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Brown J, Rashid H, Sarva ST, Tatapudi S, Kalathoor J, Srinivasan A, Daniel M, Raza S. Case Report: Three cases of clinically suspected viral myocarditis with recovery of left ventricular dysfunction. Front Cardiovasc Med 2024; 11:1345449. [PMID: 38774659 PMCID: PMC11106496 DOI: 10.3389/fcvm.2024.1345449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 04/15/2024] [Indexed: 05/24/2024] Open
Abstract
Viral myocarditis is an important cause of non-ischemic cardiomyopathy. Multiple clinical manifestations have been reported, including acute heart failure, cardiogenic shock, and ventricular arrhythmias. We present three patients with clinically suspected viral myocarditis causing acute heart failure. Serum coxsackievirus B antibodies were positive in all three patients. Each case resulted in significant clinical improvement with hemodynamic support and acute recovery of left ventricular ejection fraction. Despite an initial critical presentation concerning for cardiogenic shock, we highlight three cases of clinically suspected coxsackie myocarditis with an excellent short-term prognosis.
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Affiliation(s)
- Jonathan Brown
- Department of Internal Medicine, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Hytham Rashid
- Department of Internal Medicine, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Siva T. Sarva
- Department of Critical Care, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Suhas Tatapudi
- Department of Internal Medicine, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Jeby Kalathoor
- Department of Internal Medicine, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Aswin Srinivasan
- Department of Internal Medicine, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Michael Daniel
- Department of Cardiology, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
| | - Syed Raza
- Department of Cardiology, HCA Houston Healthcare Kingwood/University of Houston, Houston, TX, United States
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Ediger DS, Brady WJ, Koyfman A, Long B. High risk and low prevalence diseases: Myocarditis. Am J Emerg Med 2024; 78:81-88. [PMID: 38241774 DOI: 10.1016/j.ajem.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 01/02/2024] [Indexed: 01/21/2024] Open
Abstract
INTRODUCTION Myocarditis is a serious condition that carries with it a high rate of morbidity and mortality. OBJECTIVE This review highlights the pearls and pitfalls of myocarditis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Myocarditis is an inflammatory syndrome of myocardium, most often resulting from a viral infection, that can cause life-threatening cardiovascular collapse. It has a highly variable presentation and no widely available specific diagnostic test, making it a challenging diagnosis. Emergency clinicians should obtain an electrocardiogram and perform bedside ultrasound to assess cardiac function. Treatment in the ED is largely supportive, focusing on resuscitation, cardiovascular support, cardiology specialist consultation, and appropriate disposition. CONCLUSIONS An understanding of myocarditis can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- David S Ediger
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - William J Brady
- Professor, Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, VA, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Alamri AS, Khayat LT, Alzahrani AJ, Kurdi LK, Alkhameesi NF, Bahaidarah SA. Clinical Presentation of Myocarditis in the Pediatric Age Group and Predictors of Poor Early and Late Outcomes: Academic Hospital Experience. Cureus 2022; 14:e31643. [DOI: 10.7759/cureus.31643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2022] [Indexed: 11/19/2022] Open
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Türe M, Akın A, Demir M, Akay C. A paediatric case of myopericarditis post-COVID-19 mRNA vaccine. Cardiol Young 2022; 32:1688-1691. [PMID: 35082004 PMCID: PMC8861555 DOI: 10.1017/s1047951122000312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/10/2022] [Accepted: 01/18/2022] [Indexed: 11/06/2022]
Abstract
Myopericarditis is a condition, which primarily involves the pericardium, with minimal myocardial involvement. In myopericarditis, chest pain, elevated cardiac enzymes, and electrocardiographic changes occur. Although COVID-19 mRNA vaccines significantly contribute to preventing the COVID-19 disease, rarely myocarditis and/or pericarditis may develop due to these vaccines. We present a previously healthy 14-year-old male patient who developed myopericarditis after receiving the second dose of the COVID-19 mRNA vaccine.
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Affiliation(s)
- Mehmet Türe
- Department of Pediatric Cardiology, Dicle University Hospital, Diyarbakır, Turkey
| | - Alper Akın
- Department of Pediatric Cardiology, Dicle University Hospital, Diyarbakır, Turkey
| | - Muhammed Demir
- Department of Cardiology, Dicle University Hospital, Diyarbakır, Turkey
| | - Cihan Akay
- Department of Pediatric, Dicle University Hospital, Diyarbakır, Turkey
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Asllanaj B, Chang E, Dota A, McWhorter Y. Viral Myocarditis Mimicking ST-Segment Elevation Myocardial Infarction Complicated by Thrombocytopenia and Vasculitic Peripheral Neuropathy. J Investig Med High Impact Case Rep 2022; 10:23247096221139271. [PMID: 36433700 PMCID: PMC9703478 DOI: 10.1177/23247096221139271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/28/2022] [Accepted: 10/29/2022] [Indexed: 11/02/2023] Open
Abstract
Symptomatic myocarditis is classically featured by a flu-like prodrome, dyspnea on exertion, palpitations, substernal chest pain, and abnormal electrocardiogram (ECG). The clinical diagnosis has often been challenging due to its similarities to acute coronary syndrome. Our case involved a patient who presented with claudication of bilateral lower extremity and ST-segment elevation myocardial infarction (STEMI) in the inferior leads. On cardiac catheterization, nonobstructed coronary arteries with left ventricular ejection fraction (LVEF) of 30% were demonstrated. His clinical presentation was consistent with suspected myocarditis, and he improved with immunosuppression. In addition, his thrombocytopenia and severe symptoms of peripheral neuropathy responded to both immunotherapy and anticoagulation. This case highlights the interplay between history taking, physical examination, and multimodal diagnostic imaging.
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Affiliation(s)
| | - Eric Chang
- MountainView Hospital, Las Vegas, NV, USA
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6
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Azir M, Inman B, Webb J, Tannenbaum L. STEMI Mimic: Focal Myocarditis in an Adolescent Patient After mRNA COVID-19 Vaccine. J Emerg Med 2021; 61:e129-e132. [PMID: 34756746 PMCID: PMC8469220 DOI: 10.1016/j.jemermed.2021.09.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 08/20/2021] [Accepted: 09/17/2021] [Indexed: 01/06/2023]
Abstract
Background: In May 2021, the U.S. Food and Drug Administration expanded the Emergency Use Authorization for the Pfizer-BioNTech mRNA Coronavirus disease 2019 (COVID-19) Vaccine (BNT162b2) to include adolescents 12–15 years of age. As vaccine administration continues to increase, potential adverse outcomes, to include myocarditis, are being reported to the Vaccine Adverse Event Reporting System. Case Report: This case report describes a 17-year-old male patient who developed focal myocarditis mimicking an ST-segment elevation myocardial infarction (STEMI) 3 days after administration of an mRNA COVID-19 vaccine. Why Should an Emergency Physician Be Aware of This? Myocarditis is a rare complication in adolescents receiving mRNA COVID-19 vaccines. Focal myocarditis may demonstrate localizing electrocardiographic changes consistent with a STEMI. Overall, complications of the mRNA COVID-19 vaccines are extremely rare. The vaccine continues to be recommended by public health experts, as the benefits of vaccinations greatly outweigh the rare side effects.
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Affiliation(s)
- Michael Azir
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas.
| | - Brannon Inman
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - James Webb
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
| | - Lloyd Tannenbaum
- Department of Emergency Medicine, San Antonio Uniformed Services Health Education Consortium, Fort Sam Houston, Texas
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7
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Diagnosis and Management of Myocarditis: An Evidence-Based Review for the Emergency Medicine Clinician. J Emerg Med 2021; 61:222-233. [PMID: 34108120 DOI: 10.1016/j.jemermed.2021.03.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 03/17/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Myocarditis is a potentially fatal condition that can be misdiagnosed in the emergency department (ED) setting. OBJECTIVE The purpose of this narrative review article is to provide a summary of the background, pathophysiology, diagnosis, and management of myocarditis, with a focus on emergency clinicians. DISCUSSION Myocarditis occurs when inflammation of the heart musculature causes cardiac dysfunction. Symptoms may range from mild to severe and are often preceded by a viral prodrome. Laboratory assessment and an electrocardiogram can be helpful for the diagnosis, but echocardiography is the ideal test in the ED setting. Some patients may also require advanced imaging, though this will often occur during hospitalization or follow-up. Treatment is primarily focused on respiratory and hemodynamic support. Initial hemodynamic management includes vasopressors and inotropes, whereas more severe cases may require an intra-aortic balloon pump, extracorporeal membrane oxygenation, or a ventricular assist device. Nonsteroidal anti-inflammatory drugs should be avoided while intravenous immunoglobulin is controversial. CONCLUSION Myocarditis is a serious condition with the potential for significant morbidity and mortality. It is important for clinicians to be aware of the current evidence regarding the diagnosis, management, and disposition of these patients.
