Update on Myocarditis Kindermann, Ingrid, MD; Barth, Christine; Mahfoud, Felix, MD ...
Journal of the American College of Cardiology,
02/2012, Letnik:
59, Številka:
9
Journal Article
Recenzirano
Odprti dostop
Myocarditis is an inflammatory disease of the heart frequently resulting from viral infections and/or post-viral immune-mediated responses. It is one of the important causes of dilated cardiomyopathy ...worldwide. The diagnosis is presumed on clinical presentation and noninvasive diagnostic methods such as cardiovascular magnetic resonance imaging. Endomyocardial biopsy remains the gold standard for in vivo diagnosis of myocarditis. The therapeutic and prognostic benefits of endomyocardial biopsy results have recently been demonstrated in several clinical trials. Although remarkable advances in diagnosis, understanding of pathophysiological mechanisms, and treatment of acute myocarditis were gained during the last years, no standard treatment strategies could be defined as yet, apart from standard heart failure therapy and physical rest. In severe cases, mechanical support or heart transplantation may become necessary. There is some evidence that immunosuppressive and immunomodulating therapy are effective for chronic, virus-negative inflammatory cardiomyopathy. Further investigations by controlled, randomized studies are needed to definitively determine their role in the treatment of myocarditis.
Objectives This study aimed to demonstrate that the presence of late gadolinium enhancement (LGE) is a predictor of death and other adverse events in patients with suspected cardiac sarcoidosis. ...Background Cardiac sarcoidosis is the most important cause of patient mortality in systemic sarcoidosis, yielding a 5-year mortality rate between 25% and 66% despite immunosuppressive treatment. Other groups have shown that LGE may hold promise in predicting future adverse events in this patient group. Methods We included 155 consecutive patients with systemic sarcoidosis who underwent cardiac magnetic resonance (CMR) for workup of suspected cardiac sarcoid involvement. The median follow-up time was 2.6 years. Primary endpoints were death, aborted sudden cardiac death, and appropriate implantable cardioverter-defibrillator (ICD) discharge. Secondary endpoints were ventricular tachycardia (VT) and nonsustained VT. Results LGE was present in 39 patients (25.5%). The presence of LGE yields a Cox hazard ratio (HR) of 31.6 for death, aborted sudden cardiac death, or appropriate ICD discharge, and of 33.9 for any event. This is superior to functional or clinical parameters such as left ventricular (LV) ejection fraction (EF), LV end-diastolic volume, or presentation as heart failure, yielding HRs between 0.99 (per % increase LVEF) and 1.004 (presentation as heart failure), and between 0.94 and 1.2 for potentially lethal or other adverse events, respectively. Except for 1 patient dying from pulmonary infection, no patient without LGE died or experienced any event during follow-up, even if the LV was enlarged and the LVEF severely impaired. Conclusions Among our population of sarcoid patients with nonspecific symptoms, the presence of myocardial scar indicated by LGE was the best independent predictor of potentially lethal events, as well as other adverse events, yielding a Cox HR of 31.6 and of 33.9, respectively. These data support the necessity for future large, longitudinal follow-up studies to definitely establish LGE as an independent predictor of cardiac death in sarcoidosis, as well as to evaluate the incremental prognostic value of additional parameters.
Cardiovascular magnetic resonance (CMR) has become the primary tool for noninvasive assessment of myocardial inflammation in patients with suspected myocarditis. The International Consensus Group on ...CMR Diagnosis of Myocarditis was founded in 2006 to achieve consensus among CMR experts and develop recommendations on the current state-of-the-art use of CMR for myocarditis. The recommendations include indications for CMR in patients with suspected myocarditis, CMR protocol standards, terminology for reporting CMR findings, and diagnostic CMR criteria for myocarditis (i.e., “Lake Louise Criteria”).
Objectives We sought to establish the prognostic value of a comprehensive cardiovascular magnetic resonance (CMR) examination in risk stratification of hypertrophic cardiomyopathy (HCM) patients. ...Background With annual mortality rates ranging between 1% and 5%, depending on patient selection, a small but significant number of HCM patients are at risk for an adverse event. Therefore, the identification of and prophylactic therapy (i.e., defibrillator placement) in patients with HCM who are at risk of dying are imperative. Methods Two-hundred forty-three consecutive patients with HCM were prospectively enrolled. All patients underwent initial CMR, and 220 were available for clinical follow-up. The mean follow-up time was 1,090 days after CMR. End points were all-cause and cardiac mortality. Results During follow-up 20 of the 220 patients died, and 2 patients survived sudden cardiac death due to adequate implantable cardioverter-defibrillator discharge. Most events (n = 16) occurred for cardiac reasons; the remaining 6 events were related to cancer and accidents. Our data indicate that the presence of scar visualized by CMR yields an odds ratio of 5.47 for all-cause mortality and of 8.01 for cardiac mortality. This might be superior to classic clinical risk factors, because in our dataset the presence of 2 risk factors yields an odds ratio of 3.86 for all-cause and of 2.20 for cardiac mortality, respectively. Multivariable analysis also revealed the presence of late gadolinium enhancement as a good independent predictor of death in HCM patients. Conclusions Among our population of largely low or asymptomatic HCM patients, the presence of scar indicated by CMR is a good independent predictor of all-cause and cardiac mortality.
