Brazilian Society of Cardiology Guideline on Myocarditis - 2022

Management of acute myocarditis: a systematic review of clinical practice guidelines and recommendations

The management of acute myocarditis (AM) is addressed in multiple clinical guidelines. We systematically reviewed current guidelines developed by national and international medical organizations on the management of AM to aid clinical practice. Publications in MEDLINE, EMBASE and Cochrane were identified between 1 January 2013 and 12 April 2024. Additionally, the websites of relevant organizations and the Guidelines International Network, Guideline Central, and NHS knowledge and library hub were reviewed. Two reviewers independently screened titles and abstracts, two reviewers assessed the rigour of guideline development, and one reviewer extracted the recommendations. Two of the three guidelines identified showed good rigour of development. Those rigorously developed agreed on the definition of AM, sampling serum troponin as part of the workflow for AM, testing for B-type natriuretic peptides in heart failure, key diagnostic imaging in the form of cardiovascular magnetic resonance, coronary angiography to exclude significant coronary disease, indications for endomyocardial biopsy (EMB), and indications for immunosuppression and advanced treatment options. Discrepancies exist in sampling creatine kinase-myocardial bound as a marker of myocardial injury, indications for EMB, and indications for immunosuppression and treatment of uncomplicated AM. Evidence is lacking for the use of 18F-Fluorodeoxyglucose Positron Emission Tomography for myocardial imaging, exercise restriction, follow-up measures, and genetic testing, and there are few high-quality randomized trials to support treatment recommendations. Recommendations for management of AM in the guidelines have largely been developed from expert opinion rather than trial data.

Effectiveness and Safety of Shengmai San for Viral Myocarditis: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Shengmai San (SMS) is a traditional Chinese medicine formula used for supplementing Qi and Yin and can mitigate symptoms related to malignant arrhythmia and heart failure. This systematic review aimed at exploring the effectiveness and safety of SMS for viral myocarditis (VMC). Methods: Eight databases from their inception to June 2023 were searched to identified randomized controlled trials (RCTs) focusing on SMS for VMC. The Cochrane Risk of Bias Tool was used to assess methodological quality. Mean difference (MD), standardized mean difference (SMD), and risk ratio (RR) with 95% confidence interval (CI) were calculated and input into the meta-analysis using RevMan 5.4. Results: Forty-four RCTs were included involving 4298 participants. The interventions included 29 types of modified SMS decoctions and 15 patent medicines. Overall study quality was low. Compared with western medicine (WM), SMS was associated with higher recovery rate from palpitations (RR 2.3, 95% CI 1.59, 3.33, 2 RCTs, n = 89), chest pain (RR 1.57, 95% CI [1.17, 2.09], 2 RCTs, n = 89), and lower cTnI (MD -0.82 ng/ml, 95% CI -0.98, -0.66, 1 RCT, n = 60). SMS plus WM was more effective than WM in palpitation recovery rate (RR 1.52, 95% CI 1.21, 1.92, 3 RCTs, n = 136), dyspnea recovery rate (RR 1.47, 95% CI 1.12, 1.94, 3 RCT, n = 267), ECG (RR 1.43, 95% CI 1.32, 1.55, 20 RCT, n = 2035), CK-MB (MD -6.36, 95% CI -8.43, -4.28, 8 RCT, n = 946), and cTnI (MD -0.06, 95% CI -0.06, -0.05, 3 RCT, n = 307). No serious adverse events were reported using SMS alone or in combination with WM. Conclusion: SMS used alone or combined with WM may have potential effectiveness on symptom alleviation, ECG recovery rate, myocardial injury markers, and cardiac function, but the effectiveness is uncertain due to the low quality and absence of placebo-controlled trials. The exact efficacy of SMS for VMC needs to be confirmed by high-quality double-blind RCTs in the future.

Management of Metastatic Urothelial Carcinoma in Emerging Markets (EM): An Expert Opinion

Urothelial carcinoma (UC) is the 10th most common cancer globally with an almost 4 times higher prevalence in men. The main risk factors for development of urothelial carcinoma are advanced age, smoking, arsenic contamination, exposure to carcinogens. Metastatic urothelial carcinoma (mUC) has overall poor prognosis with a 5-year overall survival rate of only < 5%. The standard of care comprises of platinum-based chemotherapy, but the responses are often not sustained. A working group was established with an objective to discuss the most recent clinical data on the genitourinary tumors of interest and comprised of experts across Latin America, Emerging Asia (except China, Japan, and South Korea), Africa, and the Middle East (known as Emerging Markets or EM). There is an evident disparity in terms of uneven mortality and incidence rate distribution among various regions. There is a lack and/or insufficient data on epidemiology, treatment, and outcomes in the EM. The lack of registries impacts the healthcare decisions and the lower incidence from the region might not be reflective of the true disease burden. The treatment outcomes of mUC can be improved by understanding the current disease burden and treatment approach of mUC and identifying the gaps and challenges associated with management. Hence, a literature review was developed to summarize the current disease burden and treatment approach of mUC across EM. The review also highlights the unmet needs for mUC management in EM and suggests a way forward to improve the current situation in order to better serve the patients.