This therapeutic option is indicated in cases of GCM, eosinophilic myocarditis, cardiac sarcoidosis and in myocarditis connected with autoimmune diseases [55, 62, 76, 77]. It consists mostly of a combination of prednisone, cyclosporine and/or azathioprine [11, 149, 150, 151].
One of the first large studies dealing with the issue of efficiency of immunosuppressive therapy in myocarditis – Myocarditis Treatment Trial from 1995 [11] did not prove a beneficial effect of this therapy on cardiac function and prognosis. By contrast, 4-year-mortality rate was 56 %. Many references questioned the fact that EMB samples were evaluated just with histopathological criteria and that there was not evaluated the presence of an agent in the myocardium what could according to the references negatively influence the disease course and prognosis in those patients that were classified in the group treated with immunosuppressants [140].
This conclusion is supported even by the research from 2003 [149] in patients with acute lymphocytic myocarditis treated with immunosuppressive therapy. In patients who responded to the therapy, left ventricular EF improvement was observed (in average from original 25 % on 47 %). In “non-responding patients”, the state of health was either constant or they underwent heart transplant or died. Retrospective investigation proved in 85 % of “non-responding” patients the presence of a viral agent in the myocardium what was, on the other hand, proved in just 14 % of “responding” patients (in all cases it was hepatitis C virus) and moreover, in 90 % of them, anti-myocardial autoantibodies were detected. The conclusion of the study was that immunosuppressive therapy is beneficial in patients with the absence of a viral agent in the myocardium and in those with the production of autoantibodies.
The role of immunosuppressive therapy is investigated even in patients with ICMP. The first randomized study dealing with the issues of efficiency of this therapy specifically in ICMP was performed in 2001 and an interesting fact is that patients were involved in this study on the basis of the presence of higher HLA expression [150]. In this study, there was no difference between the group treated with placebo and group treated with immunosuppressants in the question of mortality, but in the group treated with immunosuppressive therapy, NYHA class and heart function improvement (LV EF, LV EDD, and other parameters) was observed. After three months, in this group, the improvement of the state of health was observed in 71,8 % of patients (when compared with placebo group – 20,9 %). The conclusion of the study was that even a short-time therapy with immunosuppressants (90-100 days on the basis of the medicament) may bring long-term beneficial effect.
The last published study dealing with this issue is from the year 2009 [151]. In the group of patients with immunosuppressive therapy and negative detection of a virus in the myocardium, the improvement of LV EF, EDV, ESV, LV EDD and NYHA class was observed in 88 % of patients. Remaining 12 % of patients in this group showed the constant state of health what could be explained by the fact that there could be present an agent in the myocardium, which was not concluded in PCR panel or there were present mechanisms which are not sensitive to immunosuppressive therapy.
Currently, a study comparing the therapeutic schemes of both above-mentioned studies [150, 151] in patients with myocarditis is taking place [99].
Author of the opening picture: SubDural12
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References:
11) O´CONNELL, J. B., A. HERSKOWITZ a et al. A Clinical Trial of Immunosuppressive Therapy for Myocarditis. New England Journal of Medicine. 1995, -(333), 269-275.
55) T., JR., COOPER a et al. IDIOPATHIC GIANT-CELL MYOCARDITIS — NATURAL HISTORY AND TREATMENT. The New England Journal of Medicine. 1997, 1997(336), 1860-1866.
76) Srdce a systémová onemocnění. ECardio.cz [online]. -: -, – [cit. 2017-02-05].
77) ZHANG a et al. Lupus Myocarditis: A Case–Control Study from China. Chin Med J (Engl) [online]. 2015, 128(19), 2588-2594 [cit. 2017-02-05].
99) KUCHYNKA, P. a et al. Myokarditida a zánětlivá kardiomyopatie. Kapitoly z kardiologie. 2013, 3(-), 87-91.
140) PALEČEK, T. Inflammatory cardiomyopathy: Still many questions await answers. Cor et Vasa. 2013, 55(-), E341-E344.
149) Immunosuppressive Therapy for Active Lymphocytic Myocarditis: Virological and Immunologic Profile of Responders Versus Nonresponders. Circulation [online]. 2003, 107(6), 857-863 [cit. 2017-02-28].
150) WOJNICZ, R. a et al. Randomized, Placebo-Controlled Study for Immunosuppressive Treatment of Inflammatory Dilated Cardiomyopathy. Circulation [online]. 2001, 104(1), 39-45 [cit. 2017-02-28].
151) FRUSTACI, A. a et al. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. European Heart Journal [online]. 2009, 30(16), 1995-2002 [cit. 2017-02-28].