MYOCARDITISMYOCARDITIS

DescriptionDescription When the heart is involved in an inflammatory process, When the heart is involved in an inflammatory process,

often caused by an infectious agent, myocarditis is said to often caused by an infectious agent, myocarditis is said to be presentbe present

Inflammation may involve the myocytes, interstitium, Inflammation may involve the myocytes, interstitium, vascular elements &/or pericardiumvascular elements &/or pericardium

Characterized by isolated pockets of inflamed & necrotic Characterized by isolated pockets of inflamed & necrotic myocardial cellsmyocardial cells

Myocardial involvement may be local or diffuse, but the Myocardial involvement may be local or diffuse, but the myocardial lesions are generally randomly distributed in the myocardial lesions are generally randomly distributed in the heart & thus the clinical consequences are dependent on the heart & thus the clinical consequences are dependent on the size & number of lesions and the location of the lesions; a size & number of lesions and the location of the lesions; a small single lesion residing in the conductive tissue may small single lesion residing in the conductive tissue may result in a fatal arrhythmiaresult in a fatal arrhythmia

May be chronic or acuteMay be chronic or acute Usually of sudden onsetUsually of sudden onset

Risk Factors/ Risk Factors/ EtiologyEtiology

AgeAge GenderGender RegionRegion

AA. Infectious etiology/agents. Infectious etiology/agents ::i) viral [measles, mumps, influenza]i) viral [measles, mumps, influenza] ii) bacterial [diphtheria]ii) bacterial [diphtheria] iii) fungal [aspergillosis]iii) fungal [aspergillosis] iv) protozoan [toxoplasmosis, trypanosoma]iv) protozoan [toxoplasmosis, trypanosoma] v) roundworm [trichinosis]v) roundworm [trichinosis] vi) rheumatic fevervi) rheumatic fever vii) serum sicknessvii) serum sickness viii) chemical agent [lead]viii) chemical agent [lead] ix) collagen diseaseix) collagen disease x) radiationx) radiation xi) metabolic [uremia]xi) metabolic [uremia]

      B. Toxic Etiology/ AgentsB. Toxic Etiology/ Agents

Drugs Drugs that cause hypersensitivity reactions that cause hypersensitivity reactions (clozapine, penicillin, ampicillin, (clozapine, penicillin, ampicillin, hydrochlorothiazide, methyldopa, and sulfonamide hydrochlorothiazide, methyldopa, and sulfonamide drugs)drugs)

Medications (eg, lithium, doxorubicin, cocaine, Medications (eg, lithium, doxorubicin, cocaine, numerous catecholamines, acetaminophen) that numerous catecholamines, acetaminophen) that may exert a direct cytotoxic effect on the heart. may exert a direct cytotoxic effect on the heart.

Environmental toxins include lead, arsenic, and Environmental toxins include lead, arsenic, and carbon monoxide.carbon monoxide.

Wasp, scorpion, and spider stingsWasp, scorpion, and spider stings Radiation therapy may cause a myocarditis with the Radiation therapy may cause a myocarditis with the

development of a dilated cardiomyopathy.development of a dilated cardiomyopathy.

        C. Immunologic Etiology/ AgentsC. Immunologic Etiology/ Agents

Connective tissue disorders such as Connective tissue disorders such as systemic lupus erythematosus (SLE), systemic lupus erythematosus (SLE), rheumatoid arthritis, scleroderma, and rheumatoid arthritis, scleroderma, and dermatomyositis that can often result in a dermatomyositis that can often result in a dismal prognosisdismal prognosis

Idiopathic inflammatory and infiltrative Idiopathic inflammatory and infiltrative disorders such as Kawasaki disease, disorders such as Kawasaki disease, sarcoidosis, and giant cell arteritissarcoidosis, and giant cell arteritis

Myocarditis also sometimes occurs when a Myocarditis also sometimes occurs when a person is exposed to:person is exposed to:

Certain chemicalCertain chemical. These may include substance such . These may include substance such as arsenic and hydrocarbons.as arsenic and hydrocarbons.

Medication that may cause allergic or toxic Medication that may cause allergic or toxic reactionreaction. These include antibiotics such as penicillin . These include antibiotics such as penicillin and sulfonamide drugs, as well as some illegal and sulfonamide drugs, as well as some illegal substances, such as cocainesubstances, such as cocaine

Sytemic diseaseSytemic disease. The include lupus, other connective . The include lupus, other connective tissue disorder, inflammation of blood tissue disorder, inflammation of blood vessels(vasculitis), and rare inflammatory conditions vessels(vasculitis), and rare inflammatory conditions such as Wegener’s granulomatosis.such as Wegener’s granulomatosis.

