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Myocarditis

MYOCARDITIS

 
1. Oorzaken
    
      Niet-infectieus

- toxisch:

    - medicatie:

        -  overgevoeligheid aan penicilline, sulfamethoxazole (Bactrim, Eusaprim) of sulfadiazine (Flammazine)

        - chemotherapie

        - koolwaterstoffen

    - intoxicatie

        - koolmonoxide

        - zware metalen

        - arseen

- zwangerschap: postpartum cardiomyopathie
- auto-immuunziekten: SLE, ziekte van Kawasaki, Wegener granulomatose
- sarcoidose
- transplantrejectie
- bestraling
 

      Infectieus

- parasitair:

    - Protozoa

        - ziekte van Chagas: wereldwijd grootste oorzaak van myocarditis. Enkel in Centraal en Zuid-Amerika.  Ongeveer 20 miljoen personen zijn geinfecteerd door Tryposama Cruzi.

        - Toxoplasmose

        - Trypanosomias

        - Malaria

        - Leishmaniasis

    - Spirocheten (Syfilis)

    - Rickettsia

    - Wormen (Helminthic)

        - Trichinose

        - Echinococcus

        - Schistosomias

        - Cysticercosis

- Schimmelinfectie

    - candidiasis

    - aspergillosis

    - cryptococcus

    - histoplasmosis

    - actinomycosis

- bijtwonden

    - schorpioen

    - slang

    - zwarte weduwe

- bacterieel

    - difterie

    - tuberculose

    - brucellose

    - psittacosis

    - meningococcen

    - mycoplasma

    - groep A streptococcen

- Viraal

    - enterovirus (coxsackie B)

    - adenovirus

    - herpesvirus

    - CMV

    - Hepatitis C

    - Influenza

    - Mazelen

    - Rubeola

    - Variola

    - Gele koorts

    - Rabies

    - HIV

 

 

2. Diagnostiek
- anamnese:

    - recent ontstane vermoeidheid

    - gedaalde inspanningstolerantie

    - dyspnee

    - thoracale last bij AH

    - koorts

    - hartkloppingen

- lichamelijk onderzoek:

    - matige vorm: vitale parameters: zwakke pulsaties (hypotensie, tachycardie), cyanose, opgezette venae jugularis.  Bij auscultatie S1 bedekt/zwak en zelden een diastolisch geruis.

    - fulminante vorm: reutels, opzetting halsvenen, perifeer oedeem, hepatomegalie

- ECG:

    - ST- en T-afwijkingen maar nonspecifiek en transient.

    -  ritmestoornissen.

    - Geleidingsstoornissen

- Rx Thorax: deze varieert van normaal tot cardiomegalie en longoedeem
- Labo:

    - CBC

    - CRP

    - Hartenzymen

    - infectie: virale titers, titers voor mycoplasma, antistreptolysine, hepatitistesten, monospot, CMV, bloedculturen

- Echocardio:

    - linker ventrikeldillatatie, hypertrofie.  Thrombus?

    - Rechter ventrikel: slechte functie is een slechte prognose.

    - vullingstoestand van de ventrikels.

- scintigrafie: antimyosine antilichamen, gallium 67 gelabeld of Indium 111 gelabeld.
- MRI met gadolinium: cardiale inflammatie of necrose
- biopsie rechter ventrikel

 

 
3. Therapie
    
      Eerste opvang
- eventueel longoedeem behandelen
- ritmestoornissen behandelen: behandeling van tachycardie, bradycardie.  Zo nodig transveneuze pacing.  Cave: geef GEEN NSAID in de acute fase!
 
      Spoeddienst
- cardiale therapie:

    - preload en afterload verminderen.  ACE-inhibitoren verminderen de inflammatie en de afterload.  Ook diuretica passen hierin

    - bloedverdunners bij thrombus of verminderde LV functie

    - ritmestoornissen behandelen.  Digoxine bij atriumfibrillatie

- specifieke therapie

    - CMV: hyperimmunoglobuline therapie.  Bij kinderen worden bij virale myocarditis IV immunoglobulines gegeven.

