Heart Muscle and Pericardial Diseases

This page covers two related groups. Myocardial diseases affect the heart muscle itself: myocarditis (inflammation, usually viral) and the cardiomyopathies, in which the muscle is dilated and weak, abnormally thick (hypertrophic), stiff (restrictive) or replaced by scar and fat (arrhythmogenic). Pericardial diseases affect the thin sac around the heart: pericarditis (inflammation), pericardial effusion (fluid) and constrictive pericarditis (a rigid, scarred sac).

Acute pericarditis is usually benign and settles with anti-inflammatory treatment, although it recurs in up to a third of people. Heart muscle disease is more varied: many cases are inherited, and the concerns are heart failure and dangerous rhythms, which makes accurate diagnosis and family screening important.

Symptome

• Pericarditis: sharp central chest pain that is worse on breathing in or lying flat and eases when sitting forward
• Fever and a recent viral illness before pericarditis or myocarditis
• Breathlessness, fatigue and ankle swelling
• Palpitations, dizziness or fainting, especially during exercise in hypertrophic or arrhythmogenic cardiomyopathy
• Chest pain mimicking a heart attack in myocarditis
• Swollen abdomen and legs with prominent neck veins in constriction
• No symptoms, found through family screening or an abnormal ECG

Ursachen und Risikofaktoren

Viral infection is the commonest trigger for both myocarditis and pericarditis. Pericarditis also follows heart attack or heart surgery, and occurs with autoimmune disease, kidney failure, cancer, chest radiotherapy and, in many parts of the world, tuberculosis. Dilated cardiomyopathy may be genetic or follow myocarditis, alcohol excess, chemotherapy, pregnancy or prolonged fast heart rates. Hypertrophic cardiomyopathy is inherited, affecting about 1 in 500 people. Restrictive disease is usually due to amyloidosis or other infiltration. Rarely, myocarditis follows immune checkpoint inhibitor therapy or, very rarely, mRNA vaccination, the latter usually mild.

Wie es diagnostiziert wird

• ECG: Widespread ST changes in pericarditis; voltage, conduction and rhythm clues in muscle disease.
• Blood tests: Troponin for muscle injury, CRP for inflammation, BNP for heart failure, plus thyroid, iron and autoimmune screens.
• Echocardiography: Pumping function, wall thickness, outflow obstruction, fluid around the heart and signs of constriction.
• Cardiac MRI: The key test for myocarditis and for separating types of cardiomyopathy by scar pattern.
• Holter and exercise testing: Arrhythmia burden and risk stratification.
• Genetic testing and family screening: For hypertrophic, dilated and arrhythmogenic cardiomyopathy.
• CT, catheterisation or biopsy: Pericardial thickening and calcification; pressure tracings for constriction; biopsy in selected severe myocarditis.

Behandlungsmöglichkeiten

• Anti-inflammatory therapy for pericarditis: An NSAID or aspirin plus colchicine for 3 months; steroids second line; anakinra or rilonacept for recurrent disease.
• Rest from sport: 3 to 6 months after myocarditis and until pericarditis has fully resolved.
• Heart failure medicines: ACE inhibitor, ARB or ARNI, beta blocker, mineralocorticoid antagonist and SGLT2 inhibitor for a weakened ventricle.
• Treatments specific to hypertrophic cardiomyopathy: Beta blockers, the myosin inhibitor mavacamten, and septal myectomy or alcohol septal ablation for obstruction.
• Devices: ICD for those at risk of sudden death; resynchronisation pacing; ventricular assist devices in advanced failure.
• Pericardial drainage: Needle pericardiocentesis or a surgical window for large or compressing effusions.
• Pericardiectomy: Surgical removal of the pericardium for chronic constriction.

Wenn es dringend ist

Any new chest pain needs urgent local assessment to exclude a heart attack; do not assume it is pericarditis. Call for emergency help for chest pain with breathlessness, fainting, a very fast or irregular pulse, or rapidly increasing breathlessness with light-headedness, which may mean fluid is compressing the heart (tamponade).

Reisen nach Türkiye zur Behandlung

Acute pericarditis and myocarditis are treated where you fall ill, and flying during active myocarditis is not advised. Planned visits can offer a cardiomyopathy work-up with MRI and genetic testing in 3 to 5 days, second opinions, ICD implantation, septal reduction therapy for hypertrophic cardiomyopathy, or pericardiectomy for constriction. Medication titration afterwards takes months and is done at home.

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