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In most cases, treatment is continued for 6 months or more (the dose of prednisone is gradually reduced).
The appointment of immunosuppressive therapy is indicated in the case of giant cell myocarditis confirmed by endomyocardial biopsy.
The possibilities of using immunomodulators are currently being studied; in 2002, the European randomized trial BICC (Betaferon in Chronic Viral Cardiomyopathy Trial) was launched.
The efficacy of immunoglobulin for intravenous administration in adults with myocarditis was evaluated in a multicenter study, Intervention in Myocarditis and Acute Cardiomyopathy (IMAC), in which 62 patients were randomized to infuse immunoglobulin at a dose of 2 g / kg body weight or placebo. No advantages of intravenous immunoglobulin administration were revealed, since after 6 months the increase in PV was 14% in both groups and after 12 months - 16% in the treatment group compared to 15% in the placebo group. Overall survival (events defined as death, heart transplantation or the need to use assistive devices to maintain LV function) was 91% after 1 year and 88% after 2 years; no significant differences between the groups were found.
In the complex therapy of myocarditis, the use of systemic enzyme therapy drugs is possible.
The treatment and outcome of myocarditis are significantly different depending on LV function.
With a mild course of myocarditis (suspected myocarditis) and the absence of LV dysfunction, drug therapy is not required; it is recommended to avoid aerobic exercise or lifting weights for at least 6-8 weeks. The examination, including ECG and echoCG, should be repeated 6-8 weeks after the onset of the disease to assess the progression of myocardial involvement.
With LV dysfunction in patients with heart failure, therapy is carried out according to general rules. The use of ACE inhibitors (with intolerance to angiotensin II receptor antagonists and p-adrenergic blockers) is recommended for all patients. Stagnation of the lungs or symptoms of fluid overload should be eliminated with the use of loop diuretics in the minimum effective dose. Digoxin is added to the treatment regimen in patients with NYHA FC III, however, its potential proarrhythmogenic and pro-inflammatory effects should be taken into account, prescribing it in minimum effective maintenance doses or not at all in patients with minimally expressed symptoms (FC I or II). Even with the use of cardiac glycosides in usual doses, there is a high risk of glycoside intoxication. HF with myocarditis is resistant to cardiac glycosides and diuretics. It is important to eliminate hypokalemia and acidosis. The use of peripheral vasodilators is justified for the treatment of refractory heart failure. Nitrates reduce the venous return of blood to the heart, the pressure in the vessels of the pulmonary circulation, that is, LV preload, which is manifested by clinical improvement. The use of cardiac glycosides against the background of peripheral vasodilators allows to achieve adequate digitalization in the absence of toxic effect.
In patients with fulminant myocarditis, mechanical devices can be used to support ventricular function, in cases where their condition does not improve, despite the maximum inotropic therapy.
In patients whose LV size and systolic function are fully normalized, therapy with ACE inhibitors and p-adrenoreceptor blockers can, in principle, be discontinued provided that LV function and chronic diseases are closely monitored. In many patients who have recovered, subjective limitations in functional ability and objective limitations in exercise tests may be present, possibly due to a slower restoration of LV diastolic function.
Indirect anticoagulants are prescribed for patients with thromboembolic complications (including a history), the presence of blood clots in the cavities of the heart, and atrial fibrillation in patients with cardiomegaly.
In case of rhythm disturbances, antiarrhythmic drugs are prescribed or a cardioverter-defibrillator, pacemaker are implanted.
Heart transplantation should be planned only in the later stages of the disease, especially given the high early postoperative mortality due to graft rejection in patients whose immune system is initially activated against myocyte antigens. In case of transplant rejection, which often develops in the first 3 months after heart transplantation, GCS is prescribed in high doses (pulse therapy).
In the terminal stage, two-chamber stimulation is used, hardware maintenance of ventricular contraction.
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