This document provides information about myocarditis including its definition, classification, etiology, clinical presentation, diagnostics, treatment, and prognosis. Myocarditis is an inflammatory infiltration of the myocardium that commonly has a viral cause and presents with chest pain, fever, dyspnea, and ECG/echo abnormalities. Diagnosis involves blood tests, viral cultures, PCR, and cardiac imaging. Treatment is etiology-based when a cause is identified along with supporting heart function and managing complications. Prognosis is generally good but some patients can develop dilated cardiomyopathy.

1. Myocarditis
МИОКАРДИТЫ
• Lecture for 5th year students of the Faculty of
Medicine
• Лекция для студентов 5 курса лечебного
факультета.
Prepared by: Professor Kuznetsov G.E.
Department of Internal Diseases
Подготовил: профессор Кузнецов Г.Э.
Кафедра внутренних болезней

2. Myocarditis - inflammatory infiltration of the
myocardium with necrosis and / or degeneration of
myocytes, which has a rapidly progressive course
with the development of heart failure and
arrhythmia.
(по классификации Даллас -1987)
Myocarditis (with a frequency of 1-10 per 100,000 population) is
much more common in children and young people and has no gender
differences.
It is assumed that 1-5% of SARS patients can have myocardial
damage.

3. Etiology of myocarditis
• Viral
- энтеровирусная (коксакивирусы А и В,
эховирусы)
– аденовирусы (преимущественно
2 и 5 типов )
– вирус полиомиелита
– Эпштейн-Бар вирус
– вирус герпеса
– РС-вирус
– вирусы краснухи и гепатита С
– арбовирус.
• Rickettsial
- typhus
- лихорадка скалистых гор
– Q-fever
• Bacterial
– Diphtheria
– tuberculosis
– Streptococci
– meningo-,staphylococci
– brucellosis
– Mycoplasma
– psittacosis
• Spirochete, fungal, protozoal,
helminthic
• Toxic
- after biting poisonous animals.
• Drug-induced
- cause of hypersensitive myocarditis
• Chemically induced
• Rheumatic fever, systemic
inflammatory diseases

4. Clinico-pathological classification
по Lieberman
• Fulminant myocarditis - after a prodromal period, severe
cardiovascular damage occurs with ventricular dysfunction, is
spontaneous or fatal, due to refractory heart failure.
• Acute myocarditis - occurs without prior precursors, is identified by
the presence of ventricular dysfunction - the outcome in the dilated
cardiomyopathy.

5. миокардит
Chronic active myocarditis - the initial stages of the disease are not
diagnosed, clinically and histologically, ventricular dysfunction (giant cells).
Chronic persistent myocarditis - the onset is not diagnosed, foci of necrosis
histologically without ventricular dysfunction (palpitation, pain in the chest)

7. Clinical picture
Complaints :
• chest pain
• Fever
• Sweating
• chilliness
• dyspnea.
Objectively :
• influenza-like syndrome for 1-2 weeks: fever, arthralgia, malaise,
catarrhal phenomena (pharyngitis, tonsillitis);
• toxic state or cardiogenic shock ("fulminant myocarditis" - rarely);
• in the form of syncopal conditions or sudden death due to
ventricular arrhythmias or atrioventricular blockade

8. Diagnostics
An expanded blood test :
• anemia;
• lymphocytosis or neutropenia;
• blood culture for sterility;
• ESR and C-reactive protein (with congestive heart failure, ESR is reduced,
and the protein is normal);
• viral cultures obtained by nasopharyngial or rectal washings;
• viral titres: 4-fold increase in specific titers during the reconvalescence
reliably confirms the infectious disease;
• PCR: detection of viral genomes in myocardial cells (highly informative
method);
• cardiac enzymes - the myocardial fraction of creatinine kinase is a marker
of myocardial damage, usually characterized by an elevation of the ST
segment on the ECG;
• troponin I - indicator of myocardial damage (increases one month after the
onset of infection - nonspecific);
• lactate dehydrogenase may be increased in idiopathic myocarditis.