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Sun X, Xie N, Guo M, Qiu X, Chen H, Liu H, Li H. Establishment of a Nomogram for Predicting Early Death in Viral Myocarditis. Cardiol Res Pract 2021; 2021:9947034. [PMID: 34055404 PMCID: PMC8133858 DOI: 10.1155/2021/9947034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 04/29/2021] [Accepted: 05/05/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE This research aimed to establish a nomogram for predicting early death in viral myocarditis (VMC) patients. METHOD A total of 362 consecutive VMC patients in Fujian Medical University Affiliated First Quanzhou Hospital between January 1, 2009, and December 31, 2019, were included. A least absolute shrinkage and selection operator (LASSO) regression model was used to detect the risk factors that most consistently and correctly predicted early death in VMC. The performance of the nomogram was assessed by calibration, discrimination, and clinical utility. RESULT 9 factors were screened by LASSO regression analysis for predicting the early death of VMC. Combined with the actual clinical situation, the heart failure (HF) (OR: 2.13, 95% CI: 2.76-5.95), electrocardiogram (ECG) (OR: 6.11, 95% CI: 1.05-8.66), pneumonia (OR: 3.62, 95% CI: 1.43-9.85), brain natriuretic peptide (BNP) (OR: 4.66, 95% CI: 3.07-24.06), and lactate dehydrogenase (LDH) (OR: 1.90, 95% CI: 0.19-9.39) were finally used to construct the nomogram. The nomogram's C-index was 0.908 in the training cohort and 0.924 in the validation cohort. And the area under the receiver operating characteristic curve of the nomogram was 0.91 in the training cohort and 0.924 in the validating cohort. Decision curve analysis (DCA) also showed that the nomogram was clinically useful. CONCLUSION This nomogram achieved an good prediction of the risk of early death in VMC patients.
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Affiliation(s)
- Xuejun Sun
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Naxin Xie
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Mengling Guo
- Department of Medical Record, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Xuelian Qiu
- Department of Pharmacy, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Hongwei Chen
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Haibo Liu
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
| | - Hongmu Li
- Department of Cardiovascular Surgery, Fujian Medical University Affiliated First Quanzhou Hospital, Quanzhou, China
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Getting to the Heart of the Matter: Myocardial Injury, Coagulopathy, and Other Potential Cardiovascular Implications of COVID-19. Int J Vasc Med 2021; 2021:6693895. [PMID: 34035963 PMCID: PMC8118745 DOI: 10.1155/2021/6693895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/30/2021] [Accepted: 04/08/2021] [Indexed: 01/08/2023] Open
Abstract
COVID-19 was primarily identified as a respiratory illness, but reports of patients presenting initially with cardiovascular complaints are rapidly emerging. Many patients also develop cardiovascular complications during and after COVID-19 infection. Underlying cardiovascular disease increases the severity of COVID-19 infection; however, it is unclear if COVID-19 increases the risk of or causes cardiovascular complications in patients without preexisting cardiovascular disease. The review is aimed at informing the primary care physicians of the potential cardiovascular complications, especially in patients without underlying cardiovascular disease. A comprehensive literature review was performed on cardiac and vascular complications of COVID-19. The primary cardiac and vascular complications include myocarditis, acute coronary syndrome, myocardial injury, arrhythmia, heart failure, shock, multisystem inflammatory syndrome, venous and arterial thrombotic events, stroke, and coagulopathy. A detailed analysis of the pathogenesis revealed six possible mechanisms: direct cardiac damage, hypoxia-induced injury, inflammation, a dysfunctional endothelial response, coagulopathy, and the catecholamine stress response. Autopsy reports from studies show cardiomegaly, hypertrophy, ventricular dilation, infarction, and fibrosis. A wide range of cardiac and vascular complications should be considered when treating patients with confirmed or suspected COVID-19 infection. Elevated troponin and natriuretic peptides indicate an early cardiac involvement in COVID-19. Continuous monitoring of coagulation by measuring serum D-dimer can potentially prevent vascular complications. A long-term screening protocol to follow-up the patients in the primary care settings is needed to follow-up with the patients who recovered from COVID cardiovascular complications.
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Myc is involved in Genistein protecting against LPS-induced myocarditis in vitro through mediating MAPK/JNK signaling pathway. Biosci Rep 2021; 40:225215. [PMID: 32515469 PMCID: PMC7303346 DOI: 10.1042/bsr20194472] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Revised: 05/12/2020] [Accepted: 06/08/2020] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Genistein is widely used as a pharmacological compound as well as a food additive. However, the pharmaceutical effects of Genistein on myocarditis and its potential mechanisms have not been studied in detail. METHODS H9c2 cells were continuously stimulated by lipopolysaccharide (LPS) for 12 h to simulate the in vitro model of myocarditis injury. DrugBank, String, and GEO dataset were used to investigate specific genes that interacting with Genistein. KEGG and GO enrichment analysis were employed to explore Myc-related signaling pathways. Biological behaviors of H9c2 cells were observed with the support of cell counting kit-8, MTT and flow cytometry. Expression levels of cytokines including TNF-α and ILs were evaluated by enzyme-linked immunosorbent assay. Western blot was applied to detect the expression of Myc and MAPK pathway related proteins. RESULTS Genistein alleviated the damage of H9c2 cells subjected to LPS from the perspective of elevating cells growth ability, and inhibiting cells apoptosis and inflammatory response. Through bioinformatics analysis, we identified Myc as the potential target of Genistein in myocarditis, and MAPK as the signaling pathway. Significantly, Myc was highly up-regulated in myocarditis samples. More importantly, by performing biological experiments, we discovered that Genistein relieved H9c2 cells apoptosis and inflammatory reaction which caused by LPS stimulation through inhibiting Myc expression. Additionally, the marked augmentation of p-P38 MAPK and p-JNK expression in LPS-induced cardiomyocyte model were blocked by Genistein and si-Myc. CONCLUSIONS Our research revealed that Myc mediated the protective effects of Genistein on H9c2 cells damage caused by LPS partly through modulation of MAPK/JNK signaling pathway.
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Fontes A, Dias-Ferreira N, Tavares A, Neves F. Cerebral embolism due to left atrial myxoma in a patient presenting with chest pain and ST-segment elevation: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 33442627 PMCID: PMC7793160 DOI: 10.1093/ehjcr/ytaa272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 01/31/2020] [Accepted: 07/22/2020] [Indexed: 11/14/2022]
Abstract
Background Myocarditis is an uncommon, potentially life-threatening disease that presents with a wide range of symptoms. In acute myocarditis, chest pain (CP) may mimic typical angina and also be associated with electrocardiographic changes, including an elevation of the ST-segment. A large percentage (20-56%) of myxomas are found incidentally. Case summary A 62-year-old female presenting with sudden onset CP and infero-lateral ST-elevation in the electrocardiogram. The diagnosis of ST-elevation myocardial infarction was presumed and administered tenecteplase. The patient was immediately transported to a percutaneous coronary intervention centre. She complained of intermittent diplopia during transport and referred constitutional symptoms for the past 2 weeks. Coronary angiography showed normal arteries. The echocardiogram revealed moderate to severe left ventricular systolic dysfunction due to large areas of akinesia sparing most of the basal segments, and a mobile mass inside the left atrium attached to the septum. The cardiac magnetic resonance (CMR) suggested the diagnosis of myocarditis with concomitant left atrial myxoma. The patient underwent resection of the myxoma. Neurological evaluation was performed due to mild vertigo while walking and diplopia in extreme eye movements. The head magnetic resonance imaging identified multiple infracentimetric lesions throughout the cerebral parenchyma compatible with an embolization process caused by fragments of the tumour. Discussion Myocarditis can have various presentations may mimic acute myocardial infarction and CMR is critical to establish the diagnosis. Myxoma with embolic complications requires emergent surgery. To the best of our knowledge, this is the first case reported in the applicable literature of a myxoma diagnosed during a myocarditis episode.
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Affiliation(s)
- António Fontes
- Department of Cardiology, Hospital do Divino Espírito Santo de Ponta Delgada, Avenida D. Manuel I, 9500-370 Ponta Delgada, Azores, Portugal
| | - Nuno Dias-Ferreira
- Department of Cardiology, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
| | - Anabela Tavares
- Department of Cardiology, Hospital do Divino Espírito Santo de Ponta Delgada, Avenida D. Manuel I, 9500-370 Ponta Delgada, Azores, Portugal
| | - Fátima Neves
- Department of Cardiothoracic Surgery, Centro Hospitalar Vila Nova de Gaia/Espinho, Rua Conceição Fernandes, 4434-502 Vila Nova de Gaia, Portugal
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Fernando A, Guragai N, Vasudev R, Pullatt R, Randhawa P. A Rare Case of Myocarditis Mimicking ST-Elevation Myocardial Infarction. Cureus 2020; 12:e11671. [PMID: 33391909 PMCID: PMC7769724 DOI: 10.7759/cureus.11671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Myocarditis is caused by acute injury and inflammation of cardiac myocytes and is most commonly caused by a viral infection. Myocarditis remains a rare diagnosis and manifests with a wide spectrum of non-specific symptoms that include chest pain, dyspnea, and palpitations associated with electrocardiographic abnormalities that resemble that of ST-elevation myocardial infarction (STEMI). Therefore, clinical diagnosis is often challenging and is often misdiagnosed. We present a case of a 22-year-old male who presented with left-sided non-radiating chest pain associated with shortness of breath, elevated troponin of 3.2 ng/ml (<0.03 ng/ml). Electrocardiogram (ECG) and cardiac echocardiogram revealed ST-segment elevations in the anterolateral leads and an ejection fraction of 35%, respectively. The patient was initially suspected of having a STEMI; however, cardiac catheterization revealed non-obstructed coronary arteries. Due to elevated inflammatory markers, the patient was then started on colchicine for suspected myocarditis and had complete resolution of symptoms one week after. This case highlights that a high index of clinical suspicion and prompt diagnosis is necessary to prevent any delays in appropriate therapy for myocarditis.
