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Myocarditis - Causes, Symptoms, Diagnosis And Treatment

Myocarditis. Symptoms. Diagnostics. What to do when diagnosed with myocarditis. Conservative treatment and operations.

By Artur Kh.Published 2 years ago 10 min read
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Myocarditis is an inflammation of the muscular lining of the heart (myocardium), more often of a rheumatic, infectious or infectious-allergic nature. The course of myocarditis can be acute or chronic. Acute myocarditis is manifested by shortness of breath, cyanosis, swelling of the legs, swelling of the veins in the neck, heart pain, palpitations, arrhythmias. Often, the development of myocarditis is preceded by a previous infection (diphtheria, sore throat, scarlet fever, flu, etc.). In the future, relapses of the disease (with rheumatic myocarditis), the development of heart failure and thromboembolism of the vessels of various organs are possible.

General information

Myocarditis is an inflammation of the muscular lining of the heart (myocardium), more often of a rheumatic, infectious or infectious-allergic nature. The course of myocarditis can be acute or chronic. Acute myocarditis is manifested by shortness of breath, cyanosis, swelling of the legs, swelling of the veins in the neck, heart pain, palpitations, arrhythmias. Often, the development of myocarditis is preceded by a previous infection (diphtheria, sore throat, scarlet fever, flu, etc.). In the future, relapses of the disease (with rheumatic myocarditis), the development of heart failure and thromboembolism of the vessels of various organs are possible.

The incidence of myocarditis is much higher statistically due to late diagnosis and latent forms when the disease is erased or in mild form. Signs of an inflammatory process in the myocardium in 4-9% of cases are detected only at autopsy (according to the results of pathoanatomic studies). From 1 to 7% of patients die from acute myocarditis, in young people in 17-21% of cases it becomes the cause of sudden death.

Myocarditis leads to the development of heart failure and cardiac arrhythmia, which are the leading causes of death. Myocarditis is more common in young people (the average age of patients is 30 - 40 years), although the disease can occur at any age. Men get myocarditis a little less often than women, but they often develop severe forms of the disease.

Causes of myocarditis

Myocarditis includes a large group of diseases of the heart muscle of inflammatory genesis, manifested by damage and dysfunction of the myocardium. A common cause of myocarditis are various infectious diseases:

  • viral (Coxsackie viruses, influenza, adenoviruses, herpes, hepatitis B and C);
  • bacterial (corineobacteria diphtheria, staphylococci, streptococci, salmonella, chlamydia, rickettsia);
  • fungal (aspergillus, candida),;
  • parasitic (trichinella, echinococcus), etc.

Severe myocarditis can occur with diphtheria, scarlet fever, sepsis. Viruses that cause myocarditis in 50% of cases have high cardiotropicity. Sometimes myocarditis develops in systemic connective tissue diseases: systemic lupus erythematosus, rheumatism, vasculitis, rheumatoid arthritis, allergic diseases. Also, the cause of myocarditis can be the toxic effects of certain medications, alcohol, ionizing radiation. Severe progressive course is distinguished by idiopathic myocarditis of unclear etiology.

The provoking moments of myocarditis are acute infections (more often viral), foci of chronic infection; allergoses, impaired immunological reactions; toxic effects on the body (drugs, alcohol, drugs, ionizing radiation, thyrotoxicosis, uremia, etc.).

Pathogenesis

Myocarditis in most cases is accompanied by endocarditis and pericarditis, less often the inflammatory process affects only the myocardium. Myocardial damage can occur with the direct myocardiocytolytic action of an infectious agent; under the influence of toxins circulating in the blood (in the case of systemic infection); and as a result of an allergic or autoimmune reaction. Infectious and allergic myocarditis are often found.

Immune disorders observed in myocarditis are manifested by a disorder of all parts of immunity (cellular, humoral, phagocytosis). The infectious antigen triggers the mechanism of autoimmune damage to cardiomyocytes, leading to significant changes in the myocardium: dystrophic changes in muscle fibers, the development of exudative or proliferative reactions in interstitial tissue. The consequence of inflammatory processes in myocarditis is the proliferation of connective tissue and the development of cardiosclerosis. With myocarditis, the pumping function of the heart muscle is noticeably reduced, which is often irreversible and leads to a severe state of circulatory insufficiency, heart rhythm and conduction disorders, causes disability and death at a young age.

