To introduce this topic I am going to discuss a quick case study* first. We use case studies in medicine to illustrate the salient points of a patient's medical presentation, investigations and treatment in order to elicit discussion and so educate ourselves and our peers.
A patient a few months post an acute Covid-19 infection, not admitted to hospital, had ongoing
Breathlessness at rest
Increased shortness of breath on exertion
Flares of chest pain - could come and go or be continuous
On examination heart rate was above 90 persistently
Blood tests for anaemia, inflammation, blood clots and troponin* were normal
The GP did an ECG and CXR which were normal - reassuring the GP but not the patient
They sought an opinion from a cardiologist:
ECHO - normal
CTPA - pulmonary emboli excluded
24 hour halter monitor showed frequent inappropriate sinus tachycardias - heart beating too fast
Blood test NT-BNP was raised
Cardiac MRI - showed post-covid myocarditis
The patient was prescribed Colchicine 500 mg BD - to help with inflammation of the heart and
Ivabradine 5 mg BD - to help with the tachycardias. They were also referred to exercise rehabilitation (NB not Graded Exercise Therapy)
In a May 5, 2020 article published in Heart Rhythm, titled "Recognizing COVID-19–related myocarditis: The possible pathophysiology and proposed guideline for diagnosis and management", the authors note that COVID-19-related myocarditis may be caused by a combination of direct viral injury and cardiac damage due to the host’s immune response -inflammation.
It is estimated that of the people hospitalized for COVID-19, between 10 and 25 percent of them, depending on the study, have cardiac damage. Most of these patients are older and have pre-existing heart conditions. However healthy, young people experiencing certain symptoms of SARS-CoV-2, it’s more likely to be myocarditis. Although it is a relatively rare cardiovascular disease, myocarditis has been reported in patients diagnosed with COVID-19 making it important for everyone to be aware of some of the symptoms of coronavirus that may indicate possible inflammation of the heart. We know from COVERSCAN UK that 40% of patients who had Covid-19, but were not hospitalised, had some form of cardiac damage on their cardiac MRIs.
What is Myocarditis?
Myocarditis, or inflammation of the heart muscle - the myocardium. Myocarditis can affect your heart muscle and your heart's electrical system, reducing your heart's ability to pump and causing rapid or abnormal heart rhythms (arrhythmias).
What causes Myocarditis?
Viral infections, are one of the most common causes of heart muscle inflammation. It is a condition caused by the body’s immune response to the infection.
Viruses - the common cold; COVID-19; hepatitis B and C; parvovirus, and herpes simplex virus. Gastrointestinal infections, Epstein-Barr virus and German measles It's common in people with HIV.
Bacteria. Numerous bacteria can cause myocarditis, including staphylococcus, streptococcus, and the bacteria responsible for diphtheria and Lyme disease.
Parasites. Trypanosoma cruzi and toxoplasma, the parasite of Chagas disease.
Fungi. Yeast infections such as candida; moulds, such as aspergillus; and other fungi, such as histoplasma, often found in bird droppings can sometimes cause myocarditis, particularly in people with weakened immune systems.
Medications causing an allergic/toxic reaction
These include drugs used to treat cancer; antibiotics, such as penicillin and sulfonamide drugs; some anti-seizure medications;
Illegal drugs such as cocaine.
Chemicals or radiation. Exposure to certain chemicals, such as carbon monoxide, and radiation can sometimes cause myocarditis.
Other diseases. These include disorders such as lupus, Wegener's granulomatosis, giant cell arteritis and Takayasu's arteritis.
What are the symptoms of Myocarditis
If you have a mild case of myocarditis or are in the early stages, you might have no symptoms or mild ones, such as chest pain or shortness of breath.
In serious cases, the signs and symptoms of myocarditis vary, depending on the cause of the disease. Common myocarditis signs and symptoms include:
Rapid or abnormal heart rhythms (arrhythmias)
Shortness of breath, at rest or during physical activity
Fluid retention with swelling of your legs, ankles and feet
Other signs and symptoms of a viral infection, such as a headache, body aches, joint pain, fever, a sore throat or diarrhea
Myocarditis can affect individuals of any age, gender, race, and health condition.
How is Myocarditis diagnosed?
Blood tests, physical exam, echocardiography and electrocardiograms to examine heart function, and tests to rule out other conditions.
A troponin blood test - this is a measure of troponin T or I levels in the blood and is used to detect small degrees of damage to heart muscle cells (myocytes). It is used in hospitals to confirm a myocardial infarction.
CRP, Ferritin, LDH, ESR - can be used as markers for inflammation but not specifically to the heart
D-Dimer - to rule out a clots in the lungs which also could give you breathlessness and chest pain NT-BNP - used to look for heart failure
What is the treatment for Myocarditis?
This usually involves close monitoring and medication:
Anti-inflammatory medicines such as Colchicine
Drugs to make the heart work better such as ACE Inhibitors, Beta Blockers and Diuretics
A low salt diet to stop fluid building up
Abstaining from competitive sports
What are the potential complications of Myocarditis?
The vast majority of those with myocarditis with the right treatment and advice will recover within 6 months. In long term cases myocarditis can affect your heart muscle and tissue, meaning you could go on to develop heart failure.
Severe myocarditis can permanently damage your heart muscle, possibly causing:
Heart attack or stroke
Rapid or abnormal heart rhythms (arrhythmias).
Sudden cardiac death
If you are having ongoing chest pain, breathlessness, palpitations or are concerned by any points I have raised please contact your GP for further assessment.