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 When the heart is involved in an inflammatory process, often
caused by an infectious agent, myocarditis is said to be present
 Inflammation may involve the myocytes, interstitium, vascular
elements &/or pericardium
 Characterized by isolated pockets of inflamed & necrotic
myocardial cells
 Myocardial involvement may be local or diffuse, but the
myocardial lesions are generally randomly distributed in the
heart & thus the clinical consequences are dependent on the
size & number of lesions and the location of the lesions; a
small single lesion residing in the conductive tissue may result
in a fatal arrhythmia
 May be chronic or acute
 Usually of sudden onset
Risk Factors/ Etiology
 Age
 Gender

 Region
A. Infectious etiology/agents
 :i) viral [measles, mumps, influenza]
 ii) bacterial [diphtheria]
 iii) fungal [aspergillosis]
 iv) protozoan [toxoplasmosis, trypanosoma]
 v) roundworm [trichinosis]
 vi) rheumatic fever
 vii) serum sickness
 viii) chemical agent [lead]
 ix) collagen disease
 x) radiation
 xi) metabolic [uremia]
B. Toxic Etiology/ Agents

 Drugs that cause hypersensitivity reactions (clozapine,

penicillin, ampicillin, hydrochlorothiazide, methyldopa, and
sulfonamide drugs)
 Medications (eg, lithium, doxorubicin, cocaine, numerous
catecholamines, acetaminophen) that may exert a direct
cytotoxic effect on the heart.
 Environmental toxins include lead, arsenic, and carbon
 Wasp, scorpion, and spider stings
 Radiation therapy may cause a myocarditis with the
development of a dilated cardiomyopathy.
C. Immunologic Etiology/ Agents
 Connective tissue disorders such as systemic
lupus erythematosus (SLE), rheumatoid
arthritis, scleroderma, and dermatomyositis
that can often result in a dismal prognosis

 Idiopathic inflammatory and infiltrative

disorders such as Kawasaki disease,
sarcoidosis, and giant cell arteritis
Myocarditis also sometimes occurs when a
person is exposed to:

 Certain chemical. These may include substance such

as arsenic and hydrocarbons.
 Medication that may cause allergic or toxic
reaction. These include antibiotics such as penicillin
and sulfonamide drugs, as well as some illegal
substances, such as cocaine
 Sytemic disease. The include lupus, other connective
tissue disorder, inflammation of blood
vessels(vasculitis), and rare inflammatory conditions
such as Wegener’s granulomatosis.
invasion of myocardium

production of myocardial toxin

immunologically mediated myocardial damage

Inflammation of the myocardium

Assessment Findings
Myocarditis vary from person-to-person depending on the cause
and the severity. Symptoms may appear slowly or come on

 If you have any of these symptoms you should contact your

doctor right away.
 Flu-like complaints, including fever, fatigue, muscle pain,
vomiting, diarrhea , and weakness
 Rapid heart rate
 Chest pain
 Shortness of breath and respiratory distress
 Loss of consciousness
 Sudden, unexpected death
 Sudden, intense myocarditis can lead to congestive heart failure .
 Some people have no symptoms (asymptomatic).
Diagnostic test
 laboratory Studies
 Cardiac enzyme levels
 These levels are only elevated in a minority of patients.
 Normally, a characteristic pattern of slow elevation and fall
over a period of days occurs; however, a more abrupt rise
is observed in patients with acute myocardial infarction.
 Cardiac troponin I may be more sensitive because it is
present for longer periods after myocardial damage
from any cause.2
 Erythrocyte sedimentation rate (ESR) is elevated in
60% of patients with acute myocarditis.
 Leukocytosis is present in 25% of cases.
 Imaging Studies
 Chest radiography
 A chest radiograph often reveals a normal cardiac silhouette, but pericarditis or
overt clinical CHF is associated with cardiomegaly.
 Vascular redistribution

 Interstitial and alveolar edema

 Pleural effusion

 Echocardiography
 Impairment of left ventricular systolic and diastolic function

 Segmental wall motion abnormalities

 Impaired ejection fraction

 A pericardial effusion may be present, although findings of tamponade are rare.

 Ventricular thrombus has been identified in 15% of patients studied with

 MRI is capable of showing abnormal signal intensity in the affected myocardium.
 Cardiac MRI is an emerging field in general, and contrast-enhanced T1- weighted
MRI has been shown to have sensitivities and specificities approaching 100% for
 MRI can demonstrate nodular and patchy areas of inflammation, often seen first in
the lateral and inferior wall and can be used to guide later biopsy.
 MRI is also one of the modalities used in the evaluation of young patients with
apparently idiopathic dysrhythmias, and this imaging study can differentiate focal
and diffuse inflammation from the rare electrically significant myocardial tumor.
 Other Tests
 Electrocardiography
 Sinus tachycardia is the most frequent finding.

