eMedicine Specialties > Emergency Medicine > Cardiovascular

Myocarditis: Follow-up

Author: David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
Coauthor(s): Ethan A Booker, MD, Attending Physician, Department of Emergency Medicine, Washington Hospital Center
Contributor Information and Disclosures

Updated: Aug 5, 2008

Follow-up

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.
  • 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.
  • 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.
  • 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.

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.
  • 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.

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 CHF and are discussed in Medication.

Complications

  • Congestive heart failure
    • Pulmonary edema
    • Cardiogenic shock
    • Cardiac failure
  • Dilated cardiomyopathy
  • 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.
  • Of patients who present with cardiogenic shock, elderly patients and patients with giant cell arteritis have a poor prognosis.
  • Patients with HIV and persistent viral genome expression from myocytes have dismal outcomes.
  • 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.
  • Patients who require transplantation have an increased risk of recurrent myocarditis and graft rejection.

Patient Education

  • Patients are advised to restrict activity since studies have shown that increased activity promotes progression of inflammation.

Miscellaneous

Medicolegal Pitfalls

  • Myocarditis may present subtly, but it should be considered in the patient who presents with dyspnea and chest discomfort, particularly if the history includes a recent viral illness.
    • Careful physical examination looking for signs of CHF and pericarditis is helpful. Electrocardiography, ESR, and cardiac enzyme levels are useful screening tools.
    • Patients with evidence of dysrhythmia, CHF, or thromboembolism must be admitted.
 


More on Myocarditis

Overview: Myocarditis
Differential Diagnoses & Workup: Myocarditis
Treatment & Medication: Myocarditis
Follow-up: Myocarditis
References
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References

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Further Reading

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Keywords

myocarditis, heart inflammation, dilated cardiomyopathy, inflammatory changes in the heart muscle, myocyte necrosis, viral myocarditis, acute myocarditis, inflammatory myocarditis, Chagas disease, coxsackievirus B, influenza virus, echovirus, herpes simplex virus, varicella-zoster virus, Epstein-Barr virus, cytomegalovirus, hepatitis C, HIV, diphtheria, Bartonella species, Brucella species, Leptospira species, Salmonella species, endocarditis, Borrelia burgdorferi, toxic myocarditis, parasitic myocarditis

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Contributor Information and Disclosures

Author

David S Howes, MD, Residency Program Director, Professor of Medicine, Section of Emergency Medicine, University of Chicago/Pritzker School of Medicine
David S Howes, MD is a member of the following medical societies: American College of Emergency Physicians, American College of Physicians-American Society of Internal Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Ethan A Booker, MD, Attending Physician, Department of Emergency Medicine, Washington Hospital Center
Ethan A Booker, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Eric M Kardon, MD, FACEP, Attending Emergency Physician, Georgia Emergency Medicine Specialists and Emergency Physicians of Tidewater; Division of Emergency Medicine, Athens Regional Medical Center
Eric M Kardon, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

David FM Brown, MD, Assistant Professor, Department of Medicine, Division of Emergency Medicine, Harvard Medical School; Associate-Chief, Attending Physician, Department of Emergency Medicine, Massachusetts General Hospital
David FM Brown, MD is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine
Disclosure: Schering  Honoraria Speaking and teaching

 
 
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