From the Guidelines
Myocarditis diagnosis and management should prioritize cardiac MRI as the preferred non-invasive diagnostic tool, as it can detect myocardial inflammation, edema, and fibrosis with high sensitivity, and endomyocardial biopsy remains the gold standard for definitive diagnosis. Echocardiography can identify supportive findings such as ventricular wall motion abnormalities, decreased ejection fraction, chamber dilation, and pericardial effusion, but it cannot definitively diagnose myocarditis 1.
For suspected myocarditis, the initial clinical evaluation should include ECG, cardiac biomarkers, and echocardiography, with the inclusion of CMR, with T2-weighted imaging, parametric mapping, and late gadolinium enhancement, as part of the standard of care in the initial assessment and clinical follow-up of myocarditis 1. Key considerations in the management of myocarditis include:
- Treating the underlying cause
- Supportive care
- Heart failure medications (ACE inhibitors, beta-blockers, diuretics)
- Activity restriction, with recent data suggesting that resolution of inflammation can occur 4 to 6 weeks after diagnosis, allowing for an earlier return to competitive sports 1
- Monitoring with serial echocardiograms to assess ventricular function recovery
The prognosis varies widely, with many patients recovering completely while others may develop chronic heart failure, and myocarditis is often caused by viral infections, particularly coxsackievirus and adenovirus, but can also result from bacterial infections, autoimmune conditions, or medication reactions 1. Early recognition and appropriate management are crucial to prevent long-term cardiac damage.
From the Research
Myocarditis on Echo
- Myocarditis is a potentially fatal condition that can be misdiagnosed in the emergency department (ED) setting 2.
- Echocardiography is the ideal test in the ED setting for diagnosing myocarditis, as it can evaluate cardiac chamber size, wall thickness, ventricular function, and the presence of pericardial collections 2, 3.
- A full echocardiographic evaluation is necessary to exclude other aetiologies that might present similarly to acute viral myocarditis 3.
- The diagnosis of acute viral myocarditis can be challenging, and a thorough evaluation of all echocardiographic parameters for both ventricles is important to determine the prognosis 3.
- Treatment of myocarditis is primarily focused on respiratory and hemodynamic support, with initial hemodynamic management including vasopressors and inotropes 2.
- Nonsteroidal anti-inflammatory drugs should be avoided in the treatment of myocarditis, while intravenous immunoglobulin is controversial 2.
- Colchicine has been studied as a potential treatment for myopericarditis, with some studies suggesting favorable effects on electrocardiographic indices of atrial activation parameters 4.
- However, the use of colchicine in acute myocardial infarction did not reduce the incidence of cardiovascular events in a recent trial 5.