Acute myocarditis: aetiology, diagnosis and management

Global, regional, and national burden of myocarditis and its attributable risk factors in 204 countries and territories from 1990 to 2021: updated systematic analysis

Background

Comprehending the current epidemiological trends and risk factors of myocarditis is crucial for guiding future targeted prevention and treatment strategies.

Methods

Utilizing data from the Global Burden of Diseases, Injuries, and Risk Factors Study 2021, we conducted a secondary analysis of the incidence, prevalence, death, and disability-adjusted life years (DALYs) of myocarditis by sex, age group and socio-demographic index (SDI) across 204 countries and territories from 1990 to 2021. And non-optimal temperatures, defined as same-day exposure to ambient temperatures deviating from the minimum death risk threshold, were identified as risk-factors for myocarditis-related death and DALYs.

Results

From 1990 to 2021, the global prevalence of myocarditis increased from 320,623 (95% uncertainty interval: 268,557 to 371,912) to 505,030 (432,295 to 587,819). Concurrently, the age-standardized prevalence rate (ASPR) per 100,000 people also saw a slight increase (no statistical significance) from 6.35 (5.37 to 7.36) to 6.41 (5.48 to 7.44). However, the age-standardized incidence rate (ASIR), age-standardized death rate (ASDR) and age-standardized DALY rate (ASYR) exhibited declines, with estimated annual percentage changes of -0.20 (-0.23 to -0.17), -1.37 (-1.81 to -0.92) and -1.71 (-1.95 to -1.46), respectively. SDI quintile analysis showed that the high SDI quintile had the highest ASIR and ASPR, while the middle and high-middle SDI quintiles exhibited the highest ASDR and ASYR. Furthermore, the burden of myocarditis was notably high among males and older adult populations. Non-optimal temperature, particularly low temperature, emerged as a key risk factor for myocarditis-related ASDR and ASYR.

Conclusion

Although the ASIR, ASDR and ASYR for myocarditis exhibited decreasing trends from 1990 to 2019, further efforts are needed to develop targeted public health strategies, especially for low SDI regions, males, and older adult populations.

Multifaceted roles of neutrophils in cardiac disease

Neutrophils, the most abundant leukocytes in human blood, have long been recognized as critical first responders in the innate immune system's defense against pathogens. Some of the more notable innate antimicrobial properties of neutrophils include generation of superoxide free radicals like myeloperoxidase, production of proteases that reshape the extracellular matrix allowing for easier access to infected tissues, and release of neutrophil extracellular traps, extruded pieces of DNA that ensnare bacterial and fungi. These mechanisms developed to provide neutrophils with a vast array of specialized functions to provide the host defense against infection in an acute setting. However, emerging evidence over the past few decades has revealed a far more complex and nuanced role for these neutrophil-driven processes in various chronic conditions, particularly in cardiovascular diseases. The pathophysiology of cardiac diseases involves a complex interplay of hemodynamic, neurohumoral, and inflammatory factors. Neutrophils, as key mediators of inflammation, contribute significantly to this intricate network. Their involvement extends far beyond their classical role in pathogen clearance, encompassing diverse functions that can both exacerbate tissue damage and contribute to repair processes. Here, we consider the contributions of neutrophils to myocardial infarction, heart failure, cardiac arrhythmias, and nonischemic cardiomyopathies. Understanding these complex interactions is crucial for developing novel therapeutic strategies aimed at modulating neutrophil functions in these highly morbid cardiac diseases.

Characterization of Cardiovascular Events and Prognosis in Immune Checkpoint Inhibitor-Related Myocarditis

OBJECTIVE

To evaluate the incidence, timing, and characteristics of immune checkpoint inhibitor-related myocarditis (ICIrM) and associated cardiovascular events at 3-year follow-up.

METHODS

All patients treated with immune checkpoint inhibitors (ICIs) at a multicenter institution from 2011 to 2022 were retrospectively reviewed for ICIrM. A propensity score-matched control group was identified from patients treated with ICIs without development of myocarditis (ratio of 1:4). Baseline characteristics, cardiovascular events, and mortality outcomes were manually curated during extended 3-year follow-up. Major adverse cardiovascular events (MACE) were defined as transient ischemic attack/stroke, heart failure, and myocardial infarction.

RESULTS

Of 5423 patients treated with ICIs, ICIrM occurred in 59 (1.1%), and 236 propensity score-matched patients who received ICIs without myocarditis were identified as controls. Mean age was 68.5 ± 12.3 years; 65.4% were male. Median time to development of ICIrM was 44 days (interquartile range, 28 to 102 days), with median troponin value of 364 ng/L (interquartile range, 115 to 1224 ng/L). Patients with ICIrM had increased risk of cardiac death (hazard ratio [HR], 34.0; 95% CI, 7.8 to 148.0; P<.001), MACE (HR, 5.0; 95% CI, 3.1 to 8.1; P<.001), ventricular tachycardia (HR, 12.3; 95% CI, 1.3 to 118.4; P=.03), and complete heart block (HR, 2.3; 95% CI, 1.0 to 5.1; P=.046); these occurred predominantly within 120 days after diagnosis of ICIrM. Triple-M syndrome (myocarditis, myasthenia, and myositis) occurred in 12 (20.3%), with increased risk for all-cause mortality (HR, 2.1; 95% CI, 1.0 to 4.1; P=.04) but not for cardiac death or MACE.

CONCLUSION

Immune checkpoint inhibitor-related myocarditis is associated with increased cardiovascular events that are further characterized on extended follow-up, with most occurring in the first 4 months after diagnosis.

An Injectable Multifunctional Nanosweeper Eliminates Cardiac Mitochondrial DNA to Reduce Inflammation

Myocarditis, a leading cause of sudden cardiac death and heart transplantation, poses significant treatment challenges. The study of clinical samples from myocarditis patients reveals a correlation between the pathogenesis of myocarditis and cardiomyocyte mitochondrial DNA (mtDNA). During inflammation, the concentration of mtDNA in cardiomyocytes increases. Hence, it is hypothesized that the combined clearance of mtDNA and its downstream STING pathway can treat myocarditis. However, clearing mtDNA is problematic. An innovative mtDNA scavenger is introduced, Nanosweeper (NS), which utilizes its nanostructure to facilitate the transport of NS-mtDNA co-assemblies for degradation, achieving mtDNA clearance. The fluorescent mtDNA probe on NS, bound to functional peptides, enhances the stability of NS. NS also exhibits robust stability in human plasma with a half-life of up to 10 hours. In a murine myocarditis model, NS serves as a drug delivery vehicle, targeting the delivery of the STING pathway inhibitor C-176 to the myocardium. This approach synergistically modulates the cGAS-STING axis with NS, effectively attenuating myocarditis- associated inflammatory cascade. This evaluation of NS in porcine models corroborated its superior biosafety profile and cardiac targeting capability. This strategic approach of targeted mtDNA clearance couple with STING pathway inhibition, significantly augments therapeutic efficacy against myocarditis, outperforming the conventional drug C-176, indicating its clinical potential.

Fulminant Influenza Myocarditis Requiring Extracorporeal Membrane Oxygenation (ECMO) Support

Viral infections may lead to myocarditis, which is inflammation of the myocardium. This inflammation, when severe enough, can result in left ventricular dysfunction and potentially reduce the left ventricular ejection fraction (LVEF). In rare cases, the effects of this inflammation lead to hemodynamic changes that can be life-threatening. We discuss a case of a 38-year-old female recently diagnosed with influenza A (H3 subtype) who presented to our institution's emergency department for evaluation after an episode of syncope, as well as intermittent chest pressure and dyspnea on exertion. Initial vitals displayed a heart rate of 87 bpm and blood pressure of 105/66 mmHg. The physical examination demonstrated a regular rhythm, no lower extremity edema, and lungs that were clear to auscultation. She was found to have an elevated pro-B-type natriuretic peptide level of 6152 pg/mL and a positive influenza A polymerase chain reaction (PCR) test. A transthoracic echocardiogram (TTE) was obtained and demonstrated globally reduced left ventricular systolic function with an estimated ejection fraction of 28%, as well as reduced right ventricular systolic function. Over the next six hours, the patient became progressively tachycardic and hypotensive, with a heart rate of 135 bpm and a blood pressure measured at 46/28 mmHg. She was initially admitted to the cardiovascular ICU and started on dobutamine and vasopressin. Pulmonary artery catheterization was completed for better evaluation of cardiogenic shock, and it demonstrated a severely reduced cardiac index of 0.9 L/min/m2. Due to concerns of worsening cardiogenic shock and impending circulatory collapse, mechanical circulatory support was initiated via veno-arterial extracorporeal membrane oxygenation (VA-ECMO), and she was admitted to the cardiothoracic surgery ICU. Several days later, a biventricular assist device (BiVAD) was implanted with the goal of discontinuing ECMO as a bridge to transplant. Shortly afterwards, a repeat echocardiogram demonstrated a normalized left and right ventricular systolic function, and the BiVAD was removed. Ten days after the initiation of ECMO, it was able to be discontinued, and the patient was decannulated. The patient was discharged home in stable condition. This case exemplifies how fulminant myocarditis (FM) can have positive outcomes, even in critically ill patients, when the timing of intervention is early and aggressive.

