The document discusses myocarditis, which is an inflammation of the heart muscle (myocardium). It provides classifications of myocarditis including Lieberman's clinicopathological classification and pathological classifications such as lymphocytic, eosinophilic, granulomatous, and neutrophilic myocarditis. Etiologies including infectious, drug-induced, hypersensitivity reactions, and immunological causes are described. Diagnostic evaluations and management options for myocarditis are also outlined.

1. Mrs.D.Melba Sahaya Sweety
M.Sc Nursing
GIMSAR

2. INTROUCTION
Myocardium is the muscular middle layer
of the wall of the heart It is composed of
spontaneously contracting
cardiac muscle fibers which allow the heart
to contract. Heart contraction is an
autonomic (involuntary) function of
the peripheral nervous system. The
myocardium is surrounded by
the epicardium (outer layer of the wall of
the heart) and the endocardium (inner
layer of the heart).

3. • Myocarditis is an inflammation of
the heart muscle (myocardium).
Myocarditis can affect the heart
muscle and the heart's electrical
system, reducing your heart's
ability to pump and causing rapid
or abnormal heart rhythms
(arrhythmias).
DEFINITION

4. CLASSIFICATION
There are several system of classification
of myocarditis
i. Lieberman’s clinicopathological
classification
ii. Pathological classification
iii. Etiological classification

5. Lieberman’s clinicopathological
classification :-
Fulminant Myocarditis:- Severe disease
following viral infection,leading to
sudden compromise of organ systems
Acute Myocarditis :- Patient present with
heart dysfunction,which may respond to
treatment It is typically seen in infants
and teenagers but can occur at any age.
Chronic Persistent myocarditis :-
Thy have persistent inflammation but
minimal to no heart dysfunction
CLASSIFICATION

6. Pathological classification
1,Lymphocytic – is a rare condition in
which heart muscle inflammation
(myocarditis) is caused by accumulation
of white blood cells (lymphocytes) and
is usually secondary to viral infection;
adenovirus and coxsackie are the most
commonly involved viruses.
CLASSIFICATION

7. Pathological classification
2.Eosinophillic-Eosinophilic myocarditis
is a rare and potentially lethal disease
characterized by eosinophil infiltration of
the myocardium. The association between
eosinophilia and myocardial injury is well
established and may present several etiologies,
from hypersensitivity and autoimmune diseases to
neoplasias and infections.
CLASSIFICATION

8. Pathological classification
3.Granulomatous- Granulomatous
myocarditis, more commonly known as giant
cell myocarditis (GCM), is a rare and
frequently fatal disorder characterized
pathologically by degeneration and
necrosis of myocardial fibers, foci of
lymphocytes, eosinophils, and giant cells.
GCM is thought to be mediated by T
lymphocytes.
CLASSIFICATION

9. Pathological classification
4.Neutrophilic –Bacterial,fungal
myocarditis is presence of
Neutrophilic infiltration and
microabscesses in the
myocardium with minimal
myocyte damage.
CLASSIFICATION

10. Pathological classification
5.Reperfusion type/contraction
band necrosis- Contraction band
necrosis is a type of uncontrolled
cell death (necrosis) unique to
cardiac myocytes and thought to
arise in reperfusion from
hypercontraction, which results in
sarcolemmal rupture due to certain
drugs (The sarcolemma also called
the myolemma, is the cell membrane of
a muscle cell.)
CLASSIFICATION

11. Etiological classification;-
• Infectious Myocarditis:-
A viral infection usually causes myocarditis, but it
can result from a reaction to a drug or be part of a
more general inflammatory condition.
• Post viral autoimmune mediated Myocarditis
• Autoimmune –Mediated Autoimmune
myocarditis is an autoimmune disease that
affects the heart. The condition is characterized by
inflammation of the heart muscle (myocardium).
Some people with autoimmune myocarditis have
no noticeable symptoms of the condition.
• Drug associated Myocarditis
CLASSIFICATION

12. ETIOLOGY
Infectious
Drug Induced
Hypersensitivity
reaction
Immunological

13. Infectious
Viral:- Adenovirus Coxsackie virus
ETIOLOGY

14. Hepatitis c virus
HIV
ETIOLOGY
Infectious

15. Enterovirus Parvovirus B19
ETIOLOGY
Infectious

16. Epstein Barr virus Hepatitis A virus
ETIOLOGY
Infectious

17. Dengue virus
Rubela
ETIOLOGY
Infectious

18. Yellow fever
Rabies virus, Polio
ETIOLOGY
Infectious

19. ETIOLOGY
Bacteria :-
Tuberculosis
Diphtheria
Infectious

20. Streptococcus
Mycoplasma
ETIOLOGY
Infectious

21. Treponema pallidum
(syphilis)
Lyme disease
ETIOLOGY
Infectious

22. Fungal :-
Aspergillus
Candida, histoplasma
ETIOLOGY

23. Parasites
Chagas disease
(Trypanosomiasis)
Schistosomiasis
ETIOLOGY

24. Drug Induced
 It Cause Direct toxic
effect and
Hypersensitivity
reaction
 Anticancer drug
 Anthracyclines,
 5-fluorouracil,
 Cycophosphamide
 Interleukin2
 Trastuzumab
 Cocaine
 Amphetamines
ETIOLOGY