PathophysiologyPathophysiology

invasion of myocardiuminvasion of myocardium

production of myocardial toxinproduction of myocardial toxin

immunologically mediated myocardial damageimmunologically mediated myocardial damage

Inflammation of the myocardium Inflammation of the myocardium

Assessment FindingsAssessment FindingsMyocarditis vary from person-to-person depending on the cause Myocarditis vary from person-to-person depending on the cause and the severity. Symptoms may appear slowly or come on and the severity. Symptoms may appear slowly or come on suddenly.suddenly.

If you have any of these symptoms you should contact your If you have any of these symptoms you should contact your doctor right away. doctor right away.

Flu-like complaints, including fever, fatigue, muscle pain, Flu-like complaints, including fever, fatigue, muscle pain, vomiting, vomiting, diarrheadiarrhea , and weakness , and weakness

Rapid heart rateRapid heart rate Chest painChest pain Shortness of breath and respiratory distressShortness of breath and respiratory distress Loss of consciousnessLoss of consciousness Sudden, unexpected deathSudden, unexpected death Sudden, intense myocarditis can lead to Sudden, intense myocarditis can lead to congestive heart failurecongestive heart failure . . Some people have no symptoms (asymptomatic).Some people have no symptoms (asymptomatic).

Diagnostic testDiagnostic test laboratory Studieslaboratory Studies Cardiac enzyme levelsCardiac enzyme levels

These levels are only elevated in a minority of patients.These levels are only elevated in a minority of patients. Normally, a characteristic pattern of slow elevation and fall Normally, a characteristic pattern of slow elevation and fall

over a period of days occurs; however, a more abrupt rise over a period of days occurs; however, a more abrupt rise is observed in patients with acute myocardial infarction.is observed in patients with acute myocardial infarction.

Cardiac troponin I may be more sensitive because it Cardiac troponin I may be more sensitive because it is present for longer periods after myocardial damage is present for longer periods after myocardial damage from any cause.2 from any cause.2

Erythrocyte sedimentation rate (ESR) is elevated in Erythrocyte sedimentation rate (ESR) is elevated in 60% of patients with acute myocarditis.60% of patients with acute myocarditis.

Leukocytosis is present in 25% of cases.Leukocytosis is present in 25% of cases.

Imaging StudiesImaging Studies Chest radiographyChest radiography

A chest radiograph often reveals a normal cardiac silhouette, but pericarditis or A chest radiograph often reveals a normal cardiac silhouette, but pericarditis or overt clinical CHF is associated with cardiomegaly.overt clinical CHF is associated with cardiomegaly.

Vascular redistributionVascular redistribution Interstitial and alveolar edemaInterstitial and alveolar edema Pleural effusionPleural effusion

EchocardiographyEchocardiography Impairment of left ventricular systolic and diastolic functionImpairment of left ventricular systolic and diastolic function Segmental wall motion abnormalitiesSegmental wall motion abnormalities Impaired ejection fractionImpaired ejection fraction A pericardial effusion may be present, although findings of tamponade are rare.A pericardial effusion may be present, although findings of tamponade are rare. Ventricular thrombus has been identified in 15% of patients studied with Ventricular thrombus has been identified in 15% of patients studied with

echocardiography.echocardiography. MRI is capable of showing abnormal signal intensity in the affected myocardium.MRI is capable of showing abnormal signal intensity in the affected myocardium.

Cardiac MRI is an emerging field in general, and contrast-enhanced T1- Cardiac MRI is an emerging field in general, and contrast-enhanced T1- weighted MRI has been shown to have sensitivities and specificities weighted MRI has been shown to have sensitivities and specificities approaching 100% for diagnosis.3 approaching 100% for diagnosis.3

MRI can demonstrate nodular and patchy areas of inflammation, often seen first MRI can demonstrate nodular and patchy areas of inflammation, often seen first in the lateral and inferior wall and can be used to guide later biopsy.in the lateral and inferior wall and can be used to guide later biopsy.

MRI is also one of the modalities used in the evaluation of young patients with MRI is also one of the modalities used in the evaluation of young patients with apparently idiopathic dysrhythmias, and this imaging study can differentiate apparently idiopathic dysrhythmias, and this imaging study can differentiate focal and diffuse inflammation from the rare electrically significant myocardial focal and diffuse inflammation from the rare electrically significant myocardial tumor.tumor.

Other TestsOther Tests Electrocardiography Electrocardiography 

Sinus tachycardia is the most frequent finding.Sinus tachycardia is the most frequent finding. ST-segment elevation without reciprocal depression, particularly when ST-segment elevation without reciprocal depression, particularly when

diffuse, is helpful in differentiating myocarditis from acute myocardial diffuse, is helpful in differentiating myocarditis from acute myocardial infarction.infarction.