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Affiliation(s)
- Ashen Fernando
- Cardiology, St. George's University School of Medicine, True Blue, GRD
| | - Nirmal Guragai
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Rahul Vasudev
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
| | - Raja Pullatt
- Cardiology, Saint Joseph's University Medical Center, Paterson, USA
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Cundari G, Galea N, De Rubeis G, Frustaci A, Cilia F, Mancuso G, Marchitelli L, Catapano F, Carbone I, Catalano C, Francone M. Use of the new Lake Louise Criteria improves CMR detection of atypical forms of acute myocarditis. Int J Cardiovasc Imaging 2020; 37:1395-1404. [PMID: 33190198 PMCID: PMC8026431 DOI: 10.1007/s10554-020-02097-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 11/02/2020] [Indexed: 12/14/2022]
Abstract
The purpose of our study was to compare diagnostic performance of old and new Lake Louise Criteria (oLLC and nLLC) among different clinical presentations: infarct-like (IL), cardiomyopathic (CM) and arrhythmic (AR). 102 patients with clinical suspicion of acute myocarditis underwent cardiac magnetic resonance (CMR) on a 1.5 T scanner. Protocol included cine-SSFP, T2-weighted STIR, T2 mapping, early and late gadolinium enhancement and T1 mapping acquired before and after gadolinium administration. The degree of agreement has been calculated with Cohen's K test. 42 patients also underwent endomyocardial biopsy (EMB). IL onset was present in 54/102 patients, CM in 28/102 and AR in 20/102. nLLC were positive in 58.3% of the patients, while oLLC in 37.9%, k = 0.57 (IC: 0.428-0.713). The degree of agreement between nLLC and oLLC was 0.49 (IC: 0.111-0.876) for AR onset (nLLC positive in 35% vs oLLC in 15%), 0.25 (IC: 0.035-0.459) for CM pattern (nLLC positive in 60.7% vs oLLC 17.9%) and 0.73 (IC: 0.543-0.912) for IL presentation (nLLC positive in 66.7% vs oLLC in 57.4%). Diagnostic accuracy was 75% for both nLLC and oLLC among IL onset, and 41.6% for oLLC vs 66.7% for nLLC, as regards CM clinical presentation. nLLC have improved diagnostic performance of CMR for the diagnosis of acute myocarditis, in particular for atypical clinical presentation.
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Affiliation(s)
- Giulia Cundari
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy.
| | - Nicola Galea
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Gianluca De Rubeis
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Frustaci
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesco Cilia
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Giuseppe Mancuso
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Livia Marchitelli
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Federica Catapano
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Iacopo Carbone
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Carlo Catalano
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
| | - Marco Francone
- Department of Radiological, Oncological and Anatomopathological Sciences, Sapienza University of Rome, Rome, Italy
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14
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Yuan WF, Zhao XX, Sun WJ, Wu SP, Liu YB, Tang X. LGE-MRI in the Assessment of Left-ventricular Remodelling in Myocarditis. Curr Med Imaging 2020; 15:900-905. [PMID: 32008537 PMCID: PMC7046988 DOI: 10.2174/1573405614666180912100253] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/05/2018] [Accepted: 08/19/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND The exact morbidity of myocarditis is unknown, as the treatment is generally delayed in virtue of misdiagnosis or missed diagnosis. AIM The aim of this study was to identify prognostic factors of left-ventricular remodeling on CMRI performed in patients with pathological proven myocarditis. METHODS Sixty-two cases with various presentations of myocarditis (39 cases with heart failure; 23 cases with arrhythmias) were selected. All patients, who underwent coronary angiography, endomyocardial biopsy, were divided into positive-remodeling and negative-remodelling groups to analyse LGE and cardiac cine parameters at presentation and subsequent to 3 months. RESULTS Comparison of two subgroups in CMRI is as follows: positive LGE (65.6% vs. 86.7%; p<0.05), LVEF (41.3±14.8% vs. 37.6±10.1%; p=0.62), (25.7±2.0% vs. 24.0±2.5%; p=0.81), (44.5±3.9mm vs. 46.3±5.4mm; p=0.76), (129.1±8.5ml vs. 135.3±12.2ml; p=0.26), (74.8±7.3ml vs. 79.1±10.0ml; p=0.55), (52.0±5.7g vs. 49.6±6.5g; p=0.71), (34.9±3.5ml vs. 32.4±6.2ml; p=0.68), (3.8±0.7L/min vs. 3.1±0.5L/min; p=0.64), (2.9±0.6L/min*m2 vs. 2.7±0.5L/min*m2; p=0.79). CONCLUSION LGE-MRI is rewarding as an independent predictor in left-ventricular positive and negative remodelling of myocarditis.
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Affiliation(s)
- Wei-Feng Yuan
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xin-Xiang Zhao
- Department of Radiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Wen-Jing Sun
- Department of Cardiology, The Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Shao-Ping Wu
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Ya-Bin Liu
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Xi Tang
- Department of Radiology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
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15
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Gupta K, Batool A, Hashmi AT, Marcelin M. Incidental Intramyocardial Bridging in a Myocarditis Patient Presenting With Focal ST Segment Depressions. Cureus 2020; 12:e9931. [PMID: 32968592 PMCID: PMC7505609 DOI: 10.7759/cureus.9931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Myopericarditis is an entity known to present with typical symptoms of viral prodrome and diffuse ST elevation (STE) and/or PR depressions on electrocardiogram (EKG). Atypical presentations of myocarditis such as focal STE have been cited in the literature, reflecting true coronary ischemia. However, myocarditis or pericarditis presenting with focal ST depressions is rarely seen. Myocarditis is usually overlooked as a differential for ST depressions seen on EKGs; hence, the case we present in this report highlights the importance of nonischemic causes presenting as ischemic changes on EKG. This case is unique as we have postulated a possible explanation for this finding. This report discusses the case of a young patient with myopericarditis presenting with focal ST depressions. This patient was also incidentally found to have intramyocardial bridging, usually a benign finding, on cardiac catheterization (which is shown in the case report). Our hypothesis is that the inflammation due to myocarditis in this patient led to inflammation of intramyocardial vessels, presenting as ST depressions. Since intramyocardial bridging is a common anomaly, we propose the question as to whether this could be a risk factor for sudden cardiac death and if it depends on the characteristic of the intramyocardial vessel. We would like to emphasize on the atypical presentations of this usual condition, a possible explanation for this finding, and the need for further testing for risk stratification in patients with this anomaly.
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16
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Cunha MS, Costa PAG, Correa IA, de Souza MRM, Calil PT, da Silva GPD, Costa SM, Fonseca VWP, da Costa LJ. Chikungunya Virus: An Emergent Arbovirus to the South American Continent and a Continuous Threat to the World. Front Microbiol 2020; 11:1297. [PMID: 32670231 PMCID: PMC7332961 DOI: 10.3389/fmicb.2020.01297] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/20/2020] [Indexed: 01/23/2023] Open
Abstract
Chikungunya virus (CHIKV) is an arthropod-borne virus (arbovirus) of epidemic concern, transmitted by Aedes ssp. mosquitoes, and is the etiologic agent of a febrile and incapacitating arthritogenic illness responsible for millions of human cases worldwide. After major outbreaks starting in 2004, CHIKV spread to subtropical areas and western hemisphere coming from sub-Saharan Africa, South East Asia, and the Indian subcontinent. Even though CHIKV disease is self-limiting and non-lethal, more than 30% of the infected individuals will develop chronic disease with persistent severe joint pain, tenosynovitis, and incapacitating polyarthralgia that can last for months to years, negatively impacting an individual’s quality of life and socioeconomic productivity. The lack of specific drugs or licensed vaccines to treat or prevent CHIKV disease associated with the global presence of the mosquito vector in tropical and temperate areas, representing a possibility for CHIKV to continually spread to different territories, make this virus an agent of public health burden. In South America, where Dengue virus is endemic and Zika virus was recently introduced, the impact of the expansion of CHIKV infections, and co-infection with other arboviruses, still needs to be estimated. In Brazil, the recent spread of the East/Central/South Africa (ECSA) and Asian genotypes of CHIKV was accompanied by a high morbidity rate and acute cases of abnormal disease presentation and severe neuropathies, which is an atypical outcome for this infection. In this review, we will discuss what is currently known about CHIKV epidemics, clinical manifestations of the human disease, the basic concepts and recent findings in the mechanisms underlying virus-host interaction, and CHIKV-induced chronic disease for both in vitro and in vivo models of infection. We aim to stimulate scientific debate on how the characterization of replication, host-cell interactions, and the pathogenic potential of the new epidemic viral strains can contribute as potential developments in the virology field and shed light on strategies for disease control.
