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Inflammation of the Heart

The heart is made up of 3 basic layers: an inner layer, outer layer, and middle layer. The inner layer of the heart is called the endocardium. The outer layer of the heart is called the pericardium. The middle layer of the heart (consisting of the actual myocytes, or muscle cells) is called the myocardium. Inflammation of the heart may affect only one layer, or may extend from one layer to the next. 

 

Myocarditis

Definition:

"Myo-" means muscle. "Card-" means heart. "-itis" means inflammation. So, myo-card-itis literally refers to inflammation of the heart muscle. The vast majority of cases of myocarditis are caused by infections (ie, viruses, bacteria, etc.), particularly by viral infections that involve the heart. Therefore, the majority of patients with myocarditis will have fevers at the time of diagnosis. Other causes include  auto-immune disorders (conditions where one's own immune system becomes over-reactive and attacks itself), systemic disorders (conditions that cause wide-spread, diffuse, "systemic" inflammation),  insect stings, chemotherapy, and certain medications. 

 

Signs/Symptoms:

The specific symptoms depend on the patient's age, and other body parts that may be involved.  Symptoms may include fever, chills, chest pain, palpitations, nausea, vomiting, abdominal pain, muscle aches, joint aches, joint pain, extreme fatigue and shortness of breath. Signs may include high heart rate and/or blood pressure, irritability, rash.

Diagnosis:

The diagnosis of mycarditis is based upon a thorough history and physical examination. An electrocardiogram can show subtle signs of heart muscle inflammation. The inflammation may also cause extra beats or abnormal rhythms of the heart. However, if there is a high-enough level of suspicion, blood work will also be required to measure the levels of inflammatory markers that the body has produced. An echocardiogram is useful in evaluating the function of the heart muscle. 

Treatment:  

The treatment of patients with myocarditis is largely dependent upon the cause. For instance, myocarditis resulting from a bacterial infection will require antibiotic therapy. Myocarditis from a viral infection, may or may not require treatment with an anti-viral medication, depending on the type of virus. Regardless of the cause, a large component of the treatment for myocarditis is "supportive". If there is a component of congestive heart failure (blood backing up into the lungs because of failure of the left side of the heart to pump blood forward efficiently), the patient will be treated with diuretics (medications that help reduce vascular congestion - driving out extra fluid from the lungs, body, etc.). These patients will also require medications to strengthen/support the heart's contractility (ability to pump blood). Medications may also be required to control the patient's heart rhythm, if the inflammation is causing abnormal heart ryhthms. Medications will also be used to control fever, pain, etc. Blood-thinning medications may also be used, depending on the degree of dysfunction of the heart muscle, to minimize the risk of blood clots forming within the heart - blood clots may form in any region where blood flow is too slow or "stagnant", just like how sludge develops along a river bed that's not flowing.

 

Pericarditis

Definition

"Peri-" means around. "card-" means heart, "-itis" means inflammation. So, peri-card-itis literally means inflammation around the heart. The pericardium is the outer lining of the heart. Like myocarditis, the majority of cases of pericarditis are caused by infections, although there are more varied causes, including inflammatory disorders, auto-immune disorders, medication reactions, etc.

Signs/Symptoms

Symptoms typically involve fever, chest pain, and palpitations. With more extensive inflammation, the patient may become short of breath or may start breathing more rapidly. Some patients may also complain of abdominal pain. 

Diagnosis

The diagnosis of pericarditis is based upon a thorough history and physical examination. An electrocardiogram can show subtle signs of inflammation. The inflammation may also cause extra beats or abnormal rhythms of the heart. However, if there is a high-enough level of suspicion, blood work will also be required to measure the levels of inflammatory markers that the body has produced. The blood work may also include other tests to evaluate for specific potential causes of pericarditis (ie, auto-immune disease, infections like acute rheumatic fever, etc.).  An echocardiogram is useful in evaluating the function of the heart muscle and in detecting inflammatory fluid that may collect around the heart ("pericardial effusion"). 

