Myocarditis in Emergency Medicine Treatment & Management

  • Author: David S Howes, MD; Chief Editor: David FM Brown, MD   more...
 
Updated: Dec 8, 2010
 

Emergency Department Care

Because many cases of myocarditis are not clinically obvious, a high degree of suspicion is required to identify acute myocarditis.

Fortunately, most patients have mild symptoms consistent with viral syndromes, and they recover with simple supportive care on an outpatient basis.

Standard treatment of clinically significant disease includes the detection of dysrhythmia with cardiac monitoring, supplemental oxygen, and managing fluid status.

Left ventricular dysfunction developing from myocarditis should be approached in much the same manner as other causes of CHF with some exceptions (see Medication).

In general, sympathomimetic drugs should be avoided because they increase the extent of myocardial necrosis and mortality.[18]

Beta-blockers should be avoided in the acutely decompensating phase of illness, but studies that have used carvedilol in recovery phases have shown decreases in the expression of several different histochemicals, subsequent inflammatory myocyte infiltrate, and mortality.[18]

Patients who present with Mobitz II or complete heart block require temporary pacemaker placement. Very few patients require permanent pacer or automatic implantable cardioverter-defibrillator (AICD) placement.[4]

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Consultations

Patients who require emergency room treatment for new-onset congestive heart failure (CHF), dysrhythmia, or cardiogenic shock should be admitted to the hospital with continuous cardiac monitoring and cardiology consultation.

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Contributor Information and Disclosures
Author

David S Howes, MD  Professor of Medicine and Pediatrics, Section Chief and Emergency Medicine Residency Program Director, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, 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.

Specialty Editor Board

Eric M Kardon, MD, FACEP  Attending Emergency Physician, Georgia Emergency Medicine Specialists; Physician, 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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

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.

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  Associate Professor, Division of Emergency Medicine, Harvard Medical School; Vice Chair, 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: Nothing to disclose.

References

  1. Ellis CR, Di Salvo T. Myocarditis: basic and clinical aspects. Cardiol Rev. Jul-Aug 2007;15(4):170-7. [Medline].

  2. Liu PP, Mason JW. Advances in the understanding of myocarditis. Circulation. Aug 28 2001;104(9):1076-82. [Medline].

  3. 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].

  4. Cooper LT Jr. Myocarditis. N Engl J Med. Apr 2009;360(15):1526-38. [Medline].

  5. 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].

  6. 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].

  7. 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].

  8. 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].

  9. 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].

  10. 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].

  11. 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].

  12. Braunwald E, ed. Myocarditis. In: Heart Disease. 8th ed. Saunders; 2007:1775-1791.

  13. 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].

  14. 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].

  15. 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].

  16. 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].

  17. 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].

  18. 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].

  19. Vallejo J, Mann DL. Antiinflammatory therapy in myocarditis. Curr Opin Cardiol. May 2003;18(3):189-93. [Medline].

  20. Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation. Feb 14 2006;113(6):876-90. [Medline].

  21. 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].

  22. 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].

  23. 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].

  24. 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].

  25. 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].

  26. 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].

  27. 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].

  28. 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.

  29. Chen H, Liu J, Yang M. Corticosteroids for viral myocarditis. Cochrane Database Syst Rev. Oct 18 2006;CD004471. [Medline].

  30. 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].

  31. Kuhl U, Schultheiss HP. Viral myocarditis: diagnosis, etiology and management. Drugs. 2009;69 (10):1287-302. [Medline].

  32. 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].

  33. 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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