Myocarditis Presentation PDF

MYOCARDI TIS BY NEETU CHAUHAN BSC NURSING 3RD SEM  MYOCARDITIS INTRODUCTION Myocarditis is an uncommon, potentially life threatening inflammatory disease of the heart muscle with a wide spectrum of clinical manifestation in children and adults. Myocarditis can be observed in an o...

MYOCARDI TIS BY NEETU CHAUHAN BSC NURSING 3RD SEM  MYOCARDITIS INTRODUCTION Myocarditis is an uncommon, potentially life threatening inflammatory disease of the heart muscle with a wide spectrum of clinical manifestation in children and adults. Myocarditis can be observed in an otherwise normal healthy person and can Myocardium is muscular in nature and responsible for contracting and relaxing , resulting in the pumping of blood through the heart to the rest of the body. Inflammation of this muscular layer leads to inability to pump blood effectively, which can cause Definition Myocarditis is collection of diseases of infectious, toxic, and autoimmune etiologies characterized by inflammation of the heart. Inflammation of myocardium is called myocarditis  B AD C Chronic Acute Fulminant Chronic persistent myocarditis: myocarditis myocarditi : Lieberman It usually has ais Onset ofs: viral notIt illness It is associated etiology definite is with related with and chronic to classified diverse recognizable onsetwith of myocyte inflammatory illness confirmed necrosis and clinical changes ventricular manifestation but myocarditis as without of dysfunction may ventricularwhich contractile either resolve dysfunction; dysfunctionmay follows: advance without to dilated complication or cardiomyopathy lead to death. ‘  A B C D Fulminant Acute Chronic Chronic myocarditis: myocarditis: persistent myocarditis: It usually has a It is associated myocarditis Onset of illness is viral etiology with not definite and with chronic : diverse onset of recognizable with inflammatory It is related to A B myocyte necrosis illness and confirmed clinical changes ventricular manifestation of but without dysfunction which ventricular contractile may either resolve dysfunction; may dysfunction without advance to dilated complication or cardiomyopathy lead to death. ‘  PATHO PHYSIOLOGY  Viral infection Inflammation and injury Decreased myocardial contractility Heart enlarges: increased Scarring LVEDV Dysrhthmi Increased as Decreased cardiac output LAP Pulm,Edem Increased sympathetic tone a CHF  CLINICAL IN ADULTS: MANIFESTATION History of recent infection with fever, muscle aches, sore throat , headache diarrhea Chest pain Arrhythmias -Palpitations or syncope -Ventricular arrhythmias -Atrioventricular block Heart failure symptoms: -Dyspnea, palpitations at rest or during physical activity -Fluid retention with swelling of legs, ankles and feet -Fatigue CHILDREN: The clinical manifestation in children varies according to age. Infants become sicker than adults and require respiratory and circulatory support. INFANTS: Crying Malaise , fever , poor feeding tachypnea, tachycardia and cyanosis. CHILDREN > 2 YEARS OF AGE: Chest pain, abdominal pain, myalgias , fatigue, tachypnea, cough and edema.  DIAGNOSTIC EVALUATION ELECTROCARDIOGRAM: ECG findings – nonspecific T-wave changes, ST-segment depression PR depression, and pathologic Q waves which imitate the ECG changes of acute myocardial infarction and pericarditis. CHEST X-RAY: It may show cardiomegaly ,pericardial effusion, pulmonary venous congestion, interstitial infiltrates, and pleural effusions. LABORATORY STUDIES TO DETECT: Complete blood count Elevated erythrocyte sedimentation rate Raised C- reactive protein Antibody screening Elevated cardiac enzymes-creatine kinase EHOCARDIOGRAPHY:ECHO is done to assess the cardiac chamber size, ventricle wall thickness, systolic and diastolic CARDIAC MRI: Cardiac MRI is done to detect markers namely , tissue injury , intracellular , interstitial edema, and capillary leakage leading to necrosis. ENDOMYOCARDIAL BIOPSY: The criterion standard for the diagnosis of myocarditis is endomyocardial biopsy. This is performed during cardiac catheterization, wherein a small piece of muscular tissue from the heart is extracted and examined is recommended in patients with severe cardiac dysfunction of unknown origin that is not responding to medical treatment,. MANAGEMENT OF The patient receives specific treatment for the MYOCARDITIS underlying cause if it is known(e.g. Penicillin for hemolytic streptococci) and is placed on bed rest to decrease the cardiac workload. Bed rest- helps to decrease myocardial damage and the complications of myocarditis. Physical activity should be limited for a 6 month period at least until heart size and function have returned to normal.  