acute heart failure myocarditis
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Leslie T. Cooper, Jr., MDLeslie T. Cooper, Jr., MDChair, Cardiovascular DepartmentChair, Cardiovascular Department
Mayo Clinic in FloridaMayo Clinic in Florida
Myocarditis in the Emergency Department
May 23rd, 2015
32 year old man presents to your ED with recent onset
chest pressure and dyspnea
•• He reports a flu-like illness 1 week priorHe reports a flu-like illness 1 week prior
•• Exam: HR 108 regular. BP 105/70.Exam: HR 108 regular. BP 105/70.
•• + Pericardial rub, + basilar rales+ Pericardial rub, + basilar rales
•• JVP 9 cm. No peripheral edema.JVP 9 cm. No peripheral edema.
•• Troponin T 12Troponin T 12
First Electrocardiogram
CP1291921-1
II
IIII
IIIIII
aVRaVR
aVLaVL
aVFaVF
V1V1
V2V2
V3V3
V4V4
V5V5
V6V6
Which of the following is least likely to improve his left ventricular
function over the next 6 months?
•• LisinoprilLisinopril•• CarvedilolCarvedilol•• Prednisone and AzathioprinePrednisone and Azathioprine
Inflammatory, Infiltrative, Infectious Cardiomyopthies
•• MyocarditisMyocarditisPost-viral/idiopathic, giant cell, Post-viral/idiopathic, giant cell,
rheumatologic or hypersensitivity- rheumatologic or hypersensitivity- relatedrelated
•• Sarcoidosis- Sarcoidosis- 50% 50% isolated to the heartisolated to the heart•• HIV, Chagas’ and Lyme DiseasesHIV, Chagas’ and Lyme Diseases•• AmyloidosisAmyloidosis
Cumulative Incidence Rates of Death, Heart Transplantation and Left Ventricular Recovery
in Children with Myocarditis
Time to occurrence of event (years)
Eve
nt p
roba
bilit
y
No event
Echocardiographic normalization
Death
Transplant
Foerster et al: Circ Heart Fail, 2010
According to current ESC and AHA scientific statements,
which of the following is a Class I indication for EMB in acute DCM?
•• Failure to improve with GDMT after 2 Failure to improve with GDMT after 2 weeksweeks
•• Sustained or symptomatic VTSustained or symptomatic VT•• Mobitz type 2 or higher heart blockMobitz type 2 or higher heart block•• All of the aboveAll of the above
According to a recent randomzed clinical trial which of the following are useful to
control his chest pain?
•• Colchicine, dosed by weightColchicine, dosed by weight•• Prednisone 20 mg/dayPrednisone 20 mg/day•• HydrocodoneHydrocodone•• None of the aboveNone of the above
NewNew onset heart failure of onset heart failure of 2 2 weeks to 3 monthsweeks to 3 months duration duration associated with a dilated left associated with a dilated left ventricle…andventricle…and
Class I, LOE B
Cooper, LT, et al Circulation 2007
•Ventricular arrhythmias, or•High degree heart block, or •Failure to respond to usual care within
1 to 2 weeks
Giant Cell versus Lymphocytic Myocarditis Transplant-Free Survival
CP977755-6
Survival (yr)Survival (yr)
Prop
ortio
n su
rviv
ing
Prop
ortio
n su
rviv
ing
LM groupLM groupGCM groupGCM group
Cooper, LT, NEJM 1997
25% of 72 patients 18-55 with initially unexplained AV block had GCM or cardiac sarcoidosis on endomyocardial biopsy
Circ. Arrhy and EP 2011:4(3). 303 -9
Immunohistology Predicts Outcome in Patients with Acute Myocarditis
Free
dom
from
car
diac
deat
h an
d H
Tx
Months after biopsy
Kindermann et al: Circ 118:639, 2008 CP1324648-2
Positive
Negative
P<0.001
ImmunohistologyResults
Histopathological ResultsAccording to DALLAS Criteria
1.0
0.8
0.6
0.4
0.2
0.0
Months after biopsy
DALLAS negative
DALLAS positive
P=0.192
TIMIC Study•• RCT- Biopsy guided therapy in chronic RCT- Biopsy guided therapy in chronic
DCM, n=DCM, n=8585; Screened ; Screened 512512•• AZA and prednisone-mean LVEF AZA and prednisone-mean LVEF
increased from increased from 26% to 46% 26% to 46% at 6 months at 6 months •• Immunosuppression may improve LVEF Immunosuppression may improve LVEF
in select patients with non-viral, in select patients with non-viral, inflammatory DCM that inflammatory DCM that fails to respond fails to respond to usual careto usual care
Frustaci, A, et al. Eur Heart J 2009
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