25. Hypersensitivity
reaction
 Cephalosporin group
of antibiotics
 Digoxin
 Diuretics
 Dobutamine
ETIOLOGY

26. Immunological
• Churg-strauss syndrome
• Wegener’s
Granulomatosis
• Inflammatory Bowel
disease
• Giant cell myocarditis
• Sarcoidosis
• Diabetes mellitus type I
• Systemic Lupus
Erythematosus
• Myasthenia Gravis
• Polymyositis
• Takayasu’s arteritis
• Kawasaki Disease
ETIOLOGY

27. Churg-Strauss syndrome
• Churg-Strauss syndrome is a
disorder marked by blood vessel
inflammation. This inflammation
can restrict blood flow to organs
and tissues, sometimes
permanently damaging them.
ETIOLOGY
Immunological

28. Wegener’s
Granulomatosis
• Granulomatosis with polyangiitis (GPA),
previously known as Wegener's
granulomatosis (WG), is an extremely
rare long-term systemic disorder that
involves the formation of granulomas
and inflammation of blood vessels
(vasculitis).
ETIOLOGY
Immunological

29. Inflammatory Bowel
disease
• Inflammatory bowel disease (IBD) is a
group of inflammatory conditions of the
colon and small intestine. Crohn's disease
and ulcerative colitis are the principal
types of inflammatory bowel disease.
Crohn's disease affects the small intestine
and large intestine, as well as the mouth,
esophagus, stomach and the anus, whereas
ulcerative colitis primarily affects the
colon and the rectum.
ETIOLOGY
Immunological

30. Giant cell
myocarditis
• It is characterized by inflammation of the
heart muscle (myocardium), a condition
referred to as myocarditis. Inflammation
is caused by widespread infiltration of
giant cells associated with other
inflammatory cells and heart muscle cell
destruction. Giant cells are abnormal
masses produced by the fusion of
inflammatory cells called macrophages.
ETIOLOGY
Immunological

31. Sarcoidosis
• Sarcoidosis is a disease
involving abnormal collections
of inflammatory cells that form
lumps known as granulomata.
The disease usually begins in
the lungs, skin, or lymph
nodes.
ETIOLOGY
Immunological

32. Systemic lupus
erythematosus
• Systemic lupus erythematosus
(SLE) is an autoimmune disease.
In this disease, the immune system
of the body mistakenly attacks
healthy tissue. It can affect the
skin, joints, kidneys, brain, and
other organs.
ETIOLOGY
Immunological

33. Type 1 diabetes
• Type 1 diabetes (T1D), previously
known as juvenile diabetes, is an
autoimmune disease that is a
form of diabetes in which very
little or no insulin is produced by
the islets of Langerhans
(containing beta cells) in the
pancreas.
ETIOLOGY
Immunological

34. Myasthenia gravis
• Myasthenia gravis (MG) is a long-term
neuromuscular disease that leads to
varying degrees of skeletal muscle
weakness. The most commonly affected
muscles are those of the eyes, face, and
swallowing. It can result in double vision,
drooping eyelids, trouble talking, and
trouble walking. The condition is caused
by a breakdown in communication
between nerves and muscles.
ETIOLOGY
Immunological

35. Polymyositis
• Polymyositis is a type of muscle
disease called an inflammatory
myopathy. It inflames your
muscles and their related tissues,
like the blood vessels that supply
them. It can cause muscle
weakness and pain, often on both
sides of your body.
ETIOLOGY
Immunological

36. Takayasu's arteritis
• Takayasu's arteritis is a rare type of
vasculitis, a group of disorders that cause
blood vessel inflammation. In Takayasu's
arteritis, the inflammation damages the
aorta — the large artery that carries blood
from your heart to the rest of your body —
and its main branches.The disease can lead
to narrowed or blocked arteries, or to
weakened artery walls that may bulge and
tear (aneurysm).
ETIOLOGY
Immunological

37. Kawasaki disease
• Kawasaki disease (KD), or
mucocutaneous lymph node
syndrome, is an illness that causes
inflammation in arteries, veins,
and capillaries. It also affects your
lymph nodes and causes
symptoms in your nose, mouth,
and throat. It’s the most common
cause of heart disease in children.
ETIOLOGY
Immunological