Systematic Review of COVID-19 and COVID-19 mRNA Vaccine Myocarditis in Athletes: Incidence, Diagnosis, Prognosis, and Return-to-Play Principles

OBJECTIVE

The purpose of this systematic review is to evaluate the original peer-reviewed studies on athletes who developed myocarditis after coronavirus disease (COVID-19) infection or after COVID-19 mRNA vaccination. Both entities likely have an immunologic component. We discuss elite, professional, college, and adolescent athletes. The athletes are generally young and healthy, representing a distinctive population group that differs from the general population. This review includes diagnosis of myocarditis, incidence, complications, prognosis, and return-to-play guidance for sports medicine clinicians and coaches.

DATA SOURCES

We surveyed the PUBMED, Embase, and Web of Science databases for the relevant peer-reviewed articles in the English language published from the onset of the pandemic until April 2023. Included were original observational studies and case series. Excluded were individual case reports and a small series with incomplete data. The resulting search yielded 30 original articles.

MAIN RESULTS

Reported myocardial abnormalities in athletes were rare after COVID-19 infection and even less frequent after COVID-19 mRNA vaccination. True incidence, however, may be higher because of under-reporting and frequent asymptomatic presentation. Male gender was prevalent for both manifestations; postvaccination myocarditis occurrence was the highest after the second vaccine dose. Diagnostic and return-to-play algorithms were developed and should be adopted and followed.

CONCLUSIONS

The risk of myocarditis from COVID-19 infection and COVID-19 mRNA vaccination is very low. The long-term prognosis and evolution of the observed cardiac magnetic resonance abnormalities are currently unknown. Although inferences can be made from the published data, COVID-19 and postvaccine myocarditis in athletes may represent only a small fraction of the true incidence of those who have been affected worldwide and not evaluated.

Leonurine alleviates doxorubicin-induced myocarditis in mice via MAPK/ERK pathway inhibition

OBJECTIVE

To investigate the effects of naturally derived leonurine (Leo) on doxorubicin (Dox)-induced myocarditis and analyze its potential mechanisms.

METHODS

Dox was intraperitoneally injected to establish a myocardial injury model in mice. The effect of Leo on inflammatory cytokine levels in myocardial tissue was assessed by ELISA. Pathological changes in myocardial tissue and apoptosis in myocardial cells were observed using hematoxylin-eosin (HE) and terminal deoxynucleotidyl transferase dUTP nick-end labeling (TUNEL) staining. Protein levels were analyzed by Western blot (WB). Mouse myocardial H9c2 cells were divided into control group, Dox group, Leo (10 μmol/L) + Dox group, and Leo (20 μmol/L) + Dox group. Cell viability was assessed using Cell Counting Kit-8 (CCK8), and the levels of inflammatory cytokines were measured. The oxidation level and protein levels in H9c2 cells were also detected.

RESULTS

Leo significantly reduced the levels of inflammatory cytokines in both serum and cell culture supernatant. Additionally, Leo also decreased the levels of inflammatory cytokines in cardiac tissue. Moreover, Leo suppressed Dox-induced myocardial cell apoptosis by modulating the BCL2 signaling pathway. In vitro studies revealed that both inflammatory cytokines and oxidative stress markers were decreased after treatment with Leo.

CONCLUSION

Leo exerts significant cardioprotective effects through anti-inflammatory mechanisms, likely mitigating Dox-induced myocardial inflammation by inhibiting the activation of MAPK/ERK pathways. These findings highlight Leo's potential as a promising cardioprotective agent, underscoring its therapeutic promise.

Myopericarditis and Pericardial Effusion as the Initial Presentation of Systemic Lupus Erythematosus in a Patient with Sickle Cell Trait: A Case Report

Background: Systemic lupus erythematosus (SLE) is a chronic autoimmune disease with rare but severe cardiac manifestations, including myocarditis and pericarditis. The coexistence of SLE with sickle cell trait (SCT), an inherited hemoglobinopathy prevalent among individuals of African descent, is exceptionally rare and presents significant diagnostic challenges due to overlapping clinical features. Objective: To describe the case of an Afro-Ecuadorian male with SLE and sickle cell trait who developed an uncommon presentation of myopericarditis and pericardial effusion. Case report: A 48-year-old African American male with no prior medical history presented with persistent fever, polyarticular arthralgias, and pleuritic chest pain. Investigations revealed sickle cell trait (SCT) and myopericarditis with pericardial effusion, marking the initial manifestation of SLE. Diagnostic delays occurred due to overlapping symptoms and a family history of sickle cell disease. Laboratory findings showed elevated hemoglobin S (<50%), positive ANA (1:1280, coarse speckled pattern), and anti-Smith/RNP antibodies, meeting EULAR/ACR 2019 criteria for SLE. Cardiac MRI confirmed myopericarditis. Treatment with pulse methylprednisolone, oral prednisone, and mycophenolate mofetil resulted in clinical improvement, with stable disease control on immunomodulatory therapy during follow-up. Conclusions: This case highlights the diagnostic complexity of SLE in patients with SCT, particularly when presenting with myopericarditis as the initial manifestation. It emphasizes the importance of a comprehensive diagnostic approach and timely initiation of immunosuppressive therapy to optimize clinical outcomes. This report broadens the understanding of overlapping syndromes involving SLE and SCT.

Assessing outcomes of acute myocarditis in Saudi Arabia: A retrospective tertiary center experience

OBJECTIVES

To assess the clinical course and long-term outcomes of complicated and uncomplicated AM in Saudi Arabia. Acute myocarditis (AM) can have different presentations and outcomes based on different factors, one of which is left ventricular ejection fraction (LVEF).

METHODS

Data from 382 patients with suspected AM, admitted between January 2016 and October 2023, were reviewed. Clinical course, in-hospital complications, and all-cause mortality were evaluated in both the acute and follow-up phases. Outcomes were compared between 2 groups: LVEF <50% (n=43); and normal LVEF (≥50% [n=41]) at presentation.

RESULTS

Data from 84 patients (mean [±SD] age, 33.5±10.2 years; 26.2% female) who fulfilled the inclusion criteria were analyzed. The most common symptom was chest pain (83.3%) and 11 (13.1%) patients had fulminant presentation. ST-T changes were found on electrocardiography in 45.2% of patients. The mean LVEF was 46±12.4% at presentation. Patients in the LVEF <50% group were significantly more likely to experience a first-time cardiac-related adverse event (CRAE) (hazard ratio 2.6 [95% confidence interval 1.1-6.2]; p=0.031) with a mean time of 38.8±3.8. The all-cause in-hospital and follow-up mortality rates in the LVEF <50% group were 4.7% (one-half cardiac-related) (p=0.494) and 4.7% (all cardiac-related) (p=0.494), respectively.

CONCLUSION

Of 84 patients diagnosed with AM, those with LVEF <50% were more likely to experience first-time CRAEs and exhibited low short- and long-term mortality rates.

Global, regional, and national burden of myocarditis in children aged 0-14 years, 1990-2021: analysis for the global burden of disease study 2021

Objective

There are limited epidemiological data on myocarditis in children aged 0-14 years. This study aims to investigate the trends in incidence, mortality, disability-adjusted life years (DALYs), and corresponding estimated annual percentage change (EAPC) of myocarditis in children aged 0-14 years from 1990 to 2021.

Methods

We utilized the 2021 Global Burden of Disease, Injuries, and Risk Factors Study (GBD) analytical tools to examine the incidence, mortality, and DALYs of myocarditis in children aged 0-14 years, considering factors such as age, sex, region, sociodemographic index (SDI), and data from 204 countries or regions.

Results

In 2021, a total of 155.45/1000 people cases of myocarditis were reported globally in children. The cases of myocarditis in children increased from 143.80/1000 people (95% uncertainty interval [UI], 93.13-214.67) in 1990 to 155.45/1000 people (95% UI, 100.31-232.31) in 2021, increasing by 8.1% (95% UI, 6.04-9.73%). Over 30 years, the global incidence rate decreased from 8.27 (95% UI, 5.35-12.34) to 7.73 (95% UI, 4.99-11.55) per 100,000 population. The myocarditis-associated mortality rate decreased from 0.36 (95% UI, 0.25-0.51) to 0.13 (95% UI, 0.10-0.16) per 100,000 population. In 2021, the highest incidence of myocarditis in children occurred in High SDI regions. Regionally, High-income Asia Pacific had the greatest increase in incidence (EAPC, 0.25; 95% CI, 0.22-0.28). Japan had the highest incidence rate of myocarditis in children, while Haiti reported the highest myocarditis-associated mortality rate and DALYs rate. Globally, environmental/occupational risk, nonoptimal temperature, high temperature, and low temperature were key risk factors for myocarditis-associated mortality in children.

Conclusion

Between 1990 and 2021, myocarditis in children saw declining mortality and DALYs but rising incidence, especially in males. Children under 1 year face higher mortality and DALY rates despite lower incidence, stressing early diagnosis. High SDI regions report higher incidence but lower mortality, while low SDI areas need standardized treatment. Japan had the highest 2021 incidence, and China had the most deaths. Underscoring the urgency for enhanced medical resources, comprehensive research into the disease's etiology, and improved prevention strategies.

Management Status of Myocarditis-Related Sudden Cardiac Death

Myocarditis, a life-threatening disease that can result in cardiac arrest and sudden cardiac death, has garnered significant attention in recent years. This review provides a comprehensive overview of the management of myocarditis-related sudden cardiac death, encompassing its pathology, diagnostic methods, therapeutic strategies, preventive measures, prognostic factors, and risk stratification. Additionally, the review highlights current challenges and future directions in this field. The aim is to enhance understanding of myocarditis-related sudden cardiac death and inform clinical practice, ultimately leading to improved patient outcomes.