Decreased QRS amplitude and transitory Q-wave development is very Decreased QRS amplitude and transitory Q-wave development is very suggestive of myocarditis.suggestive of myocarditis.

As many as 20% of patients will have a conduction delay, including As many as 20% of patients will have a conduction delay, including Mobitz I, Mobitz II, or complete heart block.Mobitz I, Mobitz II, or complete heart block.

Left or right bundle-branch block is observed in approximately 20% of Left or right bundle-branch block is observed in approximately 20% of abnormal ECG findings and may persist for months.abnormal ECG findings and may persist for months.

Viral isolation from other body sites may be supportive of the diagnosis.Viral isolation from other body sites may be supportive of the diagnosis. Polymerase chain reaction (PCR) identification of a viral infection from Polymerase chain reaction (PCR) identification of a viral infection from

myocardial tissue, pericardial fluid, or other body fluid sites can be myocardial tissue, pericardial fluid, or other body fluid sites can be helpful. Persistent viral genome, as detected by PCR, has been identified helpful. Persistent viral genome, as detected by PCR, has been identified as one marker of increased incidence of dilated cardiomyopathy and as one marker of increased incidence of dilated cardiomyopathy and mortality.mortality.

If a systemic disorder (eg, SLE) is suspected, antinuclear antibody (ANA) If a systemic disorder (eg, SLE) is suspected, antinuclear antibody (ANA) and other collagen vascular disorder laboratory investigations may be and other collagen vascular disorder laboratory investigations may be useful.useful.

NCPNCP

PROBLEMPROBLEM: fatigue: fatigue

NURSING DIAGNOSISNURSING DIAGNOSIS: Activity intolerance related to muscle : Activity intolerance related to muscle weaknessweakness

NURSING INTERVENTION NURSING INTERVENTION Facilitate development of appropriate activity/ rest Facilitate development of appropriate activity/ rest

schedule.schedule. Instruct patient in energy conserving techniques, e.g. Instruct patient in energy conserving techniques, e.g.

carrying out activities at a slower pacecarrying out activities at a slower pace Encourage progressive activity/self care when tolerated Encourage progressive activity/self care when tolerated

and provide assistance as needed.and provide assistance as needed.

ProblemProblem: Shortness of Breathing: Shortness of Breathing

Nursing DiagnosisNursing Diagnosis: Ineffective Breathing Pattern related : Ineffective Breathing Pattern related to depressed ventilation to depressed ventilation

NURSING INTERVENTIONSNURSING INTERVENTIONS Monitor respiratory rate, depth, and ease of Monitor respiratory rate, depth, and ease of

respiration. respiration. Note pattern of respirationNote pattern of respiration Ausculatate breath sounds noting decreased or Ausculatate breath sounds noting decreased or

absence sounds, crackles or wheezes.absence sounds, crackles or wheezes. Observe color of tongue, oral mucosa and skin color. Observe color of tongue, oral mucosa and skin color. monitor presence of pain and provide pain medication monitor presence of pain and provide pain medication

as for needed as for needed

ProblemProblem: : Risk for infectionRisk for infection

Nursing DiagnosisNursing Diagnosis: Risk for infection related to inadequate : Risk for infection related to inadequate secondary defensessecondary defenses

NURSING INTERVENTIONSNURSING INTERVENTIONS Perform/promote meticulous handwashing by caregivers Perform/promote meticulous handwashing by caregivers

and patient.and patient. Maintain strict aseptic techniques with Maintain strict aseptic techniques with

procedures/wound care.procedures/wound care. Stress need to monitor/limit visitors.Provide protective Stress need to monitor/limit visitors.Provide protective

isolation if appropriate. Restrict live plants/cut flowers..isolation if appropriate. Restrict live plants/cut flowers.. Encourage frequent position changes/ ambulation, Encourage frequent position changes/ ambulation,

coughing, and deep-breathing exercises.coughing, and deep-breathing exercises. Monitor temperature. Note presence of chills and Monitor temperature. Note presence of chills and

tachycardia with/without fever.tachycardia with/without fever.

Dietary ManagementDietary Management

salt restriction and medications to control heart salt restriction and medications to control heart rhythm may be necessary rhythm may be necessary

Avoid alcoholic beverages, cigarettes and Avoid alcoholic beverages, cigarettes and vigorous exercises. vigorous exercises.

Taking these steps can reduce the workload on Taking these steps can reduce the workload on your heart.your heart.

