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Myocarditis - Prof Djoko Soemantri, MD, PhD, FIHA(1).pdf

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  • 8/18/2019 Myocarditis - Prof Djoko Soemantri, MD, PhD, FIHA(1).pdf

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    DJOKO SOEMANTRI

    MYOCARDITIS

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    MYOCARDITISIS AN UNCOMMON DISEASE OF THE HEART CHARACTERIZED BY INFLAMMATION AND SUBSEQUENT

    MYOCARDIAL DESTRUCTION

    :

    THE AVERAGE AGE OF PATIENTS WITH MYOCARDITIS IS 42, THE MALE TO FEMALE RATIO IS 1.5 : 1

    OFTEN

    NONSPECIFIC

    ACUTE

    UNLESS

    CHFDEVELOPS

    OVERT

    I N T R O D U C T I O N

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    CAUSES OF MYOCARDITIS

    VIRUSES ARE THE MOST IMPORTANT INFECTIOUS AGENT1

    ENTEROVIRUSES

    HIV HAS BEEN SHOWN TO DIRECTLY

    ATTACK THE MYOCARDIUM

    BACTERIA, CHLAMYDIA, RICKETSSIA, FUNGI AND PROTOZOAN

    2

    ALONG WITH TOXIN & SYSTEMIC ILLNESS

     CHAGAS DISEASE THE MOST COMMON CAUSE OF MYOCARDITIS &

    CARDIOMYOPATHY IN CENTRAL AND SOUTH AMERICA

    HYPERSENSITIVITY3

    PENICILLIN, AMPICILLIN, HCT, METHYLDOPA, SULFONAMIDE

    DIRECT CYTOTOXIC EFFECT ON MYOCYTE

    4

    LITHIUM, DOXORUBICIN, COCAINE, NUMEROUS CATHECOLAMINE & ACETOMINOPHEN

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    ENVIROMENTAL TOXIN5

    SYSTEMIC DISEASE6

    LEAD, ARSENIC, CARBONMONOSIDE

    SARCOIDOSIS, CONNECTIVE TISSUE DISORDER, SLE, GIANT CELL ARTERITIS

    CAUSES OF MYOCARDITIS

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    P T I E N T P R E S E N T T I O N

    OFTEN NON SPECIFIC

    ACUTE

    CONGESTIVE

    HEART FAILURE

    DEVELOPS

    FULMINANT

    FATIGUE AND MILDDYSPNEA

    60% OF PATIENTS WITH

    ANTECEDENT VIRAL SYNDROME

     

    FEVER, FATIGUE, MYALGIA &

    MALAISE

    TYPICAL TIME

    INTERVAL

    BETWEEN VIRAL

    ILLNESS & CARDIAC

    INVOLVEMENT IS 2

    WEEKS

    ORTOPNEA,

    SHORTNESS OF

    BREATH

    35 % OF PATIENTS

    WITH CHEST PAIN

    PALPITATIONS

    MAY SIGNAL THE

    DEVELOPMENT OF AV

    BLOCK OR MALIGNANT

    DYSRYTHMIAS

    SYNCOPE

    SUDDEN CARDIAC DEATH

    PEDIATRIC (ESPECIALLY INFANTS) WILL PRESENTS WITH NON-SPECIFIC SYMPTOMPS. NEONATAL MYOCARDITIS SHOULD BE CONSIDERED

    IN ANY INFANT WITH VIRAL-LIKE ILLNESS WHO DEVELOPS COMPROMISE OF CARDIAC FUNCTION.

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    P H Y S I C L E X M I N T I O N

    MILD CASE NON-TOXIC APPEARANCE & SIMPLY APPEAR TO HAVE VIRAL SYNDROME

    SEVERE CASE HYPOTENSION

    CARDIOGENIC SHOCK

    S3 & GALLOP

    MURMUR OF MITRAL &

    TRICUSPID

    REGURGITATION

    FRICTION RUB

    PERICARDIAL EFFUSION

    TAMPONADE

    POOR PROGNOSIS

    MAY BE PRESENT DUE TO

    VENTRICULAR DILATION

    MAY BE PRESENT IF THERE IS AN

    ASSOCIATED PERICARDITIS

    PE IS COMMON, BUT SIGNS OF

    TAMPONADE IS RARE

    TACHYPNEA &

    TACHYCARDIAOFTEN OUT OF PROPORTION TO FEVER

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    SLOW ELEVATION & FALL OVER A

