Myocarditis

Mini Referat
Kgs. Mahendra Effendy
 DEFINITIONS
Inflammation of the heart muscle occurring as a
result of exposure to either discrete external
antigens, such as viruses, bacteria, parasites,
toxins, or drugs, or internal triggers, such as
autoimmune activation against self-antigens

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia, PA:
Elsevier/Saunders.
 DEFINITIONS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management,
and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur
Heart J. 2013 Sep; 34(33):2636-48.
Conceptual diagram of myocarditis

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment of
Myocarditis. Circ J. 2023;advpub:CJ-22-0696.
 EPIDEMIOLOGY
● In 2015, number of cases of myocarditis was approximately 2.2 million
● Death rate 5-6 per 100000 males and 4-5 per 100000 females
● Male predominance

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
 Classification

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment
of Myocarditis. Circ J. 2023;advpub:CJ-22-0696.
 PATHOGENESIS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and
therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J.
2013 Sep 1;34(33):2636–48.
 CLINICAL MANIFESTATIONS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
 CLINICAL MANIFESTATIONS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
 DIAGNOSTIC CRITERIA

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
AV Blok
Derajat 1
AV Blok
Derajat 2
Mobitz Type I
AV Blok
Derajat 2
Mobitz Type II
AV Blok
Derajat 3
 SUSPECTED MYOCARDITIS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
 ANCILLARY FEATURES

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
 ECG in myocarditis

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis. Circ J. 2023;advpub:CJ-22-0696.
 DIAGNOSTIC

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia,
PA: Elsevier/Saunders.
 Cardiac MRI for establishing
myocarditis

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis. Circ J. 2023;advpub:CJ-22-0696.
SPECIFIC CLINICAL PRESENTATIONS
● Acute Myocarditis
○ May have prodrome symptoms (fever, chill, myalgia, and
constitutional symptoms)
○ Fatigue, DoE, arrhythmias, palpitations, chest pain at rest
○ Laboratory : elevated Troponin levels
○ ECG : ST-segment elevation
○ Echo : segmental wall motion abnormalities
● Fulminant Myocarditis
○ Abrupt onset (2 weeks of a viral illness)
○ Hemodynamic compromise and hypotension
○ Echo : diffuse global hypofunction, cardiac dilatation,
thickening of ventricular wall
○ EMB : diffuse myocarditis

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia,
PA: Elsevier/Saunders.
SPECIFIC CLINICAL PRESENTATIONS
● Giant Cell Myocarditis
○ May not be distinguishable with other form of myocarditis
initially
○ Heart failure, arrhythmias, and heart block
○ No clinical improvement despite medical therapy
○ Improve with immunosupressive therapy
○ EMB : giant cells with active inflammation and scar tissue
● Chronic Active Myocarditis
○ Insidious onset, fatigue, dyspnea
○ EMB : active myocarditis, but borderline/generalized chronic
myopathic changes with fibrosis and myocyte dropout

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia,
PA: Elsevier/Saunders.
SPECIFIC CLINICAL PRESENTATIONS
● Eosinophilic Myocarditis
○ Allergic eosinophilic
○ Myocardial, endocardial, and valvular involvement
○ Fulminant necrotic myocarditis
● Peripartum Cardiomyopathy
○ Onset of LV dysfunction in the last month of pregnancy or within 5 months of
delivery
○ NO PREEXISTING cardiac dysfunction and NO recognized cause of the
cardiomyopathy

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia,
PA: Elsevier/Saunders.
 Predictor of prognosis

Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis. Circ J. 2023;advpub:CJ-22-0696.
Diagnostic
algorithm
for acute
myocarditi
s
Nagai T, Inomata T, Kohno T, Sato T, Tada A, Kubo T, et al. JCS 2023 Guideline on the Diagnosis and Treatment of Myocarditis. Circ J.
2023;advpub:CJ-22-0696.
TREATMENT

Mann, D. L., Zipes, D. P., Libby, P., Bonow, R. O., & Braunwald, E. (2022). Braunwald's heart disease: A textbook of cardiovascular medicine (Twelfth edition.). Philadelphia,
PA: Elsevier/Saunders.
 Proposed risk-based approach

Ammirati E, Frigerio M, Adler ED, Basso C, Birnie DH, Brambatti M, et al. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy. Circ Heart
Fail. 2020 Nov;13(11):e007405.
RCTs OF IMMUNOSUPPRESIVE DRUGS

Caforio ALP, Pankuweit S, Arbustini E, Basso C, Gimeno-Blanes J, Felix SB, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of
myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J. 2013 Sep 1;34(33):2636–48.
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