Classification

Depending on the mechanism of occurrence and development of myocarditis, the following forms are distinguished:

  • infectious and infectious-toxic (with influenza, Coxsackie group viruses, diphtheria, scarlet fever, etc.);
  • allergic (immune) (serum, infectious-allergic, transplantation, medicinal, myocarditis in systemic diseases);
  • toxic-allergic (with thyrotoxicosis, uremia and alcoholic heart disease);
  • idiopathic (unexplained nature).

According to the prevalence of inflammatory lesions, myocarditis are divided into diffuse and focal. Acute, subacute, chronic (progressive, recurrent) myocarditis are distinguished along the course. By severity - mild, myocarditis of moderate severity, severe.

By the nature of inflammation, exudative-proliferative (inflammatory-infiltrative, vascular, dystrophic, mixed) and alternative (dystrophic-necrobiotic) myocarditis are distinguished. In the development of infectious myocarditis (as the most common), there are 4 pathogenetic stages:

  1. Infectious-toxic
  2. Immunological
  3. Dystrophic
  4. Myocardiosclerotic

According to clinical variants (according to the prevailing clinical symptoms), myocarditis is distinguished:

  • low-symptomatic
  • painful or pseudocoronary
  • decompensation (with circulatory disorders)
  • arrhythmic
  • thromboembolic
  • pseudo - valvular
  • mixed

Symptoms of myocarditis

The clinical symptoms of myocarditis depend on the degree of myocardial damage, localization, severity and progression of the inflammatory process in the heart muscle. It includes manifestations of myocardial contractile function insufficiency and cardiac arrhythmias. Infectious-allergic myocarditis, unlike rheumatic, usually begins against the background of infection or immediately after it. The onset of the disease may be asymptomatic or latent.

The main complaints of patients are severe weakness and fatigue, shortness of breath during exercise, pain in the heart (aching or paroxysmal), rhythm disturbances (palpitations, interruptions), excessive sweating, sometimes joint pain. Body temperature is usually subfebrile or normal. The characteristic manifestations of myocarditis are an increase in the size of the heart, a decrease in blood pressure, and circulatory insufficiency.

The skin of patients with myocarditis is pale, sometimes with a bluish tinge. The pulse is rapid (sometimes reduced), may be arrhythmic. With severe heart failure, swelling of the cervical veins is observed. There is a violation of intracardiac conduction, which, even with small lesions, can cause arrhythmia and lead to death. Cardiac arrhythmia is manifested by supraventricular (supraventricular) extrasystole, less often by attacks of atrial fibrillation, which significantly worsens hemodynamics, increases the symptoms of heart failure.

In most cases, only some of the symptoms listed above prevail in the clinical picture of myocarditis. In about a third of patients, myocarditis may be asymptomatic. With myocarditis occurring against the background of collagen diseases, as well as viral infection, concomitant pericarditis often occurs. Idiopathic myocarditis has a severe, sometimes malignant course, leading to cardiomegaly, severe disturbances of the rhythm and conduction of the heart and heart failure.

Complications

With long-term myocarditis, sclerotic lesions of the heart muscle develop, myocarditis cardiosclerosis occurs. In the case of acute myocarditis with severe cardiac disorders, heart failure, arrhythmia, which cause sudden death, rapidly progresses.

Diagnostics

The absence of specific diagnostic criteria causes significant difficulties in the diagnosis of myocarditis. Measures to detect the inflammatory process in the myocardium include:

