Resumen
La miocarditis es una entidad heterogénea definida por la inflamación del miocardio, cuya etiología incluye causas infecciosas, inmunomediadas, tóxicas y genéticas. La presentación clínica puede variar según los casos, y el abordaje diagnóstico recomendado parte de una sospecha clínica apoyada por ECG, ecocardiografía y biomarcadores de daño miocárdico (como troponinas), seguido de resonancia magnética cardíaca (RMC) según los criterios de Lake Louise actualizados. La biopsia endomiocárdica (BEM) es esencial cuando se sospecha una etiología tratable (sarcoidosis, miocarditis eosinofílica, células gigantes o inmunoterapia). También se contempla el uso de tomografía por emisión de positrones (PET) con fluorodesoxiglucosa-18 (FDG-18) en casos no concluyentes por CRM o BEM. Se puede valorar el estudio genético en pacientes con antecedentes familiares, recurrencias o disfunción ventricular persistente con realce tardío en la CRM. El tratamiento se estratifica según la gravedad: formas no complicadas pueden manejarse con observación y analgesia, mientras que las complicadas requieren ingreso, soporte hemodinámico y tratamiento específico según el tipo de miocarditis. Se revisan terapias inmunosupresoras para entidades como: miocarditis eosinofílica, sarcoidosis o células gigantes o asociada a inhibidores de puntos de control inmunitario. Para casos con disfunción ventricular, se recomienda seguir las guías de insuficiencia cardíaca y, en algunos casos, valorar el implante de desfibrilador automático implantable (DAI).
Palabras clave
Miocarditis
Miocardiopatía inflamatoria
Resonancia magnética cardíaca
Biopsia endomiocárdica
Abstract
Myocarditis is a heterogeneous condition defined by inflammation of the myocardium. Its etiology includes infectious, immune-mediated, toxic, and genetic causes. The clinical presentation has been recognized to vary and the recommended diagnostic approach starts with a clinical suspicion supported by an ECG, echocardiogram, and myocardial damage biomarkers (such as troponins) followed by cardiac magnetic resonance imaging (CMR) according to the updated Lake Louise criteria. An endomyocardial biopsy (EMB) is essential when a treatable etiology (such as sarcoidosis, eosinophilic myocarditis, giant cell, or immunotherapy) is suspected. The use of positron emission tomography (PET) with fluorodeoxyglucose-18 (FDG-18) may also be considered in cases that are inconclusive following CMR or EMB. Genetic testing may be considered in patients with a family history, recurrences, or persistent ventricular dysfunction with late enhancement on a CMR. Treatment is stratified according to severity: uncomplicated forms can be managed with observation and analgesics while complicated forms require admission, hemodynamic support and specific treatment according to the type of myocarditis. Immunosuppressive therapies for entities such as eosinophilic myocarditis, sarcoidosis, or giant cell or immune checkpoint inhibitor-associated myocarditis are reviewed. For cases with ventricular dysfunction, it is recommended to follow the heart failure guidelines and, in some cases, consider an implantable cardioverter defibrillator (ICD).
Keywords
Myocarditis
Inflammatory cardiomyopathy
Cardiac magnetic resonance imaging
Endomyocardial biopsy
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