Unexpected Cardiac MRI Findings in Patients Presenting to the Emergency Department for Possible Acute Coronary Syndrome

BACKGROUND

Stress cardiac magnetic resonance imaging (CMR) has become increasingly used in patients presenting to the emergency department (ED) with symptoms concerning for acute coronary syndrome (ACS). We hypothesized that CMR detects a number of alternative diagnoses (diagnoses other than ACS that could explain symptoms) and incidental findings in patients presenting to the ED for potential ACS.

METHODS

We prospectively enrolled adult patients who presented to an academic ED from 2011 to 2015 for possible ACS and subsequently had an adenosine stress perfusion CMR as part of their diagnostic evaluation. All medical charts were reviewed to verify accurate prospective data collection and to collect follow-up data.

RESULTS

A total of 391 patients were included. On stress CMR, abnormalities attributable to coronary artery disease (CAD) were found in 106 (27.1%) of patients. Previously undiagnosed moderate to severe valvular disease was the most common non-CAD cardiac finding, occurring in 20 (5.1%) cases. Other alternative diagnoses were rare with 7 cases of cardiomyopathy, 1 case of aortic aneurysm, 1 case of aortic dissection, 1 case of acute myocarditis, 3 cases of pericarditis, and 2 cases of moderate pleural effusion. Cardiac incidental findings were rare. Extracardiac incidental findings were found in 79 patients (20.2%). Only 18.6% of the patients recommended for follow-up imaging had this completed within 1 year after CMR.

CONCLUSIONS

This experience suggests that stress CMR is useful in not only diagnosing symptomatic CAD but also potentially important non-CAD-related disease. These factors may impact their use in ED-based ACS workups.

[Update on myocarditis]

Myocarditis is an illness characterized by myocardial infiltration with inflammatory cells and non-ischemic myocytic necrosis. The clinical presentation of myocarditis varies widely and diagnosis is sometimes difficult to establish. The current incidence of myocarditis is also difficult to determine as endomyocardial biopsy, the diagnostic gold standard, is unfrequently used, or even not justified. The leading causes are infections, immune-mediated injury and toxins. Prognosis is most often good but, in some patients, the disease can be fulminant with progression to cardiogenic shock, or occurrence of sudden cardiac death. Prognosis in myocarditis patients varies according to the underlying aetiology. Treatment is generally symptomatic, but in some cases, a specific therapy is appropriated as a function of the corresponding aetiology. This paper aims to review current knowledge concerning myocarditis, with particular emphasis on «urgent» situations.

Predictors of acute myocarditis in complicated scrub typhus: an endemic province in the Republic of Korea

BACKGROUND/AIMS

Scrub typhus is known as a self-limited infectious disease. Cardiac complication is uncommon and usually not life-threatening. Until now, few cases of fulminant myocarditis by scrub typhus have been reported. So, we investigated incidence and predictors of acute myocarditis in severe scrub typhus.

METHODS

We retrospectively reviewed 89 patients among 91 scrub typhus confirmed patients who examined an echocardiogram and cardiac biomarkers from 2005 to 2015 in the intensive care unit at our hospital. We excluded two patients who didn't have electrocardiography. Patients were divided into two groups and compared between scrub typhus with (n = 13) and without (n = 76) acute myocarditis.

RESULTS

Age, sex, and underlying diseases were similar between the groups. The existence of eschar and duration of general ache and fever were similar between the groups. However, patients with acute myocarditis had more elevated total bilirubin, high incidence of ST elevations and paroxysmal atrial fibrillation (PAF) than those without acute myocarditis. Receiver operating characteristic analysis showed that the PAF was a predictor of myocarditis with a sensitivity of 70% and specificity of 84%. Predictive power of combination of ST-segment elevation and PAF was significantly associated with myocarditis in the multivariate analysis (odds ratio, 1.57; 95% confidence interval [CI], 1.21 to 11.7; p = 0.041) and area under the curve was 0.947 (95% CI, 0.878 to 0.983; p < 0.001).

CONCLUSIONS

Acute myocarditis with scrub typhus may be more common than previously reported. Patients with high bilirubin and PAF are at increased risk of acute myocarditis with scrub typhus. These patients warrant closer follow-up and echocardiogram would be needed.

