Viral carditis - Clinicals, Diagnosis, and Management

Cardiovascular

Clinicals - History

Fact Explanation
Fever The main aspect of this disease is inflammation of the myocardium. There are many different viral etiologies, but the commoner ones are Adenovirus, Coxsackie virus HCV and HIV (EV), Epstein-Barr Virus, Human Herpesvirus 6 (HHV 6), parvovirus B19 (PVB19) and cytomegalovirus. Fever is a nonspecific symptom but it is seen in some patients. It can be due to either the inflammatory mediators or due to the viral products itself. Fever
The main aspect of this disease is inflammation of the myocardium. There are many different viral etiologies, but the commoner ones are Adenovirus, Coxsackie virus HCV and HIV (EV), Epstein-Barr Virus, Human Herpesvirus 6 (HHV 6), parvovirus B19 (PVB19) and cytomegalovirus. Fever is a nonspecific symptom but it is seen in some patients. It can be due to either the inflammatory mediators or due to the viral products itself.
Myalgias This is also a nonspecific symptom but it is commonly seen in viral infections. Myalgias
This is also a nonspecific symptom but it is commonly seen in viral infections.
Chest pain This is due to the inflammation of the myocardium. Acute focal myocarditis can resemble a myocardial infarction, with acute onset of chest pain. Chest pain
This is due to the inflammation of the myocardium. Acute focal myocarditis can resemble a myocardial infarction, with acute onset of chest pain.
Dyspnoea This is a very common symptom. It is due to the functional left ventricular impairment.
Sometimes severe dyspnoea is due to advanced heart failure. These patients have severe global left ventricular dysfunction.
Dyspnoea
This is a very common symptom. It is due to the functional left ventricular impairment.
Sometimes severe dyspnoea is due to advanced heart failure. These patients have severe global left ventricular dysfunction.
Palpitations This can be present in a lesser number of patients.(about 18%) and is due to cardiac arrhythmia. Palpitations
This can be present in a lesser number of patients.(about 18%) and is due to cardiac arrhythmia.
Recent history of upper respiratory tract infections Some of the viruses present with a prior respiratory tract infection ( usually 3 weeks previously). Along with respiratory symptoms there can be symptoms such as diarrhea (viral gastroenteritis). Recent history of upper respiratory tract infections
Some of the viruses present with a prior respiratory tract infection ( usually 3 weeks previously). Along with respiratory symptoms there can be symptoms such as diarrhea (viral gastroenteritis).
Fulminant hemodynamic collapse Abrupt onset of hemodynamic collapse, is a serious complication resulting in shock. Fulminant hemodynamic collapse
Abrupt onset of hemodynamic collapse, is a serious complication resulting in shock.

