Myopericarditis

What is Myopericarditis?

Pericarditis is a term that refers to the inflammation or swelling of the pericardium, which is the protective sac around the heart. Myocarditis, on the other hand, is inflammation of the heart muscle itself. Both of these conditions can happen at the same time, something doctors refer to as myopericarditis.

The term myopericarditis is sometimes used in the same way as perimyocarditis. Myopericarditis generally refers to when the symptoms of pericarditis are present, but there’s also evidence that the heart muscle is involved. This evidence might be found through certain heart tests or imaging studies that show normal wall motion, which is the movement of the muscle walls of the heart.

If the tests show abnormal movement in certain areas of the heart wall with decreased heart function, the condition is more often referred to as perimyocarditis.

What Causes Myopericarditis?

In many cases, the exact cause of myopericarditis (an inflammation of the heart muscles and heart sac) isn’t known, even after extensive investigation. However, these causes are usually grouped into either infectious or non-infectious.

Infectious causes mainly stem from viruses such as Coxsackievirus, adenoviruses, herpes viruses, echovirus, Ebstein-Barr virus, cytomegalovirus, influenza virus, hepatitis C virus, and parvovirus B19. Bacterial culprits can include Mycobacterium tuberculosis, Streptococcus, Staphylococcus, Haemophilus, Legionella, Mycoplasma. Fungi like Histoplasma, Aspergillus, Blastomyces, and coccidioidomycosis can also cause it, as well as parasites, like Toxoplasma, amebic, and Chaga disease.

Non-infectious causes range from drugs that can cause harmful effects to the heart or allergic reactions such as procainamide, isoniazid, hydralazine, alcohol, anthracycline, and heavy metals. It can also come about after radiation therapy to the chest, or from systemic inflammatory diseases like lupus, rheumatoid arthritis, scleroderma, Sjogren, or mixed connective tissue disease. Other inflammatory conditions like granulomatosis and inflammatory bowel disease can trigger it too. Some types of cancer, particularly lung cancer, breast cancer, melanoma, and rhabdomyosarcoma, can also lead to myopericarditis. Hypothyroidism, kidney failure, and even certain vaccines have also been linked to it.

Risk Factors and Frequency for Myopericarditis

The exact number of people with myopericarditis, a heart condition, is not completely known. However, acute pericarditis, a related condition, is the reason for about 0.1% of all hospital admissions. According to research on military recruits, around 17 out of every 100,000 people are estimated to have myocarditis, another related condition. Additionally, sometimes myocarditis can be caused by vaccination; for example, 0.01% of military recruits have reported myocarditis after receiving the smallpox vaccine.

Signs and Symptoms of Myopericarditis

The severity and speed of an illness that inflames the layers of tissue around the heart (the pericardium) and the heart muscle itself (the myocardium) can greatly affect the symptoms people experience. These symptoms can range from mild and temporary to serious and life-threatening.

Earlier symptoms often include chest pain in the area over your heart, tiredness, difficulty breathing, heart palpitations, and fever. Some people might have symptoms similar to a common virus, such as a runny nose, joint pain, or a low-grade fever, about 1 to 2 weeks before other symptoms show up.

If the inflammation mostly affects the pericardium, people might experience a sharp pain that gets worse when they cough or breathe in, but feels better when they lean forward. If the inflammation is particularly bad in the myocardium, the pain may be constant. This kind of pain can be hard to tell apart from the pain of reduced blood flow to the heart, especially in people who already have a higher risk of heart problems. In these cases, people may also have symptoms like breathlessness, discomfort when lying down, swelling in the lower legs and ankles, and extreme tiredness. There are also rare symptoms including abnormal heart rhythms, loss of consciousness, and sudden heart failure.

Doctors may find different things when they examine someone with this condition. These findings could include a fever, a sound caused by friction between the layers of the pericardium, and signs of heart failure. They will also look for signs of other illnesses that might be contributing to the condition.

• Chest pain over the heart
• Tiredness
• Difficulty breathing
• Heart palpitations
• Fever
• Early symptoms similar to a common virus
• Pain that gets worse with coughing or breathing in, but better when leaning forward
• Constant pain that’s hard to distinguish from reduced heart blood flow, especially in those with higher heart risk
• Breathlessness
• Discomfort when lying down
• Swelling in the lower legs and ankles
• Extreme tiredness
• Rare symptoms like abnormal heart rhythms, loss of consciousness, or sudden heart failure.

Testing for Myopericarditis

When you have myopericarditis, it can cause an increase in inflammation markers in your blood, such as an increase in your white blood cell count, C-reactive protein, and markers showing heart muscle involvement. As part of the investigation into your symptoms, your doctor will often do routine blood tests to check for other possible causes like thyroid problems, hepatitis or problems with your kidneys. Blood tests specifically looking for signs of virus infection aren’t usually helpful in this case because the results don’t typically change the treatment plan.

Regarding an electrocardiogram (ECG), which measures the electrical activity of your heart, signs linked to pericarditis can be seen. These include ST-segment elevation and PR depression, both changes in the heart rhythm. If myocarditis (inflammation of the heart muscle) is also present, these typical changes may not be there, or there might be other changes such as T-wave changes or inversions. Changes in the heart rhythm can sometimes be limited to certain areas of the heart and may be accompanied by abnormal heart rhythms.

With chest X-rays, many patients with minor forms of myopericarditis have normal results. However, if the disease condition is severe, the X-ray may reveal an enlarged heart suggesting a fluid build-up around your heart or signs of heart failure.

