Myocarditis is an inflammatory disease of the myocardium that can be caused by infectious or non-infectious triggers. It is defined as inflammation of the heart muscle and can lead to dilation, thrombi formation, and degeneration of muscle fibers. Treatment involves managing symptoms through medications like ACE inhibitors, beta-blockers, and diuretics. Immunosuppressive therapy may also be used. Prognosis depends on the severity of cardiac dysfunction, with 50% resolving in 2-4 weeks but 25% developing persistent issues and 12-25% deteriorating acutely.

1. MS.B.SHYLA MERCY
M. SC (N) , MEDICAL SURGICAL NURSING
LECTURER
GANGA COLLEGE OF NURSING
COIMBATORE

2. MYOCARDITIS

5. INTRODUCTION
• Myocarditis is an inflammatory disease of the myocardium caused by
different infectious and noninfectious triggers .
• In 1995, myocarditis was defined by the World Health Organization
(WHO)/International Society and Federation of Cardiology (ISFC) as an
inflammatory disease of the heart muscle, diagnosed by established
histological, immunological, and immunohistochemical criteria
• Cases of Myocarditis have been documented as early as the 1600s, but the
term "Myocarditis", implying an inflammatory process of the
myocardium, was introduced by German physician Joseph Friedrich
Sobernheim in 1837.

6. HISTORICALASPECTS
❖1837 - J.F.Soberenheim first used the term “ Myocarditis”.
❖1897 - M.O.Abramov described pathological changes in myocarditis.
❖1990 - F.Fidler described primary idiopathic myocarditis.
❖1920s - There was overdiagnosis of myocarditis.
❖1920-50s - The term myocarditis replaced the term “Degeneration of the myocardium”
❖1949 - I. Gore ., O.Sapfir described viral and rikettsial myocarditis.
❖1980s - There was an introduction of transvenous myocardial biopsy into clinical
practice.
❖ 1992 - M .Paleev define the term “myocarditis” is a heart muscle lesion mainly of
inflammatory nature caused by influence of infection, parasitic , physical agents
or when develop in autoimmune diseases.

7. DEFINITION
Myocarditis is defined as the
inflammation of myocardium, can cause
heart dilation, thrombi on the heart wall
and infiltration of circulatory blood cells
around the coronary vessels and resulted
in degeneration of muscle fibres.

9. EPIDEMIOLOGY
1-9 % of all patients had
evidence of myocardial
inflammation.
In young adults , up to 20% of
all cases of sudden death are
due to myocarditis.
The incidence of myocarditis is
approximately 1.5 million cases
worldwide per year.

10. TYPES OF MYOCARDITIS
• ACUTE MYOCARDITIS
• SUBACUTE MYOCARDITIS
• CHRONIC MYOCARDITIS

11. 1) ACUTE MYOCARDITIS
• Acute myocarditis is commonly
caused by a viral infection that
produces myocardial necrosis
and triggers an immune
response to eliminate the
infectious agent .

12. STAGES OF VIRAL MYOCARDIUM INFECTION

13. 2) SUBACUTE
MYOCARDITIS
• Subacute phase, which covers few
weeks to several months, is defined
by activated virus-specific
T lymphocytes, which may target the
host’s organs by molecular mimicry.
• Cytokine activation (tumor necrosis
factor alpha, interleukin [IL] and
antibodies to viral and cardiac
proteins may aggravate cardiac
damage and cause impairment of the
contractile function.

14. 3) CHRONIC MYOCARDITIS
• Structural and functional damage of the myocardium,
activates the innate and adaptive immune response, which
can lead to severe inflammation .
• The immune response is eventually downregulated, and
myocardial inflammation can also persist.
• Persistent inflammation is characterized by an ongoing
damage to the cardiomyocytes and ultimately results in
dilated cardiomyopathy (DCM)

15. ETIOLOGICAL FACTORS OF
MYOCARDITIS
1.Infectious
2.Non-Infectious

16. INFECTIOUS
MYOCARDITIS
1-Viral: Coxsackievirus B, parvovirus B19 (common),Human
Herpes virus 6, HFVs and others.
2-Bacterial: Treponema palladium (Syphilis) and Borrelia
burgdorferi (Lyme disease) and Rickettsia.
3-Protozoal: Chagas disease (common), Toxoplasmosis.
4-Helminthes: Trichinella spiralis, Ascaris, Echinococcus
granulosus, Schistosoma, Taenia solium, and Wuchereria
bancrofti.
5-Fungal: Blastomycosis, Coccidiomycosis,Cryptococcosis,
and Aspergillosis.

17. NON-INFECTIOUS MYOCARDITIS
1)Autoimmune reaction due to infection or systemic
disorder:
• A-Exogenous Antigen:
• Post-Streptococcus pyogenes autoimmune reaction.(Acute
rheumatic fever).
• B-Endogenous Antigen:
• systemic lupus erythematosus , and systemic vasculitis.
• 2)Cardiotoxins(Drug-induced Myocarditis):
• A-Toxins associated with hypersensitivity reaction:
• Toxic shock syndrome toxin, Snake venom, antibiotics.
• B-Toxic Myocarditis: Carbon monoxide, Heavy metals&
Ethanol.