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Affiliation(s)
- Marcela S Cunha
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro A G Costa
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Isadora Alonso Correa
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Marcos R M de Souza
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Teles Calil
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Gustavo P Duarte da Silva
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Sara Mesquita Costa
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Vinícius Wakoff P Fonseca
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Luciana J da Costa
- Departamento de Virologia, Instituto de Microbiologia Paulo de Góes, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
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Uziębło-Życzkowska B, Mielniczuk M, Ryczek R, Krzesiński P. Myocarditis successfully diagnosed and controlled with speckle tracking echocardiography. Cardiovasc Ultrasound 2020; 18:19. [PMID: 32532287 PMCID: PMC7293120 DOI: 10.1186/s12947-020-00203-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 06/08/2020] [Indexed: 11/12/2022] Open
Abstract
Background Speckle tracking echocardiography (STE) is an objective, well-validated and reproducible technique of assessing left ventricular longitudinal deformation; it also offers a more sensitive assessment of myocardial contractility than widely used visual estimation. Evaluating global longitudinal strain may help identify patients with subclinical left ventricular systolic dysfunction. Case presentation We report the case of a 28-year-old man with myocarditis, which successfully diagnosed and followed-up with the novel echocardiography method using speckle tracking imaging. The patient was referred to our hospital with an initial diagnosis of ST-segment elevation myocardial infarction. Transthoracic echocardiography did not show any contractility abnormalities. Hence, in the course of further diagnostics, left ventricular function was assessed by STE. Depressed global longitudinal strain was noted within several segments of the left ventricle. Then, cardiac magnetic resonance imaging was performed to confirm the diagnosis of myocarditis. Conclusions STE seems to be competitive in relation to cardiac magnetic resonance imaging in the diagnosis of some diseases, such as myocarditis.
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Affiliation(s)
- Beata Uziębło-Życzkowska
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland.
| | - Marta Mielniczuk
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
| | - Robert Ryczek
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
| | - Paweł Krzesiński
- Department of Cardiology and Internal Diseases, Military Institute of Medicine, Szaserów Street 128, 04-141, Warsaw, Poland
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18
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Detorakis E, Illing R, Lasithiotaki I, Foukarakis E, Raissaki M. Role of Smoking in the Evolution of Cardiovascular Magnetic Resonance and Laboratory Findings of Acute Myocarditis. Heart Views 2020; 21:22-30. [PMID: 32082496 PMCID: PMC7006323 DOI: 10.4103/heartviews.heartviews_68_19] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 09/15/2019] [Indexed: 01/03/2023] Open
Abstract
Purpose The purpose is to investigate cardiac magnetic resonance and laboratory findings in patients with clinically suspected acute myocarditis and re-assess the evolution of findings in relation to clinical parameters and smoking habits. Methods We prospectively analyzed 68 consecutive patients (4 females, 64 males, median age 25 years) at baseline and 51 patients 12 months later with regard to age, symptoms, and signs, smoking history, cardiac troponin I, erythrocyte sedimentation rate, c-reactive protein blood levels, electrocardiography changes, and cardiac magnetic resonance findings. Statistical analysis included group comparisons and linear regression between clinical parameters and the obtained data. Results A statistically significant correlation was recorded between smoking and late gadolinium enhancement extent, both at baseline and follow-up study. Late gadolinium enhancement extent was positively associated with cardiac troponin I serum levels and c-reactive protein and negatively with left ventricular ejection fraction at baseline study. Myocardial segments 4 and 5 were most frequently involved. Late gadolinium enhancement persisted in 96% of patients with no significant extent change at 12-month follow-up, while improved. Conclusions A strong correlation was recorded between smoking patients with acute myocarditis and extent both at baseline and follow-up cardiac magnetic resonance. Myocardial segments 4 and 5 involvement was most prevalent. Late gadolinium enhancement persisted at follow-up, its incidence was higher than that reported in other studies and did not have an impact on the patient's clinical status or cardiac function. However, longer-term follow-up is highly recommended in these patients.
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Affiliation(s)
- Efstathios Detorakis
- Department of Radiology, Magnetic Resonance Imaging Unit, Affidea Diagnostic Center, Greece
| | - Rowland Illing
- Prof. Rowland Illing, Interventional Oncology Service, University College Hospital, London, UK
| | - Ismini Lasithiotaki
- Department of Thoracic Medicine, University Hospital of Heraklion, Heraklion, Crete, Greece
| | | | - Maria Raissaki
- Department of Radiology, University Hospital of Heraklion, Heraklion, Crete, Greece
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Olejniczak M, Schwartz M, Webber E, Shaffer A, Perry TE. Viral Myocarditis-Incidence, Diagnosis and Management. J Cardiothorac Vasc Anesth 2020; 34:1591-1601. [PMID: 32127272 DOI: 10.1053/j.jvca.2019.12.052] [Citation(s) in RCA: 66] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 12/25/2022]
Abstract
Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.
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Affiliation(s)
- Megan Olejniczak
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Matthew Schwartz
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Elizabeth Webber
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Andrew Shaffer
- University of Minnesota, Department of Cardiothoracic Surgery, Minneapolis, MN
| | - Tjorvi E Perry
- University of Minnesota, Department of Anesthesia, Minneapolis, MN.
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20
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Buttà C, Zappia L, Laterra G, Roberto M. Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Ann Noninvasive Electrocardiol 2019; 25. [PMID: 31778001 PMCID: PMC7958927 DOI: 10.1111/anec.12726] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 09/28/2019] [Accepted: 10/07/2019] [Indexed: 12/21/2022] Open
Abstract
Background Acute myocarditis represents a challenging diagnosis as there is no pathognomonic clinical presentation. In patients with myocarditis, electrocardiogram (ECG) can display a variety of non‐specific abnormalities. Nevertheless, ECG is widely used as an initial screening tool for myocarditis. Methods We researched all possible ECG alterations during acute myocarditis evaluating prevalence, physiopathology, correlation with clinical presentation patterns, role in differential diagnosis, and prognostic yield. Results The most common ECG abnormality in myocarditis is sinus tachycardia associated with nonspecific ST/T‐wave changes. The presence of PR segment depression both in precordial and limb leads, a PR segment depression in leads with ST segment elevation, a PR segment elevation in aVR lead or a ST elevation with pericarditis pattern favor generally diagnosis of perimyocarditis rather than myocardial infarction. In patients with acute myocarditis, features associated with a poorer prognosis are: pathological Q wave, wide QRS complex, QRS/T angle ≥ 100°, prolonged QT interval, high‐degree atrioventricular block and malignant ventricular tachyarrhythmia. On the contrary, ST elevation with a typical early repolarization pattern is associated with a better prognosis. Conclusions ECG alterations in acute myocarditis could be very useful in clinical practice for a patient‐tailored approach in order to decide appropriate therapy, length of hospitalization, and frequency of followup.
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Affiliation(s)
- Carmelo Buttà
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Luca Zappia
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giulia Laterra
- Cardiology Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Marco Roberto
- Department of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
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21
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Razzano D, Fallon JT. Myocarditis: somethings old and something new. Cardiovasc Pathol 2019; 44:107155. [PMID: 31760237 DOI: 10.1016/j.carpath.2019.107155] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 11/29/2022] Open
Abstract
"Since the pathological conditions take place at the cellular level, viral myocarditis and postinfectious autoimmunity can be suggested but not diagnosed clinically. All clinical methods including imaging techniques are misleading if infectious agents are involved. Accurate diagnosis demands simultaneous histologic, immunohistochemical, and molecular biological workup of the tissue. If the primary infectious or immune-mediated causes of the disease are carefully defined by clinical and biopsy-based tools, specific antiviral treatment options in addition to basic symptomatic therapy are available under certain conditions. These may allow a tailored cause-specific treatment that improves symptoms and prognosis of patients with acute and chronic disease." Uwe Kühl; Heinz-Peter SchultheissViral myocarditis.Swiss Medical Weekly. 144():w14010, JAN 2014 DOI:10.4414/smw.2014.14010.
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Affiliation(s)
- Dana Razzano
- New York Medical College at Westchester Medical Center, Valhalla, NY, 10595, USA.
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22
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Stukalova OV, Gupalo EM, Chumachenko PV, Samko AN, Butorova EA, Shakhnovich RM, Mironova NA, Narusov OY, Safiullina AA, Shariya MA, Golitsyn SP, Ternovoy SK, Chazova IE. The value of cardiovascular magnetic resonance in myocarditis with different clinical presentation. TERAPEVT ARKH 2019; 91:28-36. [PMID: 31094473 DOI: 10.26442/00403660.2019.04.000078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIM to assess the diagnostic meaning of cardiac magnetic resonance imaging (CMR) in various clinical forms of myocarditis. MATERIALS AND METHODS 11 (8 men, mean age 32.8±11.1 years) patients (pts), hospitalized with suspected acute coronary syndrome, while an acute myocardial infarction was excluded during the examination (group I); 48 pts (31 men, 43.1±12.7 years), with clinical and instrumental signs of dilated cardiomyopathy (DCM) - group II; and 20 patients (12 men, 39.5±14 years), with episodes of ventricular tachycardia (group III) underwent cardiac magnetic resonance imaging (CMRI). In 38 patients endomyocardial biopsy (EMB) was performed. RESULTS According to EMB, signs of active myocarditis were revealed in 10 (34.5%) group II pts and in 3 (37.5%) group III pts; signs of resolved myocarditis - in 8 (27.6%) patients in group II and in 3 (37.5%); minimal morphological changes - in 11 (37.9%) patients of group II and in 2 (25%) patients of group III. In 9 (81.9%) patients of group I MRI data allowed to establish the diagnosis of acute myocarditis. Signs of active inflammation from MRI data were detected in myocardium 5 (10.4%) in group II pts and 7 (35%) in group III pts. In 22 (45.8%) pts in group II and 10 (50%), CMR data corresponded to the picture of resolved myocarditis. In 21 (43.8%) cases of group II and 3 (15%) of group III, MRI revealed minimal structural changes. In pts with clinical and instrumental signs of DCM and/or ventricular tachycardia MRI allows to identify signs of "active myocarditis" with a sensitivity of 37.5% with a specificity of 83.4%. At the same time, in cases of resolved myocarditis and minimal morphological changes MRI has high sensitivity (70 and 71.5%) and specificity (71.5 and 75%, respectively). CONCLUSION CMR has high diagnostic significance in patients with infarct-like course of myocarditis. In patients with clinical syndrome of dilated cardiomyopathy or arrhythmias, the sensitivity of MRI in detecting active myocarditis is low (37.5%) with high specificity (83.4%). In cases of minimal structural changes in the myocardium and resolved inflammation, CMR is a good alternative to EMB.