Eosinophilic Myocarditis: Characteristics, Treatment, and Outcomes

BACKGROUND

Eosinophilic myocarditis (EM) is an acute life-threatening inflammatory disease of the heart. Neither large case series nor clinical trials on this specific myocarditis have been reported.

OBJECTIVES

Based on a systematic revision of all published histologically proven cases, this study aimed to describe the clinical presentation, treatment, and outcome of EM.

METHODS

The study screened 443 manuscripts in MEDLINE and EMBASE on cases of EM published until June 2017. The authors identified 264 patients and included in the main analysis 179 patients admitted to hospital with histologically proven EM.

RESULTS

Median age was 41 years (interquartile range: 27 to 53 years) with similar prevalence in both sexes; pediatric cases (≤16 years of age) accounted for 10.1%. The main symptom at presentation was dyspnea (59.4%), with peripheral eosinophilia observed in 75.9%. Median left ventricular ejection fraction at presentation was 35% (interquartile range: 25% to 50%). The disorders most frequently associated with EM were hypersensitivity and eosinophilic granulomatosis with polyangiitis, which accounted for 34.1% and 12.8% of cases, respectively, whereas idiopathic or undefined forms accounted for 35.7% of cases. Steroids were administered in 77.7% of patients. A temporary mechanical circulatory support (n = 30) was instituted in 16.8% of patients. In-hospital death was 22.3% (n = 40), with the highest occurrence in the hypersensitivity form (36.1%; p = 0.026).

CONCLUSIONS

EM has a poor prognosis during the acute phase, despite a publication bias that could have led to an overestimation of mortality. Associated conditions are identified in approximately 65% of cases. Specific trials and multicenter registries are needed to provide evidence-based treatments to improve in-hospital outcome.

Viral co-infections in farmed Atlantic salmon, Salmo salar L., displaying myocarditis

Several different viruses have been associated with myocarditis-related diseases in the Atlantic salmon aquaculture industry. In this study, we investigated the presence of PMCV, SAV, PRV and the recently identified Atlantic salmon calicivirus (ASCV), alone and as co-infections in farmed Atlantic salmon displaying myocarditis. The analyses were performed at the individual level and comprised qPCR and histopathological examination of 397 salmon from 25 farms along the Norwegian coast. The samples were collected in 2009 and 2010, 5-22 months post-sea transfer. The study documented multiple causes of myocarditis and revealed co-infections including individual fish infected with all four viruses. There was an overall correlation between lesions characteristic of CMS and PD and the presence of PMCV and SAV, respectively. Although PRV was ubiquitously present, high viral loads were with a few exceptions, correlated with lesions characteristic of HSMI. ASCV did not seem to have any impact on myocardial infection by PMCV, SAV or PRV. qPCR indicated a negative correlation between PMCV and SAV viral loads. Co-infections result in mixed and atypical pathological changes which pose a challenge for disease diagnostic work.

The Quest for New Approaches in Myocarditis and Inflammatory Cardiomyopathy

Myocarditis is a diverse group of heart-specific immune processes classified by clinical and histopathological manifestations. Up to 40% of dilated cardiomyopathy is associated with inflammation or viral infection. Recent experimental studies revealed complex regulatory roles for several microribonucleic acids and T-cell and macrophage subtypes. Although the prevalence of myocarditis remained stable between 1990 and 2013 at about 22 per 100,000 people, overall mortality from cardiomyopathy and myocarditis has decreased since 2005. The diagnostic and prognostic value of cardiac magnetic resonance has increased with new, higher-sensitivity sequences. Positron emission tomography has emerged as a useful tool for diagnosis of cardiac sarcoidosis. The sensitivity of endomyocardial biopsy may be increased, especially in suspected sarcoidosis, by the use of electrogram guidance to target regions of abnormal signal. Investigational treatments on the basis of mechanistic advances are entering clinical trials. Revised management recommendations regarding athletic participation after acute myocarditis have heightened the importance of early diagnosis.

Outcomes and predictors of recovery in acute-onset cardiomyopathy: A single-center experience of patients undergoing endomyocardial biopsy for new heart failure

BACKGROUND

About one-third of patients with unexplained acute-onset heart failure (HF) recover left ventricular (LV) function; however, characterization of these patients in the setting of contemporary HF therapies is limited. We aim to describe baseline characteristics and predictors of recovery in patients with acute-onset cardiomyopathy.

