ACE-INHIBITORS

ACE-I (inhibitors of angiotensin converting enzyme) is an abbreviation of a drug group, which disturbs the effect of an enzyme changing nonactive angiotensin I on active angiotensin II. Angiotensin II has a lot of receptors all around body. When angiotensin II interacts with its receptors in vessels which control the blood inflow to the organs, these vessel contract and leading to an increase of blood pressure. It leads also to a retention of fluid and an increase in the of volume of blood. Both processes mean a higher strain on the heart. The heart, which is weakened by inflammation, is strained more than is necessary. ACE-inhibitors reduce the amount of angiotensin II in blood and it leads to the decrease of blood pressure and it influences blood volume.

From a cardiology point of view, these drugs have even other favourable features (it reduces inflammatory changes, it prevents remodelling – change of heart structure and it effects positively even damage of capillaries (very thin vessels) in kidneys, e.g. at diabetes).

Some samples in this group are captopril, enalapril, linosopril, ramipril, perindopril and many others.

The side-effects of these drugs include dry cough and a bigger blood pressure decrease after the first use. It is also important to monitor kidney function. Generally, it is a very effective drug group in the treatment of heart failure and high blood pressure. They also reduce the inflammation and heart structure changes.

Picture 22: Captopril molecule (author: Benjah-bmm27)

SARTANS (BLOCKER OF ANGIOTENSIN II RECEPTORS).

This is a drug group which blocks the connection of angiotensin II with its receptors and, thanks to this, the effect of angiotensin II is decreased. Sartans are used mostly when a patient cannot be treated with ACE inhibitors for some reason, which are used more frequently in the treatment of heart failure than sartans. A reason for the use of sartans is for example intolerance of ACE inhibitors. Sartans have comparable effect with ACE inhibitors in both heart failure treatment, and high blood pressure (according to some researches they can how a lower effect on high blood pressure decrease).

Some samples of sartans are – losartan, telmisartan, valsartan and candesartan.

Medical experts make their decision about the use of sartans or ACE-inhibitors according to the actual patient´s state of health.

BLOCKERS OF BETA RECEPTOR (BETA BLOCKERS)

Beta blockers are drugs which block so called beta adrenergic receptors, so receptors for stressing hormone epinephrine (adrenalin) and norepinephrine (noradrenalin), (group of so called catecholamines). These hormones cause an increase of heart rate, heart contractility, increase of blood pressure, they extend bronchial tubes, increase the release of insulin and a number of other things, which enable higher release of energy during a stress situation.

Since the 1960s´, beta blockers are divided into beta-1 and beta-2 blockers (2 types of beta receptor). It was shown that so called non-selective (“non-choosy,” it means that they block both beta receptors) betablockers had several unfavourable effects mainly on the function of the bronchial tubes. For example, with asthmatics, the blocking of beta-2-receptors worsened the contractility of bronchial tubes and because of that breathing deteriorated. In cardiology, so called selective (“choosy”) betablockers of beta-1 receptors (2^nd generation of betablockers) are used. They block the effect of catecholamines primarily in the heart and vessels. The blockade of these receptors causes the decrease of heart rate and blood pressure. These substances are therefore used in the treatment of high blood pressure, and in small and gradually increasing dosage also during heart failure treatment. They are also used in case of some arrhythmias. During myocarditis, the use of beta-blocker is recommended when a patient is stable – which means mostly not in the acute phase of the disease.

Samples of the selective beta-blockers are for example atenolol, betaxolol, metoprolol, bisoprolol and others.

Carvedilol is also sometimes used in heart failure treatment; however, it also blocks also so called alfa receptors. Their blockade cause the decrease of blood pressure.

The side-effects of betablockers include unfavourable effect on the function of the bronchial tubes – because of this, beta-blockers are mostly not used in asthmatics. Beta-blockers can also effect the metabolism of “fat” and “sugar” in the body. In addition, betablockers cause contractions of small vessels, for example in the legs. Because of this, they are not used in patients diagnosed with diabetes, lower limb ischemia, functional spasm of peripheral vessels (cold limbs), asthma, AV blockade 2^nd or 3^rd degree, bradycardia (slowdown of the heart rate), metabolic syndrome, disorder of tolerance of glucose. In the case of chronic obstructive pulmonary disease (COPD), betablockers are not usually indicated, depending of course on patient´s general state of health.