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Affiliation(s)
- O V Stukalova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - E M Gupalo
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - P V Chumachenko
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - A N Samko
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - E A Butorova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - R M Shakhnovich
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - N A Mironova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - O Yu Narusov
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - A A Safiullina
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - M A Shariya
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - S P Golitsyn
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
| | - S K Ternovoy
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia.,I.M. Sechenov First Moscow State Medical University (Sechenov University) of the Ministry of Health of Russia, Moscow, Russia
| | - I E Chazova
- A.L. Myasnikov Research Institute of Clinical Cardiology of National Medical Research Center of Cardiology of the Ministry of Health of Russia, Moscow, Russia
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Rodriguez-Gonzalez M, Sanchez-Codez MI, Lubian-Gutierrez M, Castellano-Martinez A. Clinical presentation and early predictors for poor outcomes in pediatric myocarditis: A retrospective study. World J Clin Cases 2019; 7:548-561. [PMID: 30863755 PMCID: PMC6406197 DOI: 10.12998/wjcc.v7.i5.548] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 12/29/2018] [Accepted: 01/30/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Myocarditis is an important cause of morbidity and mortality in children, leading to long-term sequelae including chronic congestive heart failure, dilated cardiomyopathy, heart transplantation, and death. The initial diagnosis of myocarditis is usually based on clinical presentation, but this widely ranges from the severe sudden onset of a cardiogenic shock to asymptomatic patients. Early recognition is essential in order to monitor and start supportive treatment prior to the development of severe adverse events. Of note, many cases of fulminant myocarditis are usually misdiagnosed as otherwise minor conditions during the weeks before the unexpected deterioration.
AIM To provide diagnostic clues to make an early recognition of pediatric myocarditis. To investigate early predictors for poor outcomes.
METHODS We conducted a retrospective cross-sectional single-center study from January 2008 to November 2017 at the Pediatric Department of our institution, including children < 18-years-old diagnosed with myocarditis. Poor outcome was defined as the occurrence of any of the following facts: death, heart transplant, persistent left ventricular systolic dysfunction or dilation at hospital discharge (early poor outcome), or after 1 year of follow-up (late poor outcome). We analyzed different clinical features and diagnostic test findings in order to provide diagnostic clues for myocarditis in children. Multivariable stepwise logistic regression analysis was performed using all variables that had been selected by univariate analysis to determine independent factors that predicted a poor early or late outcome in our study population.
RESULTS A total of 42 patients [69% male; median age of 8 (1.5-12) years] met study inclusion criteria. Chest pain (40%) was the most common specific cardiac symptom. Respiratory tract symptoms (cough, apnea, rhinorrhea) (38%), shortness of breath (35%), gastrointestinal tract symptoms (vomiting, abdominal pain, diarrhea) (33%), and fever (31%) were the most common non-cardiac initial complaints. Tachycardia (57%) and tachypnea (52%) were the most common signs on the initial physical exam followed by nonspecific signs of respiratory tract infection (44%) and respiratory distress (35%). Specific abnormal signs of heart failure such as heart murmur (26%), systolic hypotension (24%), gallop rhythm (20%), or hepatomegaly (20%) were less prevalent. Up to 43% of patients presented an early poor outcome, and 16% presented a late poor outcome. In multivariate analysis, an initial left ventricular ejection fraction (LVEF) < 30% remained the only significant predictor for early [odds ratio (OR) (95%CI) = 21 (2-456), P = 0.027) and late [OR (95%CI) = 8 (0.56-135), P = 0.047) poor outcome in children with myocarditis. LVEF correlated well with age (r = 0.51, P = 0.005), days from the initiation of symptoms (r = -0.31, P = 0.045), and N-terminal pro-brain natriuretic peptide levels (r = 0.66, P < 0.001), but not with troponin T (r = -0.05, P = 0.730) or C-reactive protein levels (r = -0.13, P = 0.391). N-terminal pro-brain natriuretic peptide presented a high diagnostic accuracy for LVEF < 30% on echocardiography with an area under curve of 0.931 (95%CI: 0.858-0.995, P < 0.001). The best cut-off point was 2000 pg/mL with a sensitivity of 90%, specificity of 81%, positive predictive value of 60%, and negative predictive value of 96%.
CONCLUSION The diagnosis of myocarditis in children is challenging due to the heterogeneous and unspecific clinical presentation. The presence of LVEF < 30% on echocardiography on admission was the major predictor for poor outcomes. Younger ages, a prolonged course of the disease, and N-terminal pro-brain natriuretic peptide levels could help to identify these high-risk patients.
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Manolis AS, Manolis AA, Manolis TA, Melita H. Acute coronary syndromes in patients with angiographically normal or near normal (non-obstructive) coronary arteries. Trends Cardiovasc Med 2018; 28:541-551. [DOI: 10.1016/j.tcm.2018.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 05/16/2018] [Accepted: 05/17/2018] [Indexed: 02/07/2023]
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Abstract
An adolescent male with a recent history of streptococcal pharyngitis presented with severe substernal chest pain, troponin leak, and ST-segment elevation, which are suggestive of acute inferolateral myocardial infarction. The coronary angiogram was normal. The patient was subsequently diagnosed with non-rheumatic streptococcal myocarditis. He was treated with amoxicillin and had excellent recovery. Non-rheumatic streptococcal myocarditis is an important mimic of acute myocardial infarction in young adults.
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Haouzi A, Ahmed A. ‘Clinically suspected myocarditis with pseudoinfarct presentation’ complicated with left ventricular aneurysm. BMJ Case Rep 2018; 2018:bcr-2017-222114. [DOI: 10.1136/bcr-2017-222114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Tsiaras SV, Safi LM, Ghoshhajra BB, Lindsay ME, Wood MJ. Case 39-2017. A 41-Year-Old Woman with Recurrent Chest Pain. N Engl J Med 2017; 377:2475-2484. [PMID: 29262281 DOI: 10.1056/nejmcpc1707558] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sarah V Tsiaras
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Lucy M Safi
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Brian B Ghoshhajra
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Mark E Lindsay
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
| | - Malissa J Wood
- From the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Massachusetts General Hospital, and the Departments of Cardiology (S.V.T., L.M.S., M.E.L., M.J.W.) and Radiology (B.B.G.), Harvard Medical School - both in Boston
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28
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Choi YF, Siu AYC, Wong TW, Lau CC. ST Elevation is not Always Equivalent to Acute Myocardial Infarction: a Case of Brugada Syndrome. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Acute myocardial infarction (AMI) is one of the most alerting situations in emergency department. Electrocardiogram (ECG) is one of the most important diagnostic tools and the decision about thrombolytic therapy is usually based upon ECG findings when clinically suspicious. However, ST segment elevation is not always equivalent to acute myocardial infarction. We present a rare syndrome whose ECG shows persistent ST elevation not related to AMI.
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Affiliation(s)
- YF Choi
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | - AYC Siu
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
| | - TW Wong
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | - CC Lau
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
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Combination Therapy With Coenzyme Q10 and Trimetazidine in Patients With Acute Viral Myocarditis. J Cardiovasc Pharmacol 2017; 68:150-4. [PMID: 27046339 DOI: 10.1097/fjc.0000000000000396] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Acute viral myocarditis is an inflammatory disease with global impact. Although it may resolve spontaneously, its course is not easily predicted, and there is a paucity of specific treatment options available with proven efficacy. Coenzyme Q10 (CQ10) and trimetazidine possess antioxidant and antiinflammatory effects. METHODS We examined the therapeutic efficacy of these agents in acute viral myocarditis both individually and in combination. Patients were blinded and randomized to receive CQ10 (n = 42), trimetazidine (n = 39), or CQ10 + trimetazidine (n = 43) treatment. RESULTS Serum inflammatory and oxidative stress marker and myocardial enzyme levels, and heart function were measured. Both CQ10 and trimetazidine decreased inflammatory and oxidative stress biomarker levels compared with baseline measurements. However, combination therapy with CQ10 and trimetazidine showed a significantly more powerful effect not only on markers of inflammation and oxidative stress, but also on left ventricular systolic function and troponin, compared with either treatment alone. CONCLUSION This study confirmed the beneficial effect of CQ10 and trimetazidine individually, but demonstrated a superior effect of combining the therapies on cardiac left ventricular ejection fraction, and biochemical markers of myocardial damage in acute viral myocarditis.
