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JACC. Cardiovascular Imaging Feb 2020Presentation of myocarditis in athletes is heterogeneous and establishing the diagnosis is challenging with no current uniform clinical gold standard. The combined... (Review)
Review
Presentation of myocarditis in athletes is heterogeneous and establishing the diagnosis is challenging with no current uniform clinical gold standard. The combined information from symptoms, electrocardiography, laboratory testing, echocardiography, cardiac magnetic resonance imaging, and in certain cases endomyocardial biopsy helps to establish the diagnosis. Most patients with myocarditis recover spontaneously; however, athletes may be at higher risk of adverse cardiac events. Based on scarce evidence and mainly autopsy studies and expert's opinions, current recommendations generally advise abstinence from competitive sports ranging from a minimum of 3 to 6 months. However, the dilemma poses that (un)necessary prolonged disqualification of athletes to avoid adverse cardiac events can cause considerable disruption to training schedules and tournament preparation and lead to a decline in performance and ability to compete. Therefore, better risk stratification tools are imperatively needed. Using latest available data, this review contrasts existing recommendations and presents a new proposed diagnostic flowchart putting a greater focus on the use of cardiac magnetic resonance imaging in athletes with suspected myocarditis. This may enable cardiac caregivers to counsel athletes with suspected myocarditis more systematically and furthermore allow for pooling of more unified data. To modify recommendations regarding sports behavior in athletes with myocarditis, evidence, based on large multicenter registries including cardiac magnetic resonance imaging and endomyocardial biopsy, is needed. In the future, physicians might rely on combined novel risk stratification methods, by implementing both noninvasive and invasive tissue characterization methods.
Topics: Adult; Age Factors; Animals; Athletes; Cardiac Imaging Techniques; Death, Sudden, Cardiac; Electrocardiography; Female; Humans; Male; Myocarditis; Predictive Value of Tests; Prognosis; Risk Assessment; Risk Factors
PubMed: 31202742
DOI: 10.1016/j.jcmg.2019.01.039 -
European Heart Journal Apr 2021Necrotizing coronary vasculitis (NCV) is a rare entity usually associated to myocarditis which incidence, cause, and response to therapy is unreported.
AIMS
Necrotizing coronary vasculitis (NCV) is a rare entity usually associated to myocarditis which incidence, cause, and response to therapy is unreported.
METHODS AND RESULTS
Among 1916 patients with biopsy-proven myocarditis, 30 had NCV. Endomyocardial samples were retrospectively investigated with immunohistochemistry for toll-like receptor 4 (TLR4) and real-time polymerase chain reaction (PCR) for viral genomes. Serum samples were processed for anti-heart autoantibodies (Abs), IL-1β, IL-6, IL-8, tumour necrosis factor (TNF)-α. Identification of an immunologic pathway (including virus-negativity, TLR4-, and Ab-positivity) was followed by immunosuppression. Myocarditis-NCV cohort was followed for 6 months with 2D-echo and/or cardiac magnetic resonance and compared with 60 Myocarditis patients and 30 controls. Increase in left ventricular ejection fraction ≥10% was classified as response to therapy. Control endomyocardial biopsy followed the end of treatment. Twenty-six Myocarditis-NCV patients presented with heart failure; four with electrical instability. Cause of Myocarditis-NCV included infectious agents (10%) and immune-mediated causes (chest trauma 3%; drug hypersensitivity 7%; hypereosinophilic syndrome 3%; primary autoimmune diseases 33%, idiopathic 44%). Abs were positive in immune-mediated Myocarditis-NCV and virus-negative Myocarditis; Myocarditis-NCV patients with Ab+ presented autoreactivity in vessel walls. Toll-like receptor 4 was overexpressed in immune-mediated forms and poorly detectable in viral. Interleukin-1β was significantly higher in Myocarditis-NCV than Myocarditis, the former presenting 24% in-hospital mortality compared with 1.5% of Myocarditis cohort. Immunosuppression induced improvement of cardiac function in 88% of Myocarditis-NCV and 86% of virus-negative Myocarditis patients.
CONCLUSION
Necrotizing coronary vasculitis is histologically detectable in 1.5% of Myocarditis. Necrotizing coronary vasculitis includes viral and immune-mediated causes. Intra-hospital mortality is 24%. The immunologic pathway is associated with beneficial response to immunosuppression.
