Amir Farid, MD Department of Cardiology, University of California Davis Medical Center, Sacramento
Neil Beri, MD Department of Cardiology, University of California Davis Medical Center, Sacramento
David Torres-Barba, MD, PhD Department of Cardiology, University of California San Diego
Charles Whitcomb, MD Department of Cardiology, University of California Davis Medical Center, Sacramento
Address: David Torres-Barba, MD, PhD, Department of Internal Medicine, University of California, Davis, 4150 V. Street, Sacramento, CA 95817; davidtorresbarba@gmail.com
Release date: September 1, 2019 Expiration date: August 31, 2020 Estimated time of completion: 1 hour
The patient was given colchicine 1.2 mg on the first day and then 0.6 mg daily. Within 2 days, his chest pain had resolved. He did not receive any immunosuppressive agents.
DISCHARGE INSTRUCTIONS
4. Before discharge, this patient should be instructed to do which of the following?
Take over-the-counter NSAIDs to supplement the effects of colchicine
Avoid competitive sports and athletics for at least 6 months
Call to schedule repeat cardiac MRI
No further instruction is needed
NSAIDs are used by themselves or in combination with colchicine in the treatment of pericarditis, but their use may be associated with worse outcomes in myocarditis.3,21 Thus, their use is not recommended in most cases.3
,
Excessive physical activity should be avoided for at least 6 months after the clinical syndrome resolves. This recommendation is included in the most recent ESC guidelines but is based mainly on expert opinion and murine models with coxsackievirus B.3 Periodic reassessment is indicated with exercise stress testing before return to strenuous activity.3,16,32 Testing should look for exercise tolerance, and exercise electrocardiography also helps to evaluate for clinically relevant arrythmias.
Cardiac MRI can help clarify the prognosis in myocarditis, but the role of repeat testing in guiding therapy is limited.3 Indications for repeat cardiac MRI include presence of 0 or 1 of the Lake Louise criteria (recall that 2 are necessary to make the diagnosis) with recurrence of symptoms and a high suspicion for myocardial inflammation.3,9 Repeat cardiac MRI was not performed for our patient.
CASE CONCLUDED
The patient was evaluated in the cardiology clinic within 1 week of discharge. At that time, he was in sinus tachycardia with a heart rate of 102 bpm, and he was instructed to avoid any exercise until further notice.
At 6-month follow-up, the sinus tachycardia had resolved. However, because persistent tachycardia had been noted at the first postdischarge visit, and in view of the extent of myocardial involvement, he underwent exercise treadmill testing to evaluate for ventricular arrhythmias. The study did show premature ventricular complexes and 1 ventricular couplet at submaximal exercise levels. As this indicated a higher risk of exercise-induced arrhythmias, he was asked to continue normal activity levels but to abstain from exercise until the next evaluation.
During his 1-year follow-up, a repeat treadmill test showed no ventricular ectopy. Holter monitoring was ordered and showed no premature ventricular complexes, supraventricular arrhythmias, or atrioventricular block within the 48-hour period.
At his 2-year evaluation, he had returned to playing basketball and soccer on weekends and reported no recurrence of his initial symptoms.
KEY POINTS
Figure 3. Our suggested approach to suspected acute myocarditis.Cardiac MRI has emerged as an excellent noninvasive imaging modality for the diagnosis of myocarditis.
Treatment of myocarditis depends on the cause and severity of the patient’s presentation, spanning the spectrum from conservative care to immunosuppressive agents and even heart failure therapy.
Excessive physical activity should be avoided for the first 6 months after disease diagnosis and treatment.
If myocarditis is associated with pericardial involvement, colchicine is the agent of choice, and NSAIDs should be avoided.
Our suggested strategy for approaching myocarditis is shown in Figure 3.
