Are clinical features and cardiac biomarkers at admission related to severity in pediatric acute myocarditis?: Clinical features and cardiac biomarkers in pediatric acute myocarditis

Using machine learning models based on cardiac magnetic resonance parameters to predict the prognostic in children with myocarditis

OBJECTIVE

To develop machine learning (ML) models incorporating explanatory cardiac magnetic resonance (CMR) parameters for predicting the prognosis of myocarditis in pediatric patients.

MATERIALS AND METHODS

77 patients with pediatric myocarditis diagnosed clinically between January 2020 and December 2023 were enrolled retrospectively. All patients were examined by ultrasound, electrocardiogram (ECG), serum biomarkers on admission, and CMR scan to obtain 16 explanatory CMR parameters. All patients underwent follow-up echocardiography and CMR. Patients were divided into two groups according to the occurrence of adverse cardiac events (ACE) during follow-up: the poor prognosis group (n = 23) and the good prognosis group (n = 54). Four models were established, including logistic regression (LR), random forest (RF), support vector machine classifier (SVC), and extreme gradient boosting (XGBoost) model. The performance of each model was evaluated by the area under the receiver operating characteristic curve (AUC). Model interpretation was generated by Shapley additive interpretation (Shap).

RESULTS

Among the four models, the three most important features were late gadolinium enhancement (LGE), left ventricular ejection fraction (LVEF), and SAXPeak Global Circumferential Strain (SAXGCS). In addition, LGE, LVEF, SAXGCS, and LAXPeak Global Longitudinal Strain (LAXGLS) were selected as the key predictors for all four models. Four interpretable CMR parameters were extracted, among which the LR model had the best prediction performance. The AUC, sensitivity, and specificity were 0.893, 0.820, and 0.944, respectively. The findings indicate that the presence of LGE on CMR imaging, along with reductions in LVEF, SAXGCS, and LAXGLS, are predictive of poor prognosis in patients with acute myocarditis.

CONCLUSION

ML models, particularly the LR model, demonstrate the potential to predict the prognosis of children with myocarditis. These findings provide valuable insights for cardiologists, supporting more informed clinical decision-making and potentially enhancing patient outcomes in pediatric myocarditis cases.

Epidemiology and prognosis of pediatric acute myocarditis: a 5-year retrospective study in Shiraz, South of Iran running title: pediatric acute myocarditis in Iran

BACKGROUND

Early diagnosis, appropriate management, and vigilant follow-up can lead to the recovery and improved quality of life in many pediatric myocarditis cases. Due to the rarity of this condition, a comprehensive understanding of its epidemiology and outcomes is essential.

AIM

This study aims to provide a thorough epidemiological analysis of pediatric clinically suspected myocarditis and introduce a potential prognostic tool for identifying high-risk patients.

METHOD

A retrospective cross-sectional study was conducted on patients admitted to Namazi Hospital with clinically suspected myocarditis. Demographic, clinical, laboratory, imaging data, and vasoactive inotrope scores were collected from the beginning of hospitalization and throughout the patients' stay. Critical hospital events such as cardioversion, intensive care unit (ICU) care, and mechanical ventilation were documented.

RESULTS

A total of 117 children, including 103 (88%) males, were included in the final evaluation. Patients who required intubation had significantly higher inotrope scores (p-value < 0.0001). Moreover, statistically significant differences were observed in the outcomes of patients presenting with hepatomegaly and decreased left ventricular ejection fraction (P = 0.022).

CONCLUSION

The identification of hepatomegaly and reduced ejection fraction as potential prognostic indicators represents a significant contribution to the field. These findings may assist clinicians in recognizing high-risk patients who require more aggressive treatment and closer monitoring. Patients with elevated inotrope scores are more likely to necessitate mechanical ventilation and cardioversion.

Diagnostic efficacy of soluble ST2 in pediatric fulminant myocarditis

Background and aims

Early identification of fulminant myocarditis (FM) is the key to reducing mortality, but there is still a lack of effective biomarkers for diagnosis. The aim of this study was to investigate the value of soluble ST2 (sST2) in identifying FM in children.

Methods

This was a single-center clinical observational study. We consecutively enrolled 144 children younger than 14 years of age diagnosed with viral myocarditis between January 2018 and November 2023, of whom 63 were diagnosed with FM.

