Miokarditis (Inflamasi pada Otot Jantung)

Myocarditis
Myocarditis
Rahmad Isnanta, MD /
Rahmad Isnanta, MD / Zainal Safri, MD /
Zainal Safri, MD / Refli Hasan, MD
Refli Hasan, MD

Myocarditis
Myocarditis :
:
defined as inflammatory changes in
defined as inflammatory changes in
t
the heart muscle and is characterized by
he heart muscle and is characterized by
myocyte necrosis.
myocyte necrosis.

Background
Background
 Myocarditis is collection of diseases of infectious, toxic,
is collection of diseases of infectious, toxic,
and autoimmune etiologies characterized by
and autoimmune etiologies characterized by
inflammation of the heart.
inflammation of the heart. Subsequent myocardial
Subsequent myocardial
destruction can lead to dilated cardiomyopathy.
destruction can lead to dilated cardiomyopathy.
Myocarditis :
: the clinical presentation may range from
the clinical presentation may range from
nearly asymptomatic to overt heart failure requiring
nearly asymptomatic to overt heart failure requiring
transplantation
transplantation,
, and it is occasionally the unrecognized
and it is occasionally the unrecognized
culprit in cases of sudden death
culprit in cases of sudden death.
.

Sex and Age
Sex and Age
Sex
Sex
 The male-to-female ratio is 1.5
The male-to-female ratio is 1.5 :
: 1
1
Age
Age
 The average age of patients with myocarditis is
The average age of patients with myocarditis is
42 years. It is a prominent cause of sudden
42 years. It is a prominent cause of sudden
cardiac death in young adults, accounting for 8-
cardiac death in young adults, accounting for 8-
12% of such deaths.
12% of such deaths.

Clinical Manifestations
Many patients present with a nonspecific illness characterized by
Many patients present with a nonspecific illness characterized by
fatigue, mild dyspnea, and myalgias. A few patients present acutely
fatigue, mild dyspnea, and myalgias. A few patients present acutely
with fulminant congestive heart failure (CHF)
with fulminant congestive heart failure (CHF)
Small and focal areas of inflammation in electrically sensitive areas may
Small and focal areas of inflammation in electrically sensitive areas may
be the etiology in patients whose initial presentation is sudden death.
be the etiology in patients whose initial presentation is sudden death.
Most cases of myocarditis are subclinical; therefore, the patient rarely
Most cases of myocarditis are subclinical; therefore, the patient rarely
seeks medical attention during acute illness. These subclinical cases
seeks medical attention during acute illness. These subclinical cases
may have transient ECG abnormalities.
may have transient ECG abnormalities.
The appearance of cardiac-specific symptoms occurs primarily in the
The appearance of cardiac-specific symptoms occurs primarily in the
subacute virus-clearing phase; therefore, patients commonly present 2
subacute virus-clearing phase; therefore, patients commonly present 2
weeks after the acute viremia.
weeks after the acute viremia.

 An antecedent viral syndrome is present in more than one half of
An antecedent viral syndrome is present in more than one half of
patients with myocarditis.
patients with myocarditis.
 Fever is present in 20% of patients.
Fever is present in 20% of patients.
 Other symptoms include fatigue, myalgias and arthralgias, and
Other symptoms include fatigue, myalgias and arthralgias, and
malaise.
malaise.
 Chest pain
Chest pain
 Chest discomfort is reported in 35% of patients.
Chest discomfort is reported in 35% of patients.
 The pain is most commonly described as a pleuritic, sharp,
The pain is most commonly described as a pleuritic, sharp,
stabbing precordial pain.
stabbing precordial pain.
 It may be substernal and squeezing and, therefore, difficult to
It may be substernal and squeezing and, therefore, difficult to
distinguish from that typical of ischemic pain.
distinguish from that typical of ischemic pain.
 Dyspnea on exertion is common.
Dyspnea on exertion is common.