    PERIOD OF DAYS CONTRAST TO

    THE MORE ABRUPT RISE IN AMI

    P T I E N T S S E S M E N T

    LABORATORY

    CARDIAC ENZIM OTHERS

    (↑) IN MINORITY

    PATIENT  ONLY

    SPECIFIC IF THEY

    ARE

    DEMONSTRATE

    CHARACTERISTIC

    ECG PATTERN

    (↑) ESR (ERYTROCYTESEDIMENTATION RATE)  60%

    OF CASES

    (↑) LEUKOCYTOSIS  25%OF CASES

    (↑) CRP

    BLOOD CULTURE ASO

    MYCOPLASMA CULTURES

    HEPATITIS PANELMONOSPOT

    CMV SEROLOGY

    NOT TYPICALLY HELPFUL IN

    SECURING THE DIAGNOSIS INEMERGENCY DEPARTEMENT

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    P T I E N T S S E S M E N T

    CHEST X-RAY (CXR)

    OFTEN NORMAL

    CARDIAC

    SILHOUETTE

    CARDIOMEGALY

    PLEURAL EFFUSION

    ENGORGEDPULMONARY VEINS

    INTERSTITIAL

    PULMONARY EDEMA

    IN YOUNGER PEOPLE

    PRESENCE OF

    INFILTRAT BILATERAL

    LEADS TO

    MISDIAGNOSIS

    PNEUMONIA

    PAC, PVC, SVT, AF, ATRIAL FLUTTER, AV

    BLOCK

    ELECTROCARDIOGRAM (ECG)

    MAY REVEAL A WIDE VARIETY

    OF ABNORMALITES

    THE MOST COMMON ABNORMALITY IS

    SINUS TACHYCARDIA

    CARDIAC DYSRHYTHMIAS

    SYNCOPE or SUDDEN

    CARDIAC DEATH (SCD)

    TAVB(TOTAL AV BLOCK)

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    SIGNIFICANT SAMPLING ERROR

    LEADING TO ONLY 30% PATIENT WITH

    POSITIVE BIOPSIES IN WHICH DISEASE

    SUSPECTED

    DIAGNOSTIC PROCEDURE OF CHOICE

    P T I E N T S S E S M E N T

    ECHOCARDIOGRAM

    NUCLEAR MEDICINE

    STUDY

    ECHOCARDIOGRAM MYOCARDIAL BIOPSY

    IMPAIRMENT LV SYSTOLIC &

    DIASTOLIC

    IMPAIRMENT EF

    PERICARDIAL EFFUSION 

    RARE

    LV THROMBUS  15% OF CASES

    SENSITIVITY & SPECIFICITY  83%

    NEGATIVE PREDICTIVE VALUE OF 95 %

    ENDOMYOCARDIAL BIOPSY

    ACTIVE MYOCARDITIS 

    INFLAMMATORY INFILTRATE OF

    THE MYOCARDIUM WITH

    NECROSIS & DEGENERATION

    OF ADJACENT MYOCYTES NOT

    TYPICAL OF ISCHEMIA

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    P T I E N T M N G E M E N T

    MILD

    MILD SYMPTOMS & NO SIGNS

    OF CARDIAC FAILURE & NO

    DYSSRHYTMIASMAY BE TREATED OUTPATIENTS

    SEVERE

    LV DYSFUNCTION

    LUNG EDEMA

    LOW SODIUM DIET

    DIGOXIN

    VASODILATOR

    ACE ICLASS OF DRUGS HAS BEEN SHOWN TO

    BENEFICIAL IN THE TREATMENT OF AGENTS

    DIURETIC

    +

    IN GENERAL, SYMPATHOMIMETIC & BETA BLOCKER DRUGS SHOULD BE AVOIDED

    IABP

    ANTICOAGULATION

    LIFE SAVING

    REDUCE THE RISK OF

    THROMBOEMBOLIZATI

    ON IN PATIENTS WITH

    DILATED VENTRICLES

    RESTRICT ACTIVITY++

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    FOR SEVERE HF, SYNCOPE, HEART BLOCK & OTHER DYSRHYTHMIAS

    GLUCOCORTICOID, OTHER

    IMMUNOSUPPRESIVE DRUGS & NSAID

    P T I E N T M N G E M E N T

    IMMUNOSUPPRESIVE

    THERAPY

    LITTLE USE IN THE EMERGENCY

    DEPARTEMENT

    POTENTIAL TO WORSEN THE ACUTE PHASE

    OF VIRAL MYOCARDITIS

    ANTIVIRAL THERAPY

    PLECONARILBOARD SPECTRUM

    ANTIVIRAL DRUGHAS BEEN SHOWN PROMISING RESULT

    AGAINTS ENTEROVIRUSES

    ADMISSION BED RESTVIRAL MYOCARDITIS IS TYPICALLY A MILD

    DISEASE & RESPON WELL TO BED REST

    ICCU

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