METHODS

We previously described 851 patients with unexplained HF undergoing endomyocardial biopsy. In this study, 235 patients with acute-onset HF were further retrospectively examined.

RESULTS

Follow-up LV ejection fraction (LVEF) was available for 138 patients. At 1 year, 48 of 138 (33%) had LVEF recovery (follow-up LVEF ≥50%), and 90 of 138 (65%) had incomplete or lack of recovery. Higher cardiac index (P=.019), smaller LV diastolic diameter (P=.002), and lack of an intraventricular conduction delay (IVCD) (P=.002) were associated with LVEF recovery. IVCD (P=.001) and myocarditis (P=.016) were independent predictors of the composite end point of death, LV assist device placement, and/or transplant at 1 year. Those with an IVCD had a significantly lower 1-year survival than those without (P=.007).

CONCLUSIONS

Patients with a smaller LV end-diastolic diameter, higher cardiac index, and lack of IVCD at presentation for acute-onset HF were more likely to have LVEF recovery. IVCD was a poor prognostic marker in all patients presenting with acute cardiomyopathy.

Characterization of the Myocarditis during the worst outbreak of dengue infection in China

Myocarditis is a common complication of severe dengue infection. However, data about prevalence and characterization of myocarditis in dengue are still lacking. In 2014, the worst outbreak of dengue in the last two decades in China occurred. In this study, we described the clinical and laboratory diagnostic features of dengue with myocarditis. Totally, 1782 diagnosed dengue patients were admitted from August to October, 2014, all of whom were subjected to electrocardiogram, ultrasound cardiogram, and cardiac enzyme test. About 201 cases of dengue patients were diagnosed with myocarditis and the prevalence of myocarditis in hospitalized dengue was 11.28%. The prevalence of myocarditis in nonsevere dengue with warning signs and severe dengue [NSD(WS+)/SD] and nonsevere dengue without warning signs [NSD(WS-)] was 46.66% and 9.72%, respectively. The NSD(WS+)/SD patients with myocarditis presented with higher incidence of cardiac symptoms, supraventricular tachycardia (14.29% vs. 0%, P < 0.001), atrial fibrillation (25.71% vs. 10.24%, P = 0.019) and heart failure compared with NSD (WS-) patients with myocarditis. About 150 cases of dengue patients without myocarditis in the same period of time in department of Cardiology were recruited as control group. The proportion of NSD(WS+)/SD in dengue patients with and without myocarditis was 17.41% and 2.53%, respectively. Dengue patients with myocarditis experienced longer hospital stay than those without myocarditis (7.17 ± 4.64 vs. 5.98 ± 2.69, P = 0.008). There was no difference between patients with and without myocarditis in the proportion of symptoms, auxiliary methods abnormality, arrhythmia, and heart failure on the discharge day. Our study demonstrates the prevalence of myocarditis in worst outbreak of dengue in China was 11.28% and the incidence of myocarditis increased with the severity of dengue. The NSD(WS+)/SD patients with myocarditis presented with higher incidence of cardiac complication compared with NSD (WS-) patients with myocarditis. The prognosis of dengue patients with and without myocarditis had no significant difference even if myocarditis patients experienced longer hospital stay.

Prognostic value of the infarct- and non-infarct like patterns and cardiovascular magnetic resonance parameters on long-term outcome of patients after acute myocarditis

BACKGROUND

Prognostic value of the infarct- and non-infarct like patterns and cardiac magnetic resonance (CMR) parameters on long-term outcome of patients after acute myocarditis is not well known.

METHODS

Between 2006 and 2015, 112 consecutive patients with CMR-based diagnosis of acute myocarditis were identified in our institution. Of them, 88 were available for clinical follow-up and represented our studied population. Patients were divided into infarct-like group (n=48) (association of acute chest pain, elevated Troponin levels and ST-elevation) and non-infarct-like group (n=40) with any other presentation. The composite primary endpoint of major cardiovascular events (MACE) included: all-cause mortality, cardiac mortality, recurrence of myocarditis, heart failure, and sustained ventricular tachycardia.