Topics: Biopsy; Humans; Incidence; Myocarditis; Myocardium; Retrospective Studies; Stroke Volume; Vasculitis; Ventricular Function, Left
PubMed: 33355356
DOI: 10.1093/eurheartj/ehaa973 -
JACC. Cardiovascular Imaging Jul 2022Cardiac magnetic resonance (CMR) provides tissue characterization and structural and functional data. CMR has high sensitivity and specificity for myocarditis in adults...
BACKGROUND
Cardiac magnetic resonance (CMR) provides tissue characterization and structural and functional data. CMR has high sensitivity and specificity for myocarditis in adults and children. The relationship between pediatric CMR use, cost, and clinical outcome has not been studied.
OBJECTIVES
This work aims to describe temporal trends in CMR imaging for pediatric myocarditis and examine associations between CMR use, hospital cost, and outcomes.
METHODS
A retrospective cohort study of all inpatients <21 years of age with a diagnosis of myocarditis reported to the Pediatric Health Information System (2004-2019) was performed. Trends in CMR use were examined. A propensity-matched subcohort using center and patient level variables was used to assess whether outcomes differed by CMR use.
RESULTS
A total of 4,195 children with myocarditis from 47 hospitals were identified. The median age was 11.5 years (IQR: 1.5-16.0 years) and 2,617 (62%) were male. CMR was used in 23% and mortality occurred in 6%. CMR use during hospitalization increased from 2% in 2004 to 37% in 2019 (odds ratio [OR]: 1.19 [95% CI: 1.17-1.21]). After propensity score matching, CMR use was associated with higher median cost (+$5,340 [95% CI: +$1,739 to +$9,936]) and similar median length of stay (0 days [95% CI: -1 to +1 days]). Using quantile regression, CMR was associated with lower 90th percentile cost (-$77,200 [95% CI: -$127,373 to -$31,339]). More children receiving CMR were discharged alive in the first 30 days after admission (OR: 1.89 days [95% CI: 1.28-2.29]). Within the propensity matched cohort, <10 of 790 CMR recipients died compared to 42 of 790 in the non-CMR group.
CONCLUSIONS
CMR use in children with myocarditis has increased over the past 15 years. CMR use is associated with higher cost of hospitalization and similar length of stay for most children but lower cost among the sickest children. CMR use in specific patients may improve clinical outcomes at a lower cost.
Topics: Adult; Child; Female; Humans; Magnetic Resonance Imaging; Magnetic Resonance Imaging, Cine; Male; Myocarditis; Predictive Value of Tests; Retrospective Studies
PubMed: 35798399
DOI: 10.1016/j.jcmg.2022.03.023 -
Journal of Cardiovascular Translational... Jun 2020
Topics: Adaptation, Physiological; Athletes; Cardiology; Cardiomegaly, Exercise-Induced; Cardiomyopathies; Death, Sudden, Cardiac; Diagnosis, Differential; Humans; Myocarditis; Physical Endurance; Prognosis; Risk Assessment; Risk Factors; Sports Medicine
PubMed: 32542546
DOI: 10.1007/s12265-020-10043-2 -
Journal of the American Heart... Feb 2024Multisystemic inflammatory syndrome in adults is a hyperinflammatory condition following (within 4-12 weeks) SARS-CoV-2 infection. Here, the dysregulation of the... (Review)
Review
Multisystemic inflammatory syndrome in adults is a hyperinflammatory condition following (within 4-12 weeks) SARS-CoV-2 infection. Here, the dysregulation of the immune system leads to a multiorgan involvement often affecting the heart. Cardiac involvement in multisystemic inflammatory syndrome in adults has been described mainly in young men without other comorbidities and may present with different clinical scenarios, including acute heart failure, life-threatening arrhythmias, pericarditis, and myocarditis, with a nonnegligible risk of mortality (up to 7% of all cases). The heterogeneity of its clinical features and the absence of a clear case definition make the differential diagnosis with other postinfectious (eg, infective myocarditis) and hyperinflammatory diseases (eg, adult Still disease and macrophage activation syndrome) challenging. Moreover, the evidence on the efficacy of specific treatments targeting the hyperinflammatory response underlying this clinical condition (eg, glucocorticoids, immunoglobulins, and other immunomodulatory agents) is sparse and not supported by randomized clinical trials. In this review article, we aim to provide an overview of the clinical features and the diagnostic workup of multisystemic inflammatory syndrome in adults with cardiac involvement, highlighting the possible pathogenetic mechanisms and the therapeutic management, along with remaining knowledge gaps in this field.
