Myocarditis is inflammation of the muscle tissue of the heart (myocardium) that causes tissue death.
Myocarditis may be caused by many disorders, including infection, toxins and medications that affect the heart, and systemic (bodywide) disorders such as sarcoidosis, but often the cause is unknown.
Symptoms can vary and can include fatigue, shortness of breath, swelling (edema), awareness of heart beats (palpitations), and sudden death.
Diagnosis is based on electrocardiography (ECG), measurement of cardiac biomarkers, imaging of the heart, and biopsy of the heart muscle.
Treatment depends on the cause and includes medications to treat heart failure and arrhythmias and rarely surgery.
Inflammation can be spread throughout the heart muscle or confined to one or a few areas. If inflammation extends into the pericardium (the flexible 2-layered sac that envelops the heart), this causes myopericarditis. The extent of myocardial involvement and extension into the pericardium can determine the type of symptoms. Inflammation that is spread throughout the heart may cause heart failure, abnormal heart rhythms, and sometimes sudden cardiac death. Less widespread inflammation is less likely to cause heart failure but can still cause abnormal heart rhythms and sudden cardiac death. Involvement of the pericardium leads to chest pain and other symptoms typical of pericarditis. Some people have no symptoms.
Causes of Myocarditis
Myocarditis may result from infectious or noninfectious causes. Many cases are unable to be identified (idiopathic).
In the United States and most other developed nations, infectious myocarditis is most often caused by a viral infection. (Other infections are more common in lower resource areas.) The most common viral causes in the United States are parvovirus B19 and human herpesvirus 6. SARS-CoV-2, the virus that causes COVID-19, sometimes causes myocarditis. In lower resource areas, infectious myocarditis is most often caused by rheumatic fever, Chagas disease, or human immunodeficiency virus (HIV) infection.
Noninfectious causes include substances that are toxic to the heart (such as alcohol and cocaine), certain medications, and some autoimmune and inflammatory disorders. Myocarditis may also occur after mRNA-based COVID-19 vaccination and is rare. It occurs mostly in adolescent and young adult males, usually within a week of vaccination. Myocarditis caused by medications is termed hypersensitivity myocarditis.
Causes of Myocarditis
Cause | Examples |
|---|---|
Autoimmune disorders | |
Bacterial infections | |
Cardiotoxins | Alcohol Cocaine |
Medications | Penicillins Some diuretics |
Fungal infections | |
Idiopathic (the cause is unknown) | — |
Inflammatory disorders | |
Parasitic infections | |
Radiation therapy | — |
Viral infections | Coxsackie B virus Human herpes virus 6 Parvovirus B19 |
Giant cell myocarditis
Giant cell myocarditis is a rare, severe form of myocarditis that has a rapid onset. The cause is unclear but may be autoimmune. A biopsy is done for diagnosis.
In people with giant cell myocarditis, the heart is suddenly unable to pump enough blood to support the body's functions (called cardiogenic shock). People also frequently have abnormal heart rhythms that are hard to correct.
Giant cell myocarditis has a poor prognosis but immunosuppressive therapy can help improve survival.
Symptoms of Myocarditis
People may have only a few symptoms or have severe and rapidly progressing heart failure and severe heart rhythm abnormalities. Symptoms depend on the cause of the myocarditis as well as the extent and severity of inflammation.
Heart failure symptoms may include fatigue, shortness of breath, and swelling (edema).
Some people may have an awareness of heartbeats (palpitations) or fainting. In some people, the first symptom is a sudden, severe abnormal heart rhythm.
When inflammation of the pericardium occurs along with myocarditis, people may have chest pain. Dull or sharp pain may spread to the neck, back, or shoulders. Pain ranges from mild to severe. Chest pain due to pericarditis is usually made worse by movement of the chest such as coughing, breathing, or swallowing food. Pain may be relieved by sitting up and leaning forward.
People with infectious myocarditis may have symptoms of the infection, such as fever and muscle aches before myocarditis develops. Medication-related or hypersensitivity myocarditis may be accompanied by a rash. Some people may have enlarged lymph nodes.
Myocarditis can be acute, subacute or chronic. In some cases, myocarditis can lead to dilated cardiomyopathy.
Diagnosis of Myocarditis
Electrocardiography (ECG) and measuring cardiac markers
Cardiac imaging
Sometimes, endomyocardial biopsy
Tests to identify cause
Doctors suspect myocarditis when otherwise healthy people with no risk factors for heart disease have symptoms of heart failure or abnormal heart rhythms.
ECG is done to look for evidence of a heart problem.
Doctors measure levels of cardiac biomarkers (substances that are present when the heart is damaged) in the blood.
Echocardiography can show abnormalities in people with myocarditis.
Cardiac magnetic resonance imaging may show a characteristic pattern of abnormalities in people with myocarditis.
Endomyocardial biopsy in which a doctor takes a sample of tissue from the inner wall of the heart to examine under a microscope, can be done to confirm myocarditis. However, because a diagnosis depends on the doctor obtaining a tissue sample from an area that shows the disease, endomyocardial biopsy may not be the best test for diagnosing myocarditis. Therefore, if endomyocardial biopsy shows evidence of myocarditis, the disorder is confirmed, but just because a tissue sample does not show signs of myocarditis does not mean doctors can eliminate this diagnosis. In addition, because endomyocardial biopsy carries risks of severe complications, including a tear in the wall of the heart and death, it is not routinely done unless doctors suspect giant cell myocarditis (because prompt treatment of giant cell myocarditis may be life saving) or if myocarditis causes severe heart failure or heart rhythm abnormalities.
Diagnosis of cause
After myocarditis is diagnosed, tests to determine the cause are done. In a young, previously healthy adult who has a viral infection and myocarditis, an extensive evaluation is usually not necessary.
A complete blood count is helpful to look for certain types of white blood cells (eosinophils), which are present in large numbers in people with hypersensitivity myocarditis usually due to a medication allergy.
Cardiac catheterization may be useful for ruling out a decrease in blood flow to the heart because myocarditis can mimic a heart attack.
In other cases, a biopsy of heart tissue may be needed to establish a diagnosis.
Other tests, including tests for autoimmune disorders, human immunodeficiency virus infection, histoplasmosis, and other infections, may be needed.
Treatment of Myocarditis
Treatment of heart failure and abnormal heart rhythms
Treatment of underlying disorder
Treatment of heart failure includes diuretics and nitrates to relieve symptoms. In some cases of heart failure, a surgery such as placement of a left ventricular assist device (LVAD) or heart transplantation may be necessary. Long-term medication treatment of heart failure is needed.
Abnormal heart rhythms are treated with antiarrhythmic therapy. Sometimes a pacemaker is needed if abnormal heart rhythms persist.
Antibiotics or medications to treat other types of infections may sometimes be given if myocarditis is caused by an infection.
When a medication or toxin causes myocarditis, the causative substance is stopped and corticosteroids are given.
Giant cell myocarditis is treated with corticosteroids and immunosuppressive therapy.
Myocarditis caused by sarcoidosis is treated with corticosteroids.