    - Immunosuppressieve therapie: het effect is niet bewezen

- effecten op termijn:

    - mortaliteit op 5 jaar = 56%.

    - Harttransplantatie kan een oplossing bieden.

    - 20 à 33% geneest volledig.

 

 

Eerste opvang
- eventueel longoedeem behandelen
- ritmestoornissen behandelen: behandeling van tachycardie, bradycardie.  Zo nodig transveneuze pacing.  Cave: geef GEEN NSAID in de acute fase!

 

 

Spoeddienst
- cardiale therapie:

    - preload en afterload verminderen.  ACE-inhibitoren verminderen de inflammatie en de afterload.  Ook diuretica passen hierin

    - bloedverdunners bij thrombus of verminderde LV functie

    - ritmestoornissen behandelen.  Digoxine bij atriumfibrillatie

- specifieke therapie

    - CMV: hyperimmunoglobuline therapie.  Bij kinderen worden bij virale myocarditis IV immunoglobulines gegeven.

    - Immunosuppressieve therapie: het effect is niet bewezen

- effecten op termijn:

    - mortaliteit op 5 jaar = 56%.

    - Harttransplantatie kan een oplossing bieden.

- 20 à 33% geneest volledig.

 

 

REFERENTIES:

 

 

  • Caforio AL, Pankuweit S, Arbustini E, et al. Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2013; 34:2636.
  • Dec GW Jr, Palacios IF, Fallon JT, et al. Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome. N Engl J Med 1985; 312:885.
  • O'Connell JB, Mason JW. Diagnosing and treating active myocarditis. West J Med 1989; 150:431.
  • Olinde KD, O'Connell JB. Inflammatory heart disease: pathogenesis, clinical manifestations, and treatment of myocarditis. Annu Rev Med 1994; 45:481.
  • Ansari AA, Wang YC, Danner DJ, et al. Abnormal expression of histocompatibility and mitochondrial antigens by cardiac tissue from patients with myocarditis and dilated cardiomyopathy. Am J Pathol 1991; 139:337.
  • Grist NR, Bell EJ. Coxsackie viruses and the heart. Am Heart J 1969; 77:295.
  • Gerzen P, Granath A, Holmgren B, Zetterquist S. Acute myocarditis. A follow-up study. Br Heart J 1972; 34:575.
  • Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation 2006; 113:593.
  • Angelini A, Calzolari V, Calabrese F, et al. Myocarditis mimicking acute myocardial infarction: role of endomyocardial biopsy in the differential diagnosis. Heart 2000; 84:245.
  • Gutberlet M, Spors B, Thoma T, et al. Suspected chronic myocarditis at cardiac MR: diagnostic accuracy and association with immunohistologically detected inflammation and viral persistence. Radiology 2008; 246:401.
  • Mahrholdt H, Goedecke C, Wagner A, et al. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation 2004; 109:1250.
  • Kindermann I, Kindermann M, Kandolf R, et al. Predictors of outcome in patients with suspected myocarditis. Circulation 2008; 118:639.
  • Kühl U, Lauer B, Souvatzoglu M, et al. Antimyosin scintigraphy and immunohistologic analysis of endomyocardial biopsy in patients with clinically suspected myocarditis--evidence of myocardial cell damage and inflammation in the absence of histologic signs of myocarditis. J Am Coll Cardiol 1998; 32:1371.
  • Engler, RJ, Collins, LC, Gibbs, BT, et al. Myocarditis after smallpox/vaccinia immunization: Passive vaccine safety surveillance compared to prospective studies. J Allerg Clin Immunol 2009; 123:S264.
  • Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995; 333:269.
  • Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.
  • Dec GW Jr, Waldman H, Southern J, et al. Viral myocarditis mimicking acute myocardial infarction. J Am Coll Cardiol 1992; 20:85.
  • Sarda L, Colin P, Boccara F, et al. Myocarditis in patients with clinical presentation of myocardial infarction and normal coronary angiograms. J Am Coll Cardiol 2001; 37:786.