Reversible Dilated Cardiomyopathy Associated With Herpes Simplex Virus Infection: A Case Report

Dilated cardiomyopathy (DCM) is a serious condition often leading to acute heart failure (HF), with diverse etiologies including viral myocarditis. This report details a case of reversible DCM in a 34-year-old male who presented with symptoms of acute HF. Diagnostic workup revealed biventricular dilation with severe systolic dysfunction and serology confirming herpes simplex virus infection. The patient was treated with standard HF therapy and colchicine, leading to significant clinical improvement. Despite the positive viral serology, antiviral therapy was not initiated due to the patient's marked recovery, underscoring the controversial role of antivirals in viral myocarditis-associated DCM. At a one-year follow-up, the patient demonstrated substantial recovery of cardiac function. This case highlights the potential for favorable outcomes with comprehensive management, even in the absence of antiviral therapy, and emphasizes the need for individualized treatment strategies in DCM related to viral myocarditis.

Endomyocardial biopsy in patients with myocarditis-still justified in the CMR era? A single-centre experience

BACKGROUND

In the past decades, cardiovascular magnetic resonance (CMR) was established as a non-invasive tool supporting the diagnosis of myocarditis and there is often reluctance in performing EMB due to potentially severe complications. We sought to identify patient subgroups that could still benefit from EMB in the CMR era.

METHODS

Data of patients presenting with myocarditis between 01/2016 and 06/2023 were analysed according to patient risks. Prespecified risk factors were (i) left ventricular ejection fraction (LVEF) ≤ 30%; (ii) severe arrhythmias; or (iii) pre-existing autoimmune disease. Furthermore, the subgroup of recurrent myocarditis cases was analysed separately.

RESULTS

A total of 137 patients (35.5 ± 14.8 years, 80.3% male) were included. 26/137 patients had a documented LVEF ≤ 30%, 13/137 a LVEF > 30% with at least one other risk factor and 98/137 a LVEF > 30% without risk factors. EMB was performed in 21/26 patients with LVEF ≤ 30% (80.8%), in 7/13 patients with LVEF > 30% and risk factors (53.8%) and in 16/98 (16%) patients without risk factors. EMB led to the initiation of immunosuppressive therapy in 11/28 patients with risk factors (39.3%) and in none of the patients without risk factors (0/16, 0%, p = 0.003). With respect to the subgroup of patients presenting with recurrent myocarditis (n = 10), no specific therapy was initiated.

CONCLUSIONS

Due to a high therapeutic yield for initiation of immunosuppressive therapy in non-infectious myocarditis, performing EMB should be considered in all high-risk patients. In patients without clinical risk factors including cases of recurrent or relapsing myocarditis no specific therapy was initiated.

Ibuprofen for Acute Pericarditis and Associated Cardiovascular Risks: A Danish Nationwide, Population-Based Cohort Study

Purpose

Ibuprofen is used to treat acute pericarditis, but high-dose ibuprofen has also been associated with increased cardiovascular risks. We examined the cardiovascular safety of using ibuprofen for acute pericarditis.

Patients and Methods

A Danish nationwide, population-based cohort study including patients ≥18 years with first-time acute pericarditis (n=12,381) during 1996-2020 was conducted. Ibuprofen use was modelled in two ways: First, we considered patients exposed based on the tablet strength of their first ibuprofen filling (a proxy for an intention-to-treat analysis). Second, we considered patients exposed in a time-varying manner (a proxy for an as-treated analysis). The primary outcome of major adverse cardiovascular events (MACE) was a composite of myocardial infarction, ischemic stroke, congestive heart failure, and cardiovascular death.

Results

In the intention-to-treat analysis, the 1-year risk of MACE was 1.37% (95% confidence interval [CI]: 1.03-1.79) for ibuprofen initiators and 4.32% (95% CI: 3.89-4.78) for non-initiators. Compared with non-initiators within 1-year follow-up, the adjusted hazard ratio for MACE was 0.75 (95% CI: 0.67-0.85) for initiators overall, 0.38 (95% CI: 0.28-0.52) for initiators of >400 mg tablets, and 0.87 (95% CI: 0.76-0.99) for initiators of ≤400 mg tablets. In the as-treated analysis, compared with no use, the hazard ratio associated with ibuprofen use was 0.69 (95% CI: 0.54-0.89) for MACE, 0.82 (95% CI: 0.54-1.26) for myocardial infarction, 0.74 (95% CI: 0.45-1.22) for ischemic stroke, 0.67 (95% CI: 0.47-0.96) for congestive heart failure, and 0.60 (95% CI: 0.31-1.17) for cardiovascular death.

Conclusion

Ibuprofen use for acute pericarditis was not associated with increased cardiovascular risks, supporting its safety in current practice.

A real-life clinical application of cardiac magnetic resonance imaging in patients with acute myocarditis - one-center observational retrospective study

BACKGROUND

The diagnosis of acute myocarditis is complex, with cardiac magnetic resonance (CMR) being a recommended diagnostic method. This study aimed to evaluate the real-life use of CMR in the diagnosis of acute myocarditis and to correlate CMR results with the degree of myocardial damage.

METHODS

This is a retrospective, observational tertiary single-center study of 90 consecutive patients (F/M:18/72, mean age:39 ± 14 years) hospitalized between 2015-2022 with a clinical diagnosis of acute myocarditis. The study population was divided into two groups: patients who underwent CMR+ and those who did not undergo CMR - In the CMR+ group, various sequences, including T1/T2-weighted imaging, late gadolinium enhancement (LGE), and mapping techniques, were used to assess myocardial inflammation and damage.

RESULTS

CMR was performed in 39 patients (43.3%, F/M:10/29, mean age:41 ± 16 years). In this group, myocardial edema (increased T2 signal intensity) was detected in 29 patients, and LGE (signal intensity 2 standard deviations cabove normal on T1 images) was found in 39 patients. Diagnosis based on Lake Louise Criteria was possible in 29 cases. Edema negatively correlated with TnT levels (r = -0.412, p < 0.05) and positively with the number of LGE segments (r = 0.372, p < 0.05). Significant correlations were found between LVEF and LGE mass (r = -0.360, p < 0.05), and maximal TnT levels (r = -0.38, p < 0.05). CMR+ patients had lower myocardial damage markers and CRP concentrations compared to CMR- patients.

CONCLUSIONS

CMR is underused in diagnosing acute myocarditis. Myocardial damage markers correlate with CMR-detected edema and volumetric measures, but not LGE extent. More research is needed to enhance risk assessment and treatment.

Evaluation of HRR (Hemoglobin/Red Blood Cell Distribution Width Ratio) and RAR (Red Blood Cell Distribution Width/Albumin Ratio) in Myocarditis Patients: Associations with Various Clinical Parameters

Aim

This study investigates the prognostic value of the Hemoglobin/Red Blood Cell Distribution Width Ratio (HRR) and the Red Blood Cell Distribution Width/Albumin Ratio (RAR) in patients with myocarditis. We aimed to evaluate how these novel biomarkers correlate with clinical parameters, disease severity, and outcomes.

Methods

A retrospective analysis was conducted on 301 patients diagnosed with myocarditis between January 2020 and March 2024. Inclusion criteria were adults with confirmed myocarditis based on clinical, ECG and echocardiographic evaluations. Exclusion criteria included incomplete records and prior immunosuppressive therapy. We assessed various blood parameters, including HRR and RAR, and analyzed their associations with clinical outcomes, hospital stay duration, and complications.

Results

The study found that HRR and RAR were significantly associated with several clinical outcomes in myocarditis patients. Higher HRR values correlated with improved outcomes, while higher RAR values were linked to worse outcomes. HRR was associated with pericardial effusion, inotropic support, and other parameters, while RAR was correlated with similar factors, including recent gastroenteritis. Patients with longer hospital stays exhibited higher inflammation markers and lower ejection fractions, underscoring the severity of their condition.

Conclusion

HRR and RAR are promising biomarkers for assessing disease severity and prognosis in myocarditis. They provide additional prognostic information beyond traditional markers such as troponin and CRP, potentially guiding more personalized treatment strategies.

Drug-induced myocarditis: a real-world pharmacovigilance study using the FDA adverse event reporting system database

BACKGROUND

Myocarditis is a rare but potentially life-threatening inflammation of the heart muscle that can be caused by various drugs. This study aimed to comprehensively evaluate the risk of drug-induced myocarditis using data from the FDA Adverse Event Reporting System (FAERS) database.

METHODS

We queried the FAERS database for reports of myocarditis from Q1 2004 to Q4 2023. The reporting odds ratio (ROR) and proportional reporting ratio (PRR) were calculated to detect disproportionality signals for drugs associated with myocarditis.

RESULTS

A total of 8,212 myocarditis-related reports were identified in the FAERS database. The most frequently reported drugs were clozapine (N = 1269), followed by nivolumab (N = 621), pembrolizumab (N = 358), mesalazine (252), and olanzapine (N = 191). Disproportionality analysis revealed strong signals for the top 50 drugs, including mesalazine (ROR 48.01, 95% CI 42.29-54.49), cemiplimab (ROR 38.84, 95% CI 26.71-56.47), clozapine (ROR 35.21, 95% CI 33.13-37.39), nivolumab (ROR 23.21, 95% CI 21.38-25.2), atezolizumab (ROR 20.75, 95% CI 17.91-24.05) and pembrolizumab (ROR 19.90, 95% CI 17.89-22.13).