Picture 23: Betaxolol molecule (author: MarinaVladivostok)

DIURETICS

Diuretics are drugs that increase the excretion of urine. Diuretics are one of the basic tools during heart failure treatment. Their effect lies in increased excretion of water and minerals through the kidneys. The reduction of the volume of water in the blood and the body leads to the reduction of blood pressure and volume overload of the heart. This effect makes the work for the heart easier. A group of diuretics are for example so called loop diuretics (furosemide etc.).

During treatment with diuretics, the level of minerals in the blood is continuously monitorated. Some minerals (primarily sodium and potassium) are excreted in urine in higher amounts than normal and therefore diuretics are not usually indicated at patients with significant decreased production of urine (anuria).

Antagonists of aldosterone also belong to diuretics. Aldosterone is a mineralocorticoid – a hormone of the adrenal grands. Aldosterone helps to “keep” a right level of sodium in the body and vice versa it supports the excretion of potassium. Simultaneously, it belongs to substances which increase the volume of fluid in the body and participate on the increase of blood pressure. In the case of heart failure, it plays a role in structural changes to the heart. Antagonists of aldosterone block receptors for aldosterone. These antagonists can be used together with loop diuretics. Parallel use of these drugs leads to the decrease of potassium loses and to the reduction of blood volume. Some samples of aldosterone antagonists include spironolactone and eplerenone.

Picture 24: Kidney (author: Piotr Michał Jaworski)

OTHERS

Treatment of heart failure in myocarditis has already been described in previous articles. However, treatment could be refilled even with other drugs according to actual patient´s state of health.

A sample of these “other drugs” is for example ivabradine which separately slows down the formation of heart electrical impulses in sinoatrial node (see this link) and causing the heart rate to decrease. It is indicated when betablockers are not as effective as required or when the patient cannot use them.

Some arrhythmias may occur during myocarditis; however, they mostly disappear by themselves after the calming of the inflammation.

In case of severe arrhythmias, drugs from groups of antiarrhythmic agents are indicated.

In arrhythmias with slow heart rate, physicians may consider a temporary implantation of a pacemaker (it is a device that is placed under the collarbone, transmitting electrical discharges leading to a contraction of the heart muscle). Alternatively, so called electrical cardioversion may be used when the patient´s arrhythmias are “directed” with use of defibrillator discharges.

A strong contradiction during myocarditis is the use of digoxin. Drug that belongs to the group of heart glycoside. These drugs increase heart contractility and indirectly slow down the heart rate. It has an important role in the treatment of heart failure at some patients, however one of the side-effects is an increase of energy consumption for the heart to work. Digoxin may also provoke some arrhythmias and its level in the blood must be controlled to prevent overdose. Its indication is narrowly depending on the physician´s decision according to the actual and overall patient’s state of health.

During the treatment of myocarditis, some drugs that influence blood coagulability (so called anticoagulants) may be indicated. The creation of blood clots (thrombus) can be a complication of myocarditis and heart failure (even as a result of arrhythmias). Some samples of anticoagulants include heparin, Warfarin and a new generation of anticoagulants called NOAC – dabigatran, rivaroxaban, apixaban.

In severe cases of heart failure, when a patient´s state of health is getting worse quickly and there is a need to support and accelerate heart activity, the use of catecholamines is indicated (for example dopamine or epinephrine). In cases of severe heart failure, dopamine and its pharmacological “twin” dobutamine is frequently used. Both of them increase the heart rate and blood pressure.

Author of the opening picture: Benjah-bmm27.

Příspěvek Heart failure treatment pochází z Myokarditida

All over the world different research cardiological departments try to find causal treatment for myocarditis (treatment aimed at the agent-cause of myocarditis), which is really complicated. Some methods already exist, but they are still being studied. The effort of research departments to find a causal treatment is linked with the fact that myocarditis is considered to be the most frequent cause of dilated, respectively inflammatory cardiomyopathy, with increasing number of new patients every year.

A huge problem in the treatment of myocarditis (mainly its cause), primarily in its chronic form, is already mentioned limited knowledge of the disease course. Sometimes, even the principle of the effect of some drugs is not completely known and the situation is complicated even by the fact that researches, focused on the myocarditis or inflammatory cardiomyopathy treatment , are sometimes different in their conclusions.

The treatment of the cause of myocarditis in not easy from because it can be caused by an enormous number of agents (see this chapter), when each of them attack and damage the heart muscle in a different way (see this link).

