Apr 19, 2012Apr 19, 2012

內科 內科 & ER Combined & ER Combined ConferenceConference

OutlineOutline

• The differential diagnosis of non-The differential diagnosis of non-

coronary chest pain with elevated coronary chest pain with elevated

cardiac isoenzyme.cardiac isoenzyme.

• How to diagnose and treat How to diagnose and treat

myocarditis?myocarditis?

Noncoronary Chest Pain and Noncoronary Chest Pain and Elevated Cardiac IsoenzymeElevated Cardiac Isoenzyme

• MyocarditisMyocarditis

• Takotsubo cardiomyopathy Takotsubo cardiomyopathy

• Cardiac emboliCardiac emboli• Atrial fibrillationAtrial fibrillation• Patent foramen ovalePatent foramen ovale• Infective endocarditisInfective endocarditis

• Dilated cardiomyopathy Dilated cardiomyopathy

• ShockShock

Takotsubo CardiomyopathyTakotsubo Cardiomyopathy

• Broken heart syndrome, apical Broken heart syndrome, apical ballooning syndromeballooning syndrome

• Triggered by emotional stressTriggered by emotional stress

• EKG changes suggestive of AMI, ant.EKG changes suggestive of AMI, ant.

• Mild elevated cardiac isoenzymeMild elevated cardiac isoenzyme

• FemaleFemale

New-Onset Chest PNew-Onset Chest Pain, Elevated ain, Elevated Troponin and Nonobstructed CADTroponin and Nonobstructed CAD

Eur Heart J 2007; 28:1242–9

CMR findings N (%)

Myocarditis 30 (50)

Acute 19 (31.7)

Chronic 11 (18.3)

Myocardial infarction 7 (11.6)

Takotsubo cardiomyopathy 1 (1.7)

Dilated cardiomyopathy 1 (1.7)

Normal CMR findings 21 (35)

60 patientsCMR within 3 months of initial presentation

How to Diagnose Myocarditis?How to Diagnose Myocarditis?

Clinical PresentationClinical Presentation

• Acute Heart FailureAcute Heart Failure - -with dilated CMP, with dilated CMP,

within 2 wks of viral syndromewithin 2 wks of viral syndrome

• Sudden Loss of Consciousness - Sudden Loss of Consciousness - poor poor

prognosis if ventricular tachycardia or prognosis if ventricular tachycardia or

heart blockheart block

• Chest Pain - Chest Pain - wwith myopericarditsith myopericardits

No Sensitive or Specific Test for No Sensitive or Specific Test for MyocarditisMyocarditis

No Sensitivity Specificity Positive

Predictive

Negative

predictive

Troponin T 80 53% 96% 93% 56%

Troponin I 88 34% 89% ? ?

JACC 2006; 48:2085

Dallas Criteria for MyocarditisDallas Criteria for Myocarditis

• Active myocarditisActive myocarditis• inflammatory infiltrateinflammatory infiltrate of of

myocardium with myocardium with necrosis necrosis of myocytes of myocytes not typical of not typical of CAD. CAD.

• Borderline myocarditisBorderline myocarditis• inflammatory infiltrate of inflammatory infiltrate of

myocardium myocardium without without necrosis of myocytesnecrosis of myocytes. .

Expanded Criteria for Diagnosis of Expanded Criteria for Diagnosis of Myocarditis Myocarditis

• Clinical symptomsClinical symptoms

• Evidence of cardiac structural or Evidence of cardiac structural or functional perturbationfunctional perturbation in the absence of in the absence of regional coronary ischemiaregional coronary ischemia

• Cardiac MRICardiac MRI

• Myocardial biopsyMyocardial biopsy— pathologic or — pathologic or molecular analysis molecular analysis

2: 2: suggestivesuggestive, 3: , 3: compatiblecompatible, 4: , 4: high high probabilityprobability

Many Injury Can Cause Many Injury Can Cause MyocarditisMyocarditis

• Viruses: Viruses: changing spectrumchanging spectrum

• Toxin: Toxin: chemotherapychemotherapy

• RadiationRadiation

• Allergic ReactionAllergic Reaction

• Bacteria, Fungal, Protozoal InfectionsBacteria, Fungal, Protozoal Infections

• Genetic PredispositionGenetic Predisposition

EtiologyEtiology• Viral (Most Common) Viral (Most Common)

• Adenovirus Adenovirus • CoxsackievirusCoxsackievirus, enterovirus , enterovirus • Cytomegalovirus Cytomegalovirus • Parvovirus B19 Parvovirus B19 • Hepatitis C virus Hepatitis C virus • Influenza virusInfluenza virus• Dengue virusDengue virus• Herpes virusHerpes virus• Mixed infections Mixed infections

Acute MyocarditisAcute Myocarditis

• Viral prodrome Viral prodrome (20-(20-80%)80%)

• Fever, chills, Fever, chills, myalgiamyalgia

• Common symptomsCommon symptoms• Fatigue (82%)Fatigue (82%)• DOE (81%)DOE (81%)• Arrhythmias (55%)Arrhythmias (55%)• Palpitation (49%)Palpitation (49%)• Chest pain at rest Chest pain at rest

(26%)(26%)

• Elevated troponinElevated troponin

• ST segment elevation, ST segment elevation, depression, T depression, T inversioninversion

• Segmental wall Segmental wall motion abnormality motion abnormality by echoby echo

Fulminant MyocarditisFulminant Myocarditis• 10% biopsy 10% biopsy proven myocarditisproven myocarditis

• Abrupt, within 2 wks Abrupt, within 2 wks of viral illnessof viral illness

• Hemodynamic compromise and Hemodynamic compromise and hypotensionhypotension

• Diffuse global hypokinesia, rarely Diffuse global hypokinesia, rarely dilated ventricle, thick ventricular wallsdilated ventricle, thick ventricular walls

• Better prognosis compared with Better prognosis compared with chronic myocarditischronic myocarditis

Diagnostic Efficacy for Myocarditis Diagnostic Efficacy for Myocarditis Sensitivity (%) Specificity (%)

EKG changes 47 ?

Troponin > 0.1ng/mL 34-53 89-94

CPK – MB form 6 ?

Antibody to virus or myosin 25-32 40

Indium 111 antimyosin scintigraphy

85-91 34-53

Echo (ventricular dysfunction) 69 ?

Cardiac MRI 86 95

Myocardial biopsy (pathology) 35-50 78-89

Myocardial biopsy (viral genome by PCR)

38-65 80-100

? Indeterminate or poor

Gadolinium-enhanced T2-weighted

inflammation

Persistent fibrosis

Eur Heart J 2007; 28:1242–9

Cine sequence LGE

Transmural

T2-weighted

Myocarditis

LGE

Patchy epicardial

Eur Heart J 2007; 28:1242–9

CAD

How to Treat Myocarditis?How to Treat Myocarditis?

Thank youThank you

Pathophysiologic StagesPathophysiologic Stages