RESULTS

During follow-up, 21 patients (24%) experienced MACE and infarct-like patients were significantly more at risk for MACE than non-infarct-like patients (HR 2.4, 95% CI [1.01-5.80] p=0.04). Infarct-like patients exhibited in particular a higher risk of sustained ventricular tachycardia and recurrence of myocarditis (p=0.03). They had lower CMR-derived left (p=0.03) and right (p=0.001) ventricular ejection fractions, and exhibited larger areas of late gadolinium enhancement (LGE) (p=0.001). In multivariate analysis, both initial NYHA functional class >II and LGE mass were independent predictors for long-term MACE occurrence (HR 5.8 and 1.07 per gram respectively, p=0.007). Moreover, a threshold of LGE mass >17g provided a high discrimination for MACE occurrence (AUC of 0.81).

CONCLUSIONS

The infarct-like pattern of acute myocarditis is associated with MACE occurrence. Initial NYHA functional class >II and LGE are independent predictive factors of MACE during long-term follow-up after acute myocarditis.

Acute rheumatic fever: a single center experience with 193 clinical cases

BACKGROUND

Acute rheumatic fever is an inflammatory disease that develops via an auto-immune mechanism following group A beta hemolytic streptococcal tonsillopharyngitis. The aim of this study was to describe the clinical presentation of and cardiac involvement in acute rheumatic fever.

METHODS

The medical records of acute rheumatic fever patients admitted to the Pediatric Cardiology Unit between January 2001 and January 2013 were reviewed. The patients were divided into two groups: 53 patients admitted during January 2001-January 2007 were designated as group 1, and 140 patients admitted during January 2007-January 2013 were designated as group 2.

RESULTS

A total of 193 patients were evaluated, including 53 in group 1 and 140 in group 2. There was no statistically significant difference in age, gender and latent period between the two groups. There was, however, a statistically significant difference between the annual number of cases (P=0.001). Moreover, 35 (66%) patients in group 1 and 89 (64%) patients in group 2 were admitted during the spring or winter. The most common finding, as the major criteria in the current study, was concurrent carditis and arthritis. The most common minor finding was the presence of increased acute-phase reactants. We noted a statistically significant difference between the two groups in terms of valvular involvement. Group 2 had significantly higher frequencies of isolated aortic and mitral regurgitation than group 1, but the composite frequency of these was lower.

CONCLUSIONS

Acute rheumatic fever continues to be prevalent in Turkey despite the country's socioeconomic improvements. We conclude that echocardiography should be performed on all of the patients with suspected acute rheumatic fever because it markedly increases the detection of carditis.

CHANGING CLINICAL PROFILE OF ACUTE RHEUMATIC FEVER AND RHEUMATIC RECURRENCE

BACKGROUND

Clinical profile of acute rheumatic fever and rheumatic recurrence seems to have changed in countries where rheumatic fever is still endemic. The objectives of this study were to compare clinical profile and outcome of patients suffering initial and recurrent episodes of acute rheumatic fever in children.

METHODS

This prospective study was conducted in two tertiary care hospitals from January to June 2011. The diagnosis was based on the modified Jones criteria. Sixty children were included in the study, 15 having first episode of rheumatic fever and 45 with rheumatic recurrence. The severity of carditis was assessed by Clinical and echocardiography means:

RESULTS

Carditis was the commonest presentation in both first (80%) and recurrent attacks (100%). Arthritis was seen in 60% of children with first episode and in 26.7% with recurrence. The frequency of subcutaneous nodules, invariably associated with carditis, was very high (33.3% in the first and 48.3% in recurrent episodes). Carditis was generally mild during first episode (53.3%) and severe with rheumatic recurrence (55.6%). There was no death in either group. One patient with severe mitral regurgitation and rheumatic recurrence underwent mitral valve repair for intractable heart failure.

CONCLUSION

Clinical profile of rheumatic recurrence and acute rheumatic fever has changed. Rheumatic recurrence is associated with severe carditis. Carditis is more common than arthritis even in the first attack. Sub-cutaneous nodules are a frequent finding invariably associated with carditis.

