Myocarditis medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-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)
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[2]. 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[3][4]. 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[5]. 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[6][7]. 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[8].
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.
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[9].
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.
- ↑ 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.