Combination of chronic myocarditis and progressive coronary artery disease: differential diagnosis and stepwise treatment

Aim. To assess the differential diagnosis in a patient with a combination of coronary artery disease and myocarditis and the results of stepwise treatment (including immunosuppressive therapy (IST), and coronary stenting).
Material and methods. A 56-year-old female patient with hypertension, obesity (body mass index, 31,6 kg/m²), diabetes and psoriasis developed shortness of breath after a respiratory viral infection. Primary echocardiography revealed left heart dilatation, ejection fraction (EF) of 21%. Coronary angiography revealed anterior descending artery stenosis of 75%, circumflex artery — 80%, right coronary artery (RCA) — 70%. RCA stenting was performed and cardiovascular and diuretic therapy was started. However, shortness of breath and low exercise tolerance persisted.

Results. In the blood test, anti-endothelial cell antibodies were 1:320, anticardiomyocyte and anti-smooth muscle antibodies — 1:80, anti-cardiac conduction system fibers — 1:320 (N≤1:40). During myocardial perfusion scintigraphy with computed tomography, an uneven distribution of the indicator was noted. Signs of myocardial scarring and indications for further revascularization were not revealed. Cardiac magnetic resonance imaging confirmed a decrease in left ventricular (LV) contractility (LVEF 37%) and moderate dilatation. Biopsy was not performed due to dual antiplatelet therapy. The condition is regarded as infectious-immune myocarditis. IST was started with azathioprine 150 mg/day. We noted dyspnea relief and a stable increase in LVEF to 50-52%. The clinical course was complicated by sick sinus syndrome with pauses up to 6 seconds and presyncope; a pacemaker was implanted. After 5 years from the onset of IST, dyspnea episodes reappeared without exacerbation of myocarditis. As their cause, ischemia was diagnosed due to the progression of coronary atherosclerosis. Symptoms regressed after repeated coronary stenting.
Conclusion. The presence of moderate coronary atherosclerosis without signs of ischemia and myocardial infarction should not be considered as the only cause of severe systolic myocardial dysfunction. Diagnosis and treatment of myocarditis in combination with coronary artery disease is carried out according to the standard principles and can improve LV systolic function and control the heart failure symptoms.

1. 2020 Clinical practice guidelines for Stable coronary artery disease. Russian Journal of Cardiology. 2020;25:4076. (In Russ.) doi:10.15829/1560-4071-2020-4076.

2. Paleyev NR, Paleyev FN. Non-coronarogenic myocardial diseases and their classification. Russ J Cardiol. 2009;(3):5-9. (In Russ.)

3. Fujita S, Okamoto R, Takamura T, et al. Fulminant myocarditis in a patient with severe coronary artery disease. J Cardiol Cases. 2013;9(1):15-7. doi:10.1016/j.jccase.2013.08.010.

4. Frustaci A, Chimenti C, Maseri A. Global biventricular dysfunction in patients with asymptomatic coronary artery disease may be caused by myocarditis. Circulation. 1999;99(10):1295-9. doi:10.1161/01.cir.99.10.1295.

5. Nedostup AV, Blagova OV, Kogan EA, et al. Myocardial vasculitis: nosologic unit, clinical picture, diagnostics, treatment. Kardiologija i Cardiovasc Surg. 2011;4(3):85-92. (In Russ.)

6. Blagova OV, Nedostup AV. Contemporary masks of the myocarditis (from clinical signs to diagnosis). Russ J Cardiol. 2014;(5):13-22. (In Russ.) doi:10.15829/1560-4071-2014-5-13-22.

7. Blagova OV, Nedostup AV, Kogan ЕА, et al. Myocardial and pericardial diseases: from syndromes to diagnosis and treatment. Msk.: Geotar-Media, 2019. p. 884. (In Russ.)