Acute myocarditis

Question 1

Diagnosis of acute myocarditis

Myocarditis definition

Answer 1

Inflammation +/- myocardial necrosis

Question 2

Causes

Answer 2

Infectious
Autoimmune
Toxic

Question 3

MRI

Answer 3

Bcz myocardial edema (green) and in the other scar

Only MRI capacity of tissue characterisation

Question 4

Echo

Answer 4

• no pathognomonic

Question 5

MRI

Answer 5

Edema + scar pathognomonic aspect -> sub epicardial topography

Question 6

The most commmon scenario - the pseudo-infarction presentation
24yobold man ,GI viral pro drone and then chest pain
Heart attack - like enzyme dynamics ( CKMB180 )

Answer 6

Occluded artery

Treated as ST elevation MI -> send angiography as soon as possible

Question 7

Pericardial pain

Answer 7

In expiration

Irradiates to trapezius

Question 8

Differential diagnosis

Answer 8

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

Question 9

Specific imaging aspects

Answer 9

Sarcoidosis
Hypereosinophilic myocarditis -> sub endocardial scar ,high number of eosinophils in blood

Chagas myocarditis - inflammation,aneurysm image in LV

Question 10

Evolution and prognostic

Clinical presentation

Answer 10

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

Question 11

Treatment In Acute myocarditis

NO ANTIINFLAMMATORY

Answer 11

Supportive 
- Rest , no effort 
Treatment of complications 
Cardiogenic shock 
Malignant arrhythmias + conduction disorders 
HF

Pathogenic
Immunomodulators
Immunosuppressive

Question 12

Supportive treatment in acute myocarditis

Cardiogenic shock

Answer 12

1.Transfer in specialised units capable of :

Question 13

Malignant arrhythmias + conduction disorders

Answer 13

Continuous EKG monitoring
Treatment of malignant arrhythmias
External electrical shock
Antiarrhythmic

Question 14

HF - hemodynamically stable

Answer 14

Medical treatment 
Diuretics 
aCE inhibitors 
Beta blockers 
Anti aldosterone

Question 15

NSAIDS harmful to myocarditis?

Answer 15

Yes

Question 16

Pericarditis + myocarditis

Answer 16

NSAIDS

Question 17

Only myocarditis

Answer 17

No NSAIDS

Question 18

Acute myocarditis - Clinical presentation of acute coronary syndrome

Answer 18

• 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

Question 19

Sarcoidosis

Answer 19

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

Question 20

Hypereosinophilic myocarditis

Answer 20

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

Question 21

Chagas myocarditis

Answer 21

Aneurysmal formation in the LV

Question 22

Gold standard

Answer 22

MRI

Question 23

Symptoms/physical exam

the clinical presentation is broad

Answer 23

asymptomatic
heart failure findings
e.g., dyspnea on exertion, fatigability, and volume overload
arrhythmia findings
e.g., palpitations and lightheadedness
chest pain fever

Question 24

Complications

Answer 24

Dilated cardiomyopathy
Heart failure
Sudden cardiac death

Question 25

Treatment in acute myocarditis

Answer 25

``` Supportive: Rest , no effort Treatment of complications: - Cardiogenic shock - Malignant arrhythmias and conduction disorders - Heart failure ``` Pathogenic - Immunomodulator - Immunosuppresive

Question 26

Supportive treatment in acute myocarditis | Cardiogenic shock

Answer 26

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

Question 27

Supportive treatment in acute myocarditis | Malignant arrhythmias and conduction disorders

Answer 27

- Continuous EKG monitoring - Treatment of malignant arrhythmias External electrical shock Antiaarhythmic : Amiodarone Treatment - bradycardia : Temporary pacing

Question 28

Supportive treatment in acute myocarditis | Heart failure - hemodynamically stable

Answer 28

``` Medical treatment Diuretics ACE inhibitors / angiotensin receptor blockers beta blockers antialdosteronic +/- ```

Question 29

Contraindications

Answer 29

Physical effort AINS ! Especially aspirine

Question 30

Pathogenic treatment in acute myocarditis | Immunomodulator therapies

Answer 30

Antiviral therapies - Vaccines - Herpes : aciclovir , valaciclovir - Entero/adeno viruses : interferon IV imunoglobulines Immuno-absorbtion

Question 31

Myocarditis treatment

Answer 31

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