ReviewMyocarditis in Clinical Practice
Section snippets
Etiology and Epidemiology
Myocarditis can be triggered by different causes: infections (ie, viruses, bacteria, parasites), autoimmune diseases, hypersensitivity, high catecholamine states, drugs, toxic substances, or physical agents.5 Once other specific causes are ruled out, most cases of myocarditis observed in clinical practice are attributable to viral infections and/or immune reactions. In particular, even when no viruses are detected by serologic and polymerase chain reaction (PCR) analyses, an unrecognized viral
Clinical Presentation and Diagnosis
The heterogeneity of clinical presentation of myocarditis ranges from subclinical, or benign, forms to major clinical syndromes, such as severe heart failure or life-threatening ventricular arrhythmias.4 In most cases, the clinical expression of myocarditis can be exemplified by 3 main patterns of presentation4, 10: (1) recent-onset heart failure (<6 months), (2) arrhythmias, and (3) chest pain. According to the position statement on the diagnosis and management of myocarditis from the European
Role of Noninvasive and Invasive Diagnostic Testing
The diagnostic work-up of myocardial inflammatory syndromes should be tailored to the severity of clinical/instrumental presentation and the short-term response to medical therapy (Figure 2).
Natural History and Prognostic Stratification
Myocarditis is characterized by a highly variable natural history, ranging from quick resolution, to relapse, to the development of dilated cardiomyopathy and heart failure or unexpected sudden cardiac death.4 Thus, the identification of reliable early predictors of long-term prognosis is crucial for clinical management. A concise summary of the results of the main clinical trials and prospective studies reporting data on the outcome of myocarditis are reported in the Supplemental Table
Conventional and Supportive Therapy
The therapeutic management of myocarditis should be based on the pattern and severity of the clinical presentation, the short-term response to conventional treatments, and spontaneous or therapeutically induced improvement. The main pattern of presentation, ie, heart failure, arrhythmias, and myopericardial inflammatory syndromes, should be treated with standard therapeutic regimens.
In the context of active myocarditis associated with severe left ventricular dysfunction, major clinical
Conclusions and Key Points
Myocarditis is an underdiagnosed polymorphic disease with variable clinical presentation, evolution, and prognosis. The diagnostic approach and clinical management should be tailored to the clinical phenotype of the individual patient.
Patients presenting with chest pain and preserved left ventricular function typically have an excellent long-term prognosis and consequently should be managed conservatively. Once all ECG and echocardiographic abnormalities have disappeared during the short-term
Acknowledgments
We thank Professor Raffale De Caterina, MD, PhD (Institute of Cardiology, G. d'Annunzio University, Chieti, Italy), for his support and motivation.
References (50)
- et al.
CMR sensitivity varies with clinical presentation and extent of cell necrosis in biopsy-proven acute myocarditis
JACC Cardiovasc Imaging
(2014) - et al.
Utility of combination of cardiac magnetic resonance imaging and high-sensitivity cardiac troponin T assay in diagnosis of inflammatory cardiomyopathy
Am J Cardiol
(2013) - et al.
Echocardiographic findings in myocarditis
Am J Cardiol
(1988) - et al.
Echocardiographic findings in fulminant and acute myocarditis
J Am Coll Cardiol
(2000) - et al.
Diagnostic performance of CMR imaging compared with EMB in patients with suspected myocarditis
JACC Cardiovasc Imaging
(2012) - et al.
Analysis of endomyocardial biopsies in suspected myocarditis—diagnostic value of left versus right ventricular biopsy
Int J Cardiol
(2014) - et al.
2011 Consensus statement on endomyocardial biopsy from the Association for European Cardiovascular Pathology and the Society for Cardiovascular Pathology
Cardiovasc Pathol
(2012) - et al.
Survival in biopsy-proven myocarditis: a long-term retrospective analysis of the histopathologic, clinical, and hemodynamic predictors
Am Heart J
(2006) - et al.
Long-term follow-up of biopsy-proven viral myocarditis: predictors of mortality and incomplete recovery
J Am Coll Cardiol
(2012) - et al.
Arrhythmic risk prediction of acute myocarditis presenting with life-threatening ventricular tachyarrhythmias
Int J Cardiol
(2016)