Aortic aneurysm and acute aortic syndrome are not uncommon conditions. Management of acute aortic dissection and related syndromes requires a multidisciplinary approach with input from the patient, ...clinician, imager, surgeon, and anesthesiologist. This requires an integrated evaluation of pathophysiology, anatomy, and severity to enable appropriate therapy. This review includes discussion of essential anatomy of the aortic valve and the aorta that determines the candidacy for surgical repair. It also includes discussion of various imaging modalities, particularly echocardiography, cardiac computed tomography, and cardiac magnetic resonance angiography. The relative benefits and demerits of each of these techniques are reviewed. This paper is intended to help guide management decisions for patients with acute aortic dissection and related syndromes.
Abstract Cardiovascular magnetic resonance (CMR) has evolved from a pioneering research tool to an established noninvasive imaging method for detecting inducible myocardial perfusion deficits. In ...this consensus document, experts of different imaging techniques summarize the existing body of evidence regarding CMR perfusion as a viable complement to other established noninvasive tools for the assessment of perfusion and discuss the advantages and pitfalls of the technique. A rapid, standardized CMR perfusion protocol is described, which is safe, clinically feasible, and cost-effective for centers with contemporary magnetic resonance equipment. CMR perfusion can be recommended as a routine diagnostic tool to identify inducible myocardial ischemia.
Takotsubo syndrome (TTS) occurs predominantly in elderly females but young individuals and children may also be affected. There are no consistent differences between men and women regarding age, ...symptoms, prehospital delay, or clinical course. Mortality has been reported to be higher in males. The QTc interval may be disproportionately prolonged in male patients in the days after admission predisposing them to ventricular arrhythmias. The higher level of cardiac markers in males with TTS may be related to the greater frequency of physical stress before the onset of TTS. Understanding the pathogenetic background may lead to preventive/therapeutic means against this life-threatening disease.
Abstract Marfan Syndrome (MFS) is an autosomal dominant connective tissue disease associated with acute aortic dissection (AAD). We used two large registries that include MFS patients to investigate ...possible trends in the chronobiology of AAD in MFS. We queried the International Registry of Acute Aortic Dissection (IRAD) and the Genetically Triggered Thoracic Aortic Aneurysms and Cardiovascular Conditions (GenTAC) registry to extract data on all patients with MFS who had suffered an AAD. The group included 257 patients with MFS who suffered an AAD between 1980 and 2012. Chi-square tests were used for statistical testing. Mean subject age at time of AAD was 38 years and 61% of subjects were male. AAD was more likely in the winter/spring season (Nov-Apr) than the other half of the year (57% vs. 43%, p=0.05). Dissections were significantly more likely to occur during the daytime hours, with 65% of dissections occurring from 6AM to 6PM (p=0.001). Males were more likely to dissect during the daytime hours (6AM-6PM) than females (74% vs. 51%, p=0.01). These insights offer a glimpse of the times of greatest vulnerability for MFS patients who suffer from this catastrophic event. In conclusion, the chronobiology of AAD in MFS reflects that of AAD in the general population.
Although several studies have provided robust evidence about global differences for several cardiovascular emergencies, such as myocardial infarction and stroke, data were limited for aortic disease. ...The aim was to explore geographic variation in type A acute aortic dissection (TA-AAD) in a large group of consecutive patients. Patients (n = 615) from the IRAD with TA-AAD were studied with respect to presenting symptoms and signs, diagnosis, management, and outcomes in Europe versus North America. Compared with Europeans, North Americans were more likely to be older and present with atypical features and without many of the classic chest X-ray findings of AAD. In the North American cohort, electrocardiographic findings showed higher rates of nonspecific ST changes and a trend toward ST-elevation or new myocardial infarction (North Americans vs Europeans 7.9% vs 4.4%; p = 0.09). Use of imaging studies to confirm the diagnosis of AAD varied between North American and European centers. North American centers performed an average of 1.6 imaging studies compared with 1.8 in the European group (p = 0.002). Furthermore, they were significantly less likely to use computed tomography and significantly more likely to use transesophageal examination as part of the overall diagnostic algorithm. Compared with Europeans, TA-AAD occurred at smaller aortic diameters and there was a substantial delay to presentation and diagnosis in North Americans. No significant differences for early mortality rates were observed between the 2 groups. In conclusion, geographic differences in presentation and initial management were highlighted, but this did not translate into a difference in early mortality.
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