 Orthopnea
Orthopnea and
and shortness of breath
shortness of breath at rest may be noted if CHF
at rest may be noted if CHF
is present.
is present.
 Palpitations
Palpitations are common.
are common. Syncope
Syncope in a patient with a
in a patient with a
presentation consistent with myocarditis should be carefully
presentation consistent with myocarditis should be carefully
approached because it may signal
approached because it may signal high-grade atrioventricular
high-grade atrioventricular
(AV) block
(AV) block or
or risk for sudden death
risk for sudden death.
.
 Pediatric patients
Pediatric patients, particularly infants, present with nonspecific
, particularly infants, present with nonspecific
symptoms, including the following:
symptoms, including the following:
 Respiratory distress
Respiratory distress
 Poor feeding or, in cases with CHF, sweating while feeding
Poor feeding or, in cases with CHF, sweating while feeding
 Cyanosis in severe cases
Cyanosis in severe cases

Etiologi
Etiologi
Schultheiss HP., et al. 2011. The management of my

Gejala klinis
Gejala klinis
Cooper LT, et al. 20
Asimptomatik
Asimptomatik
Nyeri dada
Nyeri dada
Palpitasi
Palpitasi
Cepat lelah
Cepat lelah
Sesak napas
Sesak napas
Ortopneu
Ortopneu
Bengkak tungkai
Bengkak tungkai
Syok
Syok
Sudden death
Sudden death
Pemeriksaan
fisik
• Tanpa kelainan
• Unstable hemodinamik
• Aritmia (Extrabeat, AF)
• JVP meningkat
• Kardiomegali
• S3 / S4
• Murmur
• Rhonki basah halus
• Edema tungkai

Penunjang…
Penunjang…
Elektrokardiogram
Normal, abnormal, nonspesifik
Enzim jantung
Peningkatan enzim jantung
dapat ditemukan
Rontgen dada
Normal, Kardiomegali, Edema p
Efusi pleura
Echocardiografi
Disfungsi ventrikel dll
MRI
MRI dengan gandolinium
Skintigrafi
Antimiosin skintigrafi
Endomyocardial biopsy
Gold standart
Cooper LT, et al. 20

Diagnosis..
Diagnosis..
 Dallas criteria
Dallas criteria
 myocarditis active require the presence of
myocarditis active require the presence of
inflammatory cells simultaneous with evidence of
inflammatory cells simultaneous with evidence of
myocyte necrosis on the same microscopic section
myocyte necrosis on the same microscopic section
on examination of a myocardial biopsy
on examination of a myocardial biopsy
 Borderline myocarditis is characterized by
Borderline myocarditis is characterized by
inflammatory cell infiltrate without myocardial
inflammatory cell infiltrate without myocardial
necrosis
necrosis
Liu P., et al. 201

Diagnosis..
Diagnosis..
Category I: Clinical Symptoms
Category I: Clinical Symptoms
 Clinical heart failure
Clinical heart failure
 Fever
Fever
 Viral prodrome
Viral prodrome
 Fatigue
Fatigue
 Dyspnea on exertion
Dyspnea on exertion
 Chest pain
Chest pain
 Palpitations
Palpitations
 Presyncope or syncope
Presyncope or syncope
Liu P., et al. 201

Diagnosis..
Diagnosis..
Category II Evidence of Cardiac Structural or Functional Perturbation in
Category II Evidence of Cardiac Structural or Functional Perturbation in
the absence of Regional Coronary Ischemia
the absence of Regional Coronary Ischemia
Echocardiography
Echocardiography
 Regional wall motion abnormalities
Regional wall motion abnormalities
 Cardiac dilation
Cardiac dilation
 Regional cardiac hypertrophy
Regional cardiac hypertrophy
Troponine
Troponine
 High sensitivity (>0.1 ng/mL)
High sensitivity (>0.1 ng/mL)
Positive indium In 111 antimyosin
Positive indium In 111 antimyosin scintigraphy
scintigraphy and Normal coronary
and Normal coronary
angiography or Absence of reversible ischemia by coronary distribution on
angiography or Absence of reversible ischemia by coronary distribution on
perfusion scan
perfusion scan
Liu P., et al. 201