CONCLUSIONS

Our findings suggest a potential risk of drug-induced myocarditis associated with various medications. Close monitoring for signs and symptoms of myocarditis is crucial, especially in patients with risk factors or those receiving these drugs. Further investigations are warranted to establish causality and identify risk factors.

Injury-induced myosin-specific tissue-resident memory T cells drive immune checkpoint inhibitor myocarditis

Cardiac myosin-specific (MyHC) T cells drive the disease pathogenesis of immune checkpoint inhibitor-associated myocarditis (ICI-myocarditis). To determine whether MyHC T cells are tissue-resident memory T (TRM) cells, we characterized cardiac TRM cells in naive mice and established that they have a distinct phenotypic and transcriptional profile that can be defined by their upregulation of CD69, PD-1, and CXCR6. We then investigated the effects of cardiac injury through a modified experimental autoimmune myocarditis mouse model and an ischemia-reperfusion injury mouse model and determined that cardiac inflammation induces the recruitment of autoreactive MyHC TRM cells, which coexpress PD-1 and CD69. To investigate whether the recruited MyHC TRM cells could increase susceptibility to ICI-myocarditis, we developed a two-hit ICI-myocarditis mouse model where cardiac injury was induced, mice were allowed to recover, and then were treated with anti-PD-1 antibodies. We determined that mice who recover from cardiac injury are more susceptible to ICI-myocarditis development. We found that murine and human TRM cells share a similar location in the heart and aggregate along the perimyocardium. We phenotyped cells obtained from pericardial fluid from patients diagnosed with dilated cardiomyopathy and ischemic cardiomyopathy and established that pericardial T cells are predominantly CD69+ TRM cells that up-regulate PD-1. Finally, we determined that human pericardial macrophages produce IL-15, which supports and maintains pericardial TRM cells.

The Role of MicroRNA in the Pathophysiology and Diagnosis of Viral Myocarditis

Myocarditis is a non-ischemic condition with a heterogeneous etiology, clinical course and prognosis. The most common etiology of myocarditis are viral infections, whereas the most severe complications are acute and chronic heart failure and sudden cardiac death. The heterogeneous clinical course of the disease, as well as the availability and costs of diagnostic tools such as cardiac magnetic resonance and endomyocardial biopsy, hinder the diagnosis of myocarditis and its underlying cause. Non-coding RNAs such as micro-RNAs (miRNAs; miR) have been shown to be involved in the disease's pathophysiology; however, their potential in disease diagnosis and treatment should also be considered. Non-coding RNAs are RNAs that are not translated into proteins, and they have the ability to regulate several intracellular pathways. MiRNAs regulate gene expression by binding with their targets and inhibiting protein synthesis by interfering with the translation of coding genes or causing the degradation of messenger RNA. Several miRNAs, such as miR-1, -133, -21, -15, -98, -126, -155, -148, -203, -208, -221, -222, -203 and -590, have been shown to be involved in the pathophysiology of viral myocarditis (VMC), and some of them have been shown to have diagnostic abilities. This article summarizes the available data on miRNAs and their associations with VMC.

What are the early warning signs of myocarditis during the pathway of care?

INTRODUCTION

Myocarditis is an inflammatory disease of the myocardial layer of the heart that can be prone to dilation of chambers with presentation as heart failure secondary to dilated cardiomyopathy. Myocarditis can lead to remodeling and fibrosis that can affect the heart's relaxation-lusitropy and chronotropic function. The current techniques for identifying myocarditis, such as endomyocardial biopsy and imaging, are costly, and intrusive. The current literature aims to identify reliable, accurate, and prognostically educative biomarkers of myocarditis.

AREAS COVERED

This review covers the definition, clinical features, diagnostic markers, cardiac imaging, prognosis, and complications of myocarditis. PubMed, Embase, and the Cochrane data bank were searched from inception to 1 January 2024 for relevant articles.

EXPERT OPINION

By adopting these diagnostic and prognostic biomarkers, clinicians can have a better comprehension of the progression of the disease and provide early diagnosis and treatment for myocarditis.

C-reactive Protein (CRP) in Patients With Myocarditis: A Systematic Review and Meta-Analysis

Myocarditis is a type of cardiovascular disease related to inflammation of cardiac muscle which can be even fatal to some extent. Early and simple diagnosis is crucial for this complication; however, complex or machine-based methods, such as histological tests, x-rays, electrocardiograms, etc., are usually used for its detection. C-reactive protein (CRP) is a biomarker that naturally elevates during inflammation. Therefore, we tried to understand the correlation between CRP and myocarditis. We primarily identified 451 studies from PubMed, Google Scholar, and ScienceDirect and ultimately selected four studies as eligible. We identified the mean difference (MD) in CRP levels between the myocarditis patients and healthy controls. The study quality, outliers, sensitivity, significance, and heterogeneity were also checked. The MD (6.03 (95%CI: 2.41-9.64), p<0.00001) corresponds to a higher and significant CRP level in myocarditis as compared to the control group. The study quality was found to be high with no bias or outliers and the heterogeneity was also determined to be high (I2=99%). Using the fixed effect model, the forest plot determined a similar result as the main outcome (MD: 5.08 (95%CI: 4.85-5.32)) proving higher sensitivity and reproducibility. These findings indicated the possibility of CRP being an established biomarker for an accurate diagnosis and prognosis of myocarditis.

Pancreatitis-associated Myocarditis: Systematic Review and Meta-analysis of a Deadly Duo

Myocardial injury is a recognized complication of acute pancreatitis, whereas myocarditis has only been occasionally reported and has not been systematically evaluated. We systematically reviewed PubMed literature published up to January 2024 for studies including both "myocarditis" and "pancreatitis" as keywords. Relevant data regarding patient characteristics and outcomes were collected and analyzed. A total of 31 patients from 31 independent studies were included. The etiology of pancreatitis was viral in 52%, bacterial in 20%, toxic in 16%, autoimmune in 9%, and idiopathic in 3%. 23% of patients were immunocompromised. Median high sensitivity-cardiac troponin T was 342 (IQR 73-890) ng/L and N-terminus-pro-brain natriuretic peptide was 11053 (IQR 1397-26150) pg/mL. The average left ventricular ejection fraction was 33±13%. Fulminant myocarditis, presenting with cardiogenic shock and/or malignant ventricular arrhythmias occurred in 48% of patients, more frequently in men than in women (P=0.026). Severe myocarditis occurred in 42% of edematous and 60% of necrotizing pancreatitis (P=0.56). No association was found between the severity of myocarditis and plasma levels of amylase (P=0.98) and lipase (P=0.83). The relative frequency of severe myocarditis was 80% in pancreatitis due to Leptospirosis, and 40% in pancreatitis due to viral infections. The mortality rate was 22%: 13% died during hospitalization and 9% after. Myocarditis is a potentially lethal complication of pancreatitis and is more frequently associated with viral etiology in immunocompromised individuals. Based on such findings, cardiac troponin measurements and an electrocardiogram are advisable to exclude myocardial involvement in selected patients. Confirmatory diagnosis and prognostic assessments should be based on cardiac magnetic resonance imaging.

Novel Treatment for Pre-XDR Tuberculosis Linked to a Lethal Case of Acute Myocarditis

The management of resistant tuberculosis (tb) can be extremely difficult, especially in case of novel unpredicted complications. In this report, we present a case of a 48-year-old patient with pre-extensively drug-resistant (XDR) tb who received a treatment regimen including pretomanid, bedaquiline, linezolid, cycloserine, and amikacin and died due to myocarditis. Acquired resistance to first- and second-line drugs developed due to previous poor adherence to medication. The clinical presentation of the patient, along with her initial ultrasonographical, electrocardiogram (ECG), and laboratory examinations, were typical for acute myocarditis; however, the patient was considered unstable, and further investigations, including magnetic resonance imaging (MRI), pericardiocentesis, and endomyocardial biopsy were not performed. To our knowledge, this is the first case of myocarditis in such a patient, the clinical features of which raised a high suspicion of drug induction that could be attributed to the treatment regimen that was administered. Clinicians who manage cases of drug-resistant tb should be aware of this newly reported, potentially lethal, adverse event.

