Shauer Ayelet, Gotsman Israel, Keren Andre, Zwas Donna R, Hellman Yaron, Durst Ronen, Admon Dan
Heart Failure and Heart Muscle Disease Center, Heart Institute, Hadassah University Hospital, Jerusalem, Israel.
Isr Med Assoc J. 2013 Mar;15(3):180-5.
Acute myocarditis is one of the most challenging diseases to diagnose and treat in cardiology. The true incidence of the disease is unknown. Viral infection is the most common etiology. Modern techniques have improved the ability to diagnose specific viral pathogens in the myocardium. Currently, parvovirus B19 and adenoviruses are most frequently identified in endomyocardial biopsies. Most patients will recover without sequelae, but a subset of patients will progress to chronic inflammatory and dilated cardiomyopathy. The pathogenesis includes direct viral myocardial damage as well as autoimmune reaction against cardiac epitopes. The clinical manifestations of acute myocarditis vary widely--from asymptomatic changes on electrocardiogram to fulminant heart failure, arrhythmias and sudden cardiac death. Magnetic resonance imaging is emerging as an important tool for the diagnosis and follow-up of patients, and for guidance of endomyocardial biopsy. In the setting of acute myocarditis endomyocardial biopsy is required for the evaluation of patients with a clinical scenario suggestive of giant cell myocarditis and of those who deteriorate despite supportive treatment. Treatment of acute myocarditis is still mainly supportive, except for giant cell myocarditis where immunotherapy has been shown to improve survival. Immunotherapy and specific antiviral treatment have yet to demonstrate definitive clinical efficacy in ongoing clinical trials. This review will focus on the clinical manifestations, the diagnostic approach to the patient with clinically suspected acute myocarditis, and an evidence-based treatment strategy for the acute and chronic form of the disease.
急性心肌炎是心脏病学中最难诊断和治疗的疾病之一。该病的真实发病率尚不清楚。病毒感染是最常见的病因。现代技术提高了诊断心肌中特定病毒病原体的能力。目前，细小病毒B19和腺病毒在心肌内膜活检中最常被发现。大多数患者可康复且无后遗症，但有一部分患者会进展为慢性炎症性和扩张型心肌病。其发病机制包括病毒对心肌的直接损害以及针对心脏抗原决定簇的自身免疫反应。急性心肌炎的临床表现差异很大——从心电图上的无症状改变到暴发性心力衰竭、心律失常和心源性猝死。磁共振成像正在成为诊断和随访患者以及指导心肌内膜活检的重要工具。在急性心肌炎的情况下，对于临床情况提示巨细胞心肌炎的患者以及尽管接受了支持治疗仍病情恶化的患者，需要进行心肌内膜活检。急性心肌炎的治疗目前仍主要是支持性治疗，但对于巨细胞心肌炎，免疫治疗已被证明可提高生存率。免疫治疗和特异性抗病毒治疗在正在进行的临床试验中尚未显示出明确的临床疗效。本综述将重点关注临床表现、临床疑似急性心肌炎患者的诊断方法以及针对该疾病急性和慢性形式的循证治疗策略。