For patients with moderate to severe dysfunction, cardiac function can be supported use of : -Antibiotics -Antiviral –interferon A -Oral therapy with ACE inhibitors (Captopril, Lisinopril) -Digoxin -Diuretics -Oxygen therapy -Corticosteroids and immunosuppressants Heart Transplant Non-pharmacological treatment Bed rest Reducing salt and liquids intake No training for athletes – 6 months  PHARMACOLOGICAL MANAGEMENT Intravenous gamma - globulin in children Antibiotics in bacterial myocarditis Anti-lymphocyte monoclonal antibodies Alfa and beta interferon (positive viral PCR reaction) Immunosuppression in giant cell myocarditis and Glucocorticoids and azathioprine – debatable (negative viral PCR reaction) NSAIDs are contraindicated in the ACUTE PHASE (increase cardiomyocyte lesion and necrosis) Vasodilators (nitro-glycerine, sodium nitroprusside)  Angiotensin II converting enzyme inhibitors ( enalapril, lisinopril, ramipril) or angiotensin II receptor blockers ( valsartan, losartan, candesartan) Loop diuretics ( furosemide, torasemide)  Mineralocorticoid receptor antagonists (spironolactone, eplerenone) Beta-blockers (metoprolol succinate, bisoprolol, nebivolol, carvedilol) Drugs with positive inotropic effect (dobutamine, milrinone) Mechanical circulatory support and transplantation: In adult and pediatric patients with severe myocarditis and cardiogenic shock, the use of mechanical circulatory support, viz, extracorporeal membrane oxygenation support is life- saving. I/V Immunoglobulin: Intravenous immunoglobulin (IVIg) has immunomodulating effects and is used to treat acute viral myocarditis. The use of high-dose IVIg to treat acute myocarditis in children is very effective. Antiviral treatment: Antiviral therapy for viral myocarditis with ribavirin or interferon will reduce the disease severity and mortality among patients. Surgical treatment in Myocarditis ◆ Temporary transvenous pacing is indicated for complete heart block in myocarditis. Implantable defibrillators are indicated when extensive myocardial scarring is Short-term circulatory support such as left ventricular assistive devices (LVADs) and extracorporeal membrane oxygenation may be indicated for cardiogenic shock. VENTRICULAR ASSIST DEVICE CARDIAC TRANSPLANTATION Cardiac transplantation is indicated for patients with biopsy-proven giant cell myocarditis.  Dietetics: Low sodium and fluid restrictions if congestive heart failure symptoms present. NURSING DIAGNOSI  Decreased cardiac output related to impaired cardiac contractility due to myocarditis leading to arrhythmia, fatigue and palpitation. ➤ Assess the vital signs regularly. ➤ Observe for the signs of decreased peripheral tissue perfusion, cyanosis, pallor, etc. ➤ Continue ECG monitoring to detect arrhythmias. ➤ Regular physical assessments should be performed to identify signs and symptoms of ➤ Monitor intake/output. ➤ Monitor hemodynamic status of the patient: Monitor BP regularly, particularly when the patient is on inotropes. ➤ Administer cardiac medication as prescribed. ➤ Encourage bed rest and minimum physical activity to decrease the heart workload. ➤ Administer supplemental oxygen if required. ◆ Risk of complications related to myocarditis. ➤ Assess the patient for any complications such as stroke (disorientation or numbness and sluggishness in the body), and arrhythmia (palpitation/chest discomfort). ➤ Assess for any history of cardiotoxic drug use. ➤ Assess for any bleeding-gastrointestinal or ulcer related to nonsteroidal anti-inflammatory drugs. ◆ Knowledge deficit related to poor understanding of disease conditions and its management. ➤ Explain the side effects related to antiviral drugs- abdominal pain, vomiting, fatigue, etc. Prepare the patient for endomyocardial biopsy if required. ➤ Discharge teaching should be administered to explain any activity limitations or diet restrictions. ➤ Educate patient on the early signs and symptoms of heart failure, e.g., breathing difficulty, palpitation, fatigue, etc. ➤ Educate regarding vaccinations against measles, mumps, rubella, poliomyelitis, and influenza. ➤ Educate regarding proper hygiene. ➤ Educate to avoid crowds and people with a viral or flu-like illness. ➤ Educate regarding minimizing exposure to ticks. ➤ Educate the patient about ventricular assist devices (VAD) if required.