Chapter 1242: [1242] She stands by whom
Even myocarditis caused by infections isn’t limited to viral infections—fungi, parasites, and bacteria can all infect the myocardium. However, viral myocarditis is the most common clinical presentation, leading to the older doctors coining the term "viral myocarditis" as a standard catchphrase.
When clinicians discuss myocarditis, the conversation almost always revolves around viral myocarditis because nine out of ten patients have a viral infection.
Like myocarditis, dilated cardiomyopathy can be caused by immune factors or viral infections. Specifically, enteroviruses and cytomegaloviruses detected via myocardial biopsy have been proven to have a direct association with dilated cardiomyopathy. Interestingly enough, these same viruses are also implicated in myocarditis.
This is the crux of the debate between Li Chengyuan and Doctor Dong. Admittedly, it has not yet been definitively established whether the infection triggers both diseases simultaneously or if one disease develops first and subsequently leads to the other.
What’s the significance of this debate? It lies in the issue Xie Wanying raised earlier regarding subclinical myocarditis. The inability of clinicians to detect and diagnose it in time ultimately results in heart failure and patient death.
Li Chengyuan dismissed her argument, asserting that the patient never had subclinical myocarditis to begin with. In his view, the patient originally suffered from dilated cardiomyopathy, which explains why it went undetected clinically. The early symptoms of dilated cardiomyopathy can be more concealed, with a slow onset, and the course of the disease leading to severe symptoms can extend for over a decade.
Doctor Dong, on the other hand, leaned toward agreeing with Xie Wanying. He believed that as long as there was viral myocardial infection, there should be a progression from myocarditis to dilated cardiomyopathy. His reasoning came from seeing many such cases in his clinical practice.
This is where the difference between an internal medicine specialist and a surgeon arises. Myocarditis patients typically don’t go to cardiothoracic surgery but first to cardiovascular medicine for drug therapy. Only when the patient experiences full-fledged heart failure and heart transplantation is considered do they get referred to surgery. Surgeons focus solely on anatomical outcomes—myocarditis involves deformation and necrosis of myocardial cells, while dilated cardiomyopathy is characterized by ventricular enlargement. How could they be the same?
"Persistent myocarditis can lead to myocardial remodeling," Xie Wanying remarked.
"Indeed. She’s absolutely right," Doctor Dong clapped his hands in support of her statement.
Li Chengyuan did not back down. "What you’re saying cannot be used to definitively prove that dilated cardiomyopathy arises from persistent myocarditis. It’s entirely possible that the two conditions occur simultaneously."
Hearing these words, Xie Wanying suddenly thought of something and fell silent.
Huang Zhilei and Xin Yanjun whispered to one another, "What exactly are the two of them arguing about? Isn’t the suspicion right now supposed to be myocarditis?"
Elevated troponin levels indicate myocardial damage and serve as one of the key auxiliary indicators in the diagnostic workup of myocarditis. It has clinical value. To definitively diagnose myocarditis, the patient must exhibit clinical symptoms associated with the condition, such as chest pain, chest tightness, breathlessness, heart failure, palpitations, etc. If the patient shows no obvious symptoms, further tests are required to confirm whether it is myocarditis. Therefore, at this initial stage, the doctors are still considering myocarditis as a potential diagnosis. The next step should involve conducting an electrocardiogram and echocardiogram promptly.
If you’re asking about the gold standard for diagnosing myocarditis, it would undoubtedly be an endomyocardial biopsy.
Since Xie Wanying detected a possible ventricular enlargement during auscultation, and at Li Chengyuan’s suggestion, the differential diagnosis now includes dilated cardiomyopathy.