  • Miklozek CL, Crumpacker CS, Royal HD, et al. Myocarditis presenting as acute myocardial infarction. Am Heart J 1988; 115:768.
  • Karjalainen J, Heikkilä J. Incidence of three presentations of acute myocarditis in young men in military service. A 20-year experience. Eur Heart J 1999; 20:1120.
  • McCully RB, Cooper LT, Schreiter S. Coronary artery spasm in lymphocytic myocarditis: a rare cause of acute myocardial infarction. Heart 2005; 91:202.
  • Theleman KP, Kuiper JJ, Roberts WC. Acute myocarditis (predominately lymphocytic) causing sudden death without heart failure. Am J Cardiol 2001; 88:1078.
  • Drory Y, Turetz Y, Hiss Y, et al. Sudden unexpected death in persons less than 40 years of age. Am J Cardiol 1991; 68:1388.
  • Maron BJ, Carney KP, Lever HM, et al. Relationship of race to sudden cardiac death in competitive athletes with hypertrophic cardiomyopathy. J Am Coll Cardiol 2003; 41:974.
  • Eckart RE, Scoville SL, Campbell CL, et al. Sudden death in young adults: a 25-year review of autopsies in military recruits. Ann Intern Med 2004; 141:829.
  • Maron BJ, Doerer JJ, Haas TS, et al. Sudden deaths in young competitive athletes: analysis of 1866 deaths in the United States, 1980-2006. Circulation 2009; 119:1085.
  • Wang K, Asinger RW, Marriott HJ. ST-segment elevation in conditions other than acute myocardial infarction. N Engl J Med 2003; 349:2128.
  • Nakashima H, Katayama T, Ishizaki M, et al. Q wave and non-Q wave myocarditis with special reference to clinical significance. Jpn Heart J 1998; 39:763.
  • Caforio AL, Calabrese F, Angelini A, et al. A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis. Eur Heart J 2007; 28:1326.
  • Ukena C, Mahfoud F, Kindermann I, et al. Prognostic electrocardiographic parameters in patients with suspected myocarditis. Eur J Heart Fail 2011; 13:398.
  • Smith SC, Ladenson JH, Mason JW, Jaffe AS. Elevations of cardiac troponin I associated with myocarditis. Experimental and clinical correlates. Circulation 1997; 95:163.
  • Lauer B, Niederau C, Kühl U, et al. Cardiac troponin T in patients with clinically suspected myocarditis. J Am Coll Cardiol 1997; 30:1354.
  • Nieminen MS, Heikkilä J, Karjalainen J. Echocardiography in acute infectious myocarditis: relation to clinical and electrocardiographic findings. Am J Cardiol 1984; 53:1331.
  • Pinamonti B, Alberti E, Cigalotto A, et al. Echocardiographic findings in myocarditis. Am J Cardiol 1988; 62:285.
  • Escher F, Westermann D, Gaub R, et al. Development of diastolic heart failure in a 6-year follow-up study in patients after acute myocarditis. Heart 2011; 97:709.
  • Felker GM, Boehmer JP, Hruban RH, et al. Echocardiographic findings in fulminant and acute myocarditis. J Am Coll Cardiol 2000; 36:227.
  • Mendes LA, Picard MH, Dec GW, et al. Ventricular remodeling in active myocarditis. Myocarditis Treatment Trial. Am Heart J 1999; 138:303.
  • Friedrich MG, Sechtem U, Schulz-Menger J, et al. Cardiovascular magnetic resonance in myocarditis: A JACC White Paper. J Am Coll Cardiol 2009; 53:1475.
  • Friedrich MG, Marcotte F. Cardiac magnetic resonance assessment of myocarditis. Circ Cardiovasc Imaging 2013; 6:833.
  • Ferreira VM, Piechnik SK, Dall'Armellina E, et al. T(1) mapping for the diagnosis of acute myocarditis using CMR: comparison to T2-weighted and late gadolinium enhanced imaging. JACC Cardiovasc Imaging 2013; 6:1048.
  • Abdel-Aty H, Boyé P, Zagrosek A, et al. Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches. J Am Coll Cardiol 2005; 45:1815.
  • Baccouche H, Mahrholdt H, Meinhardt G, et al. Diagnostic synergy of non-invasive cardiovascular magnetic resonance and invasive endomyocardial biopsy in troponin-positive patients without coronary artery disease. Eur Heart J 2009; 30:2869.