Fatal ventricular arrhythmias in myocarditis: A review of current indications for defibrillator devices

Historically, patients with myocarditis were considered for implantable cardioverter defibrillator (ICD) utilization only in the chronic phase of the disease following the development of persistent cardiomyopathy refractory to medical therapy or occurrence of a major ventricular arrhythmic event. However, recent literature has indicated that ventricular arrhythmias are frequently reported even in the acute phase of the disease, challenging the long-standing perception that this disease process was largely reversible. Given this changing environment of information, the latest US and European guidelines were recently updated in 2022 to now consider ICD implantation during the acute phase which has significantly increased the number of individuals eligible for these devices. Additionally, several studies with small subgroups of patients have demonstrated a possible benefit of wearable cardioverter defibrillators (WCDs) in this patient demographic. Assuming that larger studies confirm their utility, it is possible that WCDs can assist in detection of ventricular arrhythmias and selection of high-risk candidates for ICD implantation, while providing temporary protection for a small percentage of patients before the development of a major arrhythmic event. This review ultimately serves as a comprehensive review of the most recent guidelines for defibrillator use in acute and chronic myocarditis. OPINION STATEMENT: The latest US and European guidelines support ICD use for myocarditis patients following the development of persistent cardiomyopathy refractory to medical therapy or occurrence of a major ventricular arrhythmic event. Previously, patients in the acute phase were excluded from ICD utilization even after experiencing malignant ventricular tachycardia or ventricular fibrillation due to the long-standing perception that this disease process was largely reversible. However, recent literature has indicated that ventricular arrhythmias are frequently reported even in the acute phase of the disease. Additionally, we found that the myocardial damage that is inflicted persists many years after the initial episode. Given this changing environment of information, guidelines were recently updated in 2022 to now consider ICD implantation during the acute phase which has significantly increased the number of individuals eligible for these devices. We support possible ICD utilization for secondary prevention during the acute phase of myocarditis given the elevated risk of arrhythmia recurrence and the fact that any ventricular arrhythmia can induce sudden cardiac death. Future prospective studies are needed to assess which patients may benefit most from early ICD implantation. WCDs have improved survival in patient populations at high-risk for sudden cardiac death who are not candidates for ICD implantation. After analyzing several recent studies with small subgroups of patients, WCDs appear to demonstrate similar efficacy for myocarditis patients as well. Assuming that larger studies confirm their utility, we believe that WCDs can assist in detection of ventricular arrhythmias and selection of high-risk candidates for ICD implantation. Furthermore, WCDs have the additional benefit of acting as primary prevention by providing temporary protection for a small percentage of myocarditis patients before they develop a major arrhythmic event.

When, Why and How to Re-challenge Clozapine in Schizophrenia Following Myocarditis

Clozapine-induced myocarditis (CIM) is among the most important adverse events limiting the use of clozapine as the most effective treatment for schizophrenia. CIM necessitates the immediate termination of clozapine, often resulting in its permanent discontinuation with considerable detrimental effects on patients' psychopathology and long-term outcome. Consequently, a clozapine re-challenge after CIM is increasingly regarded as a viable alternative, with published reports indicating a success rate of approximately 60%. However, published cases of re-challenges after CIM remain limited. Here, we provide a narrative review of the current state of research regarding the epidemiology, pathophysiology, risk factors, diagnosis and clinical management of CIM as well as a synthesis of current recommendations for re-challenging patients after CIM. This includes a step-by-step guide for this crucial procedure based on the current evidence regarding the pathophysiology and risk factors for CIM. Slow dose titration regimes and addressing risk factors including concomitant valproate and olanzapine are crucial both to prevent CIM and to ensure a safe and successful re-challenge. Furthermore, we discuss the utility of C-reactive protein, troponin, N-terminal-pro hormone and brain natriuretic peptide, therapeutic drug-monitoring and cardiac magnetic resonance imaging for CIM screening and diagnosis as well as for post-CIM re-challenges.

Myocarditis - A silent killer in athletes: Comparative analysis on the evidence before and after COVID-19 pandemic

Myocarditis is a rare cardiomyocyte inflammatory process, typically caused by viruses, with potentially devastating cardiac sequalae in both competitive athletes and in the general population. Investigation into myocarditis prevalence in the Coronavirus disease 2019 (COVID-19) era suggests that infection with Severe acute respiratory syndrome coronavirus (SARS-CoV-2) is an independent risk factor for myocarditis, which is confirmed mainly through cardiovascular magnetic resonance imaging. Recent studies indicated that athletes have a decreased risk of myocarditis after recent COVID-19 infection compared to the general population. However, given the unique nature of competitive athletics with their frequent participation in high-intensity exercise, athletes possess distinct factors of susceptibility for the development of myocarditis and its subsequent severe cardiac complications (e.g., sudden cardiac death, fulminant heart failure, etc.). Under this context, this review focuses on comparing myocarditis in athletes versus non-athletes, owing special attention to the distinct clinical presentations and outcomes of myocarditis caused by different viral pathogens such as cytomegalovirus, Epstein-Barr virus, human herpesvirus-6, human immunodeficiency virus, and Parvovirus B19, both before and after the COVID-19 pandemic, as compared with SARS-CoV-2. By illustrating distinct clinical presentations and outcomes of myocarditis in athletes versus non-athletes, we also highlight the critical importance of early detection, vigilant monitoring, and effective management of viral and non-viral myocarditis in athletes and the necessity for further optimization of the return-to-play guidelines for athletes in the COVID-19 era, in order to minimize the risks for the rare but devastating cardiac fatality.

Long noncoding RNA NONHSAT122636.2 attenuates myocardial inflammation and apoptosis in myocarditis

OBJECTIVE

The main pathological change of myocarditis is an inflammatory injury of cardiomyocytes. Long noncoding RNAs (lncRNAs) are closely related to inflammation, and our previous study showed that differential expression of lncRNAs is associated with myocarditis. This study aimed to investigate the impact of lncRNAs on the onset of myocarditis.

METHODS

RNA expression was measured by quantitative reverse-transcription polymerase chain reaction (RT-qPCR). Lipopolysaccharide (LPS) was used to induce inflammation in human cardiomyocytes (HCMs). The expression of inflammatory cytokines and myocardial injury markers was detected by enzyme-linked immunosorbent assay (ELISA) and RT-qPCR. Cell viability and apoptosis were measured by the cell counting kit-8 assay and flow cytometry. The binding force between lncRNA NONHSAT122636.2 and microRNA miRNA-2110 was detected using the dual-luciferase assay.

RESULTS

NONHSAT122636.2 was dynamically expressed in patients with myocarditis and negatively correlated with inflammation severity. The overexpression of NONHSAT122636.2 improved inflammatory injury in LPS-stimulated HCMs. The study observed that there was a weak binding force between NONHSAT122636.2 and miR-2110.

CONCLUSION

NONHSAT122636.2 attenuates myocardial inflammation and apoptosis in myocarditis. Additionally, its expression decreases in the peripheral blood of children suffering from myocarditis and in patients who are diagnosed for the first time showing higher diagnostic sensitivity and specificity. This decrease is negatively correlated with the degree of inflammation. Overall, the study suggests that NONHSAT122636.2 can be exploited as a potential diagnostic biomarker for pediatric myocarditis.

Cardiovascular magnetic resonance feature tracking derived strain analysis can predict return to training following exertional heatstroke

BACKGROUND

Exertional heatstroke (EHS) is increasingly common in young trained soldiers. However, prognostic markers in EHS patients remain unclear. The objective of this study was to evaluate cardiovascular magnetic resonance (CMR) feature tracking derived left ventricle (LV) strain as a biomarker for return to training (RTT) in trained soldiers with EHS.

METHODS

Trained soldiers (participants) with EHS underwent CMR cine sequences between June 2020 and August 2023. Two-dimensional (2D) LV strain parameters were derived. At 3 months after index CMR, the participants with persistent cardiac symptoms including chest pain, dyspnea, palpitations, syncope, and recurrent heat-related illness were defined as non-RTT. Multivariable logistic regression analysis was used to develop a predictive RTT model. The performance of different models was compared using the area under curve (AUC).

RESULTS

A total of 80 participants (median age, 21 years; interquartile range (IQR), 20-23 years) and 27 health controls (median age, 21 years; IQR, 20-22 years) were prospectively included. Of the 77 participants, 32 had persistent cardiac symptoms and were not able to RTT at 3 months follow-up after experiencing EHS. The 2D global longitudinal strain (GLS) was significantly impaired in EHS participants compared to the healthy control group (-15.8 ± 1.7% vs -16.9 ± 1.2%, P = 0.001), which also showed significant statistical differences between participants with RTT and non-RTT (-15.0 ± 3.5% vs -16.5 ± 1.4%, P < 0.001). 2D-GLS (≤ -15.0%) (odds ratio, 1.53; 95% confidence interval: 1.08, 2.17; P = 0.016) was an independent predictor for RTT even after adjusting known risk factors. 2D-GLS provided incremental prognostic value over the clinical model and conventional CMR parameters model (AUCs: 0.72 vs 0.88, P = 0.013; 0.79 vs 0.88, P = 0.023; respectively).

CONCLUSION

Two-dimensional global longitudinal strain (≤ -15.0%) is an incremental prognostic CMR biomarker to predict RTT in soldiers suffering from EHS.

Immune myocarditis induced by sintilimab therapy: A case report

Immunotherapy is a potent tool used in cancer treatment, but the occurrence of immune-related adverse events induced by immune checkpoint inhibitors (ICIs) cannot be overlooked. This is particularly true for rare but potentially fatal cardiovascular complications, such as myocarditis; heart muscle inflammation may lead to heart dysfunction and arrhythmia. The present case is a 68-year-old female breast cancer patient who developed palpitations and elevated cardiac enzyme levels after 1 day of ICI therapy, and the patient was eventually diagnosed with immune myocarditis. After receiving hormonal shock therapy, Ctn I, CK, CK-MB and other cardiac enzyme-related markers improved significantly, and electrocardiogram test returned to normal, and the patient recovered during hospitalization without any major adverse cardiac events. Furthermore, the present study reviewed the mechanism of immune myocarditis induced by ICI therapy, with the aim of providing a clinical foundation for the prevention and diagnosis of cardiovascular adverse events in ICI therapy.

