Miocardite
Sintomatologia
La presentazione clinica della miocardite può essere molto variabile e comprende forme:
- fulminanti caratterizzate da una grave improvvisa disfunzione cardiaca spesso letale;
- simil-infartuali, nelle quali il paziente presenza dolore toracico oppressivo associato a sopraslivellamento ST e rialzo degli indici di necrosi miocardica (una miocardite acuta nei maschi adulti può avere un esordio clinico difficile da distinguere da un infarto miocardico acuto);
- a presentazione aritmica con aritmie sopraventricolari e ventricolari anche gravi in assenza di una marcata compromissione contrattile;
- croniche (fase acuta subdola e/o misconosciuta) con progressivo scompenso cardiaco.
Può essere preceduta da un episodio particolarmente invalidante di infezione delle alte vie respiratorie o di infezione gastrointestinale e può associarsi ad interessamento dei foglietti pericardici con comparsa di dolore toracico (dolore toracico tipico pericardico, febbre, alterazioni elettrocardiografiche e versamento pericardico).
Diagnosi
L’esame obiettivo di solito è normale o presenta reperti aspecifici. Nei casi gravi si osservano segni di scompenso cardiaco, terzo tono o soffio insufficienza mitralica.
ECG: normalmente produce alterazioni aspecifiche: segni di pericardite o alterazioni della ripolarizzazione ventricolare. Alterazione del miocardio, possono provocare la comparsa di aritmie e sopraventricolari,ventricolari o blocchi atrioventricolari.
Esami di laboratorio: di solito si osserva aumento della CK-MB e delle troponine (che non si osserva nella pericardite isolata).
Radiografia del torace: può essere normale o presentare cardiomegalia con segni di congestione polmonare.
Ecocardiogramma: permette di valutare la funzione ventricolare globale la contrattilità segmentaria.
Scintigrafia miocardica: con gallio 67 o anticorpi antimiosina marcati con indio 111.
Biopsia endomiocardica (BEM): esame fondamentale rappresenta il gold standard nella diagnosi di miocardite, Secondo i criteri di Dallas, la presenza nel miocardio di di un infiltrato infiammatorio con necrosi dei miocardiociti adiacenti fornisce una diagnosi sicura di miocardite in fase attiva.
Prognosi
In molti casi la miocardite guarisce in 4-6 settimane, senza lasciare importanti esiti, soltanto con il riposo. In caso di mancata guarigione spontanea, la miocardite può cronicizzare ed evolvere verso un quadro di cardiomiopatia dilatativa o aritmie ventricolari croniche associate o meno a disfunzione ventricolare sinistra.
Terapia
Nei casi gravemente sintomatici è necessaria una terapia finalizzata al trattamento dello scompenso cardiaco (β- bloccanti, ACE inibitori) e, se necessario delle aritmie. Nei pazienti con diagnosi di miocardite e persistenza o progressione dei sintomi (scompenso, aritmie, progressiva dilatazione dei ventricoli) al di là della fase acuta, alla terapia convenzionale di supporto può essere aggiunta una terapia eziologica, basata sul quadro istologico e sui dati di biologia molecolare.
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