Myocarditis medical therapy: Difference between revisions
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According to 2010 HFSA guidelines<ref name="pmid20610207">{{cite journal| author=Heart Failure Society of America. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA et al.| title=HFSA 2010 Comprehensive Heart Failure Practice Guideline. | journal=J Card Fail | year= 2010 | volume= 16 | issue= 6 | pages= e1-194 | pmid=20610207 | doi=10.1016/j.cardfail.2010.04.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610207 }} </ref>, routine use of immunosuppressive therapies in management of myocarditis is not recommended ''(Strength of Evidence A)'' | According to 2010 HFSA guidelines<ref name="pmid20610207">{{cite journal| author=Heart Failure Society of America. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA et al.| title=HFSA 2010 Comprehensive Heart Failure Practice Guideline. | journal=J Card Fail | year= 2010 | volume= 16 | issue= 6 | pages= e1-194 | pmid=20610207 | doi=10.1016/j.cardfail.2010.04.004 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20610207 }} </ref>, routine use of immunosuppressive therapies in management of myocarditis is not recommended ''(Strength of Evidence A)'' | ||
==Lymphocytic myocarditis== | |||
Lymphocytic myocarditis is usually of viral origin<ref name="pmid1558005">{{cite journal| author=Rose NR, Neumann DA, Herskowitz A| title=Coxsackievirus myocarditis. | journal=Adv Intern Med | year= 1992 | volume= 37 | issue= | pages= 411-29 | pmid=1558005 | doi= | pmc= | url= }} </ref>. Animal studies have demonstrated better outcomes in viral myocarditis with the use of [[antiviral]] agents and [[interferon]] early in the course of infection prior to inoculation<ref name="pmid2855719">{{cite journal| author=Kishimoto C, Crumpacker CS, Abelmann WH| title=Prevention of murine coxsackie B3 viral myocarditis and associated lymphoid organ atrophy with recombinant human leucocyte interferon alpha A/D. | journal=Cardiovasc Res | year= 1988 | volume= 22 | issue= 10 | pages= 732-8 | pmid=2855719 | doi= | pmc= | url= }} </ref><ref name="pmid9529271">{{cite journal| author=Yamamoto N, Shibamori M, Ogura M, Seko Y, Kikuchi M| title=Effects of intranasal administration of recombinant murine interferon-gamma on murine acute myocarditis caused by encephalomyocarditis virus. | journal=Circulation | year= 1998 | volume= 97 | issue= 10 | pages= 1017-23 | pmid=9529271 | doi= | pmc= | url= }} </ref>. The use of antiviral therapy may be limited since patients with viral myocarditis are usually not seen in the early stages. However, it may be used in acute, fulminant myocarditis<ref name="pmid2775346">{{cite journal| author=Ray CG, Icenogle TB, Minnich LL, Copeland JG, Grogan TM| title=The use of intravenous ribavirin to treat influenza virus-associated acute myocarditis. | journal=J Infect Dis | year= 1989 | volume= 159 | issue= 5 | pages= 829-36 | pmid=2775346 | doi= | pmc= | url= }} </ref> and in institutional outbreaks. | |||
In a series, 6 months of [[beta interferon]] in patients with myocarditis secondary to [[enterovirus]] or [[adenovirus]] infection resulted in elimination of viral genomes in all patients and improvement of LV function in 68% of the patients<ref name="pmid12771005">{{cite journal| author=Kühl U, Pauschinger M, Schwimmbeck PL, Seeberg B, Lober C, Noutsias M et al.| title=Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. | journal=Circulation | year= 2003 | volume= 107 | issue= 22 | pages= 2793-8 | pmid=12771005 | doi=10.1161/01.CIR.0000072766.67150.51 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12771005 }} </ref>. | |||
==Treatment of Heart Failure== | ==Treatment of Heart Failure== | ||
Revision as of 20:20, 29 August 2011
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Varun Kumar, M.B.B.S.
Treatment
Bacterial infections are treated with antibiotics, dependent on the nature of the pathogen and its sensitivity to antibiotics. As most viral infections cannot be treated with directed therapy, symptomatic treatment is the only form of therapy for those forms of myocarditis, e.g. NSAIDs for the inflammatory component and diuretics and/or inotropes for ventricular failure. ACE inhibitor therapy may aid in left ventricular remodeling after the inflammation has begun to resolve.