Clinicals - Examination

Fact Explanation
Febrile patient Fever is a nonspecific symptom but it is seen in some patients with viral infection.. It can be due to either the inflammatory mediators or due to the viral products itself. Febrile patient
Fever is a nonspecific symptom but it is seen in some patients with viral infection.. It can be due to either the inflammatory mediators or due to the viral products itself.
Variations in pulse: sinus tachycardia This is a common sign. Factors contributing are fever and release of catecholamines in response to pain. Variations in pulse: sinus tachycardia
This is a common sign. Factors contributing are fever and release of catecholamines in response to pain.
Variations in pulse: irregularly irregular pulse This is due to atrial fibrillation, arrhythmias occur due to myocyte necrosis, replacement fibrosis , proarrhythmic effects of cytokines and
inflammatory mediators.
Variations in pulse: irregularly irregular pulse
This is due to atrial fibrillation, arrhythmias occur due to myocyte necrosis, replacement fibrosis , proarrhythmic effects of cytokines and
inflammatory mediators.
Variations in pulse: bradycardia This is due to the presence of atrioventricular blocks. Variations in pulse: bradycardia
This is due to the presence of atrioventricular blocks.
Variations in pulse: absent pulse This occurs due to appearance of pulseless VT or VF. Arrhythmias occur due to myocyte necrosis, replacement fibrosis or proarrhythmic effects of cytokines and inflammatory mediators. Variations in pulse: absent pulse
This occurs due to appearance of pulseless VT or VF. Arrhythmias occur due to myocyte necrosis, replacement fibrosis or proarrhythmic effects of cytokines and inflammatory mediators.
Low blood pressure This occurs in severe heart failure or fulminant myocarditis resulting in shock. Heart failure occurs due to inflammation and necrosis of the myocardium resulting in reduced ventricular function. Low blood pressure
This occurs in severe heart failure or fulminant myocarditis resulting in shock. Heart failure occurs due to inflammation and necrosis of the myocardium resulting in reduced ventricular function.
Edema This is a feature of advanced congestive cardiac failure (edema is the result of back pressure on the venous system). Heart failure occurs due to inflammation and necrosis of the myocardium resulting in reduced ventricular function. Edema
This is a feature of advanced congestive cardiac failure (edema is the result of back pressure on the venous system). Heart failure occurs due to inflammation and necrosis of the myocardium resulting in reduced ventricular function.
Diminished first heart sound This is present in some patients .It can be due different pathophysiologies such as mitral regurgitation or atrial fibrillation. Diminished first heart sound
This is present in some patients .It can be due different pathophysiologies such as mitral regurgitation or atrial fibrillation.
Murmurs of mitral or tricuspid insufficiency This is seen in some patients. This occurs due to weakening of the roots and cusps of the valves due to inflammation, resulting in blood flow into atria in systole and increased flow in diastole. This produces turbulence and is auscultated as a pansystolic murmur. Murmurs of mitral or tricuspid insufficiency
This is seen in some patients. This occurs due to weakening of the roots and cusps of the valves due to inflammation, resulting in blood flow into atria in systole and increased flow in diastole. This produces turbulence and is auscultated as a pansystolic murmur.
Gallop rhythm This occurs only in a few patients. This is audible in the presence of S3, S4 or both. Gallop rhythm can be an indicator of heart failure. Gallop rhythm
This occurs only in a few patients. This is audible in the presence of S3, S4 or both. Gallop rhythm can be an indicator of heart failure.
Pericardial friction rub This is a rare feature. If it is present, it is pathognomic of pericarditis. Pericardial friction rub
This is a rare feature. If it is present, it is pathognomic of pericarditis.

Investigations - Diagnosis

Fact Explanation
ECG Changes include ST-segment elevation in ≥2 contiguous leads, T-wave inversions, widespread ST-segment depressions and pathological Q waves, . There can be low voltage QRS complexes present as well. ECG
Changes include ST-segment elevation in ≥2 contiguous leads, T-wave inversions, widespread ST-segment depressions and pathological Q waves, . There can be low voltage QRS complexes present as well.
Echocardiogram There is a variation of features. Changes in thickness, systolic and diastolic dysfunction, regional wall motion abnormalities. This is useful in distinguishing fulminant myocarditis from subacute myocarditis. ,,, Echocardiogram
There is a variation of features. Changes in thickness, systolic and diastolic dysfunction, regional wall motion abnormalities. This is useful in distinguishing fulminant myocarditis from subacute myocarditis. ,,,
Chest X-ray It shows some cardiac enlargement in severe conditions. Chest X-ray
It shows some cardiac enlargement in severe conditions.
Cardiac enzymes Elevated troponin (Troponin I and T) levels have proven to be a more reliable predictor of myocardial injury than levels of creatine kinase -MB.,,, Cardiac enzymes
Elevated troponin (Troponin I and T) levels have proven to be a more reliable predictor of myocardial injury than levels of creatine kinase -MB.,,,
Viral antibody titres Viral etiology is diagnosed when seroconversion (low IgG, raised IgM, and IgA) occurs
along with the cardiac symptoms,
Viral antibody titres
Viral etiology is diagnosed when seroconversion (low IgG, raised IgM, and IgA) occurs
along with the cardiac symptoms,
Cardiovascular magnetic resonance imaging This is a highly sensitive test so it is very useful
It is used to distinguish between ischaemic and non-ischaemic cardiomyopathy.,,
Cardiovascular magnetic resonance imaging
This is a highly sensitive test so it is very useful
It is used to distinguish between ischaemic and non-ischaemic cardiomyopathy.,,
Endomyocardial biopsy Histology, viral diagnosis using PCR on a biopsy speciment can be done in specialized centers. Endomyocardial biopsy
Histology, viral diagnosis using PCR on a biopsy speciment can be done in specialized centers.