Topics: Adult; Male; Humans; Myocarditis; Patients; Heart; COVID-19; Diagnosis, Differential; Syndrome
PubMed: 38348793
DOI: 10.1161/JAHA.123.032143 -
Clinical Research in Cardiology :... Oct 2022
Topics: COVID-19; Humans; Myocarditis; Public Health; SARS-CoV-2; Social Media
PubMed: 35499709
DOI: 10.1007/s00392-022-02030-1 -
Journal of Primary Care & Community... 2021COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well....
BACKGROUND
COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well. COVID-19 may lead to cardiovascular injuries, resulting in myocarditis, with inflammation of the heart muscle.
OBJECTIVE
This systematic review collates current evidence about demographics, symptomatology, diagnostic, and clinical outcomes of COVID-19 infected patients with myocarditis.
METHODS
In accordance with PRISMA 2020 guidelines, a systematic search was conducted using PubMed, Cochrane Central, Web of Science and Google Scholar until August, 2021. A combination of the following keywords was used: SARS-CoV-2, COVID-19, myocarditis. Cohorts and case reports that comprised of patients with confirmed myocarditis due to COVID-19 infection, aged >18 years were included. The findings were tabulated and subsequently synthesized.
RESULTS
In total, 54 case reports and 5 cohorts were identified comprising 215 patients. Hypertension (51.7%), diabetes mellitus type 2 (46.4%), cardiac comorbidities (14.6%) were the 3 most reported comorbidities. Majority of the patients presented with cough (61.9%), fever (60.4%), shortness of breath (53.2%), and chest pain (43.9%). Inflammatory markers were raised in 97.8% patients, whereas cardiac markers were elevated in 94.8% of the included patients. On noting radiographic findings, cardiomegaly (32.5%) was the most common finding. Electrocardiography testing obtained ST segment elevation among 44.8% patients and T wave inversion in 7.3% of the sample. Cardiovascular magnetic resonance imaging yielded 83.3% patients with myocardial edema, with late gadolinium enhancement in 63.9% patients. In hospital management consisted of azithromycin (25.5%), methylprednisolone/steroids (8.5%), and other standard care treatments for COVID-19. The most common in-hospital complication included acute respiratory distress syndrome (66.4%) and cardiogenic shock (14%). On last follow up, 64.7% of the patients survived, whereas 31.8% patients did not survive, and 3.5% were in the critical care unit.
CONCLUSION
It is essential to demarcate COVID-19 infection and myocarditis presentations due to the heightened risk of death among patients contracting both myocardial inflammation and ARDS. With a multitude of diagnostic and treatment options available for COVID-19 and myocarditis, patients that are under high risk of suspicion for COVID-19 induced myocarditis must be appropriately diagnosed and treated to curb co-infections.
Topics: COVID-19; Contrast Media; Gadolinium; Humans; Myocarditis; SARS-CoV-2
PubMed: 34854348
DOI: 10.1177/21501327211056800 -
Journal of Neuroinflammation Apr 2023The cholinergic anti-inflammatory pathway (CAP) has been widely studied to modulate the immune response. Current stimulating strategies are invasive or imprecise....
BACKGROUND
The cholinergic anti-inflammatory pathway (CAP) has been widely studied to modulate the immune response. Current stimulating strategies are invasive or imprecise. Noninvasive low-intensity pulsed ultrasound (LIPUS) has become increasingly appreciated for targeted neuronal modulation. However, its mechanisms and physiological role on myocarditis remain poorly defined.