When physicians try to treat myocarditis – if we talk about treatment of chronic myocarditis, inflammatory cardiomyopathy or generally about the treatment of myocarditis cause, they have to consider many other factors. Apart from the cause of the disease, they have to consider the extent of myocardium damage during inflammation. The bigger damage may be associated with a lower effect of the treatment. There is another important fact – when the myocarditis was diagnosed. If it was already in an acute state or already in the phase of chronic myocarditis and inflammatory cardiomyopathy (even though myocarditis is diagnosed “in time,” it could evolve in some case into chronic myocarditis, respectively inflammatory cardiomyopathy). The treatment effect is influenced even by the possibilities of “repair” to the myocardium after the inflammation – if a lot of “scar” tissue was produced in the heart muscle and because of that, whether the heart function is affected or not. An important fact also is, whether the immune system passes to chronic stimulation etc. (see this link), alternatively if antibodies against myosin and other auto-antibodies are present is the patient´s body even after myocarditis itself, and generally if autoimmune disorders are observed (auto-antibodies).

The treatment of the cause of myocarditis is complicated even by the fact that conclusions of every research must be controlled properly. You can find news from the research of myocarditis in category Research.

Author of the opening picture: Madprime

Příspěvek Treatment possibilities pochází z Myokarditida

Picture 21: Heart scintigraphy (author: Sincefalastrum)

Catheterization is used very often at myocarditis, mostly in adult patients. It serves more to exclude other possible causes of the patient´s problems, such as heart attack, rather than to diagnose myocarditis. It is made with a small plastic catheter which is inserted into the heart through an artery in the left groin or left wrist. More frequently it is used during the examination and treatment of ischemic heart diseases (heart attack). In children catheterization is not usually done.

Author of the opening picture: Sincefalastrum

Příspěvek Scintigraphy and cardiac catheterization pochází z Myokarditida

This method is not a standard examination method in the diagnosis of myocarditis. Medical experts indicate it just in some cases and according to the decision of doctors. A disadvantage of biopsy is that it can result in a “healthy” piece of heart tissue being taken. Other indication is, when experts have a suspicious on certain types of myocarditis, when a patient´s state of health requires immunosuppressive therapy (see chapter Immunological treatment), or when a patient with inflammatory cardiomyopathy could benefit from this therapy.

The aim of this method is to determine, which form of myocarditis a patient has and what are the changes in the heart muscle. Experts also try to find out the cause of the disease from heart tissue samples using PCR.

This method may not uncover the cause of myocarditis in all cases. The cause is not detected at half of patients with myocarditis who underwent biopsy. The result is also sometimes falsely negative.

Příspěvek Endomyocardial biopsy (EMB) pochází z Myokarditida

CARDIAC SPECIFIC ENZYMES

Levels of so called cardiac specific enzymes (molecules within heart cells) are watched in myocarditis patients. Medical experts watch several of them – troponin, myoglobin, myocardial (heart) creatine kinase (CK-MB). Each of the enzymes has its certain function in the heart.

Troponin has together with other molecules an important role in heart muscle contraction. Troponin is not usually detected in blood except in very small amounts. It is released into the blood during the damage to heart cells. The level of troponin in the blood indicates the extant of heart muscle damage, rising level of troponin corresponds to rising myocardium damage. In contrast to a heart attack, troponin levels do not rise and fall rapidly. Its level rises and falls in myocarditis mostly slowly and it can be detected in blood even a long time after myocarditis itself, but in smaller amounts. Troponin does not have to be released during myocarditis. Nevertheless, it is in total a reliable marker in the diagnostic of myocarditis.

Myoglobin is a molecule which binds and transfers oxygen in muscle cells (of the heart and other muscles) and it also causes its red colour. The level of myoglobin is also observed in acute myocarditis. The problem is that myoglobin can be observed in blood even during and after damage to other muscles, big physical strain or kidney disease. Because of this, other cardiac specific enzymes are also tested.

CK-MB (myocardial creatine kinase) is a molecule (enzyme), which participates in creating energy reserves in muscle cells. It occurs in several forms, including myocardial form. During myocarditis, the level of CK-MB in the blood is usually normal.

Picture 17: Myoglobin (author: Thomas Splettstoesser)

SIGNS OF INFLAMMATION

Many signs of ongoing inflammation can be observed during myocarditis. However, none of them can confirm the disease. More likely they pointe to the fact that inflammation is taking place in the body and this can be quantified.

