Clinical & Experimental Cardiology
Open Access

The Brief Review of Viral Myocarditis and its Treatment

Cai Ying^{* *}Correspondence: Cai Ying, Department of Pulmonary and Critical Care Medicine, Qingyuan Hospital of Guangzhou Medical University, Guangzhou, China, Email:

Author info »

Description

Viral myocarditis lead to arrythmia, Dilated Cardiomyopathy (DCM), left ventricular dysfunction, and heart failure. This paper addresses the brief mechanisms of viral myocarditis and its treatment.

Viral myocarditis lead to arrythmia, dilated cardiomyopathy (DCM), left ventricular dysfunction, and heart failure. Viral myocarditis often occurs after viral respiratory infection. The common viruses in viral myocarditis include Adenoviruses (ADV) and Enteroviruses (EV) (such as coxsackie A viruses or coxsackie B viruses and echoviruses); parvovirus B19 (B19V); Human Herpes Virus 6 (HHV6); Epstein-Barr Virus (EBV) and Human Cytomegalovirus (CMV); Human Immunodeficiency Virus (HIV); Hepatitis C Virus (HCV); influenza A virus and influenza B virus; coronavirus including Middle East Respiratory Syndrome Coronavirus (MERS-CoV); Severe Acute Respiratory Syndrome Coronavirus (SARS-CoV) and SARS-CoV-2 [1,2].

The virus in viral myocarditis lead to direct and indirect cardiac injury. The virus that infects cardiomyocytes induces direct myocardial injury, including cytoskeletal disruption, cardiomyocyte necrosis, cardiomyocyte lysis, apoptosis or autophagy [3]. The loss of cardiomyocytes lead to cardiac dysfunction and dilated cardiomyopathy in the long term. The virus also infects endotheilial cell and cardiac intestial cell, that lead to cardiac dysfuction and arrythmia.

The virus’s indirect injury in viral myocarditis include inflammatory cytokines production and secondary autoimmunity. High levels of cytokines, particularly Tumor Necrosis Factor (TNF), IL-1a, IL-1b, IL-2, and Interferon-Gamma (IFN-γ), together with antibodies to viral and cardiac proteins, can further potentiate cardiac damage and compromise systolic function [2].

Treatment of viral myocarditis include antiviral therapy, supportive therapy, immunosuppressive therapy and immunomodulatory therapy.

Antiviral treatment is effective treatment for viral myocarditis, including Interferon (IFN) and special antiviral treatmemnt. Human interferons are antiviral proteins produced by human cells, especially Type 1 IFN (IFN-α, IFN-β, IFNγ). IFN-β effectively cleared the enterovirus or adenovirus with a resultant improvement in Left Ventricle (LV) function [4]. IFN-β-1b treatment lead to effective virus clearance or reduction in the virus load in patients with chronic viral cardiomyopathy. “IFNβ improve enterovirus-positive myocarditis or adenovirus-positive myocarditis viral clearance and survival” [5,6]. In special antiviral treatment, influenza virus treatment include Amantadine, Rimantadine, Zanamivir and Oseltamivir. CMV treatment include Ganciclovir and its oral prodrug valganciclovir, Foscarnet, Cidofovir and Fomivirsen. Herpes Simplex Virus (HSV) infection treatment include Acyclovir and its oral prodrug valaciclovir, Penciclovir and its oral prodrug famciclovir, Idoxuridine, Trifluridine, and Brivudin [7].

Supportive therapy include coenzyme CQ10, trimetazidine and combination therapy with coenzyme CQ10 and trimetazidine [8,9]. “Creatine phosphate sodium treatment can significantly improve the therapeutic effect of patients with viral myocarditis, and can reduce the levels of cTnI and CK-MB, Compared with conventional treatment” [10]. Targeting TRIM29-PERK axis could mitigate viral myocarditis severity [11]. Exercise and meditation is helpful for recovering heart function.

Conclusion

Early diagnosis and treatment viral myocarditis are important to prevent life-threatening, long-term complications and virus persistence of viral myocarditis. Virus vaccine may be effective in prevent viral respiratory infection and viral mycarditis. Some Inflammation cytokines inhibitor may be effective on viral myocarditis in the future.

References

1. Dennert R, Crijns HJ, Heymans S. Acute viral myocarditis. Eur Heart J. 2008;29(17):2073-2082.

   [Crossref] [Google Scholar] [PubMed]

2. Pollack A, Kontorovich AR, Fuster V, Dec GW. Viral myocarditis-diagnosis, treatment options, and current controversies. Nat Rev Cardiol. 2015;12(11):670-680.

   [Crossref] [Google Scholar] [PubMed]

3. Yajima T. Viral myocarditis: Potential defense mechanisms within the cardiomyocyte against virus infection. Future microbiol. 2011;6(5):551-566.

   [Crossref] [Google Scholar] [PubMed]

4. Kuhl U, Pauschinger M, Schwimmbeck PL, Seeberg B, Lober C, Noutsias M, et al. Interferon-β treatment eliminates cardiotropic viruses and improves left ventricular function in patients with myocardial persistence of viral genomes and left ventricular dysfunction. Circulation. 2003;107(22):2793-2798.

   [Crossref] [Google Scholar] [PubMed]

5. Schultheiss HP, Piper C, Sowade O, Waagstein F, Kapp JF, Wegscheider K, et al. Betaferon in Chronic Viral Cardiomyopathy (BICC) trial: Effects of interferon-β treatment in patients with chronic viral cardiomyopathy. Clin Res Cardiol. 2016;105:763-773.

   [Crossref] [Google Scholar] [PubMed]

6. Kühl U, Lassner D, von Schlippenbach J, Poller W, Schultheiss HP. Interferon-Beta improves survival in enterovirus-associated cardiomyopathy. J Am Coll Cardiol. 2012;60(14):1295-1296.

   [Crossref] [Google Scholar] [PubMed]

7. Clercq ED. Antivirals and antiviral strategies. Nat Rev Microbiol. 2004;2(9):704-720.

   [Crossref] [Google Scholar] [PubMed]

8. Shao L, Ma A, Figtree G, Zhang P. Combination therapy with coenzyme Q10 and trimetazidine in patients with acute viral myocarditis. J Cardiovasc Pharmacol. 2016;68(2):150-154.

   [Crossref] [Google Scholar] [PubMed]

9. Zeng M, Chen Z, Zhang Y, Pang Y. Combination of trimetazidine and coenzyme Q10 for the treatment of acute viral myocarditis: A systematic review and meta-analysis. J Infect Dev Ctries. 2024;18(05):658-665.

   [Crossref] [Google Scholar] [PubMed]

10. Wang L, Chen SF, Huang XW, Wu ZY, Zhang QM. Efficacy and safety of creatine phosphate sodium in the treatment of viral myocarditis: A systematic review and meta-analysis. PLoS One. 2025;20(1):317498. 

    [Crossref] [Google Scholar] [PubMed]

11. Wang J, Lu W, Zhang J, Du Y, Fang M, Zhang A, et al. Loss of TRIM29 mitigates viral myocarditis by attenuating PERK-driven ER stress response in male mice. Nat commun. 2024;15(1):3481.

    [Crossref] [Google Scholar] [PubMed]