[THE PREVALENCE OF SUBCLINICAL MYOCARDITIS AMONG YOUNG CHILDREN WITH ACUTE VIRAL INFECTION]

BACKGROUND

Viruses are the most prevalent ausative agents of myocarditis in young children. Studies have shown acute myocarditis in post mortem examinations during viral disease outbreaks. The aims of this study are to assess the prevalence of and risk factors for subclinical acute myocarditis in young children hospitalized with an acute viral disease.

OBJECTIVES

Evaluation of the prevalence of asymptomatic myocarditis or decrease in heart functions during viral infection.

METHODS

A prospective study was conducted between 1st January and 30th September, 2009. The study included 45 children 3-60 months old hospitalized with febrile illness with no clinical or microbiological evidence of acute bacterial infection. Serum levels of troponin were obtained, and ECG and echocardiography were performed in all the children. Parameters that determined myocarditis included: (1) ECG ST-T changes suggestive of myocarditis; (2) Increased serum troponin level; (3) Echocardiography findings including: shortening fraction less than 28%, left ventricle end diastolic diameter > than 2 standard deviations for age, abnormal mitral valve incompetence, or abnormal diastolic function. Clinical and epidemiological data were analyzed in order to determine parameters related to findings suggestive of silent acute myocarditis.

RESULTS

In 16 (35%) children at least one parameter, and in 7 (16%) at least 2 parameters of acute myocarditis were found. Impaired diastolic function was found in 11 cases (69%), ECG changes in 5 children (35%, left ventricle dilatation in 4 (25%), and decreased shortening fraction in 3 cases (18%]. Other symptoms and signs of myocarditis were not found in any of the 16 children, and no clinical or epidemiological parameter was significantly associated with silent myocarditis.

CONCLUSIONS

In a third of the patients, some evidence of myocardial dysfunction was documented. In seven of them (16% of all cases), there were two different categories of myocardial dysfunction. Those cases are suspected to be silent acute myocarditis. No clinical and epidemiological parameters associated with the disease were found. The clinical importance of this phenomenon should be determined by a long-term follow-up study.

SUMMARY

In this preliminary study, we found a high prevalence of cardiac involvement in hospitalised children with viral infections. It seems that this cardiac involvement is due to acute sub-clinical myocarditis. The importance of these findings should be evaluated.

Myocarditis in Patients With Antisynthetase Syndrome: Prevalence, Presentation, and Outcomes

Antisynthetase syndrome (aSS) corresponds to an overlapping inflammatory myopathy identified by various myositis-specific autoantibodies (directed against tRNA-synthetases). Myocardial involvement in this condition is poorly described.From a registry of 352 aSS patients, 12 cases of myocarditis were retrospectively identified on the basis of an unexplained increase in troponin T/I levels associated with either suggestive cardiac magnetic resonance imaging (MRI) findings, nonsignificant coronary artery abnormalities or positive endomyocardial biopsy.The prevalence of myocarditis in aSS is 3.4% and was not linked to any autoantibody specificity: anti-Jo1 (n = 8), anti-PL7 (n = 3), and anti-PL12 (n = 1). Myocarditis was a part of the first aSS manifestations in 42% of the cases and was asymptomatic (n = 2) or revealed by an acute (n = 4) or a subacute (n = 6) cardiac failure. It should be noted that myocarditis was always associated with an active myositis. When performed (n = 11), cardiac MRI revealed a late hypersignal in the T1-images in 73% of the cases (n = 8). Half of the patients required intensive care. Ten patients (83%) received dedicated cardiotropic drugs. Steroids and at least 1 immunosuppressive drug were given in all cases. After a median follow-up of 11 months (range 0-84) 9 (75%) patients recovered whereas 3 (25%) developed a chronic cardiac insufficiency. No patient died.The prevalence of myocarditis in aSS is similar to that of other inflammatory myopathies. Although the prognosis is relatively good, myocarditis is a severe condition and should be carefully considered as a possible manifestation in active aSS patients.

Acute myocardial infarction or acute myocarditis? Discharge registry-based study of likelihood and associated features in hospitalised patients

OBJECTIVE

To evaluate the likelihood of and patient features associated with acute myocardial infarction (AMI) versus acute myocarditis in different population segments.

DESIGN

Nationwide, multihospital observational retrospective registry study of 9.6 years in Finland.