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Wu S, Yang YM, Zhu J, Wan HB, Wang J, Zhang H, Shao XH. Clinical characteristics and outcomes of patients with myocarditis mimicking ST-segment elevation myocardial infarction: Analysis of a case series. Medicine (Baltimore) 2017; 96:e6863. [PMID: 28489781 PMCID: PMC5428615 DOI: 10.1097/md.0000000000006863] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Acute myocarditis mimicking ST-segment elevation myocardial infarction (STEMI) is highly deceptive for an accurate diagnosis, and a systematic study is lacking with regard to the clinical features and prognosis of this distinct clinical entity.Patients with suspected STEMI and eventually diagnosed with myocarditis by cardiac magnetic resonance (CMR) from January 2012 to April 2016 at Fuwai Hospital were identified by reviewing medical records and electronic databases. Follow-up was conducted by clinical visits and phone contacts in a median duration of 17 months.A total of 18 patients were included in the study, with 17 males and 1 female. They were relatively young, and their mean age was 30.8 years. 94.4% of the patients had a high prevalence of infectious prodrome, and inflammatory biomarkers were notably elevated in all patients. Late gadolinium enhancement on CMR was detected in 13 patients. Three patients underwent fulminant course, and left ventricular ejection fraction (LVEF) <45% on admission occurred in 3 patients. The median LVEF improved from 59% on admission to 65% at discharge (P <.001), and none developed cardiac insufficiency, heart transplantation, or death during a median follow-up of 17 months.Myocarditis mimicking STEMI is featured by young age and an existence of flu-like prodrome. CMR benefits the differential diagnosis of this unique clinical entity. Notably, patients with myocarditis mimicking STEMI had a favorable prognosis, and establishing an accurate diagnosis is crucial to avoid unreasonable treatments for them.
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Woudstra L, Biesbroek PS, Emmens RW, Heymans S, Juffermans LJ, van Rossum AC, Niessen HWM, Krijnen PAJ. Lymphocytic myocarditis occurs with myocardial infarction and coincides with increased inflammation, hemorrhage and instability in coronary artery atherosclerotic plaques. Int J Cardiol 2017; 232:53-62. [PMID: 28087177 DOI: 10.1016/j.ijcard.2017.01.052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2016] [Revised: 12/28/2016] [Accepted: 01/04/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE Although lymphocytic myocarditis (LM) clinically can mimic myocardial infarction (MI), they are regarded as distinct clinical entities. However, we observed a high prevalence (32%) of recent MI in patients diagnosed post-mortem with LM. To investigate if LM changes coronary atherosclerotic plaque, we analyzed in autopsied hearts the inflammatory infiltrate and stability in coronary atherosclerotic lesions in patients with LM and/or MI. METHODS The three main coronary arteries were isolated at autopsy of patients with LM, with MI of 3-6h old, with LM and MI of 3-6h old (LM+MI) and controls. In tissue sections of atherosclerotic plaque-containing coronary segments inflammatory infiltration, plaque stability, intraplaque hemorrhage and thrombi were determined via (immuno)histological criteria. RESULTS In tissue sections of those coronary segments the inflammatory infiltrate was found to be significantly increased in patients with LM, LM+MI and MI compared with controls. This inflammatory infiltrate consisted predominantly of macrophages and neutrophils in patients with only LM or MI, of lymphocytes in LM+MI and MI patients and of mast cells in LM+MI patients. Moreover, in LM+MI and MI patients this coincided with an increase of unstable plaques and thrombi. Finally, LM and especially MI and LM+MI patients showed significantly increased intraplaque hemorrhage. CONCLUSIONS This study demonstrates prevalent co-occurrence of LM with a very recent MI at autopsy. Moreover, LM was associated with remodeling and inflammation of atherosclerotic plaques indicative of plaque destabilization pointing to coronary spasm, suggesting that preexistent LM, or its causes, may facilitate the development of MI.
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Affiliation(s)
- Linde Woudstra
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands.
| | - P Stefan Biesbroek
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands; ICIN, Inter-university Cardiology Institute of the Netherlands, Utrecht, The Netherlands
| | - Reindert W Emmens
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands
| | - Stephane Heymans
- Center for Heart Failure Research, Cardiovascular Research Institute Maastricht (CARIM), University Hospital Maastricht, Maastricht, The Netherlands
| | - Lynda J Juffermans
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands
| | - Albert C van Rossum
- ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiology, VU University Medical Center, The Netherlands
| | - Hans W M Niessen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands; Department of Cardiothoracic Surgery, VU University Medical Center, The Netherlands
| | - Paul A J Krijnen
- Department of Pathology, VU University Medical Center, Amsterdam, The Netherlands; ICaR-VU, Institute for Cardiovascular Research, VU University Medical Center, The Netherlands
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Basman C, Agrawal PR, McRee C, Saravolatz L, Chen-Scarabelli C, Scarabelli TM. Diagnostic Approach to Myocarditis Mimicking Myocardial Infarction at Initial Presentation. Cardiol Res 2016; 7:209-213. [PMID: 28197294 PMCID: PMC5295512 DOI: 10.14740/cr485w] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2016] [Indexed: 12/11/2022] Open
Abstract
We present a case of a 35-year-old male patient with a 12-hour history of sudden-onset, crushing chest pain and associated complaints of profuse diaphoresis, nausea and vomiting. The patient was transferred to our institution from an outside hospital for evaluation and possible emergent catheterization. Left heart catheterization was conclusive for normal coronary arteries and a ventriculogram revealed a left ventricular ejection fraction of approximately 45%. Due to a suspicion of myocarditis based on clinical history, pertinent serology tests were ordered, which were found to be negative. Cardiac magnetic resonance on delayed enhancement imaging showed typical sub-epicardial enhancement in a pattern most consistent with myocarditis. The patient was eventually diagnosed with myocarditis and discharged home later, without needing a myocardial biopsy. We present and discuss here the indications of myocardial biopsy and compare the relative utility of cardiac magnetic resonance imaging in formulating the diagnosis of myocarditis.
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Affiliation(s)
- Craig Basman
- St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | - Pratik R Agrawal
- St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chad McRee
- University of Alabama at Birmingham (UAB) Medical Center, Birmingham, Alabama, AL, USA
| | - Louis Saravolatz
- St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Tiziano M Scarabelli
- St John Hospital and Medical Center, Wayne State University School of Medicine, Detroit, MI, USA; University of Alabama at Birmingham (UAB) Medical Center, Birmingham, Alabama, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
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Zarka S, Bouleti C, Arangalage D, Chopra H, Chillon S, Henry-Feugeas MC, Abtan J, Juliard JM, Iung B, Vahanian A, Laissy JP, Ou P. Usefulness of Subepicardial Hyperemia on Contrast-Enhanced First-Pass Magnetic Resonance Perfusion Imaging for Diagnosis of Acute Myocarditis. Am J Cardiol 2016; 118:440-5. [PMID: 27296557 DOI: 10.1016/j.amjcard.2016.05.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 05/04/2016] [Accepted: 05/04/2016] [Indexed: 11/16/2022]
Abstract
Hyperemia is a major criterion for the diagnosis of acute myocarditis on cardiac magnetic resonance imaging but its assessment is challenging and time consuming. We evaluated the usefulness of the contrast-enhanced first-pass perfusion (FPP) on magnetic resonance imaging for detecting subepicardial hyperemia in acute myocarditis. Forty-seven consecutive patients (mean age: 42 ± 15.6 years; 35 men) with a definite diagnosis of acute myocarditis according to the state-of-the-art guidelines were included and compared with 16 control subjects. FPP was evaluated by 2 blinded observers and compared with the reference late gadolinium enhancement. Detection of hyperemia was performed on both qualitative and quantitative methods. Relative increased signal intensity (SI) in the subepicardial hyperemic layer was measured with SI ratio (SI of the subepicardial layer/SI of the immediately adjacent subendocardial layer). Twenty-four patients (51%) with acute myocarditis exhibited subepicardial hyperemia, detected with a good interobserver reproducibility (kappa coefficient: 0.75). The SI in the myocardium of myocarditis patients was increased compared with controls (1.08 ± 0.03 vs 0.945 ± 0.04, p = 0.03) and the SI in myocarditis patients with hyperemia compared with those without hyperemia (1.22 ± 0.04 vs 0.94 ± 0.04, p <0.0001). Sensitivity, specificity, positive predictive, and negative predictive values of FPP for detecting hyperemia were 85%, 94%, 85%, and 93%, respectively. In conclusion, contrast-enhanced first-pass magnetic resonance imaging is a fast and useful method for assessing myocardial hyperemia in patients with acute myocarditis.
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Affiliation(s)
- Samuel Zarka
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Claire Bouleti
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Dimitri Arangalage
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Houzefa Chopra
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Sylvie Chillon
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | | | - Jérémie Abtan
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Jean-Michel Juliard
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Bernard Iung
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Paris-Diderot University, DHU FIRE, Paris, France
| | - Jean-Pierre Laissy
- Paris-Diderot University, DHU FIRE, Paris, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Phalla Ou
- Paris-Diderot University, DHU FIRE, Paris, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148 Bichat Hospital, Paris, France.