Advances in the diagnosis of myocarditis in idiopathic inflammatory myopathies: an overview of diagnostic tests

Cardiac involvement in idiopathic inflammatory myopathies (IIM) purports to worse clinical outcomes, and therefore early identification is important. Research has focused on blood biomarkers and basic investigations such as ECG and echocardiography, which have the advantage of wide availability and low cost but are limited in their sensitivity and specificity. Imaging the myocardium to directly look for inflammation and scarring has therefore been explored, with a number of new methods for doing this gaining wider research interest and clinical availability. Cardiovascular magnetic resonance (CMR) with contemporary multiparametric mapping techniques and late gadolinium enhancement imaging, is an extremely valuable and increasingly used non-invasive imaging modality for the diagnosis of myocarditis. The recently updated CMR-based Lake Louise Criteria for the diagnosis of myocarditis incorporate the newer T1 and T2 mapping techniques, which have greatly improved the diagnostic accuracy for IIM myocarditis.18F-FDG-PET/CT is a well-utilized imaging modality in the diagnosis of malignancies in IIM, and it also has a role for the diagnosis of myocarditis in multiple systemic inflammatory diseases. Endomyocardial biopsy, however, remains the gold standard technique for the diagnosis of myocarditis and is necessary for the diagnosis of specific cases of myocarditis. This article provides an overview of the important tests and imaging modalities that clinicians should consider when faced with an IIM patient with potential myocarditis.

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.

Evolving Strategies for Use of Phytochemicals in Prevention and Long-Term Management of Cardiovascular Diseases (CVD)

This report describes major pathomechanisms of disease in which the dysregulation of host inflammatory processes is a major factor, with cardiovascular disease (CVD) as a primary model, and reviews strategies for countermeasures based on synergistic interaction between various agents, including drugs and generally regarded as safe (GRAS) natural medical material (NMM), such as Ginkgo biloba, spice phytochemicals, and fruit seed flavonoids. The 15 well-defined CVD classes are explored with particular emphasis on the extent to which oxidative stressors and associated ischemia-reperfusion tissue injury contribute to major symptoms. The four major categories of pharmaceutical agents used for the prevention of and therapy for CVD: statins, beta blockers (β-blockers), blood thinners (anticoagulants), and aspirin, are presented along with their adverse effects. Analyses of major cellular and molecular features of drug- and NMM-mediated cardioprotective processes are provided in the context of their development for human clinical application. Future directions of the evolving research described here will be particularly focused on the characterization and manipulation of calcium- and calcineurin-mediated cascades of signaling from cell surface receptors on cardiovascular and immune cells to the nucleus, with the emergence of both protective and pathological epigenetic features that may be modulated by synergistically-acting combinations of drugs and phytochemicals in which phytochemicals interact with cells to promote signaling that reduces the effective dosage and thus (often) toxicity of drugs.

Rationale and design of the French cohort of acute myocarditis diagnosed by cardiac magnetic resonance imaging (MyocarditIRM)

BACKGROUND

Acute myocarditis usually presents as chest pain with rising troponin and normal coronary arteries. Despite frequent favourable evolution at the acute phase, it is associated with heart failure and ventricular rhythm disorders, and is considered the leading cause of sudden cardiac death in young, apparently healthy, adults. There are no specific recommendations for acute myocarditis diagnosis and management, only expert consensus, given the lack of large databases.

AIM

The main objective is to describe the contemporary presentation of acute myocarditis, its management and in-hospital outcomes. Secondary objectives are to investigate survival and event-free survival for up to 10years of follow-up, the determinants of prognosis, the modalities of treatment and follow-up and the gaps between expert consensus and real-life management.

METHODS

MyocarditIRM is a prospective multicentre cohort that enrolled 803 consecutive patients with acute myocarditis in 49 participating centres in France between 01 May 2016 and 28 February 2019. The diagnosis of acute myocarditis was acknowledged by cardiac magnetic resonance, using the Lake Louise Criteria. Exclusion criteria were age<18years, lack of health coverage, contraindication to cardiac magnetic resonance and refusal to participate. Detailed information was collected prospectively, starting at admission. Cardiac magnetic resonance imaging (diagnosis and follow-up) is analysed centrally by the certified core laboratory IHU ICAN. Ten years of follow-up for each patient is ensured by linking with the French National Health Database, and includes information on death, hospital admissions, major clinical events and drug consumption.

CONCLUSION

This prospective cohort with long-term follow-up represents the largest database on acute myocarditis worldwide, and will improve knowledge about its presentation, management and outcomes.

Acute myocarditis: an overview of pathogenesis, diagnosis and management

Acute myocarditis encompasses a diverse presentation of inflammatory cardiomyopathies with infectious and non-infectious triggers. The clinical presentation is heterogeneous, from subtle symptoms like mild chest pain to life-threatening fulminant heart failure requiring urgent advanced hemodynamic support. This review provides a comprehensive overview of the current state of knowledge regarding the pathogenesis, diagnostic approach, management strategies, and directions for future research in acute myocarditis. The pathogenesis of myocarditis involves interplay between the inciting factors and the subsequent host immune response. Infectious causes, especially cardiotropic viruses, are the most frequently identified precipitants. However, autoimmune processes independent of microbial triggers, as well as toxic myocardial injury from drugs, chemicals or metabolic derangements also contribute to the development of myocarditis through diverse mechanisms. Furthermore, medications like immune checkpoint inhibitor therapies are increasingly recognized as causes of myocarditis. Elucidating the nuances of viral, autoimmune, hypersensitivity, and toxic subtypes of myocarditis is key to guiding appropriate therapy. The heterogeneous clinical presentation coupled with non-specific symptoms creates diagnostic challenges. A multifaceted approach is required, incorporating clinical evaluation, electrocardiography, biomarkers, imaging studies, and endomyocardial biopsy. Cardiovascular magnetic resonance imaging has become pivotal for non-invasive assessment of myocardial inflammation and fibrosis. However, biopsy remains the gold standard for histological classification and definitively establishing the underlying etiology. Management relies on supportive care, while disease-specific therapies are limited. Although some patients recover well with conservative measures, severe or fulminant myocarditis necessitates aggressive interventions such as mechanical circulatory support devices and transplantation. While immunosuppression is beneficial in certain histological subtypes, clear evidence supporting antiviral or immunomodulatory therapies for the majority of acute viral myocarditis cases remains insufficient. Substantial knowledge gaps persist regarding validated diagnostic biomarkers, optimal imaging surveillance strategies, evidence-based medical therapies, and risk stratification schema. A deeper understanding of the immunopathological mechanisms, rigorous clinical trials of targeted therapies, and longitudinal outcome studies are imperative to advance management and improve the prognosis across the myocarditis spectrum.

Marijuana Induced Pericarditis: An Emerging Crisis

Background

The use of marijuana, derived from the Cannabis plant, has a lengthy history dating back thousands of years. With the recent legalization of marijuana in many US states, concerns about its health effects have grown. Despite traditional beliefs in its cardioprotective properties, there is a rising incidence of marijuana-induced pericarditis. This article presents a case that highlights the potential connection between marijuana use and cardiac complications. We herein present a case of a 30-year-old male with habitual marijuana use coming in with pericarditis.

Case

A 30-year-old male, a habitual marijuana user, presented to the emergency department with recurrent chest pain and shortness of breath. Notably, similar episodes were resolved when he abstained from marijuana. Diagnostic findings upon admission included elevated inflammatory markers, EKG showing diffuse ST segment elevations and PR depressions, echocardiographic evidence of pericardial effusion and EKG consistent with pericarditis. After excluding other causes, marijuana was identified as the likely trigger for his cardiac symptoms.

Decision making

NSAIDS and colchicine were started at therapeutic doses for the patient. Cardiology and Cardiothoracic Surgery were consulted. No drainage was planned as patient was clinically stable and improved with medical management alone.

Conclusion

The emerging link between marijuana use and pericarditis presents a unique clinical challenge. Comprehensive population-based studies are needed to understand the cardiovascular implications of marijuana use and to develop appropriate management guidelines. Clinicians should approach marijuana use cautiously, considering potential cardiovascular risks, and remain vigilant for pericarditis as a potential consequence of marijuana use during patient evaluations.

Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.

Recurrent myocardial injury in a de novo SON mutation ZTTK syndrome patient: a case report

BACKGROUND

Zhu-Tokita-Takenouchi-Kim syndrome (ZTTK syndrome) is a severe multi-systemic developmental disorder, caused by variants in the SON gene. A patient diagnosed with ZTTK syndrome who carried a de novo SON mutation and exhibited recurrent myocardial injury was described in this case.

CASE PRESENTATION

A 7-year-old girl was admitted to the Cardiology Department of Beijing Children's Hospital in November 2019 due to myocardial injury following respiratory infection. She displayed elevated myocardial enzymes and severe T-wave changes on electrocardiogram. Over the past three years, she had experienced myocardial injury on three occasions. Additionally, she exhibited intellectual disability, congenital amblyopia, and dysmorphic facial features. Genetic analysis revealed a de novo heterozygous mutation c.3852_3856delGGTAT in the SON gene, which was confirmed by Sanger sequencing of her parents. She received anti-infection treatment and was administered metoprolol orally. Her condition was stable at the time of discharge. Over a 42-month follow-up period at the outpatient clinic, she complained intermittent fatigue and palpitation.

CONCLUSIONS

The identified SON mutation, which plays a crucial role in heart development and mitochondrial function, may be associated with an increased susceptibility to myocardial injury or cardiomyopathy. This case report contributes novel insights into this rare condition and suggests the expansion of the ZTTK syndrome phenotype.

High risk and low prevalence diseases: Myocarditis

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.

Etiology-Based Prognosis of Extracorporeal CPR Recipients After Out-of-Hospital Cardiac Arrest: A Retrospective Multicenter Cohort Study

BACKGROUND

A better understanding of the relative contributions of various factors to patient outcomes is essential for optimal patient selection for extracorporeal CPR (ECPR) therapy for patients with out-of-hospital cardiac arrest (OHCA). However, evidence on the prognostic comparison based on the etiologies of cardiac arrest is limited.

