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成人心肌炎的自然病程和治疗

Author
Leslie T Cooper, Jr, MD
Section Editor
William J McKenna, MD
Deputy Editor
Susan B Yeon, MD, JD, FACC
Translators
任川, 主治医师

引言

心肌炎是指可经临床和组织病理学标准确定的心肌炎症。该病的临床表现差异较大，可从无症状性心电图(electrocardiogram, ECG)改变到暴发性心力衰竭(heart failure, HF)等；也可能存在心律失常、心脏传导阻滞和类似于急性心肌梗死(myocardial infarction, MI)的综合征。 (参见“成人心肌炎的临床表现和诊断”)

通过心脏以外的症状和体征，可识别出累及心脏并导致心肌炎的感染性和毒性致病因子或自身免疫性疾病。例如，发生病毒性心肌炎之前可能出现发热、肌痛和肌肉压痛这些病毒感染的前驱症状，而迟发型超敏反应可能因皮疹、嗜酸性粒细胞增多和肝酶水平升高而初显。

心肌炎的治疗既包括针对病因的特异性治疗，也包括针对临床表现(如HF和心律失常)的非特异性治疗。在讨论这些问题之前，总结有关该病自然病程的已知内容是十分有用的。心肌炎的病因、发病率、发病机制、临床表现和诊断将单独讨论。 (参见“心肌炎的病因和发病机制”和“成人心肌炎的临床表现和诊断”)

有接近一半的心包炎患者同时合并心肌炎，该疾病被称为心肌心包炎。心肌心包炎，包括痘苗病毒相关性疾病(心肌炎和/或心包炎)，将单独讨论(参见“心肌心包炎”)。

自然病程

对于社区人群心肌炎的自然病程尚无准确的了解，因为还没有可以广泛应用的非侵入性诊断性检查可以确诊心肌炎。但血清流行病学研究表明，大多数柯萨奇B组病毒感染病例为亚临床型，且具有良性病程[1]。

                             