Management - Supportive

Fact Explanation
Limit physical activity Exercise during active viral infection may increase viral replication, exertion may also precipitate heart failure. , Limit physical activity
Exercise during active viral infection may increase viral replication, exertion may also precipitate heart failure. ,
Analgesia Fever and pain management is important.In initial stages NSAIDS should not be used. Analgesia
Fever and pain management is important.In initial stages NSAIDS should not be used.
Cardiac monitoring This is important because patients can develop sudden arrhythmias. Cardiac monitoring
This is important because patients can develop sudden arrhythmias.
Regular temperature monitoring This indicates improvement of the condition. Regular temperature monitoring
This indicates improvement of the condition.
Oxygen If the patient is severe respiratory distress this is helpful. Oxygen
If the patient is severe respiratory distress this is helpful.
Fluid restriction This is to minimize edema and to reduce the load on myocardium. Fluid restriction
This is to minimize edema and to reduce the load on myocardium.
Low salt diet Sodium is an osmotically active particle that retains water so salt restriction is indicated. Low salt diet
Sodium is an osmotically active particle that retains water so salt restriction is indicated.

Management - Specific

Fact Explanation
Heart failure treatment Symptomatic management of heart failure is important. This involves the following:

1. Diuretics-(Ex Furosemide is a loop diuretic and it prevents sodium reabsorption in the thick ascending limb)

2. Beta receptor-blockers- (Blocks the effects of catecholamines on cardiac muscle)

3.Angiotensin converting enzyme-inhibitors or angiotensin II receptor blockers. , Blocks the effects of angiotensin and reduces the after-load on the heart. In severe myocarditis and symptomatic hypotension, IV inotropes such as phosphodiesterase inhibitors ( milrinone) or adrenergic agonists ( dobutamine or dopamine) are indicated.
Heart failure treatment
Symptomatic management of heart failure is important. This involves the following:

1. Diuretics-(Ex Furosemide is a loop diuretic and it prevents sodium reabsorption in the thick ascending limb)

2. Beta receptor-blockers- (Blocks the effects of catecholamines on cardiac muscle)

3.Angiotensin converting enzyme-inhibitors or angiotensin II receptor blockers. , Blocks the effects of angiotensin and reduces the after-load on the heart. In severe myocarditis and symptomatic hypotension, IV inotropes such as phosphodiesterase inhibitors ( milrinone) or adrenergic agonists ( dobutamine or dopamine) are indicated.
Arrhythmia management This depend on the type and severity of arrhythmia.
Cardioversion can be achieved either with pharmacological agents or with electro- cardioversion.
Rate control is by the following: 1.Digoxin- a cardiac glycoside with negative chronotropic and positive inotropic action
2.beta receptor-blockers- Blocks the effects of catecholamines on cardiac muscle
Anticoagulation is indicated in atrial fibrillation.
External pacing(temporary) is needed in bradyarrhythmias.
Arrhythmia management
This depend on the type and severity of arrhythmia.
Cardioversion can be achieved either with pharmacological agents or with electro- cardioversion.
Rate control is by the following: 1.Digoxin- a cardiac glycoside with negative chronotropic and positive inotropic action
2.beta receptor-blockers- Blocks the effects of catecholamines on cardiac muscle
Anticoagulation is indicated in atrial fibrillation.
External pacing(temporary) is needed in bradyarrhythmias.
Mechanical support with intra-aortic balloon pump or LV assist device This can help in the recovery process.
recovery or heart transplantation may be necessary in severe cases.
Mechanical support with intra-aortic balloon pump or LV assist device
This can help in the recovery process.
recovery or heart transplantation may be necessary in severe cases.
Antiviral therapy Antivirals are helpful in inhibiting viral proliferation, (preventing interaction of viruses with their cellular receptor) , and help to minimize myocardial damage. Antiviral therapy
Antivirals are helpful in inhibiting viral proliferation, (preventing interaction of viruses with their cellular receptor) , and help to minimize myocardial damage.
interferon-b Enteroviral and Adenoviral clearance and improvement of left ventricular function has been identified with this option. interferon-b
Enteroviral and Adenoviral clearance and improvement of left ventricular function has been identified with this option.

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