Diagnosis..
Diagnosis..
Category III: Cardiac Magnetic Resonance Imaging
Category III: Cardiac Magnetic Resonance Imaging
 Increased myocardial T2 signal on inversion recovery
Increased myocardial T2 signal on inversion recovery
sequence
sequence
 Delayed contrast enhancement after gadolinium-DTPA
Delayed contrast enhancement after gadolinium-DTPA
infusion
infusion
Liu P., et al. 201

Diagnosis..
Diagnosis..
Category IV: Myocardial biopsy (Pathologic or
Category IV: Myocardial biopsy (Pathologic or
Molecular Analysis)
Molecular Analysis)
 Pathology findings compatible with Dallas criteria
Pathology findings compatible with Dallas criteria
 Presence of viral genome by polymerase chain reaction or in
Presence of viral genome by polymerase chain reaction or in
situ hybridization
situ hybridization
Liu P., et al. 201

Diagnosis..
Diagnosis..
 Any matching feature in category = positive for category
Any matching feature in category = positive for category
 Suggestive of myocarditis
Suggestive of myocarditis
 2 positive categories
2 positive categories
 Compatible with myocarditis
Compatible with myocarditis
 3 positive categories
3 positive categories
 High probability of being myocarditis
High probability of being myocarditis
 all 4 categories positive
all 4 categories positive
Liu P., et al. 201

Tatalaksana
Tatalaksana
Liu P., et al. 201

Physical Examinations
 Physical findings can range from nearly normal
Physical findings can range from nearly normal
examination findings to signs of fulminant CHF.
examination findings to signs of fulminant CHF.
Patients with mild cases of myocarditis have a
Patients with mild cases of myocarditis have a non
non-
-
toxic appearance and simply may appear to have a
toxic appearance and simply may appear to have a
viral syndrome.
viral syndrome.
Tachypnea and tachycardia are common. Tachycardia
Tachypnea and tachycardia are common. Tachycardia
is often out of proportion to fever.
is often out of proportion to fever.
More acutely ill patients have signs of circulatory
More acutely ill patients have signs of circulatory
impairment due to left ventricular failure.
impairment due to left ventricular failure.

 A widely inflamed heart shows the classic signs of
A widely inflamed heart shows the classic signs of
ventricular dysfunction including the following:
ventricular dysfunction including the following:
 Jugular venous distention
Jugular venous distention
 Bibasilar crackles
Bibasilar crackles
 Ascites
Ascites
 Peripheral edema
Peripheral edema
 S3 or a summation gallop may be noted with
S3 or a summation gallop may be noted with
significant biventricular involvement.
significant biventricular involvement.
 Intensity of S1 may be diminished.
Intensity of S1 may be diminished.
 Cyanosis may occur.
Cyanosis may occur.

 Hypotension
Hypotension caused by
caused by left ventricular dysfunction
left ventricular dysfunction is
is
uncommon in the acute setting and indicates a poor
uncommon in the acute setting and indicates a poor
prognosis when present.
prognosis when present.
 Murmurs of mitral
Murmurs of mitral or
or tricuspid regurgitation
tricuspid regurgitation may be
may be
present due to
present due to ventricular dilation
ventricular dilation.
.
 In cases where a dilated cardiomyopathy has developed,
In cases where a dilated cardiomyopathy has developed,
signs of peripheral or pulmonary thromboembolism
signs of peripheral or pulmonary thromboembolism
may be found.
may be found.
 Diffuse inflammation may develop leading to
Diffuse inflammation may develop leading to
pericardial effusion, without tamponade, and
pericardial effusion, without tamponade, and
pericardial and pleural friction rub as the inflammatory
pericardial and pleural friction rub as the inflammatory
process involves surrounding structures.
process involves surrounding structures.