The best known inflammatory markers is CRP (C-reactive protein). It is a protein which “marks” agents of the disease for elimination by the immune system. A rapid rise of CRP above normal level points more often to bacterial infection, a lower rise is more often observed in viral infection. It is more likely an indicative test, which shows that an inflammation is taking place in the body.

Another sign of inflammation appearing in approximately a quarter patient is an increased total number of white blood cells (leucocytosis). Specifically, it means that the number of white cells is greater than  10 x 10^9 of white blood cells per litre of blood. In viral and bacterial myocarditis, increased amounts of certain types of white blood cells (specifically lymphocytes and neutrophils) are observed and in hypersensitive myocarditis eosinophils (see Chapter What´s going on in the body).

Other sign of inflammation, observable in half of myocarditis cases, is increased sedimentation of red blood cells (erythrocytes). This test indicates how quickly red blood cells fall in a test tube with blood (see Picture 18).

Picture 18: Sedimantation of red blood cells (author: Tristanb)

AUTO-ANTIBODIES AND OTHERS

The test of auto-antibodies (antibodies against tissues of own body), alternatively of other molecules, is another test that may be done at patients with myocarditis. The importance of this test is not based on a diagnostics of myocarditis, but in confirmation or reject any suspicion of some autoimmune disease or disorder. It is a test of, for example so called antinuclear antibodies (ANA), aimed at the nucleus of cells; and the rheumatoid factor, what is an antibody against a part of immunoglobulins – antibodies (more in chapter Treatment possibilities). Further, it could be an antibody against myosin (one of molecules forming the basis of muscles, including the heart muscle) and against heart receptors, which increases heart frequency (so called β1 adrenergic receptors).

Cytokines are other molecules that may be tested in association with myocarditis, however mostly in case of research. Cytokines are molecules that influence the immune response of the body to agents (cause) of myocarditis (see chapter Definition of myocarditis). Some of them are for example TNF-α and interleukin IL-1 (molecules that provoke immune reaction and cause fever) and interleukin IL-10 (it participates on regulation of immune response to the immune system do not “overdo” the reaction against the disease agent). Another molecule is so called Fas ligand, what is a substance of the membrane – the surface of cells, which together with troponin informs about the level of cells damage. High levels of these molecules are often observed at myocarditis with a dramatic course.

MICROBIOLOGY AND VIROLOGY

It is a test of blood, alternatively either a rectum or neck swab, when medical experts try to determine the cause of myocarditis. Sometimes even secretions of the upper respiratory tract are tested. These tests are however very often falsely negative – the cause of the disease is not detected by these methods.

Mostly physicians are looking to distinguish between viruses and bacteria with the use of so called cultivation (microorganism, in this case mainly bacteria, is “grown” to detect which type it is). Further, physicians are looking for the presence of antibodies against cases of myocarditis (see chapter Causes of myocarditis) and in the case of viruses even the PCR method is used, when the presence/absence of DNA or RNA of a certain virus is confirmed.

The problem is that some causes are detectable only for a limited time and these tests are in total complicated by different factors. In total, the cause of the disease is detected in only about 4% of patients with myocarditis.

Picture 19: Cultivation (author: 43trevenque)

Authors of the opening picture: 43trevenque; Bill Branson

Příspěvek Lab testing pochází z Myokarditida

In the case of myocarditis, an X-Ray of the chest is used to exclude other possible conditions like pneumonia, engorgement in pulmonary circulation (higher pressure in vessels causes their widening and afterwards transfer of fluid through the wall of vessels to lungs). An X-Ray can also show larger pericardial effusion or heart enlargement (cardiomegaly).

Picture16: X ray of a patient with and without pericardial effusion (authors: Zhangzhugang; James Heilman, MD)

Author of the opening picture: Zhangzhugang; James Heilman, MD

Příspěvek X-Ray pochází z Myokarditida

This principle is used also in cardiac magnetic resonance. It is a highly accurate method which is used in the diagnosis of myocarditis more and more. Myocarditis can be confirmed by this method with a degree of high accuracy and certainity.

CMRI also enables different types of heart projection, using different machine settings (so called sequences).