RESEARCH QUESTION

What is the etiology-based prognosis of patients undergoing ECPR for OHCA?

STUDY DESIGN AND METHODS

This retrospective multicenter registry study involved 36 institutions in Japan and included all adult patients with OHCA who underwent ECPR between January 2013 and December 2018. The primary etiology for OHCA was determined retrospectively from all hospital-based data at each institution. We performed a multivariable logistic regression model to determine the association between etiology of cardiac arrest and two outcomes: favorable neurologic outcome and survival at hospital discharge.

RESULTS

We identified 1,781 eligible patients, of whom 1,405 (78.9%) had cardiac arrest because of cardiac causes. Multivariable logistic regression analysis for favorable neurologic outcome showed that accidental hypothermia (adjusted OR, 5.12; 95% CI, 2.98-8.80; P < .001) was associated with a significantly higher rate of favorable neurologic outcome than cardiac causes. Multivariable logistic regression analysis for survival showed that accidental hypothermia (adjusted OR, 5.19; 95% CI, 3.15-8.56; P < .001) had significantly higher rates of survival than cardiac causes. Acute aortic dissection/aneurysm (adjusted OR, 0.07; 95% CI, 0.02-0.28; P < .001) and primary cerebral disorders (adjusted OR, 0.12; 95% CI, 0.03-0.50; P = .004) had significantly lower rates of survival than cardiac causes.

INTERPRETATION

In this retrospective multicenter cohort study, although most patients with OHCA underwent ECPR for cardiac causes, accidental hypothermia was associated with favorable neurologic outcome and survival; in contrast, acute aortic dissection/aneurysm and primary cerebral disorders were associated with nonsurvival compared with cardiac causes.

Coxsackie B virus-induced myocarditis in a patient with a history of lymphoma: A case report and review of literature

INTRODUCTION

In rare occasions, coxsackievirus infections can cause serious illness, such as encephalitis and myocarditis. The immunotherapies of cancer could increase the risk of myocarditis, especially when applying immune checkpoint inhibitors. Herein, we report a rare case of Coxsackie B virus-induced myocarditis in a patient with a history of lymphoma.

CASE PRESENTATION

A 32-year-old woman was admitted to the hospital with recurrent fever for more than 20 days, and she had a history of lymphoma. Before admission, the positron emission tomography/computed tomography result indicated that the patient had no tumor progression, and she was not considered the cancer-related fever upon arriving at our hospital. Patient's red blood cell, platelet count, and blood pressure were decreased. In addition, she had sinus bradycardia and 3 branch blocks, which was consistent with acute high lateral and anterior wall myocardial infarction. During hospitalization, the patient had recurrent arrhythmia, repeated sweating, poor mentation, dyspnea, and Coxsackie B virus were detected in patient's blood samples by pathogen-targeted next-generation sequencing. The creatine kinase, creatine kinase MB, and N-terminal pro-brain natriuretic peptide were persistently elevated. Consequently, the patient was diagnosed with viral myocarditis induced by Coxsackie B virus, and treated with acyclovir, gamma globulin combined with methylprednisolone shock therapy, trimetazidine, levosimendan, sildenan, continuous pump pressors with m-hydroxylamine, entecavir, adefovir, glutathione, pantoprazole, and low-molecular-weight heparin. Her symptoms worsened and died.

CONCLUSION

We reported a case with a history of lymphoma presented with fever, myocardial injury, who was ultimately diagnosed with Coxsackie B virus-induced myocarditis. Moreover, pathogen-targeted next-generation sequencing indeed exhibited higher sensitivity compared to mNGS in detecting Coxsackie B virus.

Paradigm shift in myocarditis treatment

Although most cases of myocarditis are self-limiting with a gradual improvement in cardiac function, the involvement of myocarditis in sudden cardiac death among children and young adults remains substantial, with rates of 3-17 % and 8.6-12 %, respectively. Moreover, the risk of developing chronic dilated cardiomyopathy ranges from 21 % to 30 % in all cases confirmed by biopsy. Current therapeutic strategies for myocarditis and its complications range from standard supportive care for heart failure and arrhythmias to etiologically oriented, case-based therapeutic options. For example, immunosuppression is indicated only in certain forms of acute myocarditis with clinical or endomyocardial biopsy evidence of immune checkpoint inhibitor-induced myocarditis and autoimmune diseases, including giant cell myocarditis, eosinophilic myocarditis, vasculitis, or cardiac sarcoidosis. However, our views on myocarditis treatment have changed considerably over the past two decades, thanks to the emergence of regenerative cells/tissues as well as drug and gene delivery systems. Cell-based therapies are now growing in popularity in any field of medicine. Studies evaluating the therapeutic efficacy of different stem cells in the treatment of acute myocarditis and its chronic complications have shown that although the experimental characteristics varied from study to study, in general, these strategies reduced inflammation and myocardial fibrosis while preventing myocarditis-induced systolic dysfunction and adverse remodeling in animal models.

Coxsackievirus-Induced Myocarditis With Acute Onset of Heart Failure With Pleural Effusion

This is a case of a 45-year-old Caucasian female with coxsackievirus-induced myocarditis. Myocarditis is an inflammation of the heart muscles, which can be difficult to diagnose at times because its symptoms overlap with other cardiovascular diseases. At times, when the patient presents, the full impact of the etiology would have either improved or resolved. In this case, the patient presented with symptoms closely resembling that of acute coronary syndrome but did not fit the typical age category. After lab and imaging workup, the coxsackievirus panel was positive, complicated with a new diagnosis of systolic heart failure with an ejection fraction of 30%-35% along with pericardial effusion.

Empagliflozin attenuates inflammation levels in autoimmune myocarditis through the STAT3 pathway and macrophage phenotype transformation

OBJECTIVE

To investigate the anti-inflammatory actions and molecular mechanisms of the sodium/glucose cotransporter 2 (SGLT-2) inhibitor empagliflozin on autoimmune myocarditis.

METHODS

The experimental autoimmune myocarditis (EAM) mouse model was constructed using peptides, and the therapeutic effects of empagliflozin on cardiac inflammation and fibrosis were observed using hematoxylin and eosin (HE), Sirius red staining, and Masson's trichome staining. Western blotting was used to identify the actions of empagliflozin on the surface marker expression levels of M2 macrophages and inflammatory factors. In vitro, experiments were completed using lentiviral overexpression of SGLT-2 in macrophages. Macrophage inflammation and anti-inflammatory models were constructed using lipopolysaccharide and interleukin-4, respectively. Enzyme-linked immunosorbent assay, immunofluorescence staining, and reverse-transcription polymerase chain reaction were applied to detect the effects of empagliflozin on the levels of inflammatory factors and macrophage surface markers. Western blotting was used to identify variability in SGLT-2 expression and the role of empagliflozin on the signal transducer and activator of the transcription 3 (STAT3) pathway. The Genomic Spatial Event 142564 dataset was studied in an EAM mouse model. We selected single-cell sequencing results from day 0 and day 21 of modeling to visualize differentially expressed genes. Immune cell infiltration correlation analysis was implemented to explore the expression of inflammatory factors and phenotypic markers.

RESULTS

Empagliflozin increased the expression of the M2 macrophage surface marker CD206 and reduced the level of inflammatory factors in the EAM mouse model while reducing the levels of inflammation and fibrosis. In vitro experiments revealed that the phosphorylation of STAT3 pathway was enhanced after macrophages were polarized to M1 phenotype by LPS, the phosphorylation of STAT3 pathway was inhibited after empagliflozin intervention, and the levels of inflammatory factors were decreased.

CONCLUSION

Empagliflozin can reduce the level of inflammation in autoimmune myocarditis through the STAT3 pathway and macrophage phenotype transformation. These results indicate the expression of SGLT-2 can be a target for autoimmune myocarditis therapy.

Myocarditis and Pericarditis

Pericarditis typically presents with classic symptoms of acute sharp, retrosternal, and pleuritic chest pain. It can have several different underlying causes including viral, bacterial, and autoimmune etiologies. The mainstays of pericarditis treatment are nonsteroidal anti-inflammatory drugs and colchicine with glucocorticoids or other immunosuppressive drugs used for refractory cases and relapse. Myocarditis is an inflammatory disease of the cardiac muscle that is caused by a variety of infectious and noninfectious conditions. It mainly affects young adults (median age 30-45 years), and men more than women. The clinical manifestations of myocarditis are highly variable, so a high level of suspicion in the early stage of disease is important to facilitate diagnosis. The treatment of myocarditis includes nonspecific treatment aimed at complications such as heart failure and arrhythmia, as well as specific treatment aimed at underlying causes. Pericarditis and myocarditis associated with vaccine have been extremely rare before coronavirus disease 2019 (COVID-19). There is a small increase of incidence after COVID-19 messenger ribonucleic acid vaccine, but the relative risk for pericarditis and myocarditis due to severe acute respiratory syndrome coronavirus 2 infection is much higher. Therefore, vaccination against COVID-19 is currently recommended for everyone aged 6 years and older.

