Circulation. 2001;104:1076-1082
doi: 10.1161/hc3401.095198
doi: 10.1161/hc3401.095198
(Circulation. 2001;104:1076.)
© 2001 American Heart Association, Inc.
Clinical Cardiology: New Frontiers |
Advances in the Understanding of Myocarditis
From the Department of Medicine (J.W.M.), University of Kentucky, Lexington, Ky, and the Heart & Stroke/Richard Lewar Centre of Excellence, University of Toronto and Toronto General Hospital, University Health Network, Toronto, Canada (P.P.L.).
Correspondence to Jay W. Mason, MD, Department of Medicine, University of Kentucky, Kentucky Clinic J525, Lexington, KY 40536-0284. E-mail jmason@pop.uky.edu
Key Words: myocarditis • viruses • cardiomyopathy • heart failure • immunology
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The Many "Faces" of Myocarditis |
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Myocarditis is a poorly understood disease because it progresses through stages with distinctly different mechanisms and manifestations. The objective of this article is to better define myocarditis for both clinicians and clinical scientists by setting it in the framework of 3 phases of disease. In phase 1, the viral stage, we review recent discoveries about the way viruses gain access to target tissue and how they trigger immune responses. In the second, autoimmune phase of disease, we examine the roles of autoreactive T cells, cytokines, and cross-reacting antibodies and reconsider the relevance of recent therapy trials. In the third phase of the disease, dilated cardiomyopathy, we consider the remodeling processes. We then offer current recommendations for diagnosis and therapy and conclude with a look to the future.
Myocarditis is a continuum of 3 distinct disease processes, one evolving into the other with transitional periods of indistinctness. For each of the 3 processes, pathogenesis, diagnosis, and treatment differ considerably. Without precise knowledge of the point to which an individual patient’s myocarditis has evolved in this continuum, the clinician can only use diagnostic tools and therapeutic interventions haphazardly.
It is likely that the majority of cases of myocarditis, except in countries in which Chagas’ disease or diphtheria is common, result from viral infection, which may progress to an autoimmune phase after resolution or reduction of the initial infection, and then finally to progressive dilatation after resolution or reduction of the autoimmune injury (Figure 1). A viral cause can only be
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