According to 2010 HFSA guidelines[1], routine use of immunosuppressive therapies in management of myocarditis is not recommended (Strength of Evidence A)
Lymphocytic myocarditis
Lymphocytic myocarditis is usually of viral origin[2]. Animal studies have demonstrated better outcomes in viral myocarditis with the use of antiviral agents and interferon early in the course of infection prior to inoculation[3][4]. The use of antiviral therapy may be limited since patients with viral myocarditis are usually not seen in the early stages. However, it may be used in acute, fulminant myocarditis[5] and in institutional outbreaks.
In a series, 6 months of beta interferon in patients with myocarditis secondary to enterovirus or adenovirus infection resulted in elimination of viral genomes in all patients and improvement of LV function in 68% of the patients[6].
Treatment of Heart Failure
As heart failure in patients with myocarditis has poor prognosis, it is important to prevent progression or worsening of cardiac dysfunction[7]. These patients should be treated with low sodium intake, diuretics and ACE inhibitors. Few animal studies report that mortality rate is high with digoxin in comparison to beta blocker in viral myocarditis[8][9]. Studies have also demonstrated that usage of carvedilol during recovery phase decreases expression of several histochemicals and subsequently myocardial inflammation and there by improving survival[10]. The Beta-blockers should however be avoided in the acutely decompensating phase of illness.
If heart failure or cardiogenic shock does not respond to medical therapy, circulatory support with an intraaortic balloon pump should be considered which could be used in fulminant myocarditis as a bridge to spontaneous recovery[11][12]. Implantation of ICD in severe heart failure should be deferred for several months to allow sufficient time for recovery of ventricular function. Following the initial circulatory stabilization, further treatment of cardiac dysfunction should follow current ACC/AHA recommendations[13]. Anticoagulation may be considered in patients with severe/chronic heart failure as they are at risk for developing thromboembolic complications.
For more information on heart failure treatment, click here
Treatment of Arrhythmia
Arrhythmias or conduction abnormalities can occur in patients with myocarditis. Treatment should be initiated only if arrhythmias are symptomatic or sustained. Caution should be observed while using antiarrhythmics as majority of these agents have negative inotropic property which may worsen heart failure. Regular monitoring with ECG is important as it enables early detection and treatment of asymptomatic yet life threatening arrhythmias.
Supraventricular tachycardia(SVT) can aggravate heart failure. Symptomatic and sustained SVT should be immediately converted electrically. While, patients with recurrent sustained SVT should be treated with antiarrhythmics and rate controlling agents. Implantation of ICD should be considered in patients with recurrent ventricular arrhythmia refractory to medical therapy.
Myocarditis patients presenting with conduction abnormalities, particularly Mobitz type II and complete heart block require temporary pacemaker usually during the acute phase. Implantation of permanent pacemaker or ICD may be necessary in few patients[14].
ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death[15]
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Class I 1. Temporary pacemaker insertion is indicated in patients with symptomatic bradycardia and/or heart block during the acute phase of myocarditis. (Level of Evidence: C) 2. Acute aortic regurgitation associated with VT should be treated surgically unless otherwise contraindicated. (Level of Evidence: C) Class IIa 1. ICD implantation can be beneficial in patients with life-threatening ventricular arrhythmias who are not in the acute phase of myocarditis, as indicated in the ACC/AHA/NASPE 2002 Guideline Update for Implantation of Cardiac Pacemakers and Antiarrhythmia Devices[16] who are receiving chronic optimal medical therapy, and who have reasonable expectation of survival with a good functional status for more than 1 year. (Level of Evidence: C) 2. Antiarrhythmic therapy can be useful in patients with symptomatic NSVT or sustained VT during the acute phase of myocarditis. (Level of Evidence: C) Class III 1. ICD implantation is not indicated during the acute phase of myocarditis. (Level of Evidence: C) |
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References
- ↑ Heart Failure Society of America. Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA; et al. (2010). "HFSA 2010 Comprehensive Heart Failure Practice Guideline". J Card Fail. 16 (6): e1–194. doi:10.1016/j.cardfail.2010.04.004. PMID 20610207.