 ST-segment elevation without reciprocal depression, particularly when diffuse, is

helpful in differentiating myocarditis from acute myocardial infarction.
 Decreased QRS amplitude and transitory Q-wave development is very suggestive
of myocarditis.
 As many as 20% of patients will have a conduction delay, including Mobitz I,
Mobitz II, or complete heart block.
 Left or right bundle-branch block is observed in approximately 20% of abnormal
ECG findings and may persist for months.
 Viral isolation from other body sites may be supportive of the diagnosis.
 Polymerase chain reaction (PCR) identification of a viral infection from myocardial
tissue, pericardial fluid, or other body fluid sites can be helpful. Persistent viral
genome, as detected by PCR, has been identified as one marker of increased
incidence of dilated cardiomyopathy and mortality.
 If a systemic disorder (eg, SLE) is suspected, antinuclear antibody (ANA) and other
collagen vascular disorder laboratory investigations may be useful.
PROBLEM: fatigue

NURSING DIAGNOSIS: Activity intolerance

related to muscle weakness

 Facilitate development of appropriate activity/
rest schedule.
 Instruct patient in energy conserving
techniques, e.g. carrying out activities at a
slower pace
 Encourage progressive activity/self care when
tolerated and provide assistance as needed.
Problem: Shortness of Breathing

Nursing Diagnosis: Ineffective Breathing

Pattern related to depressed ventilation

 Monitor respiratory rate, depth, and ease of
 Note pattern of respiration

 Ausculatate breath sounds noting decreased

or absence sounds, crackles or wheezes.
 Observe color of tongue, oral mucosa and
skin color.
 monitor presence of pain and provide pain
medication as for needed
Problem: Risk for infection

Nursing Diagnosis: Risk for infection related to

inadequate secondary defenses

 Perform/promote meticulous handwashing by
caregivers and patient.
 Maintain strict aseptic techniques with
procedures/wound care.
 Stress need to monitor/limit visitors.Provide
protective isolation if appropriate. Restrict live
plants/cut flowers..
 Encourage frequent position changes/ ambulation,
coughing, and deep-breathing exercises.
 Monitor temperature. Note presence of chills and
tachycardia with/without fever.
Dietary Management
 salt restriction and medications to control heart
rhythm may be necessary
 Avoid alcoholic beverages, cigarettes and

vigorous exercises.
Taking these steps can reduce the workload on
your heart.
Medical Intervention
 Management of myocarditis involves treating the
underlying cause, such as the particular infection
that may have set the stage for your heart
 There’s no specific theraphy for cosackievirus B
–the most common type of virus that causes
myocarditis- other than treatment to relieve pain
and other symptoms
Treating mild cases
 In mild cases of inflammation, your doctor may
advise rest and prescription medication to give
your body a chance to fight off the underlying
infection while your heart recovers.
 If bacteria are causing your infection, your
doctor will prescribe antibiotics.
 If it is viral, antiviral agents will be prescribed.
 Immunosuppressive therapy may be used if
myocarditis is due to an autoimmune disorder
such as lupus or scleroderma.
Drugs to help your heart
Beta-adrenergic blockers
 Beta-blockers should be avoided in the acutely decompensated phase of CHF and

fulminant case of myocarditis but show long-term improvements in mortality.

Loop diuretics
 These agents are used for management of fluid overload.

Calcium channel blockers

 Although they have limited use in ischemic causes of CHF, calcium channel

blockers may prove to be useful in myocarditis-related myopathies. Amlodipine,

in particular, perhaps due to its effect on nitric oxide, showed benefit in animal
models and in a placebo controlled trial.
Angiotensin converting enzyme inhibitors
 These agents are beneficial in the management of blood pressure and LV function

in heart failure. Captopril, in particular, has been shown to be beneficial in the

treatment of significant LV dysfunction. Other ACE inhibitors have not shown the
same effect in animal trials, indicating captopril's oxygen radical scavenging
properties in the morbidity effect.
Treating severe cases
 In many cases, the myocardial inflammation
subsides, leading to a complete recovery.
 In people without symptoms, their heart get
better spontaneously.
 Even people with very severe congestive heart
failure may improve dramatically, often in just
few day.
Surgical Management
 Place of a pump in the aorta (intra-aortic
ballon pump)
 Use of temporay artificial heart (assist

 Consideration of urgent heart

Client teaching
 Teach to monitor pulse rate and rhythm, encourage taking CPR
 Advice to continue self monitoring and to schedule clinical follow
up appointment

Myocarditis is hard to prevent. To help reduce your chances of getting

myocarditis, reduce your exposure to identified causes. Some
examples include:
 Practice good hygiene to avoid the spread of infection. For

example, wash your hands regularly.

 Always use latex condoms during sexual activity.

 Have sex with only one partner, who has sex only with you.

 Do not use illegal drugs.