A five-year follow-up of a patient with fulminant myocarditis who underwent a stepwise and goal-oriented individualized comprehensive cardiac rehabilitation program

Abstract

A 39-year-old man developed fulminant myocarditis and was transferred on mechanical ventilation and a ventricular-assist device to our hospital. On Hospital Day 10, he was weaned from all medical engineering devices, and bedside rehabilitation was initiated. Although a multidisciplinary cardiac rehabilitation team had intervened since Hospital Day 3, he could not be encouraged to begin ambulation because of hypotension and tachycardia. Moreover, he complained of loss of self-confidence and anxiety regarding physical strength, and expansion of activities was difficult. Exercises reflecting his immediate desires and daily activities were used as activity goals, and we developed an individualized exercise program with stepwise increase in load to motivate him to perform rehabilitation. At the time of discharge, his cardiac function recovered to nearly normal levels; however, muscle strength and respiratory function had not recovered. While the intervention was continued at the cardiac rehabilitation outpatient unit, improvement was observed in physical health and mental health-related scale scores. The patient returned to work 4 months after onset of his myocarditis. Moreover, the cardiac rehabilitation team provided support to him for his long-term overseas assignment in the fifth year after myocarditis onset. Long-term comprehensive support by the cardiac rehabilitation team was feasible and useful.

<Learning objective: Comprehensive intervention by a cardiac rehabilitation team from the acute phase may be helpful for motivating patients not only to participate in rehabilitation during hospitalization, but also to continue it on an outpatient basis after discharge. Moreover, continuous outpatient intervention can lead to recovery of physical/mental function in patients that is not achievable with only inpatient intervention, and support can be provided to patients for setting new life goals.>

Introduction

In many cases, acute myocarditis is a reversible impairment of cardiac function associated with inflammation [1]. In fulminant myocarditis which leads to cardiopulmonary emergency early after onset, recovery of cardiac function can be expected, if a medical emergency can be avoided. However, follow-up monitoring is required even after the acute phase, due to concerns over transition to chronic cardiac failure and arrhythmia [2]. Healthcare professionals may not be providing precise instructions, as there are few long-term follow-up and treatment guidelines that can be used as instructions for patients who have overcome transient cardiopulmonary emergency in the acute phase and achieved recovery of cardiac function. We herein report a 5-year follow-up of a patient with fulminant myocarditis who regained normal cardiac function but continued participating in a comprehensive cardiac rehabilitation program; the program used stepwise activity indices incorporated with his desires during hospitalization and on outpatient basis after discharge due to decreased physical ability and anxiety regarding disease recurrence. The rehabilitation program allowed him to return to satisfactory social life.

Case report

The patient was a 39-year-old male journalist. He had experienced cold-like symptoms. He visited a general hospital, and abnormal heart sounds were detected on examination. Immediately after he started noticing chest pain, and lost consciousness. After he was placed on mechanical ventilation with intratracheal intubation and hemodynamic assistance using percutaneous cardiopulmonary support, he was transferred to our hospital. On arrival, his vital signs included a blood pressure of 70/55 mmHg and heart rate of 98 beats/min. The electrocardiogram showed non-sustained ventricular tachycardia. Cardiac ultrasonography revealed decreased circumferential wall motion. Fulminant myocarditis was diagnosed, and treatments to maintain cerebral and cardiopulmonary function were immediately initiated (Fig. 1). The cardiac rehabilitation team started intervention on Hospital Day 3. While the use of medical engineering devices was required, the intervention mainly consisted of physical therapies, such as respiratory rehabilitation and prevention of contracture. His cardiac function recovered smoothly. The patient was allowed to perform activities, such as indoor walking with assistance and getting into a wheelchair on Hospital Day 10. However, because malaise was caused by slight exercise (due to hypotension and tachycardia), we were unable to encourage him to begin ambulation. The patient himself started complaining of loss of self-confidence and anxiety regarding physical strength, and his rehabilitation stagnated. Thus, before he became able to walk independently in the ward, exercise therapy under the supervision of a doctor in the rehabilitation room was adopted, and various programs were started. Moreover, in consideration of the patient's desires, familiar activities that were achievable were set as goals, and he was started on a rehabilitation program with exercises incorporating familiar and desired activities, such as “walking alone to a restroom” and “walking to an in-hospital store to buy a newspaper.” In addition to a goal of simply expanding the range of activities, actions naturally performed in daily life, such as “holding an infant daughter,” were regarded as exercises. We proposed a program aimed at regaining the ability to perform such actions. Furthermore, walking exercise was performed with targeted distance and speed of walking that were set on the assumption that he would walk in the nearby shopping mall. Attention was paid to provide exercise programs that would help him imagine life after discharge. As described above, the rehabilitation program was carried out with incremental goals (Table 1). At the time of discharge, his cardiac function had recovered to nearly normal levels; however, muscle strength and the respiratory function had not fully recovered (Fig. 2). After discharge, intervention was continued at the cardiac rehabilitation outpatient unit. Three months after hospital discharge, cardiac rehabilitation was performed at his weekly visits. Later, he returned to the hospital once a month for therapy and then guided exercise therapy was carried out at home. The guided therapy content was reviewed every 3 months as he recovered. As his upper and lower limb muscle strength and respiratory function gradually improved, his exercise tolerance also improved. Two component summary scores of the Medical Outcomes Study 36-Item Short Form Survey (SF-36) [3] showed that the Mental Component Summary (MCS) score increased along with the Physical Component Summary (PCS) score. The patient returned to work 4 months after myocarditis onset, and oral administration of angiotensin-converting enzyme inhibitors that had been continued since hospitalization was discontinued at 1 year after onset. We provided comprehensive support consisting of cardiac function test performed every 6 months and exercises to regain the ability to perform activities he desired. The intensity of exercise which he performed in his home exercise program was led by the optimum loading amount and we put a subjective symptom into effect as an index based on the results of a cardiopulmonary exercise testing. At present, 5 years after onset, he consulted us as to whether he could work in an overseas position. After reconfirming that his current cardiopulmonary function was within the normal range and that no post-hospitalization arrhythmia had occurred, we permitted him to accept an overseas assignment. In preparation for sudden changes in medical conditions, we informed him of a core hospital in the vicinity of the new job and prepared a patient referral document.

