Prevalence and Significance of an Early Repolarization Electrocardiographic Pattern and Its Mechanistic Insight Based on Cardiac Magnetic Resonance Imaging in Patients With Acute Myocarditis

Chlamydia psittaci-related pleuro-myocarditis

Chlamydia psittaci ‒ related community-acquired pneumonia associated to acute myocarditis was diagnosed in a young man with no medical history, and a professional exposition to birds. The diagnosis was confirmed with positive specific polymerase chain reaction in bronchoalveolar lavage. The patient was treated with spiramycin for two weeks with anti-inflammatory treatment for myocarditis for three months. Clinical and biological improvement was rapidly observed followed by normalization of electrocardiogram and chest CT scan. No relapse was reported for over a two-year follow-up.

Association between ECG parameters and late gadolinium enhancement along the course of myocarditis

PURPOSE

Numerous electrocardiogram (ECG) abnormalities and late gadolinium enhancement (LGE) in cardiac magnetic resonance imaging (CMR) have been related to poor prognosis in acute myocarditis. We evaluated whether ECG parameters are associated with the distribution and dynamic of LGE along the course of myocarditis.

METHODS

Fifty-one patients with CMR confirmed acute myocarditis were included who underwent CMR with LGE and 12-lead ECG at baseline and 3-month follow-up at our institution. The association between the presence, regional distribution and change of ECG parameters and LGE was investigated using linear regression analysis. LGE was quantified as visual presence score (VPS) and visual transmurality score (VTS).

RESULTS

Among many ECG parameters only > 1 mm ST-elevation (STE) was associated with VPS and VTS at baseline (β = 3.08 [95%CI: 1.75; 4.41], p = < 0.001 and β = 5.40 [95%CI: 1.92; 8.88], p = 0.004; respectively). STE was most frequent in lateral and inferior ECG-leads (48% and 31%) and it was associated with VPS and VTS in these localizations (p < 0.05 all), however no association between anterior-septal STE and LGE could be confirmed. At follow-up the regression of STE was associated with the regression of VPS and VTS in univariate analysis (β=-1.49 [95%CI: -2.41; -0.57], p = 0.003 and β=-4.87 [95%CI: -7.18; -2.56], p = 0.001, respectively), which remained significant for VTS using a multivariate model (β=-2.39 [95%CI: -3.32; -0.47], p = 0.019).

CONCLUSION

Although we demonstrated some promising associations between STE and LGE, the usability of ECG to estimate the territorial involvement and dynamical changes of LGE along the course of myocarditis is generally limited and cardiac magnetic resonance should be considered for this purpose.

Clinical and electrocardiographic characteristics in patients with fulminant myocarditis

Background

The purpose of this study was to evaluate clinical and electrocardiographic characteristics in patients with fulminant myocarditis.

Methods

A total of 72 patients were divided into three groups: pericarditis (control: n = 25), acute myocarditis (n = 27), and fulminant myocarditis (n = 20). Patients' characteristics and electrocardiograms on admission were retrospectively analyzed in the three groups.

Results

BNP levels in the fulminant group were significantly higher than those in the other two groups. ST elevation was observed at lead aVR in the fulminant myocarditis group, whereas ST depression was observed at lead aVR in the other groups (p = .001). The maximum degree of ST elevation among the three groups was similar. However, the number of ST‐elevation leads in the fulminant myocarditis group was significantly lower than that in the other groups (p = .004). The voltage of R wave in lead V5 in the fulminant myocarditis group was significantly lower than that in the other groups (p = .005). Moreover, in the Cabrera sequence, the prevalence of ST elevation in the inferior leads, aVR, and V3–V6 in the fulminant myocarditis group was significantly or nearly significantly lower than that in the other groups.

Conclusions

In fulminant myocarditis, ST‐segment elevation was observed in lead aVR, and contrarily, the number and extent of ST‐segment elevation and R wave voltage were smaller than those in the other groups. These results suggest that the number of myocytes with maintained action potential may be reduced following progressive myocardial damage and interstitial edema due to severe inflammation.

Early Repolarization Pattern and Idiopatic Sustained Monomorphic Ventricular Tachycardia: an Infrequent Combination

Malignant early repolarization as cause of sudden death has taken on great importance in recent years. It has been described as an entity capable of producing ventricular arrhythmic events, causing from episodes of syncope to sudden cardiac death. Ventricular fibrillation is the typical arrhythmia in these patients, with no clear relationship to date with idiopathic monomorphic ventricular tachycardia. Electrocardiographic markers related to the development of arrhythmic events in early repolarization syndrome have been described. They seem not only related to the development of ventricular fibrillation, but also to sustained monomorphic ventricular tachycardia, as is the case described in the article.

Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes

Fulminant myocarditis (FM) is characterized by a rapid progressive decline in cardiac function and a high mortality rate. Since the first report of FM patients in the 1980s, several clinical trials and research studies have been published increasing our knowledge regarding FM. Currently, the diagnosis of FM depends on various techniques including electrocardiography, echocardiography, endomyocardial biopsy, and cardiac magnetic resonance. The development of mechanical circulation support (MCS) devices and progress in our understanding of the pathophysiological mechanisms underlying FM, treatment regimens have evolved from simple symptomatic treatment to a life support-based comprehensive treatment approach. The core mechanism underlying the development of FM is the occurrence of an inflammatory cytokine storm. This review provides a comprehensive account of the current understanding of FM pathophysiology and knowledge regarding its etiology, pathophysiology, treatments, and outcomes.

Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review

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.