18. PATHOPHYSIOLOGY

19. CLINICAL
MANIFESTATIONS
EARLY SYSTEMIC MANIFESTATION
Fatigue
Malaise
Myalgia
Pharyngitis
Dyspnea
Lymphadenopathy
Nausea and vomiting.
Fever

20. EARLY CARDIAC SIGNS
➢Pleuritic chest pain
➢Pericardial friction rub
➢Pericardial effusion
LATE CARDIAC SIGNS
➢S3 heart sound
➢Crackles
➢Syncope
➢Angina

21. PLEURITIC CHEST PAINPERICARDIAL FRICTION RUB

22. PERIPHERAL EDEMA JUGULAR VEIN DISTENTION

23. DIAGNOSTIC EVALAUTION
1. HISTORY COLLECTION
History of Rheumatic fever .
2. PHYSICAL EXAMINATION
• Peripheral Edema
• Auscultation of Heart and Lung Sounds
• Jugular vein distension.
3. BLOOD TESTS
• Leukocytosis
• Elevated ESR and CRP level
• Elevated levels of Myocardial markers such as troponin
• Elevated Viral titers

24. 4) ELECTROCARDIOGRAM
Diffuse ST Segment Changes

25. 5) ENDOMYOCARDIAL BIOPSY
• Histologic confirmation of myocarditis is
through an Endomyocardial biopsy.
• A biopsy done during the first 6 weeks of
acute illness .
6) NUCLEAR SCANS
7) ECHOCARDIOGRAPHY

26. 8) MRI

27. MANAGEMENT
• PHARMACOLOGICAL MANAGEMENT
• SUPPORTIVE THERAPY
• DIETARY&LIFESTYLE
• NURSING MANAGEMENT

28. Myocarditis resolves in about 50% of cases in the first 2–4
weeks, but about 25% will develop persistent cardiac
dysfunction and
12–25% may acutely deteriorate and either die or progress to
end-stage DCM with a need for heart transplantation.
The core principles of treatment in myocarditis are
optimal care of Arrhythmia and Heart failure

29. PHARMACOLOGICAL MANAGEMENT
1) ANGIOTENSIN - CONVERTING ENZYME INHIBITORS
Captopril , Lisinopril and Ramipril relax the blood vessels in heart and
help blood flow more easily.
2) ꞵ - ADRENERGIC BLOCKERS
Metoprolol ,Bisoprolol and Carvedilol to treat heart failure and control
arrhythmias.
3) DIURETICS
Furosemide to relieve sodium and fluid retention.
4) IMMUNOSUPPRESSIVE THERAPY
5) ANTICOAGULATION THERAPY

30. DIGOXIN
It improves myocardial contractility and reduces the heart rate.
It is used cautiously in a patients with myocarditis , since the
condition predisposes patients to drug related dysrhythmias and
toxicity.

31. TREATMENT GUIDELINES

32. SUPPORTIVE
THERAPY
• Oxygen therapy
• Bed rest
• Restricted activity

33. IN CASES OF SEVERE HEART FAILURE
INTRAAORTIC BALLOON
THERAPY VENTRICULAR ASSIST DEVICES

34. DIETARY& LIFESTYLE MANAGEMENT
1) Restrict salt intake to 2-3 gm of sodium per
day.
2) Restrict the amount of fluids you drink and
avoid smoking.
3) Rest and reducing the workload on your heart .
4) Exercise especially during the acute phase of
virus myocarditis enhances viral replication
rate, enhances immune mechanisms and
increases inflammatory lesions and necrosis.
5) Resumption of physical activity can take place
within 2 months of the acute disease.

35. • Assess complaints of chest pain, observe the factors that
aggravate. Notice the nonverbal cues of discomfort.
• Assess vital signs and cardiovascular assessment.
• Evaluate patients' pulse and apical rate for signs of
tachycardia and gallop rhythm indications that heart failure
is recurring.
• Ensure measures to decrease cardiac workload.
• Passive and active exercises , Elastic compression stockings to
prevent venous thrombosis.
NURSING MANAGEMENT

36. NURSING DIAGNOSIS
❖Acute chest pain related to
myocardial inflammation as
evidenced by pain score.
❖Decreased cardiac output related
to degeneration of heart muscle
as evidenced by tachycardia.
❖Impaired peripheral tissue
perfusion related to reduced
cardiac output.

37. COMPLICATIONS

38. CONCLUSION
Myocarditis is an inflammatory disease of the heart frequently
resulting from viral infections or post-viral immune-mediated
responses. It is one of the important causes of dilated
cardiomyopathy worldwide.
Endomyocardial biopsy remains the gold standard for in vivo
diagnosis of myocarditis. Treatment for myocarditis consists
of managing associated heart symptoms.

39. BIBLIOGRAPHY
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Philadelphia .F.A. Davis company publication.