Results

The sST2 level in the FM group was significantly higher than that in the non-FM group [104.40 (68.80, 150.10) vs. 38.30 (19.85, 55.05), p < 0.001]. ROC curves showed that the optimal cut-off values of sST2, TNI, NT-proBNP and CRP for FM were 63.8 ng/ml, 13.3 ng/ml, 3182 pg/ml and 26.5 mg/L, respectively. The sensitivity and specificity of sST2 were 84.13% and 88.9%, indicating the highest early diagnosis efficiency. Multifactorial correction showed that sST2 ≥ 63.8 ng/ml and NT-proBNP ≥ 3182 pg/ml were independent diagnostic predictors of FM (OR = 22.374, 95% CI: 8.140 ∼ 61.499, P < 0.001), and (OR = 3.208, 95% CI: 1.163 ∼ 8.846, P = 0.024).

Conclusions

With high sensitivity and specificity, sST2 may serve as a strong predictor of pediatric FM.

Clinical Significance of B-Type Natriuretic Peptide and N-Terminal Pro-B-Type Natriuretic Peptide in Pediatric Patients: Insights into Their Utility in the Presence or Absence of Pre-Existing Heart Conditions

The clinical significance of B-type natriuretic peptide (BNP) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) in pediatric patients remains an area of evolving understanding, particularly regarding their utility in the presence or absence of pre-existing heart conditions. While clear cutoff values and established roles in heart failure are understood in adult patients, pediatric norms vary with age, complicating interpretation. Notably, the emergence of multi-system inflammatory syndrome in children (MIS-C) has highlighted the importance of these markers not only in the detection of acute heart failure but also as a marker of disease severity and even as a differential diagnosis tool. This review summarizes current knowledge on the utility of BNP and NT-proBNP in pediatric patients. Their unique physiology, including circulation and compensation mechanisms, likely influence BNP and NT-proBNP release, potentially even in non-heart failure states. Factors such as dynamic volemic changes accompanying inflammatory diseases in children may contribute. Thus, understanding the nuanced roles of BNP and NT-proBNP in pediatric populations is crucial for the accurate diagnosis, management, and differentiation of cardiac and non-cardiac conditions.

Pediatric Chest Pain: A Review of Diagnostic Tools in the Pediatric Emergency Department

Pediatric chest pain is a common chief complaint in the emergency department. Not surprisingly, children with chest pain are usually brought to the emergency department by their parents out of fear of heart disease. However, chest pain in the pediatric population is generally a benign disease. In this review, we have identified musculoskeletal pain as the most prevalent etiology of chest pain in the pediatric population, accounting for 38.7-86.3% of cases, followed by pulmonary (1.8-12.8%), gastrointestinal (0.3-9.3%), psychogenic (5.1-83.6%), and cardiac chest pain (0.3-8.0%). Various diagnostic procedures are commonly used in the emergency department for cardiac chest pain, including electrocardiogram (ECG), chest radiography, cardiac troponin examination, and echocardiography. However, these examinations demonstrate limited sensitivity in identifying cardiac etiologies, with sensitivities ranging from 0 to 17.8% for ECG and 11.0 to 17.2% for chest radiography. To avoid the overuse of these diagnostic tools, a well-designed standardized algorithm for pediatric chest pain could decrease unnecessary examination without missing severe diseases.

Heart Disease and Arboviruses: A Systematic Review and Meta-Analysis

Dengue fever, chikungunya, and zika are highly prevalent arboviruses transmitted by hematophagous arthropods, with a widely neglected impact in developing countries. These diseases cause acute illness in diverse populations, as well as potential cardiovascular complications. A systematic review was carried out to investigate the burden of cardiac involvement related to these arboviruses. Multiple databases were searched for articles that investigated the association of cardiovascular diseases with arboviruses, published up to March 2022. Relevant articles were selected and rated by two independent reviewers. Proportion meta-analysis was applied to assess the frequency-weighted mean of the cardiovascular findings. A total of 42 articles were selected (n = 76,678 individuals), with 17 manuscripts on dengue and 6 manuscripts on chikungunya undergoing meta-analysis. The global pooled incidence of cardiac events in dengue fever using a meta-analysis was 27.21% (95% CI 20.21–34.83; I² = 94%). The higher incidence of dengue-related myocarditis was found in the population younger than 20 years old (33.85%; 95% CI 0.00–89.20; I² = 99%). Considering the studies on chikungunya (n = 372), the global pooled incidence of cardiac involvement using a meta-analysis was 32.81% (95% CI 09.58–61.49, I² = 96%). Two Zika studies were included that examined cases of infection by vertical transmission in Brazil, finding everything from structural changes to changes in heart rate variability that increase the risk of sudden death. In conclusion, cardiac involvement in arboviruses is not uncommon, especially in dengue fever.