCM on ECHO and symptoms and tratment

Answer 20

Fatigue, SOB(worse onnexertion, possible orthopoea and PND
ECHO - dilated L and often R ventricles w dysfunctional contractility
Cardiac resynchronisation therapy incl ICD, ventricular assist devicce and heart transplant

Question 21

Types of myocarditis

Answer 21

acute myocarditis (AM) - generally <1 month),
chronic inflammatory cardiomyopathy (infl-CMP) -> myocardial inflammation with DCM or hypokinetic nondilated phenotype >1 month
Chronic myocarditis between above

eosinophilic, lymphocytic, giant cells, or granulomatous

Question 22

What if ulminant myocarditis

Answer 22

severe forms of acute myocarditis
with fast evolution and hemodynamic compromise (low-output syndrome or cardiogenic shock) requiring inotropes or MCS