PARTICIPANTS

All consecutive patients aged ≥18 years hospitalised with a primary diagnosis of AMI (n=89 399) or acute myocarditis (n=2131) in 22 hospitals with a coronary catheterisation laboratory.

PRIMARY OUTCOME MEASURES

Likelihood of AMI versus acute myocarditis and associated patient features.

RESULTS

Men were over-represented in patients with AMI (59.8%) and in patients with acute myocarditis (76.1%). Age distributions of AMI and acute myocarditis were opposite as a majority of patients with myocarditis were aged 18-29 years, while the number of patients with AMI increased gradually up to 80 years of age. Patients aged 18-29 years were more likely to have acute myocarditis as the cause of hospitalisation (relative risk (RR)=11.4; 95% CI 7.6 to 16.1 for myocarditis, p<0.0001), but after 30 years of age the likelihood of infarction was higher with exponentially increasing RR for AMI. In youngest patients (18-29 years), the likelihood of AMI was higher in women, but men had higher odds for AMI after 40 years of age. Overall, men had OR of 1.97 (95% CI 1.74 to 2.23, p<0.0001) for AMI versus myocarditis when compared with women. Hypercholesterolaemia, chronic coronary artery disease, diabetes and hypertension predicted AMI in multivariate analysis. Odds for myocarditis were significantly higher if the patient had an otolaryngeal infection (OR 18.13; 95% CI 8.96 to 36.67, p<0.0001).

CONCLUSIONS

Acute myocarditis is more common than AMI in hospitalised patients aged 18-29 years, but the risk of AMI increases exponentially thereafter. Hypercholesterolaemia, diabetes and hypertension predict AMI regardless of age and gender.

Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association

BACKGROUND

Acute rheumatic fever remains a serious healthcare concern for the majority of the world's population despite its decline in incidence in Europe and North America. The goal of this statement was to review the historic Jones criteria used to diagnose acute rheumatic fever in the context of the current epidemiology of the disease and to update those criteria to also take into account recent evidence supporting the use of Doppler echocardiography in the diagnosis of carditis as a major manifestation of acute rheumatic fever.

METHODS AND RESULTS

To achieve this goal, the American Heart Association's Council on Cardiovascular Disease in the Young and its Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee organized a writing group to comprehensively review and evaluate the impact of population-specific differences in acute rheumatic fever presentation and changes in presentation that can result from the now worldwide availability of nonsteroidal anti-inflammatory drugs. In addition, a methodological assessment of the numerous published studies that support the use of Doppler echocardiography as a means to diagnose cardiac involvement in acute rheumatic fever, even when overt clinical findings are not apparent, was undertaken to determine the evidence basis for defining subclinical carditis and including it as a major criterion of the Jones criteria. This effort has resulted in the first substantial revision to the Jones criteria by the American Heart Association since 1992 and the first application of the Classification of Recommendations and Levels of Evidence categories developed by the American College of Cardiology/American Heart Association to the Jones criteria.

CONCLUSIONS

This revision of the Jones criteria now brings them into closer alignment with other international guidelines for the diagnosis of acute rheumatic fever by defining high-risk populations, recognizing variability in clinical presentation in these high-risk populations, and including Doppler echocardiography as a tool to diagnose cardiac involvement.

Effect of intravenous immunoglobulin for fulminant myocarditis on in-hospital mortality: propensity score analyses

BACKGROUND

Fulminant myocarditis (FM) is a rare but life-threatening disease. Intravenous immunoglobulin (IVIG) is not recommended for acute or chronic myocarditis in Western nations owing to the lack of rigorous evidence, but it is widely used in other countries, including Japan. This nationwide retrospective cohort study focused on evaluating the effect of IVIG in FM patients.

METHODS AND RESULTS

Using the Diagnosis Procedure Combination database in Japan, we identified 603 FM patients aged ≥16 years who received mechanical circulatory support within 7 days after admission. We performed propensity score analyses to compare the in-hospital mortality and total costs between IVIG users (n = 220; 36.5%) and nonusers (n = 383; 63.5%). Among propensity score-matched patients (164 pairs), there was no significant difference in in-hospital mortality between IVIG users and nonusers (36.6% vs 37.2%; P = .909). A multivariable logistic regression analysis showed no significant association between IVIG use and in-hospital mortality (adjusted odds ratio 0.91; 95% confidence interval 0.52 to 1.58; P = .733). The median total costs were significantly higher for IVIG users than for nonusers (US $44,226 vs $33,280; P < .001).

