Myocarditis in Emergency Medicine Follow-up
- Author: David S Howes, MD; Chief Editor: David FM Brown, MD more...
Further Inpatient Care
Patients admitted to the hospital are treated for the complications of myocarditis.
The increased use of MRI for targeting biopsy, novel immunohistochemical staining, and PCR for viral genome detection have lead to improved accuracy of the technique of endomyocardial biopsy and have secured its continued place in the evaluation and treatment of patients with suspected myocarditis.[17, 4]
Although temporary pacemaker placement for advanced degrees of heart block is indicated, in the setting of myocarditis, these conduction disturbances are usually transitory. Therefore, permanent pacemaker placement usually is not necessary.[20]
Bedrest with restriction of activity and sodium intake is beneficial.
Mechanical assist devices and extracorporeal membrane oxygenation are growing in use as bridges to recovery or heart transplant.[7, 24]
Patients with fulminant heart failure may require transplantation, which can be life saving. Unfortunately, these patients have a higher rate of rejection than patients whose underlying cause of heart failure is not myocarditis.[1]
Further Outpatient Care
The clinician may consider the placement of a Holter monitor to recognize dysrhythmias on an outpatient basis. This may be undertaken after the initial ED evaluation of a patient who shows no sign of acute dysrhythmia, CHF, or other complication. A Holter monitor may also be placed after the initial inpatient treatment.[25]
Upon discharge from the hospital, all patients with myocarditis should have follow-up visits with a cardiologist.
Recovered patients should have restricted activity for 6 months because rapid return to activity has provoked recurrent inflammation in animal models.[12]
Inpatient & Outpatient Medications
Treatment of pain with a narcotic analgesic (eg, acetaminophen with codeine) is appropriate.
Avoid nonsteroidal anti-inflammatory drugs (NSAIDs), which are relatively contraindicated in this condition.
Other outpatient medications are associated with managing the resultant congestive heart failure (CHF) and are discussed in Medication.
Complications
- Congestive heart failure - Pulmonary edema, cardiogenic shock, cardiac failure
- Dysrhythmias
- Recurrent myositis
Prognosis
Most cases are believed to be clinically silent and resolve spontaneously without sequelae; therefore, making accurate statements concerning the prognosis of myocarditis is difficult.
Patients who present with CHF experience morbidity and mortality based on the degree of left ventricular dysfunction.
Despite very serious illness initially, with aggressive support including temporary left ventricular assist device (LVAD), patients with fulminant disease and cardiovascular collapse have a good long-term prognosis.[9]
Elderly patients and patients with giant cell arteritis have a poor prognosis.[26]
Persistent viral genome expression within myocytes or the presence of antimyosin autoantibodies results in long-term ventricular dysfunction and poor outcomes.[4, 5]
One half of patients who present with new-onset CHF experience considerable improvement of cardiac function with treatment. One fourth of patients who present with CHF stabilize with compromised cardiac function. The conditions of the remaining one fourth of patients continue to deteriorate.[9]
Patients who require heart transplantation have an increased risk of recurrent myocarditis and graft rejection.
Patient Education
Patients are advised to restrict activity because studies have shown that increased activity promotes progression of inflammation.
Ellis CR, Di Salvo T. Myocarditis: basic and clinical aspects. Cardiol Rev. Jul-Aug 2007;15(4):170-7. [Medline].
Liu PP, Mason JW. Advances in the understanding of myocarditis. Circulation. Aug 28 2001;104(9):1076-82. [Medline].
Fuse K, Kodama M, Okura Y, Ito M, Hirono S, Kato K, et al. Predictors of disease course in patients with acute myocarditis. Circulation. Dec 5 2000;102(23):2829-35. [Medline].
Cooper LT Jr. Myocarditis. N Engl J Med. Apr 2009;360(15):1526-38. [Medline].
Lauer B, Schannwell M, Kuhl U, Strauer BE, Schultheiss HP. Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis. J Am Coll Cardiol. Jan 2000;35(1):11-8. [Medline].
Diaz FJ, Loewe C, Jackson A. Death caused by myocarditis in Wayne County, Michigan: a 9-year retrospective study. Am J Forensic Med Pathol. Dec 2006;27(4):300-3. [Medline].
Khabbaz Z, Grinda JM, Fabiani JN. Extracorporeal life support: an effective and noninvasive way to treat acute necrotizing eosinophilic myocarditis. J Thorac Cardiovasc Surg. Apr 2007;133(4):1122-3; author reply 1123-4. [Medline].
