Viral myocarditis and dilated cardiomyopathy
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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

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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.)


Questions

Questions?


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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