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Literature review current through: 2017-06 . | This topic last updated: 2015-08-28.
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References
Top
  1. O'Connell, JB. Diagnosis and medical treatment of inflammatory cardiomyopathy. In: Cardiovascular Medicine, Topol, E, Nissen, J (Eds), Lippincott-Raven, Philadelphia 1998.
  2. Felker GM, Thompson RE, Hare JM, et al. Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med 2000; 342:1077.
  3. Wentworth P, Jentz LA, Croal AE. Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. Can Med Assoc J 1979; 120:676.
  4. Mason JW, O'Connell JB, Herskowitz A, et al. A clinical trial of immunosuppressive therapy for myocarditis. The Myocarditis Treatment Trial Investigators. N Engl J Med 1995; 333:269.
  5. Hosenpud JD, McAnulty JH, Niles NR. Unexpected myocardial disease in patients with life threatening arrhythmias. Br Heart J 1986; 56:55.
  6. Frustaci A, Chimenti C, Bellocci F, et al. Histological substrate of atrial biopsies in patients with lone atrial fibrillation. Circulation 1997; 96:1180.
  7. McNamara DM, Holubkov R, Starling RC, et al. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation 2001; 103:2254.
  8. Mendes LA, Picard MH, Dec GW, et al. Ventricular remodeling in active myocarditis. Myocarditis Treatment Trial. Am Heart J 1999; 138:303.
  9. Miklozek CL, Kingsley EM, Crumpaker CS, et al. Serial cardiac function tests in myocarditis. Postgrad Med J 1986; 62:577.
  10. Kearney MT, Cotton JM, Richardson PJ, Shah AM. Viral myocarditis and dilated cardiomyopathy: mechanisms, manifestations, and management. Postgrad Med J 2001; 77:4.
  11. Liu PP, Mason JW. Advances in the understanding of myocarditis. Circulation 2001; 104:1076.
  12. Caforio AL, Goldman JH, Haven AJ, et al. Circulating cardiac-specific autoantibodies as markers of autoimmunity in clinical and biopsy-proven myocarditis. The Myocarditis Treatment Trial Investigators. Eur Heart J 1997; 18:270.
  13. Lauer B, Schannwell M, Kühl U, et al. Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis. J Am Coll Cardiol 2000; 35:11.
  14. Caforio AL, Vinci A, Iliceto S. Anti-heart autoantibodies in familial dilated cardiomyopathy. Autoimmunity 2008; 41:462.
  15. Grogan M, Redfield MM, Bailey KR, et al. Long-term outcome of patients with biopsy-proved myocarditis: comparison with idiopathic dilated cardiomyopathy. J Am Coll Cardiol 1995; 26:80.
  16. Goldberg, LR, Suk, J, Patton, KK, et al. Predictors of adverse outcome in biopsy-proven myocarditis (abstract). J Am Coll Cardiol 1999; 33:A850.
  17. McCarthy RE 3rd, Boehmer JP, Hruban RH, et al. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med 2000; 342:690.
  18. Cappola TP, Felker GM, Kao WH, et al. Pulmonary hypertension and risk of death in cardiomyopathy: patients with myocarditis are at higher risk. Circulation 2002; 105:1663.
  19. Lieberman EB, Hutchins GM, Herskowitz A, et al. Clinicopathologic description of myocarditis. J Am Coll Cardiol 1991; 18:1617.
  20. Amabile N, Fraisse A, Bouvenot J, et al. Outcome of acute fulminant myocarditis in children. Heart 2006; 92:1269.
  21. Kühl U, Pauschinger M, Seeberg B, et al. Viral persistence in the myocardium is associated with progressive cardiac dysfunction. Circulation 2005; 112:1965.
  22. Kindermann I, Kindermann M, Kandolf R, et al. Predictors of outcome in patients with suspected myocarditis. Circulation 2008; 118:639.
  23. Frustaci A, Chimenti C, Calabrese F, et al. Immunosuppressive therapy for active lymphocytic myocarditis: virological and immunologic profile of responders versus nonresponders. Circulation 2003; 107:857.
  24. Fuse K, Kodama M, Okura Y, et al. Predictors of disease course in patients with acute myocarditis. Circulation 2000; 102:2829.
  25. Sheppard R, Bedi M, Kubota T, et al. Myocardial expression of fas and recovery of left ventricular function in patients with recent-onset cardiomyopathy. J Am Coll Cardiol 2005; 46:1036.
  26. Nishii M, Inomata T, Takehana H, et al. Serum levels of interleukin-10 on admission as a prognostic predictor of human fulminant myocarditis. J Am Coll Cardiol 2004; 44:1292.
  27. Kodama M, Matsumoto Y, Fujiwara M, et al. A novel experimental model of giant cell myocarditis induced in rats by immunization with cardiac myosin fraction. Clin Immunol Immunopathol 1990; 57:250.
  28. Cooper LT Jr, Berry GJ, Shabetai R. Idiopathic giant-cell myocarditis--natural history and treatment. Multicenter Giant Cell Myocarditis Study Group Investigators. N Engl J Med 1997; 336:1860.
  29. Rose NR, Neumann DA, Herskowitz A. Coxsackievirus myocarditis. Adv Intern Med 1992; 37:411.
  30. Kishimoto C, Crumpacker CS, Abelmann WH. Ribavirin treatment of murine coxsackievirus B3 myocarditis with analyses of lymphocyte subsets. J Am Coll Cardiol 1988; 12:1334.
