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Inflammations of the heart muscle: myocarditis

By Cristiano Antonino Last updated Jun 1, 2023

Myocarditis is an inflammation that affects the heart muscle. The name comes from the myocardium, the muscular component of the heart that makes up its walls and enables it to perform its pumping function

It can happen, for various causes – immune dysfunction, action of viruses, bacteria and fungi – that myocardial cells, called myocytes, stop functioning properly due to an inflammatory process.

A serious condition but with a good chance of full recovery, especially if no other cardiac pathology is present, with proper therapy it can be resolved without any particular consequences.

Where the heart muscle is already weak because it is affected by other pathologies, the situation can evolve unfavourably, compromising cardiac function forever and setting the patient on the road to heart failure.

Myocarditis can affect people of all ages and both sexes equally.

Among acquired heart diseases, it is, in fact, the one that most frequently affects young people.

The characteristic symptoms of myocarditis may occur after an episode of fever and may include palpitations, breathlessness, chest pain and fatigue.

Myocarditis, the causes

A cardiac inflammation such as myocarditis can have several causes, some more frequent than others.

Myocarditis from infections or systemic and metabolic diseases

When the heart muscle comes into contact with viruses, fungi and bacteria, an inflammatory response is generated that can induce structural damage.

Patients with diseases that cause immunodepression are more prone to develop this type of infection.

When a viral infection occurs, the immune system is sufficiently responsive to intervene and resolve the situation, but if this does not function properly, the body does not perceive the pathogen and the situation worsens.

Some bacteria can attack the myocardium making it oedematous, swollen and weak, preventing the heart from pumping an adequate amount of blood.

The consequence can be heart failure.

Myocarditis can be caused by autoimmune diseases such as systemic lupus erythematosus (SLE) or infectious diseases such as Chagas disease, an infection caused by an insect bite that leads to progressive atrophy and destruction of the heart muscle.

Myocarditis due to exposure to toxic substances

Myocarditis can be caused by exposure to and/or intake of toxic substances.

These include alcohol abuse, exposure to heavy metals (such as arsenic and lead), substances such as hydrocarbons and carbon monoxide, or radiation.

Similarly, another cause that frequently causes myocarditis is hypersensitivity to certain types of drugs.

Finally, myocarditis can be the consequence of rejection following a heart transplant.

When is fulminant myocarditis defined?

Myocarditis is called fulminant if it suddenly appears with severe inflammation of the myocardium.

Typical symptoms are ventricular dysfunction, cardiovascular shock and heart failure.

Fortunately, it is very rare and, if the patient is treated promptly, the prognosis is positive with a good recovery and no serious long-term damage.

Myocarditis: the symptoms

Myocarditis is, more often than not, a sneaky disease, presenting as asymptomatic or with minor discomfort that does not suggest a serious health problem.

Especially in young people, it is not uncommon for it to be diagnosed only after a premature death from heart attack, as has happened to some athletes.

Patients report a non-specific symptomatology with general malaise often not attributable to problems of cardiac origin.

In these cases, the only investigation that can help to raise the suspicion of myocarditis is an abnormal trend in the ECG curve.

Among the most frequent symptoms of the presence of the disease, in addition to a feeling of malaise, are

Fever of infectious origin and frequent tiredness. All flu-like symptoms such as malaise, headache, joint and muscle pain, fever, sore throat and gastrointestinal problems could be related to the presence of myocarditis.
Chest pain associated with cardiac arrhythmias, palpitations and shortness of breath, both during activity and at rest.
Frequent syncopes and sudden fainting, because the blood flow is suddenly reduced and cannot carry blood throughout the body,
Water retention that leaves the lower limbs swollen, sore and tingling.

This symptomatology often occurs in patients with previous heart disease or other concomitant cardiac conditions.

One of these is pericarditis, the inflammation of the membrane that lines the heart.

When myocarditis is in its last stage, the symptoms are heart failure, i.e. a dysfunction of the muscle leading to a slow degeneration of the myocardium, the ultimate manifestation of which may be sudden cardiac arrest.

