Description
Myocarditis is a condition that occurs when there is inflammation in the heart muscle. The causes of myocarditis can vary widely and include viral infections, bacterial infections, fungal infections, drug reactions, and autoimmune disorders. Symptoms of myocarditis can include chest pain, shortness of breath, fatigue, palpitations, and fever. Treatment of myocarditis depends on the underlying cause, but may involve rest, medications to reduce inflammation or control the immune system, and supportive care such as fluids and oxygen. In severe cases of myocarditis, complications can occur such as heart failure, arrhythmias, and even sudden cardiac death. Prevention of myocarditis involves avoiding exposure to infectious agents and seeking prompt medical attention if symptoms develop.
Résumé
- Myocarditis is an inflammatory disease of the heart muscle caused by various infectious and non-infectious conditions. It can be classified as acute, subacute, or chronic, and can present with focal or diffuse involvement. Inherited forms, like Chagas disease or arrhythmogenic right ventricular cardiomyopathy, may mimic acute or chronic myocarditis.
- Diagnosing myocarditis is challenging due to its ill-defined frequency, variable presentation, and lack of a definitive diagnostic test. Clinical manifestations are broad, ranging from fatigue and chest pain to arrhythmias, heart failure, and sudden cardiac death. ECG abnormalities, such as ST-T wave changes, and echocardiographic findings, including ventricular dysfunction, can be suggestive.
- Clinical-pathological classification uses histologic and clinical features to aid diagnosis and management. Acute forms include fulminant and acute myocarditis, while chronic forms include active and persistent myocarditis, each with distinct clinical profiles.
- Presentations vary, including acute coronary syndrome-like symptoms, new-onset or worsening heart failure, and hemodynamic instability with arrhythmias or cardiac shock. Subacute/chronic myocarditis can manifest as frequent relapses (chronic active) or persistent chest pain without significant ventricular dysfunction (chronic persistent).
- Physical examination findings are generally non-specific but may reveal signs of volume overload or cardiac dysfunction, such as new murmurs or pericardial friction rubs. Elevated markers like CRP, ESR, BNP, and troponins can be seen in laboratory investigations.
- ECG findings can range from normal to ST-T wave changes and complex ventricular arrhythmias. High-grade AV block is more common in Lyme disease, cardiac sarcoidosis, or Chagas disease-related myocarditis. Chest X-rays can show cardiomegaly and pulmonary congestion.
- Endomyocardial biopsy, guided by the Dallas criteria, can be useful, but its decision should be based on the likelihood of impacting management. Outcome predictors include low initial ejection fraction, sustained ventricular arrhythmias, and low cardiac output syndrome.
- Management involves standard heart failure therapy, including diuretics, ACE inhibitors/ARBs, beta-blockers, and mineralocorticoid receptor antagonists. In severe cases, mechanical circulatory support (LVAD, ECMO) may be necessary. Antiarrhythmic therapy and ICD implantation can be considered for life-threatening arrhythmias.
- Immunosuppressive therapy with agents like steroids, mycophenolate mofetil, cyclosporine, or IVIG may be considered, although the evidence for benefit is not definitive. Etiological factors should be targeted with specific therapies when possible.
- Avoidance of strenuous exercise is crucial. Follow-up involves regular echocardiograms (initially every 1-3 months) to assess disease progression. Cardiac function assessments should be performed at 1 and 6 months, followed by long-term monitoring.
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