Another common test is the echocardiogram, an ultrasound of the heart, which can show heart function and whether there is a substantial fluid build-up around the heart (pericardial effusion). In some patients, there may be brightness around the heart (pericardium), which can indicate inflammation, but this finding is not very specific.

In some cases, a significant buildup of fluid around the heart can be seen, which may affect heart function (known as tamponade physiology). Your doctor can also examine the functioning of the left and right sides of your heart and any heart valve abnormalities using an echocardiogram.

Coronary angiography, another test that looks at the coronary arteries, isn’t typically done in young patients showing classic signs of myopericarditis. However, for those at risk of atherosclerosis (hardening of the arteries), it may be hard to rule out heart damage due to poor blood supply just based on non-invasive tests. Hence, cardiac catheterization might be needed to rule out any acute problems with the blood supply to the heart muscle.

Cardiac magnetic resonance imaging (CMR) is useful to see the extent of myopericarditis. In such patients, inflammation of the heart muscle can be detected, usually in specific heart regions, along with the assessment of left ventricular function.

In a few severe cases, where patients worsen even after standard care, endomyocardial biopsy might be needed. This test, which involves taking a small sample of heart tissue, is recommended if the results can change the treatment plan.

Diagnosis of myopericarditis generally involves a combination of your symptoms history, physical exam findings, EKG changes, and increased cardiac biomarkers. Echocardiogram is then performed to check the functioning of your heart’s left ventricle and any pericardial involvement. If you have risk factors for artery disease, you might need cardiac catheterization to rule out coronary artery disease.

Acute pericarditis gets diagnosed if you have two or more of the following signs: chest pain, abnormal sound on the heart exam, changes in EKG, or pericardial effusion. Myopericarditis is diagnosed if there’s an additional feature such as increased heart biomarkers, a decrease in left ventricular function based on imaging, or inflammation of the heart muscle.

Treatment Options for Myopericarditis

Although there is limited information available for treating myopericarditis (inflammation of the heart muscle and tissue surrounding the heart), the overall outlook for this condition is generally very good, and most patients don’t experience any long-term effects.

If a patient’s symptoms are primarily related to pericarditis (inflammation of the tissue around the heart) and their heart function is still good, they might be treated with Nonsteroidal anti-inflammatory drugs (NSAIDs). These are a group of medications that reduce inflammation and pain. However, if the heart muscle is significantly affected, doctors usually use NSAIDs with caution and at as small doses as possible to relieve symptoms. This is because these drugs may reduce heart functionality further.

In circumstances where there’s a lot of fluid buildup around the heart (which is called pericardial effusion) that’s causing the heart to struggle, a procedure to drain this fluid may be required to stabilize the patient’s condition. If symptoms of heart failure (where the heart isn’t pumping blood as well as it should be) appear due to myocardial involvement (which is when the heart muscle is affected), doctors may recommend heart failure treatments such as beta blockers (drugs that slow down the heart rate) and angiotensin-converting enzyme inhibitors (drugs that relax blood vessels) or diuretics (drugs that remove excess fluid from the body).

In myopericarditis patients, a drug called colchicine is often used for treating pericarditis, but its usefulness in treating myopericarditis is not well established. Corticosteroids (medicines that suppress the immune system and reduce inflammation) are typically used in special cases like giant cell myocarditis (a rare type of heart muscle disease) or recurrent pericarditis (inflammation of the lining around the heart that keeps happening).

In order to prevent further harm to the heart, patients with myocardial involvement are usually advised to avoid physical activities for up to 3 months. In the case of those participating in competitive contact sports, the restriction on physical activities might need to be extended depending on individual circumstances.

In some rare cases, a condition called vaccine-associated myopericarditis might develop. This condition is characterized by symptoms and signs of myopericarditis appearing within 30 days of receiving a vaccine. It has mainly been reported after the smallpox vaccine, and the rate of occurrence is very low. The tests for diagnosing and treatments for managing this condition are the same as those for other types of myopericarditis. Most patients recover naturally. However, a small number of individuals with active viral infection, proven by a laboratory test called polymerase chain reaction (PCR), may need treatment with a medication called vaccinia immune globulin.

What else can Myopericarditis be?

Here is a list of various heart and lung conditions:

• Alcoholic cardiomyopathy (a disease of the heart caused by prolonged heavy alcohol use)
• Cardiac tamponade (pressure on the heart caused by fluid in the sac surrounding it)
• Cardiogenic shock (a severe condition where the heart cannot pump enough blood)
• Chagas disease (a tropical parasitic disease that can affect the heart)
• Cocaine-related  cardiomyopathy (heart damage due to cocaine use)
• Coronary artery atherosclerosis (hardening and narrowing of the arteries that supply heart)
• Dilated cardiomyopathy (a disease of heart muscle where it becomes stretched and thin)
• Hypertrophic cardiomyopathy (a condition in which the heart muscle becomes abnormally thick)
• Interstitial pulmonary fibrosis (a lung disease that occurs when lung tissue becomes damaged and scarred)
• Neurogenic pulmonary edema (a condition resulting in fluid accumulation in the lungs due to a sudden shift in the body’s nervous system)
• Peripartum cardiomyopathy (a rare type of heart failure that occurs during the last month of pregnancy or up to five months after giving birth)
• Restrictive cardiomyopathy (the heart’s chambers become rigid and can’t expand to fill with blood properly)
• Sudden cardiac death (an unexpected death caused by loss of heart function)
• Unstable angina (a condition where the blood supply to the heart muscle is suddenly blocked)
• Ventricular tachycardia (a type of fast heart rhythm that arises from improper electrical activity in the ventricles of the heart)