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Current treatment options in (peri)myocarditis and inflammatory cardiomyopathy

Aktuelle Behandlungsoptionen bei (Peri-)Myokarditis und inflammatorischer Kardiomyopathie

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Abstract

In inflammatory dilated cardiomyopathy and myocarditis there is—apart from heart failure and antiarrhythmic therapies—no alternative to an aetiologically driven specific treatment. Prerequisite are noninvasive and invasive biomarkers including endomyocardial biopsy and PCR on cardiotropic agents. This review deals with the different etiologies of myocarditis and inflammatory cardiomyopathy including the genetic background, the predisposition for heart failure and inflammation. It analyses the epidemiologic shift in pathogenetic agents in the last 20 years, the role of innate and aquired immunity including the T- and B-cell driven immune responses. The phases and clinical faces of myocarditis are summarized. Up-to-date information on current treatment options starting with heart failure and antiarrhythmic therapy are provided. Although inflammation can resolve spontaneously, specific treatment directed to the causative aetiology is often required. For fulminant, acute and chronic autoreactive myocarditis immunosuppressive treatment is beneficial, while for viral cardiomyopathy and myocarditis ivIg can resolve inflammation and is as successful as interferon therapy in enteroviral and adenoviral myocarditis. For Parvo B19 and HHV6 myocarditis eradication of the virus is still a problem by any of these treatment options. Finally, the potential of stem cell therapy has to be tested in future trials. In virus-negative, autoreactive perimyocardial disease a locoregional approach with intrapericardial instillation of high local doses of triamcinolone acetate has been shown to be highly efficient and with few systemic side-effects.

Zusammenfassung

Bei Myokarditis und inflammatorischer Kardiomyopathie gibt es neben der ohnehin durchzuführenden Herzinsuffizienzbehandlung heute keine echte Alternative zu einer ätiologisch-kausalen Therapie. Diese stützt sich unverändert auf die histologischen, immunhistologischen und molekularbiologischen Befunde aus der Endomyokardbiopsie, wobei nicht-invasive serologische Biomarker (CRP, BNP, Troponin, Gal-3 u. a.) und nicht-invasives Imaging hilfreich bei der Diagnosestellung sind. Die spezifische Therapie orientiert sich bei autoreaktiver virusnegativer Myokarditis an den Ergebnissen der TIMIC- und der ESETCID-Studie, die eine immunsuppressive Behandlung nahelegen, ähnlich wie bei Sarkoidose, Riesenzellmyokarditis und eosinophiler Myokarditis. Bei autoreaktiver, virusnegativer Perimyokarditis vermeidet eine intraperikardiale Triamcinoloninstillation in der Regel die systemischen Nebenwirkungen einer peroralen Kortikoidtherapie. Bei viraler inflammatorischer Kardiomyopathie können i.v.-Immunglobuline stets die Entzündung, die virale Ursache jedoch nicht so regelmäßig eliminieren.

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Acknowledgement

This work was supported by a grant of the Bundesministerium für Wissenschaft und Forschung (BMBF) in the German Competence Net of Heart Failure (KNHI) for Prof. Dr. Bernhard Maisch and Sabine Pankuweit, by the Dr. Reinfried Pohl Foundation, by the Marburg Heart Foundation (VFDK) and by the UKGM Foundation for Prof. Dr. Bernhard Maisch.

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On behalf of all authors, the corresponding author states that there are no conflicts of interest.

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  1. Department of Internal Medicine and Cardiology, University Hospital Gießen & Marburg, 35043, Marburg, Germany

    B. Maisch MD, FESC, FACC & S. Pankuweit

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  1. B. Maisch MD, FESC, FACC
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Correspondence to B. Maisch MD, FESC, FACC.

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Maisch, B., Pankuweit, S. Current treatment options in (peri)myocarditis and inflammatory cardiomyopathy. Herz 37, 644–656 (2012). https://doi.org/10.1007/s00059-012-3679-9

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