Myocarditis can strike at all ages and is among the most common heart diseases among young people, adolescents and children.

In all these categories, the typical symptoms are general malaise with manifestations very similar to those of a trivial flu, i.e. cough, fever, poor appetite and abdominal pain that may evolve into breathing difficulties and cyanosis.

The prognosis of myocarditis can be very positive, with the disorder resolving completely.

However, there are more serious cases in which the disease worsens until the heart is irreparably damaged to the extent that a transplant is required.

Diagnosis

Myocarditis cannot always be diagnosed by a doctor’s examination alone because more in-depth investigations are often required to be certain of its presence.

After collecting the patient’s medical history, thanks to which the clinical history is reconstructed and the symptoms are investigated, an objective test is carried out during which one’s general practitioner, or cardiologist, performs auscultation, which, however, is often normal.

Since myocarditis is not detectable with the naked eye, the diagnosis includes the prescription of certain diagnostic tests.

An electrocardiogram (ECG) and echocardiogram are the first step and allow the health of the heart to be assessed and any abnormalities of the heart rhythm to be detected.

Imaging techniques, such as a chest X-ray, may follow to assess the severity of the problem.

Blood tests may also be prescribed.

A blood count is useful to show any increase in white blood cells, an indicator of an ongoing infectious process.

In more serious cases, in order to understand the cause and assess the extent of myocarditis, the cardiologist may opt to perform a myocardial biopsy, during which a small sample of myocardial tissue is taken for study.

These tests allow the presence of oedema or inflammation to be detected, as well as the presence of possible immunity cells.

Biopsy remains an underused diagnostic technique because it is very invasive.

Myocarditis, treatments

Treatments for myocarditis vary from patient to patient after careful consideration of the underlying causes, the degree of inflammation, age and the result of diagnostic investigations.

If myocarditis is caused by an infection

This type of myocarditis is, in the first instance, treated with antibiotic treatment aimed at eliminating the bacteria that caused it.

In addition, drugs may be prescribed to reduce inflammation and improve cardiac activity.

The most commonly used of these are analgesics, anti-inflammatory drugs and diuretics.

Another treatment option involves the use of drugs that increase the contraction force of the myocardium, which is impaired by inflammation, thus reducing the risk of developing heart failure.

Diuretics reduce water retention that causes swelling in the legs, ankles and feet, making the work of the heart muscle less tiring.

If myocarditis is caused by toxic substances

In this context, toxic substances mean not only alcohol, heavy metals or chemicals, but also certain drugs that can create even serious adverse effects.

Treatment consists in stopping their intake or removing the underlying cause.

What happens when myocarditis becomes chronic

If myocarditis becomes chronic, drug therapies are administered to help the heart function properly, such as ACE inhibitors and beta-blockers.

Those who do not respond to therapy may be subjected to immunosuppressive treatments (which limit the immune response), vasopressors (which act on blood vessel activity) or cardiac surgery (ventricular assist devices).

For all those situations that do not resolve with any type of therapy, cardiac transplantation is envisaged.

Can myocarditis be prevented?

Myocarditis is a disease for which there is no real prevention.

It is often caused by infection by viruses, bacteria and fungi, which cannot be detected in advance until the disease actually occurs.

For this reason, if you have an infection in progress, it is essential to visit a doctor immediately to receive the most appropriate treatment.

Annual flu vaccination is recommended because it reduces the risk of incurring the flu, which can complicate into myocarditis.

Particularly in the elderly and those suffering from chronic diseases, the vaccine prevents the onset of dangerous complications.

As with all other diseases, myocarditis has a prognosis that also varies depending on the patient’s general health and age.

If the disease is recognised in time and treated immediately, it is more likely to heal completely within a few weeks

In more severe cases, in which it becomes chronic or arises abruptly, heart wall lesions and heart failure may persist even once the acute inflammation is resolved.

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