Myocarditis as a concomitant condition in patients with post-infarction myocardial fibrosis and acute decompensated heart failure

Background. Acute decompensated heart failure (ADHF) in patients with post-infarction cardiosclerosis, even with previously performed optimal coronary revascularization, is typically considered a manifestation of ischemic heart disease progression. However, in clinical practice acute decompensation can also be influenced by non-ischemic mechanisms, including myocarditis. Such a combination of conditions appears particularly significant in patients with reduced left ventricular ejection fraction (LVEF) and a history of coronary revascularization in the absence of signs of ongoing myocardial ischemia.

Aim: To assess the prevalence of myocarditis and myocardial viral antigen expression in patients hospitalized with ADHF, reduced LVEF, post-infarction myocardial fibrosis, and a history of coronary revascularization.

Material and Methods. The study included 26 patients admitted with ADHF. Acute coronary syndrome and other conditions, such as anemia, pneumonia, sepsis, influenza, decompensation of diabetes mellitus, tumors, cachexia, or severe valvular heart stenosis, capable of independently causing HF decompensation were excluded. Median LVEF was 29.5% (IQR 22.0–32.0). All patients underwent transthoracic echocardiography, invasive coronary angiography, and right ventricular endomyocardial biopsy. Histological and immunohistochemical (IHC) analyses were performed to identify myocardial inflammation and viral antigen expression. Endomyocardial biopsy of the right ventricle was performed, with three myocardial samples obtained from each patient, followed by pathohistological and immunohistochemical examination.

Results. Myocarditis was diagnosed in 18 patients (69%), including viral myocarditis in 13 (50%), viral-autoimmune myocarditis in 3 (12%), and autoimmune myocarditis in 1 patient (4%). Viral antigen expression in the myocardium was detected in 89% of cases. The frequency of viral antigen detection was as follows: enterovirus – 77%, human herpesvirus type 1 – 8%, type 2 – 8%, type 6 – 50%, Epstein-Barr virus – 23%, cytomegalovirus – 8%; parvovirus B19 and adenovirus were not detected. Viral antigen expression was observed in 94% of patients with myocarditis (except for one case of autoimmune myocarditis) and in 75% of patients without histological signs of myocardial inflammation.

Conclusion. In patients with ADHF, reduced LVEF, post-infarction cardiosclerosis, and a history of coronary revascularization, myocarditis was detected in 69% of cases and represented a frequent comorbid condition. In the absence of myocardial ischemia, inflammation of the myocardium may contribute to the development of ADHF, which should be considered during diagnostic evaluation.

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