  • Laissy JP, Messin B, Varenne O, et al. MRI of acute myocarditis: a comprehensive approach based on various imaging sequences. Chest 2002; 122:1638.
  • De Cobelli F, Pieroni M, Esposito A, et al. Delayed gadolinium-enhanced cardiac magnetic resonance in patients with chronic myocarditis presenting with heart failure or recurrent arrhythmias. J Am Coll Cardiol 2006; 47:1649.
  • O'Connell JB, Henkin RE, Robinson JA, et al. Gallium-67 imaging in patients with dilated cardiomyopathy and biopsy-proven myocarditis. Circulation 1984; 70:58.
  • Takano H, Nakagawa K, Ishio N, et al. Active myocarditis in a patient with chronic active Epstein-Barr virus infection. Int J Cardiol 2008; 130:e11.
  • Lieberman EB, Hutchins GM, Herskowitz A, et al. Clinicopathologic description of myocarditis. J Am Coll Cardiol 1991; 18:1617.
  • McCarthy RE 3rd, Boehmer JP, Hruban RH, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 2000; 342:690.
  • Blauwet LA, Cooper LT. Myocarditis. Prog Cardiovasc Dis 2010; 52:274.
  • Howlett JG, McKelvie RS, Arnold JM, et al. Canadian Cardiovascular Society Consensus Conference guidelines on heart failure, update 2009: diagnosis and management of right-sided heart failure, myocarditis, device therapy and recent important clinical trials. Can J Cardiol 2009; 25:85.
  • Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation 2006; 113:1807.
  • Elliott P, Andersson B, Arbustini E, et al. Classification of the cardiomyopathies: a position statement from the European Society Of Cardiology Working Group on Myocardial and Pericardial Diseases. Eur Heart J 2008; 29:270.
  • Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013; 128:1810.
  • Chimenti C, Pieroni M, Maseri A, Frustaci A. Histologic findings in patients with clinical and instrumental diagnosis of sporadic arrhythmogenic right ventricular dysplasia. J Am Coll Cardiol 2004; 43:2305.
  • Pieroni M, Dello Russo A, Marzo F, et al. High prevalence of myocarditis mimicking arrhythmogenic right ventricular cardiomyopathy differential diagnosis by electroanatomic mapping-guided endomyocardial biopsy. J Am Coll Cardiol 2009; 53:681.
  • Rahman JE, Helou EF, Gelzer-Bell R, et al. Noninvasive diagnosis of biopsy-proven cardiac amyloidosis. J Am Coll Cardiol 2004; 43:410.
  • Frustaci A, Verardo R, Caldarulo M, et al. Myocarditis in hypertrophic cardiomyopathy patients presenting acute clinical deterioration. Eur Heart J 2007; 28:733.
  • Cooper LT, Baughman KL, Feldman AM, et al. The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology. Circulation 2007; 116:2216.
  • Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1987; 1:3.
  • Wu LA, Lapeyre AC 3rd, Cooper LT. Current role of endomyocardial biopsy in the management of dilated cardiomyopathy and myocarditis. Mayo Clin Proc 2001; 76:1030.
  • Frustaci A, Chimenti C, Calabrese F, et al. Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders. Circulation 2003; 107:857.
  • Kühl U, Pauschinger M, Seeberg B, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation 2005; 112:1965.
  • Martin AB, Webber S, Fricker FJ, et al. Acute myocarditis. Rapid diagnosis by PCR in children. Circulation 1994; 90:330.
  • Kühl U, Pauschinger M, Noutsias M, et al. High prevalence of viral genomes and multiple viral infections in the myocardium of adults with "idiopathic" left ventricular dysfunction. Circulation 2005; 111:887.
  • Caforio AL, Mahon NG, Baig MK, et al. Prospective familial assessment in dilated cardiomyopathy: cardiac autoantibodies predict disease development in asymptomatic relatives. Circulation 2007; 115:76.

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