Medical InterventionMedical Intervention

Management of myocarditis involves treating Management of myocarditis involves treating the underlying cause, such as the particular the underlying cause, such as the particular infection that may have set the stage for your infection that may have set the stage for your heart inflammation.heart inflammation.

There’s no specific theraphy for cosackievirus There’s no specific theraphy for cosackievirus B –the most common type of virus that causes B –the most common type of virus that causes myocarditis- other than treatment to relieve myocarditis- other than treatment to relieve pain and other symptomspain and other symptoms

Treating mild casesTreating mild cases In mild cases of inflammation, your doctor In mild cases of inflammation, your doctor

may advise rest and prescription medication to may advise rest and prescription medication to give your body a chance to fight off the give your body a chance to fight off the underlying infection while your heart recovers.underlying infection while your heart recovers.

If bacteria are causing your infection, your If bacteria are causing your infection, your doctor will prescribe antibiotics.doctor will prescribe antibiotics.

If it is viral, antiviral agents will be prescribed.If it is viral, antiviral agents will be prescribed. Immunosuppressive therapy may be used if Immunosuppressive therapy may be used if

myocarditis is due to an autoimmune disorder myocarditis is due to an autoimmune disorder such as lupus or scleroderma.such as lupus or scleroderma.

Drugs to help your heartDrugs to help your heart

Beta-adrenergic blockersBeta-adrenergic blockers Beta-blockers should be avoided in the acutely decompensated phase of CHF and Beta-blockers should be avoided in the acutely decompensated phase of CHF and

fulminant case of myocarditis but show long-term improvements in mortality.fulminant case of myocarditis but show long-term improvements in mortality.Loop diureticsLoop diuretics These agents are used for management of fluid overload.These agents are used for management of fluid overload.Calcium channel blockersCalcium channel blockers Although they have limited use in ischemic causes of CHF, calcium channel Although they have limited use in ischemic causes of CHF, calcium channel

blockers may prove to be useful in myocarditis-related myopathies. Amlodipine, blockers may prove to be useful in myocarditis-related myopathies. Amlodipine, in particular, perhaps due to its effect on nitric oxide, showed benefit in animal in particular, perhaps due to its effect on nitric oxide, showed benefit in animal models and in a placebo controlled trial.models and in a placebo controlled trial.

Angiotensin converting enzyme inhibitorsAngiotensin converting enzyme inhibitors These agents are beneficial in the management of blood pressure and LV function These agents are beneficial in the management of blood pressure and LV function

in heart failure. Captopril, in particular, has been shown to be beneficial in the in heart failure. Captopril, in particular, has been shown to be beneficial in the treatment of significant LV dysfunction. Other ACE inhibitors have not shown the treatment of significant LV dysfunction. Other ACE inhibitors have not shown the same effect in animal trials, indicating captopril's oxygen radical scavenging same effect in animal trials, indicating captopril's oxygen radical scavenging properties in the morbidity effect.properties in the morbidity effect.

Treating severe casesTreating severe cases

In many cases, the myocardial inflammation In many cases, the myocardial inflammation subsides, leading to a complete recovery.subsides, leading to a complete recovery.

In people without symptoms, their heart get In people without symptoms, their heart get better spontaneously.better spontaneously.

Even people with very severe congestive heart Even people with very severe congestive heart failure may improve dramatically, often in just failure may improve dramatically, often in just few day.few day.

Surgical Management Surgical Management

Place of a pump in the aorta (intra-aortic Place of a pump in the aorta (intra-aortic ballon pump)ballon pump)

Use of temporay artificial heart (assist Use of temporay artificial heart (assist device)device)

Consideration of urgent heart Consideration of urgent heart transplantationtransplantation

Client teachingClient teaching Teach to monitor pulse rate and rhythm, encourage taking Teach to monitor pulse rate and rhythm, encourage taking

CPR traing.CPR traing. Advice to continue self monitoring and to schedule clinical Advice to continue self monitoring and to schedule clinical

follow up appointmentfollow up appointment

Myocarditis is hard to prevent. To help reduce your chances of Myocarditis is hard to prevent. To help reduce your chances of getting myocarditis, reduce your exposure to identified getting myocarditis, reduce your exposure to identified causes. Some examples include: causes. Some examples include:

Practice good hygiene to avoid the spread of infection. For Practice good hygiene to avoid the spread of infection. For example, wash your hands regularly.example, wash your hands regularly.

Always use latex condoms during sexual activity.Always use latex condoms during sexual activity. Have sex with only one partner, who has sex only with you.Have sex with only one partner, who has sex only with you. Do not use illegal drugs.Do not use illegal drugs.