38. PATHOPHYSIOLOGY
Due to etiological factors
Inflammation and Injury of the myocardium
Decreased cardiac output
Decreased myocardial contractibility
Heart enlarges
IncreasedLeft ventricular end diastolic pressure
Increased Sympathetic tone
Congestive heart failure
Increased Left
arterial
pressure
Pulmonary
edema
Scarring
Dysrhythmias

39.  Fatigue
 Fever
 Chest pain
 Shortness of Breath
 Palpitation (a feeling of racing heart)
 Symptoms of viral infection like
(Diarrhoea,Vomiting,Joint pain ,
running nose ,
Headache,Bodyache,sore throat)
CLINICAL MANIFESTATION

40. Swelling of Feet
Low urine output
Chest Tightness
Symptoms of Cardiac failure
may manifest such as
Pulmonary edema,Peripheral
edema,hypoxemia,pulse
alternans,low blood pressure
CLINICAL MANIFESTATION

41. • History collection-
Regarding the Immunological
disorders and other etiological
factors
• Physical Examination- On
auscultation hear soft first
heart sound and S4 Gallop,
Assess the sign of
Vasculitis,cardiac failure
DIAGNOSTIC EVALUATION

42. • ECG- It can show the changes
similar to those of a heart attack or
arrhythemias and heart block
• Blood Test – Complete blood count
which shows Increased
WBC,ESR,CRP
• Blood tests can also detect antibodies
against viruses and other organisms
that might indicate a myocarditis-
related infection.
DIAGNOSTIC EVALUATION

43. • Cardiac makers such as Troponin I
and Troponin T which are elevated
• Chest X ray – usually it shows
normal but it may show changes if
there is any complication like heart
failure and pericarditis
• Echocardiography- It might detect
enlargement of your heart, poor
pumping function, valve problems, a
clot within the heart or fluid around
your heart.
DIAGNOSTIC EVALUATION

44. • Cardiac MRI –
to differentiate
between MI and
Myocarditis
DIAGNOSTIC EVALUATION

45. • Nuclear Imaging
with gallium 67 or
indium 111 – anti-
myosin antibodies
DIAGNOSTIC EVALUATION

46. • Serological
test- to
conform
autoimmune
diseases and
viruses
DIAGNOSTIC EVALUATION

47. • Endomyocardical
Biopsy – To rule out
the pathological
myocarditis
DIAGNOSTIC EVALUATION

48. • Viral Myocarditis :- antiviral medications
• Giant cell and eosinophilic myocarditis:-
combination of cyclosporine and
corticosteroids , Immunosuppresed
• Heart failure or arrhythmias :-
 Angiotensin-converting enzyme (ACE)
inhibitors. These medications, such as
enalapril , captopril , lisinopril, Prinivil) and
ramipril , relax the blood vessels in your
heart and help blood flow more easily.
MEDICAL MANAGEMENT

49.  Angiotensin II receptor blockers
(ARBs). These medications, such as
losartan and valsartan , relax the blood
vessels in your heart and help blood flow
more easily.
 Beta blockers. Beta blockers, such as
metoprolol , bisoprolol and carvedilol ,
work in multiple ways to treat heart
failure and help control arrhythmias.
MEDICAL MANAGEMENT

50. Diuretics. These medications, such as
furosemide (Lasix), relieve sodium and
fluid retention.
• In some severe cases of myocarditis,
aggressive treatment might include:
Intravenous (IV) medications. These
might improve the heart-pumping
function more quickly.
MEDICAL MANAGEMENT

51. • Extracorporeal membrane oxygenation
(ECMO). With severe heart failure, this
device can provide oxygen to the body.
When blood is removed from the body, it
passes through a special membrane in the
ECMO machine that removes carbon
dioxide and adds oxygen to the blood. The
newly oxygenated blood is then returned
to the body.
• The ECMO machine takes over the work of
the heart. This treatment may be used to
allow the heart to recover or while
waiting for other treatments, such as a
heart transplant.
MEDICAL MANAGEMENT

52. • Ventricular assist
devices. Ventricular assist
devices (VADs) are mechanical
pumps that help pump blood
from the lower chambers of
your heart (the ventricles) to the
rest of your body. VADs are
used in people who have
weakened hearts or heart
failure. This treatment may be
used to allow the heart to
recover or while waiting for
other treatments, such as a
heart transplant.
SURGICAL
MANAGEMENT

53. • Intra-aortic balloon pump. An
intra-aortic balloon pump (IABP) is a
mechanical device that helps the heart
pump blood.
• This device is inserted into the aorta,
the body's largest artery. It is a long,
thin tube called a catheter with a
balloon on the end of it. If you are
hospitalized, your doctor may insert
an IABP. Your doctor will numb an
area of your leg and thread the IABP
through the femoral artery in your leg
into your aorta.
SURGICAL MANAGEMENT

