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Lasica R, Djukanovic L, Savic L, Krljanac G, Zdravkovic M, Ristic M, Lasica A, Asanin M, Ristic A. Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment. Diagnostics (Basel) 2023; 13:3073. [PMID: 37835816 PMCID: PMC10572782 DOI: 10.3390/diagnostics13193073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/15/2023] Open
Abstract
Although the frequency of myocarditis in the general population is very difficult to accurately determine due to the large number of asymptomatic cases, the incidence of this disease is increasing significantly due to better defined criteria for diagnosis and the development of modern diagnostic methods. The multitude of different etiological factors, the diversity of the clinical picture, and the variability of the diagnostic findings make this disease often demanding both for the selection of the diagnostic modality and for the proper therapeutic approach. The previously known most common viral etiology of this disease is today overshadowed by new findings based on immune-mediated processes, associated with diseases that in their natural course can lead to myocardial involvement, as well as the iatrogenic cause of myocarditis, which is due to use of immune checkpoint inhibitors in the treatment of cancer patients. Suspecting that a patient with polymorphic and non-specific clinical signs and symptoms, such as changes in ECG and echocardiography readings, has myocarditis is the starting point in the diagnostic algorithm. Cardio magnetic resonance imaging is non-invasive and is the gold standard for diagnosis and clinical follow-up of these patients. Endomyocardial biopsy as an invasive method is the diagnostic choice in life-threatening cases with suspicion of fulminant myocarditis where the diagnosis has not yet established or there is no adequate response to the applied therapeutic regimen. The treatment of myocarditis is increasingly demanding and includes conservative methods of treating heart failure, immunomodulatory and immunospressive therapy, methods of mechanical circulatory support, and heart transplantation. The goal of developing new diagnostic and therapeutic methods is to reduce mortality from this complex disease, which is still high.
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Affiliation(s)
- Ratko Lasica
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Lazar Djukanovic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
| | - Lidija Savic
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Gordana Krljanac
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Marija Zdravkovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Medical Center Bezanijska Kosa, 11000 Belgrade, Serbia
| | - Marko Ristic
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
| | | | - Milika Asanin
- Department of Cardiology, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (L.D.); (L.S.); (G.K.); (M.A.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
| | - Arsen Ristic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia;
- Department of Cardiology, University Clinical Center of Serbia, 11000 Belgrade, Serbia;
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Adamopoulos S, Miliopoulos D, Karavidas A, Nikolaou M, Lazaros G, Gkouziouta A, Manginas A, Sevastos G, Karvounis H, Karamitsos TD, Hahalis G, Leopoulou M, Grigoriou K, Balta D, Avgeropoulou CC, Kasiakogias A, Mantas I, Daskalopoulos N, Varvarousis D, Parthenakis FI, Patrianakos AP, Patsilinakos S, Karanikas S, Konstantinides SV, Tziakas DN, Kouvelas N, Ntoliou P, Manolis AJ, Tsinivizov P, Iliodromitis EK, Vrettou AR, Kakouros SN, Douras A, Mpaka N, Makridis P, Karapatsoudi E, Papoulidis N, Sideris A, Parissis JT, Triposkiadis F, Trikas A, Filippatos G. HEllenic Registry on Myocarditis SyndromES on behalf of Hellenic Heart Failure Association: The HERMES-HF Registry. ESC Heart Fail 2020; 7:3676-3684. [PMID: 32935475 PMCID: PMC7754904 DOI: 10.1002/ehf2.12894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 05/29/2020] [Accepted: 06/24/2020] [Indexed: 01/05/2023] Open
Abstract
AIMS Despite the existence of many studies, there are still limited data about the characteristics of myocarditis in Greece. This led to the creation of the Greek Myocarditis Registry aiming to document the different symptoms and treatment of myocarditis, assess possible prognostic factors, and find similarities and differences to what is already published in literature. This paper is a preliminary descriptive analysis of this Registry. METHODS AND RESULTS We analysed data for the hospitalization period of all patients included in the Registry from December 2015 until November 2017. Statistics are reported as frequency (%) or median and inter-quartile range (IQR) as appropriate. In total, 146 patients were included; 83.3% of the patients reported an infection during the last 3 months. The most common symptom, regardless of the underlying infection, was chest pain (82.2%) followed by dyspnoea (18.5%), while the most common finding in clinical examination was tachycardia (26.7%). Presentation was more frequent in the winter months. ECG findings were not specific, with the repolarization abnormalities being the most frequent (60.3%). Atrial fibrillation was observed in two patients, both of whom presented with a reduced ventricular systolic function. Left ventricular ejection fraction changed significantly during the hospitalization [55% (IQR: 50-60%) on admission vs. 60% (IQR: 55-60%) on discharge, P = 0.0026]. Cardiac magnetic resonance was performed in 88 patients (61%), revealing mainly subepicardial and midcardial involvement of the lateral wall. Late gadolinium enhancement was present in all patients, while oedema was found in 39 of them. Only 11 patients underwent endomyocardial biopsy. Discharge medication consisted mainly of beta-blockers (71.9%) and angiotensin-converting enzyme inhibitors (41.8%), while 39.7% of the patients were prescribed both. CONCLUSIONS This preliminary analysis describes the typical presentation of myocarditis patients in Greece. It is a first step in developing a better prognostic model for the course of the disease, which will be completed after the incorporation of the patients' follow-up data.