Treatment

Like myocarditis, the treatment of patients with pericarditis is largely dependent upon the cause. For instance, pericarditis resulting from a bacterial infection will require antibiotic therapy; certain bacteria may produce a significant amount of inflammatory or infectious fluid ("purulent pericarditis") that requires drainage via a procedure called pericardiocentesis. Pericarditis from a viral infection, may or may not require treatment with an anti-viral medication, depending on the type of virus. Regardless of the cause, a large component of the treatment for myocarditis is "supportive". Anti-inflammatory drugs may be used to suppress the inflammatory process; occasionally steroids may be required. 

 

Endocarditis

Definition

"Endo-" means within. "card-" means heart, "-itis" means inflammation. So, endo-card-itis literally means inflammation within the heart. The endocardium is the inner-most lining of the heart. This includes the lining that covers the myocardium (middle lining of the heart) in addition to the heart valves. Endocarditis therefore refers to inflammation of this lining, which may affect the function of the myocytes (myocardium) or the heart valves (valvu-litis), resulting in leaking of the valves. The most common cause of endocarditis is infectious (ie, viruses, bacteria, etc). Some auto-immune disease, however (ie, systemic lupus erythematosus), may also result in endocarditis.

Signs/Symptoms

The signs and symptoms of endocarditis are highly variable, although may include general, non-specific signs/symptoms such as fever, chills, anorexia, weight loss, malaise/fatigue, headache, muscle pain, joint pain, shortness of breath and cough.  Signs and symptoms of congestive heart failure may occur if there is enough inflammation of the heart valves to result in a significant amount of leakage. This leakage typically results in a back-up of fluid into the lungs ("pulmonary vascular congestion"). Signs and symptoms of a stroke may also occur if small pockets of bacteria ("thrombi" or "emboli") that collect on the valve get dislodged ("embolized") and are pumped by the heart into the bloodstream (and into the blood supplying the brain).  

Diagnosis

The diagnosis of endocarditis is largely dependent upon a careful history, physical examination, and blood work. The cornerstone of blood work in evaluation of infectious endocarditis (ie, endocarditis resulting from an infectious organism), is obtaining several blood cultures - ie, testing for the presence of bacteria in the blood ("bacteremia"). If a bacterium is detected, it will be identified in the microbiology laboratory and tested to determine which antibiotics are best suited to eradicate the bacteria (ie, to which antibiotic(s) is the bacteria "sensitive"). Several sets of blood cultures are usually obtained to account for the possibility of contamination, which may yield falsely positive results. Other blood work may be ordered to evaluate the degree of inflammation that has resulted, and to determine any effects on the kidney, bone marrow, etc. Specific blood work for evaluation of "sterile" or "non-infectious" endocarditis may also be required if clinically indicated. An echocardiogram may be performed in select cases if there is enough clinical concern for infection of the heart muscle or heart valves (ie, "vegetations" or collections of bacteria, typically localized to the heart valves); an echocardiogram can support the diagnosis of endocarditis, but cannot make the diagnosis alone without the clinical history and appropriate blood work. In fact, a normal echocardiogram does NOT rule-out the diagnosis of infectious endocarditis (ie, non-bacterial causes such as viruses or fungi, or bacterial infections that may have been previously treated with antibiotics resulting in a negative blood culture). 

Treatment

Like treatment of myocarditis and pericarditis, the treatment of patients with endocarditis is largely dependent on the cause and also involves supportive care. The cornerstone of treatment of infectious endocarditis is antibiotics. The antibiotics will be administered intravenously after blood cultures have been drawn. The initial antibiotic(s) may differ from the antibiotic used for the duration of treatment; the initial antibiotic has a broad-spectrum of activity, able to target many different bacteria. A more specific antibiotic may be later chosen when the microbiology lab has tested that specific bacteria with several different antibiotics, finding the one that is most suitable. This approach ensures that the right antibiotic is chosen for the right bacteria involved and seeks to avoid the development of bacterial resistance - too frequent usage of broad-spectrum antibiotics will result in bacteria "remodeling" and learning to evade these drugs in order to survive, rendering them ineffective. The duration of antibiotic treatment is dependent upon multiple factors including the patient's clinical history, blood work, and presence or absence of valvular disease, though typically involves four to six weeks of intravenous antibiotics.

 

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