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35
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Chopra H, Arangalage D, Bouleti C, Zarka S, Fayard F, Chillon S, Laissy JP, Henry-Feugeas MC, Steg PG, Vahanian A, Ou P. Prognostic value of the infarct- and non-infarct like patterns and cardiovascular magnetic resonance parameters on long-term outcome of patients after acute myocarditis. Int J Cardiol 2016; 212:63-9. [PMID: 27035605 DOI: 10.1016/j.ijcard.2016.03.004] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 03/12/2016] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Houzefa Chopra
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Dimitri Arangalage
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France
| | - Claire Bouleti
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France
| | - Samuel Zarka
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Florence Fayard
- Gustave Roussy, Service de Biostatistique et d'Epidémiologie, Villejuif, 94805, France; CESP Centre for Research in Epidemiology and Population Health, INSERM U1018 (Team 2, Methodology and clinical epidemiology in molecular oncology), Université Paris-Sud, Villejuif 94805, France
| | - Sylvie Chillon
- Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France
| | - Jean-Pierre Laissy
- Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148 Bichat Hospital, Paris, France
| | | | - Philippe-Gabriel Steg
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France; INSERM U1148 Bichat Hospital, Paris, France
| | - Alec Vahanian
- Department of Cardiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France; INSERM U1148 Bichat Hospital, Paris, France
| | - Phalla Ou
- Faculté de Médecine, Paris-Diderot University, Paris, France; DHU Fire, Paris-Diderot University, France; Department of Radiology, Assistance Publique-Hôpitaux de Paris, Bichat Hospital, Paris, France; INSERM U1148 Bichat Hospital, Paris, France.
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Abstract
The editors of Cochrane Heart consider this title as low priority for the current portfolio of the Heart Group and therefore this title is not open to a new author team. The editorial group responsible for this previously published document have withdrawn it from publication.
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Affiliation(s)
- Zhao Lan Liu
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese Medicine11 Bei San Huan Dong Lu, Chaoyang DistrictBeijingChina100029
| | - Zhi Jun Liu
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese Medicine11 Bei San Huan Dong Lu, Chaoyang DistrictBeijingChina100029
| | - Jian Ping Liu
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese Medicine11 Bei San Huan Dong Lu, Chaoyang DistrictBeijingChina100029
| | - Joey SW Kwong
- West China Hospital, Sichuan UniversityChinese Evidence‐Based Medicine CenterNo. 37, Guo Xue XiangChengduSichuanChina610041
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Wang ZQ, Li YG. An unusual case of fulminant myocarditis closely mimicking ST-segment elevation myocardial infarction and presenting as refractory cardiogenic shock complicated by multiple life-threatening arrhythmias. Rev Port Cardiol 2015; 34:771.e1-5. [PMID: 26632110 DOI: 10.1016/j.repc.2015.03.030] [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: 01/04/2015] [Accepted: 03/21/2015] [Indexed: 11/27/2022] Open
Abstract
We report a case of severe fulminant myocarditis that closely mimicked acute inferior ST-segment elevation myocardial infarction (STEMI) and presented with refractory cardiogenic shock, multiple life-threatening arrhythmias and rapidly progressive liver failure. This case was successfully differentiated from STEMI by emergency coronary angiography. Recurrent cardiogenic shock was reversed by intra-aortic balloon pumping (IABP). Life-threatening arrhythmias including ventricular tachycardia, ventricular fibrillation, and high-degree atrioventricular block (AVB) were terminated by immediate cardioversion and temporary pacemaker. High-dose hydrocortisone effectively attenuated the inflammatory injury to the myocardium. The patient recovered and was well at the follow-up visit four months after discharge.
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Affiliation(s)
- Zhi-quan Wang
- Department of Cardiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China.
| | - Yi-Gang Li
- Department of Cardiology, Xinhua Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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38
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An unusual case of fulminant myocarditis closely mimicking ST-segment elevation myocardial infarction and presenting as refractory cardiogenic shock complicated by multiple life-threatening arrhythmiasAn unusual case of fulminant myocarditis. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2015. [DOI: 10.1016/j.repce.2015.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Small Bowel Obstruction Masquerading as Acute ST Elevation Myocardial Infarction. Case Rep Cardiol 2015; 2015:685039. [PMID: 26587291 PMCID: PMC4637458 DOI: 10.1155/2015/685039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2015] [Accepted: 10/13/2015] [Indexed: 11/23/2022] Open
Abstract
ST segment elevation on EKG remains among the most important presentations of acute myocardial infarction. Due to the urgency of intervention for this finding, other clinical scenarios causing ST elevations on EKG may sometimes go unaddressed and can lead to fatal complications. We present a case of an 86-year-old male presenting with small bowel obstruction leading to EKG findings of ST segment elevation in the absence of critical coronary obstruction. The EKG finding resolved after the improvement of small bowel obstruction reflecting the reversible cause of the changes.
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Jbeli AH, Anuwatworn A, Petrasko MS. Myocarditis mimicking acute coronary syndrome: the role of cardiac magnetic resonance imaging and immunoglobulin therapy. Am J Emerg Med 2015; 33:1717.e3-4. [DOI: 10.1016/j.ajem.2015.03.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Revised: 03/19/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022] Open
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Pollack A, Kontorovich AR, Fuster V, Dec GW. Viral myocarditis--diagnosis, treatment options, and current controversies. Nat Rev Cardiol 2015; 12:670-80. [PMID: 26194549 DOI: 10.1038/nrcardio.2015.108] [Citation(s) in RCA: 340] [Impact Index Per Article: 37.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Myocarditis--a frequent cause of dilated cardiomyopathy and sudden cardiac death--typically results from cardiotropic viral infection followed by active inflammatory destruction of the myocardium. Characterization of this disease has been hampered by its heterogeneous clinical presentations and diverse aetiologies. Advances in cardiac MRI and molecular detection of viruses by endomyocardial biopsy have improved our ability to diagnose and understand the pathophysiological mechanisms of this elusive disease. However, therapeutic options are currently limited for both the acute and chronic phases of myocarditis. Several randomized, controlled trials have demonstrated potential benefit with immunosuppressive and immunomodulatory therapies, but further investigations are warranted. In this Review, we explore the pathophysiology, natural history, and modes of diagnosis of myocarditis, as well as evidence-based treatment strategies. As novel imaging techniques and human in vitro models of the disease emerge, the landscape of therapies for myocarditis is poised to improve.
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Affiliation(s)
- Ari Pollack
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Amy R Kontorovich
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - Valentin Fuster
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, New York, NY 10029, USA
| | - G William Dec
- Cardiology Division, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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van den Hoogen P, van den Akker F, Deddens JC, Sluijter JPG. Heart Failure in Chronic Myocarditis: A Role for microRNAs? Curr Genomics 2015; 16:88-94. [PMID: 26085807 PMCID: PMC4467309 DOI: 10.2174/1389202916999150120153344] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 12/20/2014] [Accepted: 01/06/2015] [Indexed: 12/22/2022] Open
Abstract
Myocarditis is an inflammatory disease of the heart, which can persist over a long time. During this time, known as the chronic phase of myocarditis, ongoing inflammation damages the cardiomyocytes. The loss of cardiac cells culminates in the development of dilated cardiomyopathy, often followed by non-ischemic heart failure due to diminished cardiac function. During the course of the disease, expression levels of non-coding small RNAs, called microRNAs (miRNAs), change. Although mainly studied in the acute setting, some of these changes in expression level appear to persist in the chronic phase. In addition to being a much-needed diagnostic tool, these miRNA could provide new treatment options. miRNA-based intervention strategies already showed promising results in the treatment of ischemic cardiovascular diseases in preclinical animal models. By implementing more knowledge on the role of miRNAs in the progression towards heart failure, this can potentially be used in the development of miRNA-based therapeutic interventions in the treatment of myocarditis and thereby preventing the progression towards heart failure. The first part of this review will focus on the natural course of myocarditis and the progression towards heart failure. Secondly, we will discuss the current knowledge on alterations of miRNA expression patterns, and suggest some possible future interventions.
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Affiliation(s)
- P van den Hoogen
- Department of Cardiology, University Medical Center Utrecht, the Netherlands; ; ICIN - Netherlands Heart Institute, Utrecht, The Netherlands
| | - F van den Akker
- Department of Cardiology, University Medical Center Utrecht, the Netherlands
| | - J C Deddens
- Department of Cardiology, University Medical Center Utrecht, the Netherlands
| | - J P G Sluijter
- Department of Cardiology, University Medical Center Utrecht, the Netherlands; ; ICIN - Netherlands Heart Institute, Utrecht, The Netherlands
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Mody KP, Lyons JJ, Jorde UP, Uriel N. A cold taken to heart. Circulation 2015; 131:1703-11. [PMID: 25964280 DOI: 10.1161/circulationaha.114.013355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kanika P Mody
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (K.P.M.); Department of Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY (J.J.L.); Department of Cardiology, Montefiore Medical Center, Bronx, NY (U.P.J.); and Department of Cardiology, University of Chicago Medicine, IL (N.U.).
| | - James J Lyons
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (K.P.M.); Department of Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY (J.J.L.); Department of Cardiology, Montefiore Medical Center, Bronx, NY (U.P.J.); and Department of Cardiology, University of Chicago Medicine, IL (N.U.)
| | - Ulrich P Jorde
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (K.P.M.); Department of Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY (J.J.L.); Department of Cardiology, Montefiore Medical Center, Bronx, NY (U.P.J.); and Department of Cardiology, University of Chicago Medicine, IL (N.U.)
| | - Nir Uriel
- From Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York (K.P.M.); Department of Cardiology, Vassar Brothers Medical Center, Poughkeepsie, NY (J.J.L.); Department of Cardiology, Montefiore Medical Center, Bronx, NY (U.P.J.); and Department of Cardiology, University of Chicago Medicine, IL (N.U.)