CONCLUSION

IVIG for FM was not significantly associated with a decrease in in-hospital mortality.

Rate and patient features associated with recurrence of acute myocarditis

BACKGROUND

Rate and patient features associated with recurrence after acute myocarditis are largely unknown.

METHODS AND RESULTS

First recurrence of acute myocarditis was studied in 1662 patients aged 16-70 years using a registry data of 29 hospitals in Finland (median follow-up 4.5 years). Matched intoxication patients served as controls. Incidence rate of first time hospitalization due to acute myocarditis was 5.52 (CI 5.26-5.79) per 100,000 person-years during 2001-2008. During the first 30 days 5.5% (CI 3.5-4.4%) of patients were re-admitted to hospital with acute myocarditis (p<0.0001 vs. controls). After 30 days, recurrence rate was 7.0% (CI 5.7-8.6%; p<0.0001 vs. controls). Acute myocarditis recurred after 365 days in 4.7% (CI 3.2-6.7%) of patients (p<0.0001 vs. controls). During the whole follow-up, recurrence rate was 10.3% (CI 8.8-12.1%; p<0.0001 vs. controls) with median recurrence time of 34.5 days. Prolonged (>7 days) initial admission was associated with recurrences during (HR 2.9; CI 1.6-5.2) and after first month (HR 1.8; CI 1.2-3.2), and overall (HR 2.0; CI 1.3-3.2). Ventricular arrhythmia at initial occurrence was associated with recurrence after 30 days (HR 8.6; CI 2.5-30.1), after 1 year (HR 22.6; CI 2.5-201.4) and overall (HR 6.7; CI 2.3-6.7). Other features associated with recurrence were younger age (>365 days), inflammatory bowel disease (during first month), and chronic pulmonary disease (≥ 30 days).

CONCLUSIONS

Acute myocarditis reoccurs in a significant proportion of patients. Prolonged initial admission, ventricular arrhythmias, younger age, inflammatory bowel disease and chronic pulmonary disease are associated with recurrences at different phases after acute myocarditis.

Prevalence of myocarditis and cardiotropic virus infection in Africans with HIV-associated cardiomyopathy, idiopathic dilated cardiomyopathy and heart transplant recipients: a pilot study: cardiovascular topic

Background:

The prevalence of myocarditis and cardiotropic viral infection in human immunodeficiency virus (HIV)-associated cardiomyopathy is unknown in Africa.

Methods

Between April 2002 and December 2007, we compared the prevalence of myocarditis and cardiotropic viral genomes in HIV-associated cardiomyopathy cases with HIV-negative idiopathic dilated cardiomyopathy patients (i.e. negative controls for immunodeficiency) and heart transplant recipients (i.e. positive controls for immunodeficiency) who were seen at Groote Schuur Hospital, Cape Town, South Africa. Myocarditis was sought on endomyocardial biopsy using the imunohistological criteria of the World Heart Federation in 33 patients, 14 of whom had HIV-associated cardiomyopathy, eight with idiopathic dilated cardiomyopathy and 11 heart transplant recipients.

Results

Myocarditis was present in 44% of HIV-associated cardiomyopathy cases, 36% of heart transplant recipients, and 25% of participants with idiopathic dilated cardiomyopathy. While myocarditis was acute in 50% of HIV- and heart transplant-associated myocarditis, it was chronic in all those with idiopathic dilated cardiomyopathy. Cardiotropic viral infection was present in all HIV-associated cardiomyopathy and idiopathic dilated cardiomyopathy cases, and in 90% of heart transplant recipients. Multiple viruses were identified in the majority of cases, with HIV-associated cardiomyopathy, heart transplant recipients and idiopathic dilated cardiomyopathy patients having an average of 2.5, 2.2 and 1.1 viruses per individual, respectively.

Conclusions

Acute myocarditis was present in 21% of cases of HIV-associated cardiomyopathy, compared to none of those with idiopathic dilated cardiomyopathy. Infection with multiple cardiotropic viruses may be ubiquitous in Africans, with a greater burden of infection in acquired immunodeficiency states.