Firstly, it facilitates observing the heart´s function. A big advantage of CMRI is that changes to the heart structure and function (including ejection fraction) are observable in more details than when using other imaging methods (see video). Tissue structure can be observed by other sequences (e.g. oedema of heart muscle).

An important part of CMRI is, when medical experts administers patient a special contrast medium, containing gadolinium. In case of myocarditis, it is used to look for evidence of inflammatory changes in the myocardium, when some places of MRI “picture,” where possibly inflammation is taking (or took) place, are showed “brighter” than healthy heart tissue (see Picture 14). In medical terminology, it is called late gadolinium enhancement (LGE).  The principle of the contrast substance is that healthy tissues absorb the substance, vice versa in area of inflammation, the contrast substance stays in the spaces between the cells for a longer time and it shows as a “brighter” area. Apart from this, it is also possible to observe during this examination, whether pericardial effusion is present or not.

Picture 14: MRI of the heart (author: Clinic of Imaging Methods FN Motol)

A big advantage of this type of examination is its high accuracy rate and low load for the body. However, it is important to inform medical experts about metal parts in a patient´s body (for example joint prosthesis, pacemaker), because in some cases MRI could not be done due to the strong magnetic field. There are some disadvantages of CMRI like higher noise levels (which can be reduced by ear plugs).

Additionally, the narrow space of the machine can be quite claustrophobic and over a longer time of the examination which sometimes may take over an hour. Because of this from time to time small children are put to sleep during MRI.

Picture 15: MRI machine (author: Tomáš Vendiš)

Author of the opening picture: Clinic of Imaging Methods

Příspěvek Cardiac magnetic resonance imaging (CMRI) pochází z Myokarditida

Picture 12: ECHO (authors: Patrick J. Lynch a C. Carl Jaffe)

Picture13: Doppler ECHO (author: J. Heuser)

Similar to an ECG, even in case of ECHO there are no specific findings that could diagnose myocarditis. ECHO primarily provides information about changes in the heart´s structure and function. It shows disorders of systolic and diastolic function of the ventricles (during the contraction and filling of the ventricles). It is also used to exclude other possible causes of patient´s problems (e.g. valvular diseases).

Some of the most common ECHO findings during myocarditis are changes mostly of the structure and function of the left ventricle – dilatation (“widening”) of the heart ventricles, disorder of contractility, alternatively even changes of thickness of the heart wall. A common complication shows up in ECHO, is pericardial effusion (see Picture 13); sometimes clots are observed. The finding can be also normal.

During more complicated cases of myocarditis, signs of heart failure are observed. They indicate a worsening heart function and are observed in the left ventricle and some cases even in the right ventricle.

Apart from above mentioned information, ECHO is also used for observing the systolic “performance” of the left ventricle – ejection fraction of left ventricle. It is a ratio between thevolume of blood pumped by the left ventricle during systole and total bloody volume in case of maximal fulfilment of the left ventricle during diastole (“filling”). Essentially it is the ratio between “filled” blood and “pumped” blood. The ratio is expressed as a percentage and gives doctors an information, how much blood is pumped from heart ventricles to the body during systole. Usually the value of the left ventricle ejection fraction is between 55 and 70 %.

Picture 14: Pericardial effusion (author: Kalumet); PE – Pericardial effusion; LA – Left atrium; LV – Left ventricle; RV – Right ventricle

Authors of the opening picture: Kalumet; Espinola-Zavaleta N, Soto ME, Castellanos LM, Játiva-Chávez S, Keirns C.

Příspěvek Echocardiography (ECHO) pochází z Myokarditida

Picture 4: Electrical conduction (author: Icewalker)

The electrocardiograph records this electrical heart activity and transfers it to the form of an ECG curve, which is separated into several waves and sections (segments):

Picture 5: ECG curve (author:  Agateller – Anthony Atkielski)

In reality, an ECG record looks like this (see picture 6):

Picture6: Normal ECG curve (author: Bionerd)

The first part of the ECG curve is a record of electrical potentials (“electrical heart activity) recorded from the extremities (leads I – III and aVR, aVL and aVF) and the second part is the record from leads on the chest (leads V1 – V6), see picture 7.

Picture 7: ECG leads (authors: Medic a Adnav)

During myocarditis, there are a lot of different changes on the ECG curve. None of them is completely typical for myocarditis. ECG findings of patients with myocarditis are highly variable. Sometimes, physicians observe ECG curves changes, which are also observed during heart attack or pericarditis (inflammation of pericardium – outer heart wrap).

