Overview

Myopericarditis is a complex cardiovascular condition that involves inflammation of both the myocardium (heart muscle) and the pericardium (the protective sac surrounding the heart). It represents a combination of two distinct but related conditions: myocarditis and pericarditis. 

This condition can result from a variety of causes, including viral infections (such as Coxsackievirus, herpes viruses, Ebstein-Barr virus, influenza virus and hepatitis C virus), bacterial infections (such as Mycobacterium tuberculosis, Streptococcus and Staphylococcus), and fungal infections (such as Aspergillus and Blastomyces). Autoimmune diseases, including lupus and rheumatoid arthritis, contribute to the risk, as do other factors like medication. reactions (from procainamide or isoniazid) and metastatic cancers (such as lung cancer and breast cancer).¹ 

The symptoms of myopericarditis may typically include chest pain, which can be sharp and worsen with deep breaths or lying down. Other symptoms include fatigue, fever, and shortness of breath, reflecting both pericardial and myocardial inflammation. Myopericarditis can lead to serious problems such as heart failure, irregular heartbeats, fluid around the heart, and in severe cases, pressure on the heart that can be life-threatening. Thus, early diagnosis and close monitoring of the symptoms are necessary to manage the condition effectively.

In this article, we will explore the different treatment options for myopericarditis, ranging from medical management to interventional and surgical approaches.

Diagnosis of myopericarditis

The diagnosis of myopericarditis is carried out using various tests to detect the cause of inflammation, evaluate the functioning of the heart and rule out other conditions.² The diagnostic tests may include

Clinical evaluation

The symptoms of myopericarditis can range from mild chest pain and fatigue to severe heart failure and shock, depending on the extent of inflammation. Early signs include chest pain, fatigue, shortness of breath, and fever, often following a viral illness, with severe cases showing heart failure symptoms and potentially life-threatening complications.¹

Laboratory tests

Elevated cardiac enzymes (troponins)³, inflammatory markers (C-reactive protein, erythrocyte sedimentation rate, white blood cells), and viral serologies³ can be indicative of myopericarditis. ¹

Electrocardiogram

This test records the heart's electrical activity and may show heart rhythm pattern changes that occur due to myopericarditis.² 

Chest radiography

An X-ray of the chest can show if the heart looks larger than normal, which can happen if there is fluid around it.¹

Echocardiogram

An echocardiogram is a common test that checks the heart's function and looks for any fluid around the heart. It can show if there's inflammation or problems with how well the heart is pumping, especially in patients with severe heart issues.¹

Coronary angiography

Coronary angiography is typically avoided in young patients with myopericarditis symptoms. However, in older patients with risk factors for heart disease, it may be necessary to distinguish between heart muscle issues and blocked arteries using this procedure.¹

Cardiac magnetic resonance imaging

Cardiac magnetic resonance imaging (CMR) is used to assess heart muscle and outer lining (pericardium) inflammation in myopericarditis patients, showing inflammation and fluid across various heart areas.¹ 

Treatment options for myopericarditis

Once myocarditis is diagnosed, treatment should be tailored based on the severity of the condition, underlying cause, and patient-specific factors.¹ Here are the different treatment options for myopericarditis–

Medical management

A range of medications may be used to improve symptoms, which include:

Nonsteroidal anti-inflammatory drugs (NSAIDs)

NSAIDs are often the first line of treatment for myopericarditis due to their anti-inflammatory and analgesic properties.⁴

Commonly used NSAIDs include:⁴

• Ibuprofen
• Aspirin

These medications work by inhibiting cyclooxygenase (COX) enzymes, which play a key role in the inflammatory process.⁵ The benefits of NSAIDs include rapid relief from chest pain and reduction in inflammation. However, potential side effects such as gastrointestinal discomfort, ulcers, and renal impairment must be considered.⁶

Colchicine

Colchicine is often added to NSAID therapy for its anti-inflammatory properties and ability to prevent recurrent pericarditis. Colchicine disrupts microtubule formation, thereby reducing leukocyte migration and inflammation.⁷ Common side effects of colchicine include gastrointestinal discomfort, which can be reduced by taking the medication with food.

Corticosteroids

Corticosteroids are potent anti-inflammatory agents that may be used in cases of myopericarditis that do not respond to NSAIDs or colchicine. They are effective but can increase the risk of recurrent myopericarditis.⁷ Commonly used corticosteroids include prednisone.

The benefits of corticosteroids include rapid symptom relief and reduced inflammation. However, they come with significant risks such as weight gain, hyperglycaemia, and osteoporosis. 