Fig. 1.

Activity performance and course of treatment. CR, cardiac rehabilitation; ECUM, extracorporeal ultrafiltration method; IABP, intra-aortic balloon pumping; PCPS, percutaneous cardiopulmonary support.

Table 1.

Time elapsed and patient hope.

Hospital days	Activity performance	Patient hope	Disincentive	Special program
10th	Only on bed	Go to the toilet on his own	Tachycardia Hypotension Muscle weakness	Low-load resistance training Compression stockings
30th	Hospital free	Go to the bookstore in hospital	Muscle weakness	Low-load resistance training
40th	Ambulatory in hospital	Hold his little daughter	Muscle weakness	Carry sandbag weights the same as the weight of his daughter
450th	Social life	Challenge half marathon	Improvement of cardiopulmonary function	Aerobic exercise Strength training
1460th	Social life	Working abroad	Understanding of foreign medical system	Request for emergency response and provide information to local medical institutions

Fig. 2.

Exercise tolerance and SF-36 scores. At the time of discharge, cardiac function (despite improved exercise tolerance) was not improved. With outpatient cardiac rehabilitation intervention, exercise tolerance and SF-36 scores increased. In addition, cardiac rehabilitation brought good results in respiratory function. SF-36, Medical Outcomes Study 36-Item Short Form Survey; PI, pulmonary intake pressure; PE, pulmonary expiratory pressure; NT-ProBNP, N-terminal pro-brain natriuretic peptide; HRrest, heart rate at rest; ΔHRexercise, heart rate change during exercise; RRrest, respiratory rate at rest; ΔRRexercise, respiratory rate change during exercise; VO₂max, maximal oxygen uptake.

Discussion

The guidelines issued by the Japanese Circulation Society recommend that cardiac rehabilitation intervention should be undertaken in the acute phase when intensive care is necessary for the treatment of acute cardiac failure [4]. At our hospital, a multidisciplinary cardiac rehabilitation team starts intervention in the acute phase. As in the case of fulminant myocarditis, among those patients who inevitably fall into temporary unconsciousness due to sudden disease progression, there are some who complain of anxiety or confusion because of the differences in physical ability between before onset and after the return to consciousness 5, 6. In the present case, there was a period when the patient facing rapidly impaired physical function complained of anxiety over exercises, despite a tendency toward recovery of cardiac function. In order to help him build a sense of accomplishment and gain motivation and confidence in recovery of physical function, we proposed a program in which, as long as his disease state permitted, activities desired by him were incorporated into exercises considered feasible during his hospital stay. Moreover, rather than setting excessive targets that required much time to accomplish, accumulation of accomplishment of small targets brought greater satisfaction [7]. Although the goals of the special program were familiar activities, an innovation of stepwise increases in load kept him motivated to participate in rehabilitation. One of the reasons why such a program could be executed may be that consistent intervention by the cardiac rehabilitation team from the acute phase allowed early detection of problems with the patient.

When patients participating in cardiac rehabilitation during hospitalization need to continue to do so on an outpatient basis, motivation for rehabilitation is considered important [8]. In the present case, although cardiac function already recovered to nearly normal levels at the time of discharge, physical function did not sufficiently recover. In the patients whose cardiac function was reduced, the increments of cardiac output and skeletal muscle perfusion were markedly limited. As a result, exercise tolerance was diminished in the patients who had limited cardiac function [9]. Both the MCS and PCS scores of the SF-36 were low and did not reach the standard values in terms of physical and mental aspects. Although patient pathological conditions are understood from physical findings and physiological test results obtained in general outpatient examination in cardiovascular medicine, improved test results are not always associated with improved patient physical ability. Patients admitted to hospital for cardiac disease are discharged after recovery from the disease; however, their physical ability does not always recover sufficiently by the time of discharge. Cardiac rehabilitation is a field in which feasible physical activities are proposed based on the patient's pathological conditions, and support is provided for executing the activities [10]. Diminished exercise tolerance in cardiac disease patients brought on the reduction of abilities for activity. In patients with reduced cardiac function, the low scores of MCS and PCS improved in parallel to the incremental improvement in ability for activity [9]. In the present case, continuous participation in cardiac rehabilitation after discharge contributed to improvement in not only upper and lower limb muscle strength, but also in respiratory function, while the PCS and MCS scores also increased. It is highly likely that continuous intervention by the cardiac rehabilitation team from the acute phase might have been helpful for motivating the patient to participate in outpatient cardiac rehabilitation and achieving recovery of physical function which could not have been achieved by only inpatient rehabilitation.

Based on the present case, we consider that stepwise programs to accomplish familiar goals with gradually incremented load are effective. This program is effective especially in patients with discrepancies between their real and imagined physical abilities caused by sudden disease progression.

Conflict of interest

There is no conflict of interest to be declared in this case report.