METHODS
The mouse model of experimental autoimmune myocarditis was established. Low-intensity pulsed ultrasound was targeted at the spleen to stimulate the spleen nerve. Under different ultrasound parameters, histological tests and molecular biology were performed to observe inflammatory lesions and changes in immune cell subsets in the spleen and heart. In addition, we evaluated the dependence of the spleen nerve and cholinergic anti-inflammatory pathway of low-intensity pulsed ultrasound in treating autoimmune myocarditis in mice through different control groups.
RESULTS
The echocardiography and flow cytometry of splenic or heart infiltrating immune cells revealed that splenic ultrasound could alleviate the immune response, regulate the proportion and function of CD4+ Treg and macrophages by activating cholinergic anti-inflammatory pathway, and finally reduce heart inflammatory injury and improve cardiac remodeling, which is as effective as an acetylcholine receptor agonists GTS-21. Transcriptome sequencing showed significant differential expressed genes due to ultrasound modulation.
CONCLUSIONS
It is worth noting that the ultrasound therapeutic efficacy depends greatly on acoustic pressure and exposure duration, and the effective targeting organ was the spleen but not the heart. This study provides novel insight into the therapeutic potentials of LIPUS, which are essential for its future application.
Topics: Animals; Mice; Myocarditis; Spleen; Ultrasonography; Disease Models, Animal
PubMed: 37069636
DOI: 10.1186/s12974-023-02773-2 -
Wiener Medizinische Wochenschrift (1946) May 2023This article presents the case of a 15-year-old adolescent presenting with myocarditis 4 days after receiving the 2nd dose of BNT162b2 mRNA vaccine (Comirnaty®) with...
This article presents the case of a 15-year-old adolescent presenting with myocarditis 4 days after receiving the 2nd dose of BNT162b2 mRNA vaccine (Comirnaty®) with no other identifiable cause. The main clinical symptom at presentation was chest pain. We found an elevated level of Troponin‑I with preserved left ventricular systolic function. The cardiac MRI showed a clear pathologic result. With symptomatic therapy and strict bed rest, the symptoms resolved quickly and revealed a mild course.
Topics: Adolescent; Humans; BNT162 Vaccine; Myocarditis; Vaccines, Synthetic; mRNA Vaccines
PubMed: 36040634
DOI: 10.1007/s10354-022-00959-6 -
Clinical Infectious Diseases : An... Aug 2022Myocarditis following coronavirus disease 2019 (COVID-19) mRNA vaccines (Pfizer-BioNTech and Moderna) has been increasingly reported. Incidence rates in the general...
BACKGROUND
Myocarditis following coronavirus disease 2019 (COVID-19) mRNA vaccines (Pfizer-BioNTech and Moderna) has been increasingly reported. Incidence rates in the general population are lacking, with pericarditis rather than myocarditis diagnostic codes being used to estimate background rates. This comparison is critical for balancing the risk of vaccination with the risk of no vaccination.
METHODS
A retrospective case series was performed using the Mayo Clinic COVID-19 Vaccine Registry. We measured the incidence rate ratio (IRR) for myocarditis temporally related to COVID-19 mRNA vaccination compared with myocarditis in a comparable population from 2016 through 2020. Clinical characteristics and outcomes of the affected patients were collected. A total of 21 individuals were identified, but ultimately 7 patients met the inclusion criteria for vaccine-associated myocarditis.
RESULTS
The overall IRR of COVID-19-related myocarditis was 4.18 (95% confidence interval [CI], 1.63-8.98), which was entirely attributable to an increased IRR among adult males (IRR, 6.69; 95% CI, 2.35-15.52) compared with females (IRR 1.41; 95% CI, .03-8.45). All cases occurred within 2 weeks of a dose of the COVID-19 mRNA vaccine, with the majority occurring within 3 days (range, 1-13) following the second dose (6 of 7 patients, 86%). Overall, cases were mild, and all patients survived.
CONCLUSIONS
Myocarditis is a rare adverse event associated with COVID-19 mRNA vaccines. It occurs in adult males with significantly higher incidence than in the background population. Recurrence of myocarditis after a subsequent mRNA vaccine dose is not known at this time.
Topics: Adult; COVID-19; COVID-19 Vaccines; Female; Humans; Incidence; Male; Myocarditis; RNA, Messenger; Retrospective Studies; Vaccines, Synthetic; mRNA Vaccines
PubMed: 34734240
DOI: 10.1093/cid/ciab926