Causes (1)
Causes (1)
 The causes of myocarditis are numerous and can
The causes of myocarditis are numerous and can
be roughly divided into:
be roughly divided into:
 infectious,
infectious,
 toxic, and
toxic, and
 immunologic etiologies, with viral etiologies.
immunologic etiologies, with viral etiologies.

Causes (2)
Causes (2)
 Amongst the infectious causes, viral acute myocarditis is by far
Amongst the infectious causes, viral acute myocarditis is by far
the most common
the most common.
.
 Identification of the
Identification of the coxsackie-adenovirus
coxsackie-adenovirus receptor protein explains the
receptor protein explains the
prevalence of these viruses as a frequent cause. The receptor is the
prevalence of these viruses as a frequent cause. The receptor is the
common target of coxsackievirus B
common target of coxsackievirus B
 Other viruses implicated in myocarditis include
Other viruses implicated in myocarditis include influenza virus,
influenza virus,
echovirus, herpes simplex virus, varicella-zoster virus, hepatitis,
echovirus, herpes simplex virus, varicella-zoster virus, hepatitis,
Epstein-Barr virus, and cytomegalovirus. Hepatitis C
Epstein-Barr virus, and cytomegalovirus. Hepatitis C
 Human immunodeficiency virus (HIV)
Human immunodeficiency virus (HIV) deserves special mention
deserves special mention
because it seems to function differently than other viruses. Although
because it seems to function differently than other viruses. Although
some evidence indicates that HIV directly invades myocytes
some evidence indicates that HIV directly invades myocytes

Causes (3)
Causes (3)
 Toxic myocarditis has a number of etiologies including
Toxic myocarditis has a number of etiologies including
both medical agents and environmental agents.
both medical agents and environmental agents.
 Among the most common drugs that cause hypersensitivity
Among the most common drugs that cause hypersensitivity
reactions are
reactions are clozapine, penicillin, ampicillin,
clozapine, penicillin, ampicillin,
hydrochlorothiazide, methyldopa, and sulfonamide drugs.
hydrochlorothiazide, methyldopa, and sulfonamide drugs.
 Numerous medications has been associated with
Numerous medications has been associated with
myocarditis.eg,
myocarditis.eg, lithium, doxorubicin, cocaine, numerous
lithium, doxorubicin, cocaine, numerous
catecholamines, acetaminophen) may exert a direct cytotoxic
catecholamines, acetaminophen) may exert a direct cytotoxic
effect on the heart
effect on the heart.
. Zidovudine (AZT
Zidovudine (AZT)
)
 Environmental toxins include
Environmental toxins include arsenic
arsenic, and
, and carbon monoxide.
carbon monoxide.
Cases have been attributed to Chinese sumac.
Cases have been attributed to Chinese sumac.
 Wasp, scorpion, and spider stings
Wasp, scorpion, and spider stings
 Radiation therapy may cause a myocarditis with the
Radiation therapy may cause a myocarditis with the
development of a dilated cardiomyopathy.
development of a dilated cardiomyopathy.

Causes (4)
Causes (4)
 Immunologic etiologies
Immunologic etiologies
 Connective tissue disorders such as systemic lupus
Connective tissue disorders such as systemic lupus
erythematosus (SLE), rheumatoid arthritis, scleroderma,
erythematosus (SLE), rheumatoid arthritis, scleroderma,
and dermatomyositis
and dermatomyositis
 Idiopathic inflammatory and infiltrative disorders such
Idiopathic inflammatory and infiltrative disorders such
as Kawasaki disease, sarcoidosis, and giant cell arteritis
as Kawasaki disease, sarcoidosis, and giant cell arteritis