  • Collection of anamnesis
  • Physical examination of the patient - symptoms range from moderate tachycardia to decompensated ventricular failure: swelling, swelling of the cervical veins, cardiac arrhythmia, congestion in the lungs.
  • ECG is a violation of the heart rhythm, excitability and conduction. ECG changes in myocarditis are not specific, as they are similar to changes in various heart diseases.
  • Echocardiography - myocardial pathology is detected (expansion of the heart cavities, decreased contractility, impaired diastolic function) to varying degrees depending on the severity of the disease.
  • General, biochemical, and immunological blood tests are not so specific for myocarditis and show an increase in the content of α2 and γ - globulins, an increase in the titer of antibodies to the heart muscle, a positive RTML (lymphocyte migration inhibition reaction), a positive test for C-reactive protein, an increase in sialic acids, and the activity of cardiospecific enzymes. The study of immunological parameters should be carried out in dynamics.
  • Lung radiography helps to detect an increase in the size of the heart (cardiomegaly) and stagnant processes in the lungs.
  • Back-seeding of blood to identify the pathogen, or PCR diagnostics.
  • Endomyocardial biopsy using probing of the heart cavities, including histological examination of myocardial biopsies, confirms the diagnosis of myocarditis in no more than 37% of cases due to the fact that focal myocardial lesion may occur. The results of repeated myocardial biopsy make it possible to assess the dynamics and outcome of the inflammatory process.
  • Scintigraphy (radioisotope study) of the myocardium is a physiological study (the natural migration of leukocytes to the focus of inflammation and suppuration is traced).
  • Magnetic resonance imaging (MRI of the heart) with contrast gives visualization of the inflammatory process, edema in the myocardium. The sensitivity of this method is 70-75%.

Treatment of myocarditis

The acute stage of myocarditis requires hospitalization in the cardiology department, restriction of physical activity, strict bed rest for 4 to 8 weeks until blood circulation compensation is achieved and the normal size of the heart is restored. The diet for myocarditis involves the limited use of table salt and liquid, enriched protein and fortified nutrition to normalize metabolic processes in the myocardium.

Myocarditis therapy is carried out simultaneously in four directions, carrying out etiological, pathogenetic, metabolic symptomatic treatment. Etiological treatment is aimed at suppressing the infectious process in the body. Therapy of bacterial infections is carried out with antibiotics after isolation and determination of the sensitivity of the pathogenic microorganism. With myocarditis of viral genesis, the appointment of antiviral drugs is indicated.

A prerequisite for the successful treatment of myocarditis is the identification and rehabilitation of infectious foci that support the pathological process: tonsillitis, otitis, sinusitis, periodontitis, adnexitis, prostatitis, etc. After the rehabilitation of foci (surgical or therapeutic), a course of antiviral or antibacterial therapy, it is necessary to conduct microbiological control of cure.

The pathogenetic therapy of myocarditis includes anti-inflammatory, antihistamines and immunosuppressive drugs. The appointment of nonsteroidal anti-inflammatory drugs is carried out individually, with the selection of dosages and duration of treatment; the criterion for cancellation is the disappearance of laboratory and clinical signs of inflammation in the myocardium. In severe, progressive course of myocarditis, glucocorticoid hormones are prescribed. Antihistamines help to block inflammatory mediators.

To improve the metabolism of the heart muscle in myocarditis, potassium preparations, inosine, vitamins, ATP, cocarboxylase are used. Symptomatic treatment of myocarditis is aimed at eliminating arrhythmias, arterial hypertension, symptoms of heart failure, prevention of thromboembolism. The duration of treatment of myocarditis is determined by the severity of the disease and the effectiveness of complex therapy and averages about six months, and sometimes longer.

Forecast

With a latent, low-symptomatic course of myocarditis, spontaneous clinical cure is possible without long-term consequences. In more severe cases, the prognosis of myocarditis is determined by the prevalence of myocardial damage, the features of the inflammatory process and the severity of the background disease.

With the development of heart failure, 50% of patients have an improvement in the results of treatment, a quarter have a stabilization of cardiac activity, the remaining 25% have a progressive deterioration. The prognosis for myocarditis complicated by heart failure depends on the severity of left ventricular dysfunction.

An unsatisfactory prognosis is noted in some forms of myocarditis: giant cell (100% mortality with conservative therapy), diphtheria (mortality is up to 50-60%), myocarditis caused by Chagas disease (American trypanosomiasis), etc. In these patients, the issue of heart transplantation is being resolved, although the risk of recurrent myocarditis and transplant rejection is not excluded.

Prevention

To reduce the risk of myocarditis, it is recommended to take precautions when contacting infectious patients, sanitize foci of infection in the body, avoid tick bites, vaccinate against measles, rubella, influenza, mumps, polio.

Patients who have suffered from myocarditis undergo follow-up by a cardiologist 1 time every 3 months with a gradual restoration of the regime and activity.

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About the Creator

Artur Kh.

Writer, doctor and businessman. I blog about self-development, personal growth, health and new ways of making money.

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