  31. Kishimoto C, Crumpacker CS, Abelmann WH. Prevention of murine coxsackie B3 viral myocarditis and associated lymphoid organ atrophy with recombinant human leucocyte interferon alpha A/D. Cardiovasc Res 1988; 22:732.
  32. Matsumori A, Tomioka N, Kawai C. Protective effect of recombinant alpha interferon on coxsackievirus B3 myocarditis in mice. Am Heart J 1988; 115:1229.
  33. Yamamoto N, Shibamori M, Ogura M, et al. Effects of intranasal administration of recombinant murine interferon-gamma on murine acute myocarditis caused by encephalomyocarditis virus. Circulation 1998; 97:1017.
  34. Ray CG, Icenogle TB, Minnich LL, et al. The use of intravenous ribavirin to treat influenza virus-associated acute myocarditis. J Infect Dis 1989; 159:829.
  35. Kühl U, Pauschinger M, Schwimmbeck PL, et al. Interferon-beta treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation 2003; 107:2793.
  36. Daliento L, Calabrese F, Tona F, et al. Successful treatment of enterovirus-induced myocarditis with interferon-alpha. J Heart Lung Transplant 2003; 22:214.
  37. Tomioka N, Kishimoto C, Matsumori A, Kawai C. Effects of prednisolone on acute viral myocarditis in mice. J Am Coll Cardiol 1986; 7:868.
  38. Monrad ES, Matsumori A, Murphy JC, et al. Therapy with cyclosporine in experimental murine myocarditis with encephalomyocarditis virus. Circulation 1986; 73:1058.
  39. Padalko E, Verbeken E, Matthys P, et al. Mycophenolate mofetil inhibits the development of Coxsackie B3-virus-induced myocarditis in mice. BMC Microbiol 2003; 3:25.
  40. Mason JW, Billingham ME, Ricci DR. Treatment of acute inflammatory myocarditis assisted by endomyocardial biopsy. Am J Cardiol 1980; 45:1037.
  41. Jones SR, Herskowitz A, Hutchins GM, Baughman KL. Effects of immunosuppressive therapy in biopsy-proved myocarditis and borderline myocarditis on left ventricular function. Am J Cardiol 1991; 68:370.
  42. Maisch B, Schönian U, Hengstenberg C, et al. Immunosuppressive treatment in autoreactive myocarditis--results from a controlled trial. Postgrad Med J 1994; 70 Suppl 1:S29.
  43. O'Connell JB, Mason JW. Diagnosing and treating active myocarditis. West J Med 1989; 150:431.
  44. Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, et al. Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. Circulation 2001; 104:39.
  45. Frustaci A, Russo MA, Chimenti C. Randomized study on the efficacy of immunosuppressive therapy in patients with virus-negative inflammatory cardiomyopathy: the TIMIC study. Eur Heart J 2009; 30:1995.
  46. Aretz HT, Billingham ME, Edwards WD, et al. Myocarditis. A histopathologic definition and classification. Am J Cardiovasc Pathol 1987; 1:3.
  47. Baughman KL. Diagnosis of myocarditis: death of Dallas criteria. Circulation 2006; 113:593.
  48. Parrillo JE. Inflammatory cardiomyopathy (myocarditis): which patients should be treated with anti-inflammatory therapy? Circulation 2001; 104:4.
  49. Magnani JW, Dec GW. Myocarditis: current trends in diagnosis and treatment. Circulation 2006; 113:876.
  50. Müller J, Wallukat G, Dandel M, et al. Immunoglobulin adsorption in patients with idiopathic dilated cardiomyopathy. Circulation 2000; 101:385.
  51. Wallukat G, Müller J, Hetzer R. Specific removal of beta1-adrenergic autoantibodies from patients with idiopathic dilated cardiomyopathy. N Engl J Med 2002; 347:1806.
  52. Staudt A, Böhm M, Knebel F, et al. Potential role of autoantibodies belonging to the immunoglobulin G-3 subclass in cardiac dysfunction among patients with dilated cardiomyopathy. Circulation 2002; 106:2448.
  53. Staudt A, Dörr M, Staudt Y, et al. Role of immunoglobulin G3 subclass in dilated cardiomyopathy: results from protein A immunoadsorption. Am Heart J 2005; 150:729.
  54. Vignola PA, Aonuma K, Swaye PS, et al. Lymphocytic myocarditis presenting as unexplained ventricular arrhythmias: diagnosis with endomyocardial biopsy and response to immunosuppression. J Am Coll Cardiol 1984; 4:812.
  55. Robinson JL, Hartling L, Crumley E, et al. A systematic review of intravenous gamma globulin for therapy of acute myocarditis. BMC Cardiovasc Disord 2005; 5:12.
  56. Gullestad L, Aass H, Fjeld JG, et al. Immunomodulating therapy with intravenous immunoglobulin in patients with chronic heart failure. Circulation 2001; 103:220.
  57. Costanzo-Nordin MR, Reap EA, O'Connell JB, et al. A nonsteroid anti-inflammatory drug exacerbates Coxsackie B3 murine myocarditis. J Am Coll Cardiol 1985; 6:1078.
  58. Rezkalla S, Khatib G, Khatib R. Coxsackievirus B3 murine myocarditis: deleterious effects of nonsteroidal anti-inflammatory agents. J Lab Clin Med 1986; 107:393.
  59. Khatib R, Reyes MP, Smith F, et al. Enhancement of coxsackievirus B4 virulence by indomethacin. J Lab Clin Med 1990; 116:116.
  60. Drucker NA, Colan SD, Lewis AB, et al. Gamma-globulin treatment of acute myocarditis in the pediatric population. Circulation 1994; 89:252.