Lab Studies
Lab Studies
 Cardiac enzyme levels
Cardiac enzyme levels
 These levels are only elevated in a minority of patients.
These levels are only elevated in a minority of patients.
 Normally, a characteristic pattern of
Normally, a characteristic pattern of slow elevation
slow elevation and
and fall
fall
over a period of days
over a period of days occurs; however, a more abrupt rise is
occurs; however, a more abrupt rise is
observed in patients with acute myocardial infarction.
observed in patients with acute myocardial infarction.
 Cardiac troponin I
Cardiac troponin I may be more sensitive because it is
may be more sensitive because it is
present for
present for longer periods
longer periods after myocardial damage
after myocardial damage
from any cause.2
from any cause.2
 Erythrocyte sedimentation rate (ESR)
Erythrocyte sedimentation rate (ESR) is elevated in
is elevated in
60% of patients with acute myocarditis.
60% of patients with acute myocarditis.
 Leukocytosis
Leukocytosis is present in 25% of cases.
is present in 25% of cases.

Imaging Studies (1)
Imaging Studies (1)
 Chest radiography
Chest radiography
 A chest radiograph often reveals a
A chest radiograph often reveals a normal
normal
cardiac
cardiac silhouette
silhouette, but
, but pericarditis
pericarditis or overt
or overt
clinical CHF is associated with
clinical CHF is associated with cardiomegaly.
cardiomegaly.
 Vascular redistribution
Vascular redistribution
 Interstitial and alveolar edema
Interstitial and alveolar edema
 Pleural effusion
Pleural effusion

Myocarditis Infectious/Inflammatory
Myocarditis Infectious/Inflammatory

 Sinus tachycardia
Sinus tachycardia is the most frequent finding.
is the most frequent finding.
 ST-segment elevation
ST-segment elevation without reciprocal depression,
without reciprocal depression,
particularly when diffuse, is helpful in differentiating
particularly when diffuse, is helpful in differentiating
myocarditis from acute myocardial infarction.
myocarditis from acute myocardial infarction.
 Decreased QRS
Decreased QRS amplitude and transitory Q-wave
amplitude and transitory Q-wave
development is very suggestive of myocarditis.
development is very suggestive of myocarditis.
 As many as 20% of patients will have a conduction delay,
As many as 20% of patients will have a conduction delay,
including Mobitz I, Mobitz II, or complete heart block.
including Mobitz I, Mobitz II, or complete heart block.
 Left or right bundle-branch block is observed in
Left or right bundle-branch block is observed in
approximately 20% of abnormal ECG findings and may
approximately 20% of abnormal ECG findings and may
persist for months.
persist for months.
Electrocardiography
Electrocardiography

Echocardiography
Echocardiography
 Impairment of left ventricular systolic and diastolic
Impairment of left ventricular systolic and diastolic
function
function
 Segmental wall motion abnormalities
Segmental wall motion abnormalities
 Impaired ejection fraction
Impaired ejection fraction
 A pericardial effusion may be present, although
A pericardial effusion may be present, although
findings of tamponade are rare.
findings of tamponade are rare.
 Ventricular thrombus has been identified in 15%
Ventricular thrombus has been identified in 15%
of patients studied with echocardiography.
of patients studied with echocardiography.

Imaging Studies (3)
Imaging Studies (3)
 MRI
MRI is capable of showing abnormal signal intensity in the
is capable of showing abnormal signal intensity in the
affected myocardium.
affected myocardium.
 Cardiac MRI is an emerging field in general, and contrast-enhanced
Cardiac MRI is an emerging field in general, and contrast-enhanced
T1- weighted MRI has been shown to have sensitivities and
T1- weighted MRI has been shown to have sensitivities and
specificities approaching 100% for diagnosis.3
specificities approaching 100% for diagnosis.3
 MRI can demonstrate nodular and patchy areas of inflammation,
MRI can demonstrate nodular and patchy areas of inflammation,
often seen first in the lateral and inferior wall and can be used to
often seen first in the lateral and inferior wall and can be used to
guide later biopsy.
guide later biopsy.
 MRI is also one of the modalities used in the evaluation of young
MRI is also one of the modalities used in the evaluation of young
patients with apparently idiopathic dysrhythmias, and this imaging
patients with apparently idiopathic dysrhythmias, and this imaging
study can differentiate focal and diffuse inflammation from the rare
study can differentiate focal and diffuse inflammation from the rare
electrically significant myocardial tumor.
electrically significant myocardial tumor.

