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Clinical protocol for the provision of medical care to patients with myocarditis

Heading for ICD-10: W, W, W.4

Conditions in which medical care should be provided

Features of the examination and treatment depend on the prevalence and course of myocarditis. Patients with focal myocarditis are subject to outpatient examination and treatment at the place of residence. Examination can be carried out in district clinics, and if necessary, additional examinations - in city cardiology dispensaries and diagnostic centers. Patients with diffuse myocarditis of moderate severity or with a severe course require inpatient treatment in cardiological hospitals at the place of residence with the obligatory continuation of therapy on an outpatient basis.

Diagnostic program

Mandatory studies

1. Collection of complaints and medical history.

2. Clinical examination.

3. Measurement of blood pressure.

4. A study of laboratory parameters (general blood and urine tests, AlAT ,?

AsAT, bilirubin, creatinine, CRP, CPK or CF-fraction MV, troponin T or I, antistreptolysin-O titer, cholesterol, blood glucose).

5. An etiological study with the determination of titers of neutralizing antibodies to Coxsackie viruses of group B, ECHO (enteric cytopathogenic human orphan virus), herpes, hepatitis C, etc. (immunoglobulins of classes G and M (IgM, IgG)) in plasma, as well as polymerase chain reaction.

6. Determination of indicators of the immunological state.

7. ECG in 12 leads.

8. Echocardiography and Doppler study.

9. Chest x-ray.

Additional research

1. Daily ECG monitoring.

2. For the diagnosis of chronic myocarditis, radioisotope scintigraphy using isotopes: technetium (99tTc), gallium citrate (67Ga) or monoclonal antibodies to myosin labeled with indium (111 In).

3. CT or MRI using a contrast such as gadodiamide.

4. Endomyocardial biopsy with the definition of modern histological criteria, the so-called consensus for the definition of myocarditis.

Treatment program

List and scope of compulsory medical services

According to modern algorithms approved by the Congress of Cardiology of Ukraine (2004), the treatment of myocarditis differs depending on the prevalence of myocardial damage and the severity of the disease.

In acute isolated myocarditis

Etiological treatment: antiviral drugs interferon, antibacterial drugs, etc.

B-adrenergic blockers.

NSAIDs.

Systemic enzyme therapy.

Metabolic therapy.

Symptomatic treatment:

¦ antiarrhythmic drugs;

¦ disaggregants;

¦ diuretics.

In chronic isolated myocarditis

1. B-adrenergic blockers.

2. NSAIDs.

3. Systemic enzyme therapy.

4. Metabolic therapy.

5. Symptomatic treatment:

¦ antiarrhythmic drugs;

¦ disaggregants;

¦ diuretics.

In acute diffuse myocarditis

1. Etiological treatment: interferon preparations, antiviral and antibacterial drugs, etc.

2. R-adrenergic receptor blockers and / or ACE inhibitors or angiotensin II receptor blockers (AP).

3.
Diuretics.

4. Disaggregants and / or anticoagulants.

5. Antiarrhythmic drugs.

6. Systemic enzyme therapy.

7. Metabolic therapy.

8. At this stage, it is also possible to use:

¦ GCS (as immunosuppressants for idiopathic or autoimmune myocarditis);

¦ sympathomimetics - to maintain hemodynamic parameters for symptoms of acute severe heart failure and cardiogenic shock.

In chronic diffuse myocarditis

1. The course of treatment with hormones and / or cytotoxic drugs.

2. Symptomatic treatment of heart failure:

Р p-adrenergic receptor blockers (metoprolol, carvedilol, bisoprolol, nebivolol);

¦ ACE inhibitors, with intolerance angiotensin II receptor blockers;

¦ diuretics;

¦ digoxin.

3. Treatment and prevention of complications:

¦ disaggregants and / or anticoagulants;

¦ antiarrhythmic drugs.

4. Systemic enzyme therapy.

5. Metabolic therapy.

List and scope of additional medical services

1. In the presence of indications - sanitation of foci of chronic infections.

2. In severe course of diffuse myocarditis:

¦ implantation of a cardioverter-defibrillator in the presence of recurrent ventricular fibrillation or persistent ventricular tachycardia and their resistance to antiarrhythmic drugs;

¦ implantation of a three-chamber EX in DDDR mode during refractory to drug therapy of heart failure, in patients with significant disorders of intraventricular conduction and desynchronization of ventricular contraction;

¦ heart transplantation during transformation in DCMP and severe course.

Description of the final expected outcome of treatment

Recovery with a mild course, lack of progression of heart failure, increased life expectancy.

Treatment duration

The timing of inpatient treatment is determined by the degree of heart failure and the effect of treatment. The terms of outpatient treatment are determined individually, depending on the prevalence and severity of myocarditis. The total duration of treatment can be up to 6 months, and in severe cases of diffuse myocarditis, symptomatic therapy can be carried out for an indefinitely long period.

Treatment Quality Criteria

General condition improvement. Positive dynamics of laboratory and instrumental research methods. In chronic severe diffuse myocarditis - elimination or reduction of the severity of subjective symptoms of HF, increased LVEF, increased quality of life, lengthening the period between hospitalizations.

Possible side effects and complications

Side effects of drugs according to their pharmacological properties are possible.

Outpatient recommendations

Patients need observation for 6 months after inpatient treatment. In chronic diffuse myocarditis, patients should be registered at the place of residence and examined at least 1 time in 2 months or more often (in a specific clinical situation).
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Clinical protocol for the provision of medical care to patients with myocarditis

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