0521779407-01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:45
Acute Myocarditides 43➣Protozoal: Trypanosomiasis (Chagas’ disease, caused by T. cruzi,
reduviid bug vector, Central/ South America, decade(s) latent
period; associated with megaesophagus, megacolon, apical and
multiple LV aneurysms), toxoplasmosis
➣Metazoal: echinococcus (hydatid cyst: intramyocardial), trichi-
nosis
■Toxin exposure: anthracyclines, cytotoxic drugs, emetine, cate-
cholamines (cocaine, pheochromocytoma), heavy metals (lead,
cobalt, antimony, arsenic), venoms (snake, scorpion), anaphylaxis,
and others
■Giant cell myocarditis: possibly immune or autoimmune etiology,
usually rapidly fatal, often young-to-middle aged adults
■Hypersensitivity reactions: sulfonamides, hydrochlorothiazide,
penicillins, methyldopa, and othersmanagement
(See also acute and chronic heart failure chapters, and chapters per-
taining to specific etiology)What to Do First
■Check and monitor vital signs, oxygenation and ECG
■Evaluate for underlying etiology (see differential diagnosis), espe-
cially sepsis, myocardial ischemia/ infarction, cardiac mechanical
abnormalities (valvular, VSD, etc)
■Treat underlying etiology (i.e. myocardial infarction- thrombolysis,
primary PTCA)
■Treat acute heart failure with management as described in acute
heart failure chapter
■Attempt to define etiology (if giant cell myocarditis, consider early
empiric course of immunosuppressive therapy)General Measures
■Usually more comfortable sitting upright with legs dangling
■Restore and maintain oxygenation: morphine, supplemental oxy-
gen, non-invasive positive pressure ventilation (BiPAP), mechanical
ventilation
■Reduce volume overload (preload): morphine, diuretics, nitrates
■Reduce afterload: nitroglycerin, nitroprusside
■Improve cardiac function: positive inotropes (dobutamine, milri-
none), intraaortic balloon counterpulsation, left ventricular assist
device
■Maintain blood pressure, renal perfusion: dopamine (low dose)