Midwall septal and posterior edema (arrows) on T2-weighted cardiac MRI (A)
and on CT (C and D) with corresponding areas of late gadonlinium
enhancement on the cardiac MRI (B).

Other Test (
Other Test (4
4)
)
 Viral isolation from other body sites may be supportive
Viral isolation from other body sites may be supportive
of the diagnosis.
of the diagnosis.
 Polymerase chain reaction (PCR)
Polymerase chain reaction (PCR) identification of a
identification of a
viral infection from myocardial tissue, pericardial fluid,
viral infection from myocardial tissue, pericardial fluid,
or other body fluid sites can be helpful. Persistent viral
or other body fluid sites can be helpful. Persistent viral
genome, as detected by PCR, has been identified as one
genome, as detected by PCR, has been identified as one
marker of increased incidence of dilated
marker of increased incidence of dilated
cardiomyopathy and mortality.
cardiomyopathy and mortality.
 If a
If a systemic disorder (eg, SLE)
systemic disorder (eg, SLE) is suspected,
is suspected,
antinuclear antibody (ANA) and other collagen vascular
antinuclear antibody (ANA) and other collagen vascular
disorder laboratory investigations may be useful.
disorder laboratory investigations may be useful.

Medication
Medication
 Medical therapy for myocarditis is an area of avid
Medical therapy for myocarditis is an area of avid
research interest but with little success in human
research interest but with little success in human
trials.
trials.
 Treatment primarily involves managing the
Treatment primarily involves managing the
complications of myocarditis
complications of myocarditis
 thromboembolism, dysrhythmia, and CHF
thromboembolism, dysrhythmia, and CHF

Drug Category
Drug Category
 Angiotensin converting enzyme inhibitors
Angiotensin converting enzyme inhibitors. Ex :
. Ex :
Captopril.
Captopril.
 Calcium channel blockers
Calcium channel blockers. Ex. : Amlodipine
. Ex. : Amlodipine
 Loop diuretics
Loop diuretics. Ex. : Furosemide (Lasix).
. Ex. : Furosemide (Lasix).
 Cardiac glycosides
Cardiac glycosides. Ex. : Digoxin
. Ex. : Digoxin
 Beta-adrenergic blockers
Beta-adrenergic blockers. Ex. : Carvedilol
. Ex. : Carvedilol

Complications
Complications
 Congestive heart failure
Congestive heart failure
 Pulmonary edema
Pulmonary edema
 Cardiogenic shock
Cardiogenic shock
 Cardiac failure
Cardiac failure
 Dilated cardiomyopathy
Dilated cardiomyopathy
 Dysrhythmias
Dysrhythmias
 Recurrent myositis
Recurrent myositis

Prognosis (1)
Prognosis (1)
 Most cases are believed to be clinically silent and
Most cases are believed to be clinically silent and
resolve spontaneously without sequelae
resolve spontaneously without sequelae
 Patients who present with CHF experience
Patients who present with CHF experience
morbidity and mortality based on the degree of left
morbidity and mortality based on the degree of left
ventricular dysfunction.
ventricular dysfunction.
 Of patients who present with cardiogenic shock,
Of patients who present with cardiogenic shock,
elderly patients and patients with giant cell arteritis
elderly patients and patients with giant cell arteritis
have a poor prognosis.
have a poor prognosis.

Prognosis (2)
Prognosis (2)
 Patients with HIV and persistent viral genome expression
Patients with HIV and persistent viral genome expression
from myocytes have dismal outcomes.
from myocytes have dismal outcomes.
 Patients who require transplantation have an increased risk
Patients who require transplantation have an increased risk
of recurrent myocarditis and graft rejection.
of recurrent myocarditis and graft rejection.

Miokarditis (Inflamasi pada Otot Jantung)

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