  61. McNamara DM, Rosenblum WD, Janosko KM, et al. Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy. Circulation 1997; 95:2476.
  62. Litovsky SH, Burke AP, Virmani R. Giant cell myocarditis: an entity distinct from sarcoidosis characterized by multiphasic myocyte destruction by cytotoxic T cells and histiocytic giant cells. Mod Pathol 1996; 9:1126.
  63. Menghini VV, Savcenko V, Olson LJ, et al. Combined immunosuppression for the treatment of idiopathic giant cell myocarditis. Mayo Clin Proc 1999; 74:1221.
  64. Cooper LT Jr, Hare JM, Tazelaar HD, et al. Usefulness of immunosuppression for giant cell myocarditis. Am J Cardiol 2008; 102:1535.
  65. Moloney ED, Egan JJ, Kelly P, et al. Transplantation for myocarditis: a controversy revisited. J Heart Lung Transplant 2005; 24:1103.
  66. Cooper LT, Zehr KJ. Biventricular assist device placement and immunosuppression as therapy for necrotizing eosinophilic myocarditis. Nat Clin Pract Cardiovasc Med 2005; 2:544.
  67. Kim JS, Judson MA, Donnino R, et al. Cardiac sarcoidosis. Am Heart J 2009; 157:9.
  68. Winters SL, Cohen M, Greenberg S, et al. Sustained ventricular tachycardia associated with sarcoidosis: assessment of the underlying cardiac anatomy and the prospective utility of programmed ventricular stimulation, drug therapy and an implantable antitachycardia device. J Am Coll Cardiol 1991; 18:937.
  69. Frustaci A, Cuoco L, Chimenti C, et al. Celiac disease associated with autoimmune myocarditis. Circulation 2002; 105:2611.
  70. Rezkalla S, Kloner RA, Khatib G, Khatib R. Effect of delayed captopril therapy on left ventricular mass and myonecrosis during acute coxsackievirus murine myocarditis. Am Heart J 1990; 120:1377.
  71. Tominaga M, Matsumori A, Okada I, et al. Beta-blocker treatment of dilated cardiomyopathy. Beneficial effect of carteolol in mice. Circulation 1991; 83:2021.
  72. Matsumori A, Igata H, Ono K, et al. High doses of digitalis increase the myocardial production of proinflammatory cytokines and worsen myocardial injury in viral myocarditis: a possible mechanism of digitalis toxicity. Jpn Circ J 1999; 63:934.
  73. Rockman HA, Adamson RM, Dembitsky WP, et al. Acute fulminant myocarditis: long-term follow-up after circulatory support with left ventricular assist device. Am Heart J 1991; 121:922.
  74. Chen JM, Spanier TB, Gonzalez JJ, et al. Improved survival in patients with acute myocarditis using external pulsatile mechanical ventricular assistance. J Heart Lung Transplant 1999; 18:351.
  75. TILLES JG, ELSON SH, SHAKA JA, et al. EFFECTS OF EXERCISE ON COXSACKIE A9 MYOCARDITIS IN ADULT MICE. Proc Soc Exp Biol Med 1964; 117:777.
  76. European Heart Rhythm Association, Heart Rhythm Society, Zipes DP, et al. ACC/AHA/ESC 2006 guidelines for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: a report of the American College of Cardiology/American Heart Association Task Force and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Develop Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death). J Am Coll Cardiol 2006; 48:e247.
  77. PEARCE JM. Heart disease and filtrable viruses. Circulation 1960; 21:448.
  78. Miller, H, Abelmann, WH. Effects of dietary ethanol upon experimental Trypanosomal (T. cruzi) myocarditis. Proc Soc Exp Biol Med 1967; 126:193.
  79. O'Connell JB, Dec GW, Goldenberg IF, et al. Results of heart transplantation for active lymphocytic myocarditis. J Heart Transplant 1990; 9:351.
  80. O'Connell JB, Breen TJ, Hosenpud JD. Heart transplantation in dilated heart muscle disease and myocarditis. Eur Heart J 1995; 16 Suppl O:137.
  81. Dong R, Liu P, Wee L, et al. Verapamil ameliorates the clinical and pathological course of murine myocarditis. J Clin Invest 1992; 90:2022.
  82. Yamada T, Matsumori A, Sasayama S. Therapeutic effect of anti-tumor necrosis factor-alpha antibody on the murine model of viral myocarditis induced by encephalomyocarditis virus. Circulation 1994; 89:846.
  83. Kishimoto C, Takada H, Hiraoka Y, Shiraki K. Effects of naloxone, an opiate receptor antagonist, on coxsackievirus B3 myocarditis in the mouse. Cardiovasc Res 1995; 29:80.
  84. Wang Y, Afanasyeva M, Hill SL, et al. Nasal administration of cardiac myosin suppresses autoimmune myocarditis in mice. J Am Coll Cardiol 2000; 36:1992.
  85. Liu JP, Yang M, Du XM. Herbal medicines for viral myocarditis. Cochrane Database Syst Rev 2004; :CD003711.
  86. Murphy JG, Wright RS, Bruce GK, et al. Eosinophilic-lymphocytic myocarditis after smallpox vaccination. Lancet 2003; 362:1378.
  87. Dec GW Jr, Palacios IF, Fallon JT, et al. Active myocarditis in the spectrum of acute dilated cardiomyopathies. Clinical features, histologic correlates, and clinical outcome. N Engl J Med 1985; 312:885.
  88. Matsumori A, Crumpacker CS, Abelmann WH, Kawai C. Virus vaccine and passive immunization for the prevention of viral myocarditis in mice. Jpn Circ J 1987; 51:1362.