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Affiliation(s)
- Stamatis Adamopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, 356 Syngrou Avenue, 176 74 Kallithea, Athens, Greece
| | - Dimitrios Miliopoulos
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, 356 Syngrou Avenue, 176 74 Kallithea, Athens, Greece
| | | | - Maria Nikolaou
- Cardiology Department, General Hospital 'Sismanogleio-Amalia Fleming', Athens, Greece
| | - George Lazaros
- 1st Cardiology Clinic, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Angeliki Gkouziouta
- Heart Failure and Transplant Unit, Onassis Cardiac Surgery Centre, 356 Syngrou Avenue, 176 74 Kallithea, Athens, Greece
| | - Athanassios Manginas
- Interventional Cardiology and Cardiology Department, Mediterraneo Hospital, Athens, Greece
| | - George Sevastos
- Interventional Cardiology and Cardiology Department, Mediterraneo Hospital, Athens, Greece
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodoros D Karamitsos
- 1st Department of Cardiology, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Hahalis
- Department of Cardiology, University of Patras Medical School, Patras, Greece
| | - Marianna Leopoulou
- Department of Cardiology, University of Patras Medical School, Patras, Greece
| | | | - Despoina Balta
- Cardiology Department, General Hospital 'G. Gennimatas', Athens, Greece
| | | | - Alexandros Kasiakogias
- 1st Cardiology Clinic, 'Hippokration' General Hospital, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Ioannis Mantas
- Department of Cardiology, General Hospital of Chalkida, Chalkida, Greece
| | | | | | | | | | | | - Stavros Karanikas
- Department of Cardiology, Konstantopoulio General Hospital, Athens, Greece
| | | | - Dimitrios N Tziakas
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Kouvelas
- Department of Cardiology, 251 Airforce General Hospital, Athens, Greece
| | - Paraskevi Ntoliou
- Department of Cardiology, 251 Airforce General Hospital, Athens, Greece
| | | | - Pavlos Tsinivizov
- Department of Cardiology, Asklepeion General Hospital, Athens, Greece
| | | | - Agathi-Rosa Vrettou
- 2nd Department of Cardiology, Attikon University Hospital, University of Athens, Athens, Greece
| | | | - Alexandros Douras
- Department of Cardiology, Achillopouleio General Hospital, Volos, Greece
| | - Nikoleta Mpaka
- Department of Cardiology, Achillopouleio General Hospital, Volos, Greece
| | | | | | | | - Antonios Sideris
- Laboratory of Cardiac Electrophysiology, 'Evangelismos' General Hospital of Athens, Athens, Greece
| | - John T Parissis
- 2nd Department of Cardiology, Attikon University Hospital, University of Athens, Athens, Greece
| | | | - Athanasios Trikas
- Department of Cardiology, 'Elpis' General Hospital of Athens, Athens, Greece
| | - Gerasimos Filippatos
- 2nd Department of Cardiology, Attikon University Hospital, University of Athens, Athens, Greece
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