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E d. Viral Myocarditis and Dilated Cardiomyopathy. Kristine Scruggs, MD AM Report 10 March 2010. Signs & Symptoms of Myocarditis. Excessive fatigue Chest pain Unexplained sinus tachycardia Acute pericarditis S3, S4 or summation gallop Abnormal electrocardiogram

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viral myocarditis and dilated cardiomyopathy

E

d

Viral Myocarditis and Dilated Cardiomyopathy

Kristine Scruggs, MD

AM Report

10 March 2010

signs symptoms of myocarditis
Signs & Symptoms of Myocarditis
  • Excessive fatigue
  • Chest pain
  • Unexplained sinus tachycardia
  • Acute pericarditis
  • S3, S4 or summation gallop
  • Abnormal electrocardiogram
  • Abnormal echocardiogram
  • New cardiomegaly on CXR
  • Atrial or ventricular arrhythmia
  • Partial or complete heart block
  • New onset CHF
  • Atypical MI
  • Cardiogenic shock
  • Sudden, unexpected death
etiologies of dcm felker et al
Etiologies of DCM (Felker, et al.)
  • Idiopathic (50%)
  • Myocarditis (9%)
    • Viral, Bacterial, Fungal, Protozoal, Helminth
  • Ischemic heart disease (7%)
  • Infiltrative disease (5%)
    • Amyloidosis, Sarcoidosis, Hemochromatosis
  • Peripartumcardiomyopathy (4%)
  • Hypertension (4%)
  • HIV infection (4%)
  • Connective Tissue Disease(3%)
    • Scleroderma, SLE, etc
  • Substance abuse (3%)
    • Cocaine, EtOH
  • Doxorubicin (1%)
  • Other (10%)
    • Restrictive CM, Familial CM, Valvular heart dz, Endocrine, Neuromuscular, Neoplastic, Drugs (other), Critical illness, etc.
viral etiologies of myocarditis
Viral Etiologies of Myocarditis
  • Enterovirus (e.g. Coxsackie B)*
  • Adenovirus*
  • Hepatitis C
  • CMV
  • Echovirus
  • Influenza
  • EBV
  • Parvovirus B-19
  • HHV-6

*Associated with progression to DCM (Bowles, et al.)

diagnosis
Diagnosis
  • Serologies
  • Cultures
  • PCR (direct examination of cardiac tissue)
  • Incidence/prevalence of viral myocarditis difficult to assess
    • No non-invasive “gold standard”
    • 3.5-5% cardiac involvement during coxsackie outbreak
    • 6% at autopsy of SCD in young athletes
  • 149 pts w/ DCM unknown etiology, + PCR in 20% (Bowles, et al)
    • Versus 1.4% in controls
    • All adenovirus (60%) and enterovirus (40%)
  • 1230 pts w/ DCM, mycarditis the cause in 9% (Felker, et al.)
pathophysiology of viral myocarditis dcm
Pathophysiology of Viral Myocarditis --> DCM
  • Late sequela of acute or chronic viral myocarditis
  • Due to
    • direct viral injury (viral toxicity, perforin-mediated cell lysis, cytokine expression)
    • persistence of virus (initial immune response is protective)
    • autoimmune phenomenon (“anti-heart” antibodies)
  • In one study, 93% of patients with myocarditis on biopsy had history of preceding viral illness (Bowles, et al.)
  • Initial immune response is probably protective
    • Decreases inflammation
    • Stronger humoral and cellular immune response linked to less severe initial disease
take home points
Take Home Points
  • Viral infection (esp. with adeno, entero) causes myocarditis in up to 5% of cases
  • In patients with newly diagnosed DCM, 9% have been traced to viral myocarditis
  • Incidence/prevalence is difficult to assess as there is no “gold standard” for diagnosis
  • Damage is caused by direct viral injury, persistent viral infection/inflammation, and auto-immune phenomena.
  • Prognosis is thought to be generally good, as only the severe cases present with clinical findings
    • Recent onset IDCM (<6 mo) showed improvement from baseline EF 25% to 42% in one year
    • Transplant free survival 92% at one year and 88% at two years (McNamara, et al.)
references
References
  • Bowles NE, et al. Detection of Viruses in Myocardial Tissues by Polymerase Chain Reaction: Evidence of Adenovirus as a Common Cause of Myocarditis in Children and Adults. J Am Coll of Card. 2003. 42: 3. 466-472.
  • Cooper LT, et al. Etiology and Pathogenesis of Myocarditis. UpToDate. 2009.
  • Felker GM, et al. Underlying Causes and Long-term Survival in Patients with Initially Unexplained Cardiomyopathy. New Engl J of Med. 2000. 342: 15. 1077-1081.
  • McNamara DM, et al. Controlled Trial of Intravenous Immune Globulin in Recent-Onset Dilated Cardiomyopathy. Circulation. 2001; 103:2254-2259.
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