Antiviral and antibacterial therapies

Treatment for viral myopericarditis primarily focuses on supportive care and managing the heart failure symptoms.⁸ The use of medications such as diuretics, angiotensin-converting enzyme (ACE) inhibitors and beta blockers to address fluid overload and improve cardiac function. Bacterial myopericarditis requires prompt antibiotic therapy to eradicate the infection. Commonly used antibiotics include penicillin, ciprofloxacin, and vancomycin. Monitoring for antibiotic resistance and potential side effects, such as gastrointestinal disturbances and allergic reactions, is essential.⁹

Immunosuppressive therapy

For patients with autoimmune-related myopericarditis (such as systemic lupus erythematosus, rheumatoid arthritis), immunosuppressive therapy may be required. This can include-

• Azathioprine
• Methotrexate

These medications help control the underlying autoimmune process and reduce cardiac inflammation. Patients on immunosuppressive therapy require close monitoring for side effects and complications.¹⁰ 

Hospitalisation and advanced treatments

Hospitalisation is required for patients with severe myopericarditis, particularly those with complications such as cardiac tamponade, heart failure, or arrhythmias. Intensive monitoring and management are necessary to stabilise these patients and prevent further complications.¹

The advanced treatments may include the following–

Intravenous immunoglobulin (IVIG)

IVIG is sometimes used in severe cases of myopericarditis, especially when associated with myocarditis. It has immunomodulatory effects and can be beneficial in reducing inflammation and improving cardiac function.⁵

Pericardiocentesis

This procedure involves the drainage of excess fluid from the pericardial sac to relieve pressure on the heart. It is indicated in cases of cardiac tamponade or significant pericardial effusion. The procedure is performed under ultrasound guidance to minimise risks. Complications include bleeding, infection, and damage to the heart or surrounding structures.

Surgical interventions

In rare cases, surgical intervention such as pericardiectomy (removal of the pericardium) may be necessary for recurrent or constrictive pericarditis. This surgery is considered when other treatments have failed and involves significant risks, including infection, bleeding, and complications related to anaesthesia.

Lifestyle and supportive care

Here are the key aspects of lifestyle and supportive care for this condition–

Rest and activity modifications

Rest is crucial during the acute phase of myopericarditis to allow the heart to heal. Patients should avoid strenuous activities and gradually return to normal activities as symptoms improve. A gradual increase in physical activity, under medical supervision, helps prevent recurrence and promotes recovery.¹¹

Diet and nutrition

A heart-healthy diet is essential for patients with myopericarditis. It is advised to include a diet rich in fruits, vegetables, whole grains, lean proteins, and healthy fats. Reducing sodium intake helps manage fluid retention and blood pressure. 

Regular follow-up care

Regular follow-up with a healthcare provider is essential to monitor recovery and adjust treatment plans as needed. Follow-up tests such as echocardiograms, ECGs, and blood tests help assess heart function and detect any recurrence of inflammation. 

Emerging treatments and research

Emerging treatments and research are focused on improving diagnosis, management, and therapeutic approaches. Here are some notable areas of advancement–

• Biologics: Drugs like anakinra (an interleukin-1 receptor antagonist) and tocilizumab (an interleukin-6 receptor antagonist) have shown promise in treating recurrent pericarditis by modulating the immune response¹²
• Cardiac MRI: Cardiac MRI can provide detailed information on myocardial inflammation and fibrosis, guiding therapy decisions. This approach allows for more personalised treatment plans and monitoring of disease progression and response to therapy
• Stem cell therapy: Stem cell therapy is an experimental treatment being studied for myocarditis and myopericarditis. The potential regenerative properties of stem cells could help repair damaged myocardium and reduce inflammation
• Genetic and molecular research: Understanding genetic predispositions to myopericarditis is helping in identifying at-risk populations and tailoring personalised treatment strategies. Research into the molecular mechanisms of inflammation and fibrosis in myopericarditis is leading to new therapeutic targets¹³
• Telemedicine and remote monitoring: Telemedicine facilitates early diagnosis and continuous monitoring of patients with myopericarditis, especially in remote or underserved areas. Wearable devices and mobile health apps are also enhancing patient engagement and adherence to treatment plans¹⁴

FAQs

What is the best treatment for myocarditis?

The best treatment for myocarditis includes rest, medications to manage symptoms (like anti-inflammatory drugs, ACE inhibitors, or beta-blockers), and addressing the underlying cause. Severe cases may require advanced therapies such as intravenous medications or mechanical support. Always follow a healthcare provider’s guidance for personalised treatment.

Can you recover from myopericarditis?

Yes, recovery from myopericarditis is possible. Most patients recover with rest and appropriate medical treatment, including anti-inflammatory medications. Monitoring and follow-up care are essential to manage symptoms and prevent complications. Severe cases may require more intensive interventions. Consult a healthcare provider for tailored advice.

Is myopericarditis permanent?

Myopericarditis is not typically permanent. Most individuals recover fully with appropriate treatment, which includes rest and medications. However, some cases may lead to chronic issues or complications if not properly managed. Continuous medical follow-up is crucial to ensure complete recovery and monitor for any long-term effects.

Can the heart muscle repair itself after myocarditis?

Yes, the heart muscle can repair itself after myocarditis, especially with early and effective treatment. Most people recover fully, though the extent of recovery can vary. Rest, medications, and avoiding strenuous activities aid in healing. Severe cases might result in lasting damage, necessitating ongoing medical care.

Summary

Myopericarditis is a complex condition requiring a multifaceted treatment approach. Medical treatments such as NSAIDs, colchicine, and corticosteroids are the cornerstone of therapy, while antiviral and antibacterial therapies are crucial for infection-related cases. Immunosuppressive therapy is reserved for severe or recurrent cases, and advanced treatments such as IVIG, pericardiocentesis, and surgery are used in specific situations. Lifestyle modifications and supportive care play an essential role in recovery and preventing recurrence. It is essential for patients to work closely with their healthcare providers to develop individualised treatment plans tailored to their specific needs.