TNF-α protects from exacerbated myocarditis and cardiac death by suppressing expansion of activated heart-reactive CD4+ T cells

AIMS

Tumour necrosis factor α (TNF-α) represents a classical pro-inflammatory cytokine, and its increased levels positively correlate with the severity of many cardiovascular diseases. Surprisingly, some heart failure patients receiving high doses of anti-TNF-α antibodies showed serious health worsening. This work aimed to examine the role of TNF-α signalling on the development and progression of myocarditis and heart-specific autoimmunity.

METHODS AND RESULTS

Mice with genetic deletion of TNF-α (Tnf+/- and Tnf-/-) and littermate controls (Tnf+/+) were used to study myocarditis in the inducible and the transgenic T cell receptor (TCRM) models. Tnf+/- and Tnf-/- mice immunized with α-myosin heavy chain peptide (αMyHC) showed reduced myocarditis incidence, but the susceptible animals developed extensive inflammation in the heart. In the TCRM model, defective TNF-α production was associated with increased mortality at a young age due to cardiomyopathy and cardiac fibrosis. We could confirm that TNF-α as well as the secretome of antigen-activated heart-reactive effector CD4+ T (Teff) cells effectively activated the adhesive properties of cardiac microvascular endothelial cells (cMVECs). Our data suggested that TNF-α produced by endothelial in addition to Teff cells promoted leucocyte adhesion to activated cMVECs. Analysis of CD4+ T lymphocytes from both models of myocarditis showed a strongly increased fraction of Teff cells in hearts, spleens, and in the blood of Tnf+/- and Tnf-/- mice. Indeed, antigen-activated Tnf-/- Teff cells showed prolonged long-term survival and TNF-α cytokine-induced cell death of heart-reactive Teff.

CONCLUSION

TNF-α signalling promotes myocarditis development by activating cardiac endothelial cells. However, in the case of established disease, TNF-α protects from exacerbating cardiac inflammation by inducing activation-induced cell death of heart-reactive Teff. These data might explain the lack of success of standard anti-TNF-α therapy in heart failure patients and open perspectives for T cell-targeted approaches.

Trends in the Incidence and Mortality Rates of Myocarditis in the Chinese Population During 1990-2019: Joinpoint Regression and Age-Period-Cohort Analysis

BACKGROUND

This study aimed to analyze trends in the burden of myocarditis in the Chinese population during 1990-2019.

METHODS

The Global Burden of Disease (GBD) database aims to assess the burden of various diseases and injuries on a global scale, and the contribution of relevant risk factors to the burden of disease was also included. In this study, we collected age-standardized incidence and mortality rates for myocarditis in China from 1990 to 2019 using GBD 2019. The age-period-cohort model was utilized to calculate local drift, longitudinal age patterns, as well as the ratios of period and cohort.

RESULTS

The age-standardized incidence and mortality rates of myocarditis in both men and women presented a decreasing trend during 1990-2019 [average annual percentage change (AAPC) of men = -0.202 (95% CI: -0.213 to -0.191); AAPC of women = -0.263 (95% CI: -0.27 to -0.256) for incidence; AAPC of men = -0.233 (95% CI: -0.371 to -0.094); AAPC of women = -0.872 (95% CI: -1.112 to -0.631) for mortality]. Longitudinal age curves showed that myocarditis incidence and mortality rates elevated with age among individuals aged 15-95+ years, with a higher growth rate in men than in women. The period and cohort ratios for both men and women showed similar decreasing trends. Local drift values for the incidence and mortality rates of myocarditis showed an increasing trend among individuals aged 70-75 years and above.

CONCLUSION

Although the overall burden of myocarditis in China presented a decreasing trend during 1990-2019, the male and elderly populations still have a higher risk of incidence and mortality. Therefore, it is essential for the health-care system to introduce effective prevention and treatment measures for myocarditis.

A Narrative Review of Preclinical In Vitro Studies Investigating microRNAs in Myocarditis

According to the World Health Organization's statement, myocarditis is an inflammatory myocardium disease. Although an endometrial biopsy remains the diagnostic gold standard, it is an invasive procedure, and thus, cardiac magnetic resonance imaging has become more widely used and is called a non-invasive diagnostic gold standard. Myocarditis treatment is challenging, with primarily symptomatic therapies. An increasing number of studies are searching for novel diagnostic biomarkers and potential therapeutic targets. Microribonucleic acids (miRNAs) are small, non-coding RNA molecules that decrease gene expression by inhibiting the translation or promoting the degradation of complementary mRNAs. Their role in different fields of medicine has been recently extensively studied. This review discusses all relevant preclinical in vitro studies regarding microRNAs in myocarditis. We searched the PubMed database, and after excluding unsuitable studies and clinical and preclinical in vivo trials, we included and discussed 22 preclinical in vitro studies in this narrative review. Several microRNAs presented altered levels in myocarditis patients in comparison to healthy controls. Moreover, microRNAs influenced inflammation, cell apoptosis, and viral replication. Finally, microRNAs were also found to determine the level of myocardial damage. Further studies may show the vital role of microRNAs as novel therapeutic agents or diagnostic/prognostic biomarkers in myocarditis management.

Immune checkpoint inhibitors associated cardiovascular immune-related adverse events

Immune checkpoint inhibitors (ICIs) are specialized monoclonal antibodies (mAbs) that target immune checkpoints and their ligands, counteracting cancer cell-induced T-cell suppression. Approved ICIs like cytotoxic T-lymphocyte antigen-4 (CTLA-4), programmed death-1 (PD-1), its ligand PD-L1, and lymphocyte activation gene-3 (LAG-3) have improved cancer patient outcomes by enhancing anti-tumor responses. However, some patients are unresponsive, and others experience immune-related adverse events (irAEs), affecting organs like the lung, liver, intestine, skin and now the cardiovascular system. These cardiac irAEs include conditions like myocarditis, atherosclerosis, pericarditis, arrhythmias, and cardiomyopathy. Ongoing clinical trials investigate promising alternative co-inhibitory receptor targets, including T cell immunoglobulin and mucin domain-containing protein 3 (Tim-3) and T cell immunoreceptor with immunoglobulin and ITIM domain (TIGIT). This review delves into the mechanisms of approved ICIs (CTLA-4, PD-1, PD-L1, and LAG-3) and upcoming options like Tim-3 and TIGIT. It explores the use of ICIs in cancer treatment, supported by both preclinical and clinical data. Additionally, it examines the mechanisms behind cardiac toxic irAEs, focusing on ICI-associated myocarditis and atherosclerosis. These insights are vital as ICIs continue to revolutionize cancer therapy, offering hope to patients, while also necessitating careful monitoring and management of potential side effects, including emerging cardiac complications.

Myocardial Oedema as a Consequence of Viral Infection and Persistence-A Narrative Review with Focus on COVID-19 and Post COVID Sequelae

Microvascular integrity is a critical factor in myocardial fluid homeostasis. The subtle equilibrium between capillary filtration and lymphatic fluid removal is disturbed during pathological processes leading to inflammation, but also in hypoxia or due to alterations in vascular perfusion and coagulability. The degradation of the glycocalyx as the main component of the endothelial filtration barrier as well as pericyte disintegration results in the accumulation of interstitial and intracellular water. Moreover, lymphatic dysfunction evokes an increase in metabolic waste products, cytokines and inflammatory cells in the interstitial space contributing to myocardial oedema formation. This leads to myocardial stiffness and impaired contractility, eventually resulting in cardiomyocyte apoptosis, myocardial remodelling and fibrosis. The following article reviews pathophysiological inflammatory processes leading to myocardial oedema including myocarditis, ischaemia-reperfusion injury and viral infections with a special focus on the pathomechanisms evoked by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In addition, clinical implications including potential long-term effects due to viral persistence (long COVID), as well as treatment options, are discussed.

Exploring cardiovascular implications in systemic lupus erythematosus: A holistic analysis of complications, diagnostic criteria, and therapeutic modalities, encompassing pharmacological and adjuvant approaches

Systemic lupus erythematosus (SLE) poses a diagnostic challenge due to its heterogeneity. This study examines the cardiac complications of SLE comprehensively, covering pericarditis, myocarditis, pleural effusion, valvular disease, atherosclerosis, and cardiac arrhythmias. Nearly one-third of SLE-related deaths are attributed to cardiovascular diseases, necessitating a deeper understanding of cardiac pathophysiology. The impact of SLE on the cardiovascular system manifests in various ways, including recurrent and resistant pericarditis, severe myocarditis, and pleural effusion. Valvular diseases, atherosclerosis, and cardiac arrhythmias are prevalent, with immune complex deposition playing a role in atherosclerosis. Diagnostic criteria involve clinical features, laboratory findings, and autoantibodies, emphasizing the need for early diagnosis and a multidisciplinary diagnostic approach. The review explores pharmacological and non-pharmacological modalities for managing cardiac manifestations in SLE. Recommendations include NSAIDs, colchicine, and proton pump inhibitors for acute pericarditis, while selective immunosuppressive therapy is emerging for myocarditis. Valvular diseases require individualized treatment approaches, and careful corticosteroid management is crucial to avoid increased cardiovascular events. Anti-malarial therapy, particularly hydroxychloroquine, shows promise in mitigating cardiovascular risk factors. Non-pharmacological modifications, such as diet, exercise, and smoke cessation, significantly contribute to cardiovascular health in SLE patients. Adjuvant therapies involving glutathione and glutathione peroxidase focus on redox balance, offering potential interventions. This integrated approach combines diagnostic insights with diverse treatment modalities, providing a holistic strategy for managing cardiac complications in SLE. Ongoing research is essential to refine these strategies and optimize individualized treatment plans for improved patient outcomes.