Myocarditis

Myocarditis and its sequela, dilated cardiomyopathy (DCM), cause substantial morbidity and mortality, especially in children and young adults. Physicians should include myocarditis in the differential diagnosis of all patients who have new symptoms of heart failure, arrhythmia, or chest pain syndromes of unclear cause, and should strongly consider performing endomyocardial biopsy (EMB) to establish the diagnosis. It may be necessary to perform multiple or serial biopsies to increase sensitivity. Patients with myocarditis and symptomatic heart failure, chest pain, or arrhythmias need hospitalization for evaluation and treatment. Patients with symptomatic left ventricular dysfunction should be treated with conventional heart failure therapy, including angiotensin-converting enzyme (ACE) inhibitors, digitalis, diuretics, and beta-blockers. Patients with arrhythmias or syncope may require electrophysiologic evaluation. In addition to conventional therapy, physicians should consider a course of immunosuppressive therapy in selected patients. The clinical course, response to therapy, and left ventricular function need close monitoring. Patients with myocarditis and rapidly progressive heart failure or cardiogenic shock should be referred early to an advanced heart failure center for implantation of a ventricular assist device and consideration for cardiac transplantation.