The most typical ECG changes at patients with myocarditis are illustrated in the following ECG records.

During the disease, different ECG changes are observed. One of the most typical findings are so called negative (or inversed) T waves. This means that T waves are recorded on the ECG curve in the inverse position when compared to a usual record (see picture 8 and compare with picture 5 and 6).

Picture 8: ECG curve – T waves (author: Ped. Clinic FN Motol)

Other ECG changes observed during myocarditis are so called elevation or depression of ST segment (see picture 9 and 10).

Picture 9: ECG curve – ST elevation (auttor: Ped. Clinic FN Motol)

Usually, the wave S should be “deeper” than the Q wave. At the same time, the ST segment should be on the same level as the PQ segment. In the case of the ST elevation, ST segment is “raised” above the PQ segment.

Picture 10: ST elevation (author: Bron 766)

In the case of ST depression, this segment is by contrast under the level of the PQ segment. During myocarditis also tachycardia (accelerated heart rhythm even in rest) may be observed. The pulse can be periodic, but also even non-periodic. Also different types of extrasystoles (“extra” electrical impulses – e.g. of QRS complex – see picture 5) may be recorded. They can be created in the atrium and/or in ventricles. Further, atrioventricular (AV) blocks may be observed. It means that some electrical impulses from the heart atrium are not led “right” through the AV node or the bundle of His to ventricles (see picture 4).

In some cases, this disorder can show lower in the heart ventricles in the form of a block of Tawara´s branches. Sometimes, even changes of QRS complex are observed in the form of widened QRS complex. Physicians can also find some changes of the PQ complex and the Q wave or other sights that some changes in the function or structure of the heart has happened (e.g. “thicker” heart muscle).

Generally, it could be said that the ECG curve does not diagnose myocarditis, but it is a part of the diagnosis and it records the course and potential complication of the disease like arrhythmias, symptoms of pericarditis etc.

The ECG record does not distinguish the severity of heart muscle damage, but it helps with the diagnosis and during subsequent monitoring.

Some types of arrhythmias can persist even after myocarditis itself, but mostly they disappeared without any treatment.

Author of the opening picture: Agateller – Anthony Atkielski

Příspěvek Electrocardiogram (ECG) pochází z Myokarditida

• Increased temperature (subfebrile) or fever (febrile temperature)
• Increased jugular pressure (high pressure in right atrium and ventricle of heart accompanied with increased filling of jugular “neck” veins)
• Enlargement of liver during manual examination (hepatomegaly)
• Increased amount of fluid in abdominal cavity (ascites)
• Peripheral swelling (e. g. symmetric swelling of ankles/shank)
• Accelerated breathing (tachypnoea)
• Accelerated heart rate (tachycardia), which is not proportional to increased body temperature
• Increased blood volume (hypervolemia)
• Bluish colour of skin and mucosa (cyanosis)

During the examination with a stethoscope, some pathological (“unhealthy”) findings can be observed:

• Weakening of the 1^st heartbeat, alternatively presence of the 3^rd (and 4^th) heartbeat, instead of two “normal” (bordered) heartbeats.
• Murmur under the mitral valve (valve between left atrium and ventricle) and/or tricuspid valve (valve between right atrium and ventricle)
• Pericardial and/or pleural murmur (the first one is present during the beginning of pericarditis, still without pericardial effusion. Pleural murmur is in translation a murmur caused by a mutual friction of pleural and visceral sheets (in expert terminology it means sheets – “membranes” of pleura. Mostly, the pleural murmur is reliant on breathing movements.)
• An important finding is an auscultatory finding of crackles on the bases (lower part) of lungs in some cases. The crackles indicate blood engorgement during a so called left-side circulation failure. When the function of the left heart ventricle and atrium get worse, the result is that a lower blood volume is pumped from the lungs to the body. Then blood accumulates in the alveolus (air sacks), where the “exchange” of carbon dioxide and oxygen is performed.

In some cases or in situation, when we are talking about a rare type of myocarditis or myocarditis, which is caused by another disease, some other symptoms may be observed:

• Thromboembolic symptoms (production of blood clots)
• Increased lymph nodes
• Itchiness and rash (this can associate with hypersensitive myocarditis)
• Symptoms of rheumatic fever

Author of the opening picture: Johannes Jansson

Příspěvek Physical examination pochází z Myokarditida