54. • Intra-aortic balloon pump.
• The doctor will use an X-ray machine
during this procedure to help accurately
position the IABP. The IABP improves the
function of only your left ventricle, since
this is the chamber that pumps blood into
your aorta. Here's how an IABP works:
• After your left ventricle has finished
contracting, the balloon inflates. This
inflation helps increase blood flow to the
heart and the rest of the body.
• As your left ventricle is about to pump out
blood, the balloon deflates. This deflation
creates extra space in the aorta, allowing
the heart to pump out more blood. This
decreases the workload on the heart.
SURGICAL
MANAGEMENT

55. • Heart transplantation.
• A heart transplant is an
operation in which a failing,
diseased heart is replaced with
a healthier, donor heart. Heart
transplant is a treatment that's
usually reserved for people
who have tried medications or
other surgeries, but their
conditions haven't sufficiently
improved
SURGICAL MANAGEMENT

56. • Severe myocarditis can permanently
damage your heart muscle, possibly
causing:
• Heart failure. Untreated,
myocarditis can damage your heart's
muscle so that it can't pump blood
effectively. In severe cases,
myocarditis-related heart failure may
require a ventricular assist device or
a heart transplant.
COMPLICATION

57. COMPLICATION
• Heart attack or stroke. If your
heart's muscle is injured and
can't pump blood, the blood
that pools in your heart can
form clots. If a clot blocks one
of your heart's arteries, you can
have a heart attack. If a blood
clot in your heart travels to an
artery leading to your brain
before becoming lodged, you
can have a stroke.

58. • Rapid or abnormal heart
rhythms (arrhythmias). Damage
to your heart muscle can cause
arrhythmias.
• Sudden cardiac death. Certain
serious arrhythmias can cause
your heart to stop beating (sudden
cardiac arrest). It's fatal if not
treated immediately.
COMPLICATION

59. • Administer oxygen therapy 4-6 l/min to help
patient in breathing effectively through
supplementing oxygen
• Monitor arterial blood gas , carbon dioxide,
oxygen saturation hourly and document to monitor
signs of respiratory acidosis
• Inspect thorax for symmetry of respiratory
movementDetermines adequacy of
breathingObserve breathing pattern for SOB,
nasal flaring, pursed-lip breathing or
prolonged expiratory phase and use of
accessory muscles
NURSING MANAGEMENT

60. • Encourage and provide small frequent meals
reach in proteins helping in repairing worn-out
tissues
• Monitor vital signs , heart and lung sound,
level of consciousness to evaluate how effectively
the organs like the heart and the lungs are
working
• Schedule nursing activities to allow rest
• Encourage and assist patient to cough and
deep breath to promote chest expansion
• Provide tepid sponging to reduce raised body
temperature by evaporation and conduction
NURSING MANAGEMENT

61. • Encourage patient on exercises in order to
improve patients mobility through making
the body physically fit
• Make yourself available to the patient and
nurse with love and respond well to his/her
questions to array pain and anxiety
• Educate the patient on disease process to
make patient cope up with therapy and the
condition,
• Advice the client to follow sodium restriction.
• Monitor urine output, noting amount and
color, as well as time of day when diuresis
occur.
NURSING MANAGEMENT

62.  Infective breathing pattern related to
inflammation of heart muscle as
evidenced by use of accessory muscle,
dyspnea
 Acute pain (stabbing Chest pain ) related
to inflammed myocardium as evidenced
by vocalization,facial
expression,purposeless body movements
 Impaired gas exchange related to
pulmonary congestion caused by
myocardial failure (decreased cardiac
output)as manifested by
palpitation,dyspnea,tachycardia
NURSING DIAGNOSIS

63. • Activity intolerance related to decreased
cardiac output or excessive fluid volume, or
both as manifest by difficulty in engaging
activites,discomfort,fatigue
• Excess Fluid VolumeRelated FactorsReduced
glomerular filtration rate as manifested by
peripheral edma,decreased urine out,jugular
vein distension
• Anxiety related to fear of death, surgical
procedures, and hospitalization as evidenced
by restlessness,poor eye contact,verbalization
NURSING DIAGNOSIS

64. • Deficient KnowledgeRelated Factors Lack of
understanding,misconceptions about
interrelatedness of cardiac
function,disease,failure as manifested by
Questioning ,Statements of
concern,misconceptions
• PowerlessnessMay be related to chronic
illness and hospitalizations as manifested by
depression ,apathy
• Ineffective management Therapeutic
Regimen related to complexity of regimen,
economic limitations as manifested by
verbalization,inadequate support system
NURSING DIAGNOSIS