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The spectrum of electrocardiographic manifestations of acute myocarditis: An expanded understanding. J Electrocardiol 2014; 47:941-7. [DOI: 10.1016/j.jelectrocard.2014.07.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 11/17/2022]
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45
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Chest pain in adolescent Japanese male mimicking acute coronary syndrome. Case Rep Crit Care 2014; 2014:176520. [PMID: 25202456 PMCID: PMC4151487 DOI: 10.1155/2014/176520] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 07/17/2014] [Indexed: 11/30/2022] Open
Abstract
Acute chest pain with very elevated troponin level and abnormal EKG in adult population is considered sine qua non to acute coronary syndrome (ACS) unless proved otherwise. Similar presentation in adolescent population is seen less often but raises suspicion for ACS. Most common etiology for chest pain with cardiac enzyme elevation in adolescent population is usually viral myopericarditis. The adolescent population presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for ACS and other etiologies including myocarditis, myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. We report one Japanese adolescent male with mycoplasma pneumoniae myocarditis who presented to the ER with chest pain, elevated cardiac enzymes, and abnormal EKG.
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46
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Abstract
Acute chest pain with elevated troponin and CK-MB levels and focal ST elevation on electrocardiogram is considered to be myocardial infarction unless proven otherwise. The cardiac enzymes can be elevated in other etiologies of chest pain including myopericarditis, pulmonary embolism, acute rheumatic fever, and trauma. Therefore, patients presenting with chest pain and elevated cardiac enzymes should be carefully evaluated for other etiologies after ruling out acute coronary process. We report 2 male adolescents with myopericarditis who presented to the emergency department with chest pain and elevated cardiac enzymes.
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47
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Ischemic cardiac events and other adverse events following ACAM2000(®) smallpox vaccine in the Vaccine Adverse Event Reporting System. Vaccine 2014; 32:4758-65. [PMID: 24951868 DOI: 10.1016/j.vaccine.2014.06.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 05/22/2014] [Accepted: 06/06/2014] [Indexed: 11/20/2022]
Abstract
BACKGROUND The Vaccine Adverse Event Reporting System (VAERS) is a passive reporting system, used for monitoring the safety of all US licensed vaccines. In March 2008, ACAM2000(®) replaced Dryvax(®) as the only licensed smallpox vaccine and is administered to all persons entering military service and certain civilian researchers. In 2011, routine data mining of VAERS identified a vaccine safety concern resulting in acute ischemic cardiac events (ICE) following ACAM2000(®). METHODS During March 1, 2008 through June 30, 2013, we reviewed all serious reports received following ACAM2000(®)and classified them by diagnostic category. We identified possible ICE cases by searching the Medical Dictionary for Regulatory Affairs (MedDRA(®)) terms for "myocardial ischaemia," "acute myocardial infarction," "myocardial infarction," and "ischaemia," and applied standardized surveillance case definitions. RESULTS VAERS received 1149 reports following ACAM2000(®) administration; 169 (14.7%) were serious (resulting in permanent disability, hospitalization or prolongation of hospitalization, life-threatening illness or death), including one death. The two most frequent diagnostic categories for serious reports were cardiovascular and other infectious conditions. The MedDRA(®) search found 31 reports of possible ICE after receipt of ACAM2000(®) vaccine. Of a total 30 possible ICE cases with demographic information, all but one was male; the age range was 20-45 years (median 32) and median interval to onset of symptoms was 12 days. On clinical review there were 16 cases of myocarditis/pericarditis and 15 ICE cases. CONCLUSIONS Our review of the data mining signal did not substantiate the concerns about ICE after ACAM2000(®). Our study also suggests that with current pre-vaccination screening, cardiac morbidity in generally healthy vaccinated populations remains uncommon.
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48
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Bitar ZI, Swede M, Almerri K. ST elevation without myocardial infarction. BMJ Case Rep 2014; 2014:bcr-2013-201160. [PMID: 24711464 DOI: 10.1136/bcr-2013-201160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Acute myocarditis may mimic myocardial infarction because the affected patients report 'classical' chest pain; the ECG changes and echocardiography are identical to those observed in acute coronary syndromes, and serum markers are increased. We describe a case with ST segment elevation on admission ECG, and coronary angiography was normal. Cardiac magnetic resonance with myocardial delayed enhancement sequences is a non-invasive alternative for diagnosing myocarditis.
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49
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Yahalom M, Roguin N, Suleiman K, Turgeman Y. Clinical Significance of Conditions Presenting with ECG Changes Mimicking Acute Myocardial Infarction. Int J Angiol 2014; 22:115-22. [PMID: 24436595 DOI: 10.1055/s-0033-1343357] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The electrocardiogram (ECG) is the primary tool in the diagnosis of acute myocardial infarction (AMI). However, other clinical conditions, both cardiac and noncardiac originated pathologies, may result in ECG tracing of AMI. This may lead to an incorrect diagnosis, exposing the patients to unnecessary tests and potentially harmful therapeutic procedures. The aim of this report is to increase the still insufficient awareness of clinicians from multiple disciplines, regarding the different clinical syndromes, both cardiac and noncardiac, associated with ECG abnormalities mimicking AMI, to avoid unjustified thrombolytic therapy or intervention procedures. During a 9-year period, the data from six patients (five females, one male; mean age, 50 years [range, 18 to 78 years]) who were admitted to cardiac care unit (CCU) with transient ECG changes resembling AMI were recorded retrospectively. During this 9-year period, 5,400 patients were hospitalized in CCU: 1,350 patients were diagnosed as ST-elevation myocardial infarction (STEMI) and 4,050 patients were diagnosed as non-ST-elevation myocardial infarction (NSTEMI). Only two out of six patients had chest pain with ECG changes criteria suspicious of AMI. STEMI was suspected in four out of six patients. All patients, but one, had normal left ventricular (LV) function. One patient had transient LV dysfunction. All patients, but one, with perimyocarditis, had normal serum cardiac markers. In four out of six patients, who underwent coronary arteries imaging during hospitalization (by angiography or by CT scan), normal coronary arteries were documented. Two patients who underwent ambulatory cardiac CT scan imaging after being discharged from hospital documented patent coronary arteries (case no. 3), or some insignificant irregularities (case no. 4). The discharge diagnoses from CCU were as follows: postictal syndrome, pericarditis, hypothermia, stress-induced ("tako-tsubo") cardiomyopathy, anaphylactic reaction, and status of postchemotherapy. All patients experienced full recovery with normal ECG tracing. During the 5-year follow-up, all patients were alive, and cardiac morbidity was not reported. We conclude that both cardiac and noncardiac clinical syndromes may mimic AMI. Comprehensive clinical examination and profound medical history are crucial for making the correct diagnosis in conditions with ECG changes mimicking AMI.
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Affiliation(s)
- Malka Yahalom
- Heart Institute, HaEmek Medical Center, Afula, Israel
| | - Nathan Roguin
- Rappaport School of Medicine, Technion, Haifa, Israel
| | | | - Yoav Turgeman
- Heart Institute, HaEmek Medical Center, Afula, Israel ; Rappaport School of Medicine, Technion, Haifa, Israel
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50
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Mody KP, Takayama H, Landes E, Yuzefpolskaya M, Colombo PC, Naka Y, Jorde UP, Uriel N. Acute mechanical circulatory support for fulminant myocarditis complicated by cardiogenic shock. J Cardiovasc Transl Res 2014; 7:156-64. [PMID: 24420915 DOI: 10.1007/s12265-013-9521-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 11/19/2013] [Indexed: 11/29/2022]
Abstract
In fulminant myocarditis complicated by cardiogenic shock, early mechanical circulatory support (MCS) may prevent cardiomyopathy and death. We sought to examine the outcomes of patients with fulminant myocarditis supported with MCS. A retrospective review of patients with acute cardiogenic shock treated with MCS from 2007 to 2013 was conducted, and patients with a diagnosis of fulminant myocarditis were included in this series. At our center, 260 patients received MCS for acute cardiogenic shock, and 11 were implanted for fulminant myocarditis. Eight received the Centrimag biventricular assist device (BIVAD), and three received veno-arterial extracorporeal membrane oxygenator (VA ECMO), though 1 VA ECMO-supported patient was transitioned to BIVAD due to refractory shock. The mean acute support time was 14.7 ± 4.4 days. Two patients required long-term left ventricular assist devices and were further supported for 55 and 112 days. Eight patients recovered with a mean ejection fraction of 54 ± 7 %, and one was successfully transplanted. Eight patients survived to discharge (73 %) with mean follow-up: 292.6 ± 306.8 days. All three deaths were due to neurologic complications. MCS should be considered in patients with fulminant myocarditis complicated by shock. With aggressive medical therapy, early utilization of MCS carries promising outcomes.
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Affiliation(s)
- Kanika P Mody
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, New York, NY, 10032, USA
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