Chau EM, Chow WH, Chiu C, Wang E. Treatment and outcome in biopsy proven fulminant myocarditis in adults. Int J Cardiol. Jun 2006;110 (3):405-6. [Medline].
Magnani JW, Danik HJ, Dec GW Jr, DiSalvo TG. Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors. Am Heart J. Feb 2006;151(2):463-70. [Medline].
Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis: emergency department clinical findings and diagnostic evaluation. Pediatrics. Dec 2007;120 (6):1278-85. [Medline].
Kuhl U, Pauschinger M, Seeberg B, Lassner D, Noutsias M, Poller W, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation. Sep 27 2005;112(13):1965-70. [Medline].
Braunwald E, ed. Myocarditis. In: Heart Disease. 8th ed. Saunders; 2007:1775-1791.
Smith SC, Ladenson JH, Mason JW, Jaffe AS. Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates. Circulation. Jan 7 1997;95(1):163-8. [Medline].
Abdel-Aty H, Boye P, Zagrosek A, Wassmuth R, Kumar A, Messroghli D, et al. Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. J Am Coll Cardiol. Jun 7 2005;45(11):1815-22. [Medline].
Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiadis A, Vogelsberg H, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. Mar 16 2004;109(10):1250-8. [Medline].
Nelson KH, Li T, Afonso L. Diagnostic approach and role of MRI in the assessment of acute myocarditis. Cardiol Rev. Jan-Feb 2009;17(1):24-30. [Medline].
Ardehali H, Kasper EK, Baughman KL. Diagnostic approach to the patient with cardiomyopathy: whom to biopsy. Am Heart J. Jan 2005;149(1):7-12. [Medline].
Wang JF, Meissner A, Malek S, Chen Y, Ke Q, Zhang J, et al. Propranolol ameliorates and epinephrine exacerbates progression of acute and chronic viral myocarditis. Am J Physiol Heart Circ Physiol. Oct 2005;289(4):H1577-83. [Medline].
Vallejo J, Mann DL. Antiinflammatory therapy in myocarditis. Curr Opin Cardiol. May 2003;18(3):189-93. [Medline].
Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation. Feb 14 2006;113(6):876-90. [Medline].
Hia CP, Yip WC, Tai BC, Quek SC. Immunosuppressive therapy in acute myocarditis: an 18 year systematic review. Arch Dis Child. Jun 2004;89(6):580-4. [Medline].
McNamara DM, Holubkov R, Starling RC, Dec GW, Loh E, Torre-Amione G, et al. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation. May 8 2001;103(18):2254-9. [Medline].
Packer M, O'Connor CM, Ghali JK, Pressler ML, Carson PE, Belkin RN, et al. Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group. N Engl J Med. Oct 10 1996;335(15):1107-14. [Medline].
Chandra D, Kar B, Idelchik G, et al. Usefulness of percutaneous left ventricular assist device as a bridge to recovery from myocaditis. Am J Cardiol. Jun 2007;99 (12):1755-6. [Medline].
Maury P, Chilon T, Dumonteil N, Fontan A. Complete atrioventricular block persisting after regression of infectious myocarditis. Journal of Electrocardiology. Nov-Dec 2008;41 (6):665-7. [Medline].
Cooper LT Jr, Hare JM, Tazelaar HD, Edwards WD, Starling RC, Deng MC, et al. Usefulness of immunosuppression for giant cell myocarditis. Am J Cardiol. Dec 1 2008;102(11):1535-9. [Medline].
Brady WJ, Ferguson JD, Ullman EA, Perron AD. Myocarditis: emergency department recognition and management. Emerg Med Clin North Am. Nov 2004;22(4):865-85. [Medline].
Checchia P, Kulik P. Guidelines for the Treatment of Myocarditis in Infants and Children and Proceedings of the 2005 Pediatric Cardiac Intensive Care Symposium. November 2006.
Chen H, Liu J, Yang M. Corticosteroids for viral myocarditis. Cochrane Database Syst Rev. Oct 18 2006;CD004471. [Medline].
Friederich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance imaging in myocarditis: A JACC White Paper. J Am Coll Cardiol. Apr 2009;53(17):1475-87. [Medline].
Kuhl U, Schultheiss HP. Viral myocarditis: diagnosis, etiology and management. Drugs. 2009;69 (10):1287-302. [Medline].
von Korn H, Yu J, Lotze U, et al. Tako-Tsubo-like cardiomyopathy: specific ECG findings, characterization and clinical findings in a European single center. Cardiology. 2009;112 (1):42-48. [Medline].
Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, Glanowska G, Wilczewski P, Niklewski T, et al. Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. Circulation. Jul 3 2001;104(1):39-45. [Medline].
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