- ↑ Rose NR, Neumann DA, Herskowitz A (1992). "Coxsackievirus myocarditis". Adv Intern Med. 37: 411–29. PMID 1558005.
- ↑ Kishimoto C, Crumpacker CS, Abelmann WH (1988). "Prevention of murine coxsackie B3 viral myocarditis and associated lymphoid organ atrophy with recombinant human leucocyte interferon alpha A/D". Cardiovasc Res. 22 (10): 732–8. PMID 2855719.
- ↑ Yamamoto N, Shibamori M, Ogura M, Seko Y, Kikuchi M (1998). "Effects of intranasal administration of recombinant murine interferon-gamma on murine acute myocarditis caused by encephalomyocarditis virus". Circulation. 97 (10): 1017–23. PMID 9529271.
- ↑ Ray CG, Icenogle TB, Minnich LL, Copeland JG, Grogan TM (1989). "The use of intravenous ribavirin to treat influenza virus-associated acute myocarditis". J Infect Dis. 159 (5): 829–36. PMID 2775346.
- ↑ Kühl U, Pauschinger M, Schwimmbeck PL, Seeberg B, Lober C, Noutsias M; et al. (2003). "Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction". Circulation. 107 (22): 2793–8. doi:10.1161/01.CIR.0000072766.67150.51. PMID 12771005.
- ↑ Magnani JW, Danik HJ, Dec GW, DiSalvo TG (2006). "Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors". Am Heart J. 151 (2): 463–70. doi:10.1016/j.ahj.2005.03.037. PMID 16442915.
- ↑ Tominaga M, Matsumori A, Okada I, Yamada T, Kawai C (1991). "Beta-blocker treatment of dilated cardiomyopathy. Beneficial effect of carteolol in mice". Circulation. 83 (6): 2021–8. PMID 1674900.
- ↑ Matsumori A, Igata H, Ono K, Iwasaki A, Miyamoto T, Nishio R; et al. (1999). "High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity". Jpn Circ J. 63 (12): 934–40. PMID 10614837.
- ↑ Wang JF, Meissner A, Malek S, Chen Y, Ke Q, Zhang J; et al. (2005). "Propranolol ameliorates and epinephrine exacerbates progression of acute and chronic viral myocarditis". Am J Physiol Heart Circ Physiol. 289 (4): H1577–83. doi:10.1152/ajpheart.00258.2005. PMID 15923319.
- ↑ Rockman HA, Adamson RM, Dembitsky WP, Bonar JW, Jaski BE (1991). "Acute fulminant myocarditis: long-term follow-up after circulatory support with left ventricular assist device". Am Heart J. 121 (3 Pt 1): 922–6. PMID 2000764.
- ↑ Chen JM, Spanier TB, Gonzalez JJ, Marelli D, Flannery MA, Tector KA; et al. (1999). "Improved survival in patients with acute myocarditis using external pulsatile mechanical ventricular assistance". J Heart Lung Transplant. 18 (4): 351–7. PMID 10226900.
- ↑ Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG; et al. (2009). "2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation". Circulation. 119 (14): e391–479. doi:10.1161/CIRCULATIONAHA.109.192065. PMID 19324966.
- ↑ Cooper LT (2009). "Myocarditis". N Engl J Med. 360 (15): 1526–38. doi:10.1056/NEJMra0800028. PMID 19357408.
- ↑ European Heart Rhythm Association. Heart Rhythm Society. Zipes DP, Camm AJ, Borggrefe M, Buxton AE; et al. (2006). "ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death)". J Am Coll Cardiol. 48 (5): e247–346. doi:10.1016/j.jacc.2006.07.010. PMID 16949478.
- ↑ Gregoratos G, Abrams J, Epstein AE, Freedman RA, Hayes DL, Hlatky MA; et al. (2002). "ACC/AHA/NASPE 2002 guideline update for implantation of cardiac pacemakers and antiarrhythmia devices: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/NASPE Committee to Update the 1998 Pacemaker Guidelines)". Circulation. 106 (16): 2145–61. PMID 12379588.