9. ECG diagnostics in myocarditis
 Changes in myocardial repolarization - biphasic,
isoelectric or negative T wave
 Sinus tachycardia (rarely bradycardia, arrhythmia)
 Decrease in the amplitude of all waves
 The offset of the interval S-T (depression or elevation) in
one or more leads
 AV-blockades of various degrees
 Blockade of legs of Gis bundle
 Atrial and ventricular extrasystoles
 Atrial fibrillation

10. ECG diagnostics in myocarditis
AV blockade of the 1st degree: interval PQ - 0.25 s
AV-blockade of II degree: Mobitz II holding 2: 1
AV-blockade of II degree: Mobitz I, periodicals of Wenkebach-Samoilov

11. Atrial fibrillation
ECG diagnostics in myocarditis

12. BIGEMENIA: 1 extrasystole after each normal complex
Paired monotone VES
Paroxysm of ventricular tachycardia (3 or
more in a row VES)
ECG diagnostics in myocarditis

13. Echocardiography changes in
myocarditis
 Increased size of heart cavities
 Hypo- or akinesia of myocardial areas, signs of
total akinesia
 Biventricular type of heart damage
 Rounded apex of the heart
 Reduction of contractile function of the
myocardium (cardiac output)
 The symptoms of mitral regurgitation (relative
insufficiency of valves)

14. X-ray examination of the chest.
 With a light course of myocarditis, the size of the heart is not changed,
its pulsation is normal. With myocarditis of moderate severity and
severe form, the size of the heart is significantly increased, with
pronounced cardiomegaly the heart seems to blur on the diaphragm, its
arcs smooth out, pulsation weakens. In the lungs, moderate venous
stasis, broad roots (can be noted for their blurry, fuzzy), strengthening
of the venous pattern can be detected.

15. PRINCIPLES OF TREATMENT
 Not medicamentous:
 Restriction of physical activity
 Complete nutrition with limited intake of salt
 Etiological treatment - when an agent is detected
 Medicinal nonspecific:
 Nonspecific anti-inflammatory therapy
 Influence on inflammatory, autoimmune and allergic processes
 Restoration and maintenance of hemodynamics
 Effects on myocardial metabolism
 Symptomatic therapy of complications

16. Etiological treatment
 Immediate introduction of the pathogen (Staphylococcus
aureus). Often there is dissemination of the infection
with the formation of abscesses in other organs.
Treatment: before determining the sensitivity to
antibiotics - vancomycin.
 The effect of toxins Corynebacterium diphtheriae. The
defeat of the heart is noted in 20% of cases. Occurs at
the end of the first week and is the most common cause
of death from diphtheria. Treatment: antibiotic therapy
+ emergency introduction of antidiphtheria serum.
Immunization for primary prevention

17.  Etiotropic treatment of myocarditis
 Enteroviruses (Coxsackie viruses A and B, ECHO viruses,
poliomyelitis virus). The most common cause of infectious
myocarditis. Treatment: maintenance therapy. Limit physical
activity. Glucocorticosteroids (GCS) are not shown. Recovery
usually occurs within a few weeks, however, ECG and EchoCG
disorders can persist for several months
 Borrelia burgdorferi (Lyme disease). The carriers of infection
are ixodid mites. The disease begins with a rash (chronic
migratory erythema). After a few weeks or months,
neurological symptoms appear (meningoencephalitis, bilateral
facial nerve lesion, sciatica), arthritis (asymmetric lesion of
large joints), heart damage (conduction disorders, up to full
atrioventricular blockage). Treatment: ceftriaxone, 2 g,
intravenous infusion once a day or benzylpenicillin, 18-21
million IU / day, intravenous infusion divided into 6 doses

18. Treatment
Therapy of complications
In order to reduce preload - diuretics
If cardiac output is not supported by less invasive methods, non-
glycosidic inotropic agents are prescribed-dopamine, dobutamine,
amrinone, or milrinone
In order to reduce afterload, in the acute phase of the disease, if there
is no arterial hypotension - intravenous injection of nitroprusside,
inamrion and milrinone, followed by a transition to oral
administration of ACE inhibitors.
The use of intravenous gammaglobulin for left ventricular failure -
increases survival
To maintain an adequate function of the heart - digitalization; The
saturation dose should not exceed 0.03 mg / kg, and the
maintenance dose is 1/5 - 1/8 of the saturation dose

19. CRITERIA OF TREATMENT
EFFECTIVENESS
 Improvement of the patient's clinical
condition, normalization of blood counts
 Positive dynamics of ECG
 Improve systolic and diastolic function of
the myocardium

20. Prognosis
 With easy flow - a favorable (up to 90% of cases
within 1-2 months ends in recovery)
 In other cases, 10-33% of patients develop
dilated cardiomyopathy
 The fatal outcome is due to:
 progressive congestive heart failure
 ventricular fibrillation
 complete AV blockade
 pulmonary thromboembolism