Myocardites ACC 2024 Flashcards
(17 cards)
Three Classic Presentations of Myocarditis ?
chest pain
arrythmia
heart failure/ cardiogenic shock
CMR Criteria for Nonischemic Myocardial Inflammation, as Seen in Myocarditis, Based on the Updated Lake Louise Criteria (2018) ?
Main criteria :
One T2 based criteria (T2W or T2 map)
PLUS
One T1 based criteria (T1 map Or ECV Or LGE)
ESC diagnostic criteria for myocarditis from noninvasive testing included ?
1 criteria + clinical presentation OR 2 criterias
- Newly abnormal 12-lead ECG and/or Holter and/or stress testing, any of the following: first- to thirddegree atrioventricular block or bundle branch block, ST/T-wave change (ST elevation or non-ST elevation, T-wave inversion), sinus arrest, ventricular tachycardia or fibrillation and asystole, atrial fibrillation, reduced R-wave height, intraventricular conduction
delay, abnormal Q waves, low voltage, frequent premature beats, or supraventricular tachycardia. - Elevation in circulating cTn with a time course similar to that of acute myocardial infarction or a prolonged and sustained release (weeks or months).
- New, otherwise unexplained LV and/or RV structure and function abnormality on cardiac imaging (echocardiography/ventriculogram/CMR), including incidental finding in apparently asymptomatic patients:
regional wall motion or global systolic or diastolic function abnormality, with or without ventricular
dilation, increased wall thickness, pericardial effusion, or endocavitary thrombi. - New abnormal tissue characterization suggestive of inflammation by CMR: structural myocardial changes
suggestive of myocardial inflammation, such as myocardial edema, tissue changes, or fibrosis.
Risk Factors to Define Stage A At-Risk for Myocarditis
1.Genetic variants : Pathogenic gene variants linked to dilated and
arrhythmogenic cardiomyopathy and neuromuscular disorders Disease-causing variants in DSP (desmoplakin) and TTN (titin) are consistently associated with myocarditis
- History of myocarditis n Personal history of prior episode of myocarditis
Family history of myocarditis - Cardiotoxins : Prescribed medications, including immune
checkpoint inhibitors, doxorubicin, trastuzumab,
clozapine Illicit substances: cocaine, methamphetamine - Thymoma
- Systemic immune-mediated/
connective tissue disease
Sarcoidosis, systemic lupus, rheumatoid arthritis,
scleroderma, myositis, or vasculitis - Hypereosinophilia
- Infectious agents Particularly viruses (eg, adenovirus, enterovirus,
parvovirus, human herpes virus 6, influenza, HIV, SARS-CoV-2) but also other organisms, including bacteria, fungi, and parasites
Vaccines Including smallpox, mRNA COVID-19
When to Perform EMB (Endomyocardial Biopsy) in Patients With Suspected Myocarditis ?
- Stage B myocarditis in the context of ICI (immune checkpoint inhibitor) therapy
- Stage C myocarditis with any of the following:
- LV dysfunction or
Symptomatic heart failure or
Arrhythmia, such as:
High-degree AV block
Frequent multifocal PVCs, VT, or VF - Peripheral eosinophilia
- Uncertain diagnosis and unable to acquire CMR (cardiac MRI)
- Stage D myocarditis
stage A treatment and surveillance ?
STAGE A — AT-RISK FOR MYOCARDITIS
Monitor for progression to higher stages of myocarditis
Remove offending agent and avoid reexposure when feasible
Counsel patient of risk
stage B treatment and surveillance ?
STAGE B — MYOCARDITIS
Hospitalization depending on clinical context and severity of myocardial involvement
Reassess for presence of symptoms
Obtain ECG if not done before
Remove offending agent and avoid reexposure when feasible
Treat by etiology
stage C treatment and surveillance ?
STAGE C — MYOCARDITIS
Hospitalization if not low-risk presentation
Triage for referral to advanced heart failure center with myocarditis team
Endomyocardial biopsy in select patients
Pharmacological treatment as appropriate:
Immunosuppression
Directed at etiology
GDMT (Guideline-Directed Management and Therapy) for HF
Restrict strenuous physical activity for 3–6 months (avoid excessive sedentary behavior)
stage D treatment and surveillance ?
ICU admission
Refer to an advanced heart failure center with a myocarditis team
Treat arrhythmia
Provide hemodynamic support, including temporary circulatory support if needed
Endomyocardial biopsy
Pharmacological treatment:
Immunosuppression
Directed at etiology
GDMT for HF and shock
Consider durable LVAD or heart transplant if no recovery
Restrict strenuous physical activity for 3–6 months (avoid excessive sedentary behavior)
Not all patients with myocarditis require immunosuppressive therapy
General consensus is to administer immunosuppressive therapy for the following conditions:
Eosinophilic myocarditis
Giant cell myocarditis
Granulomatous myocarditis (sarcoid)
Associated with immune checkpoint inhibitor therapy
In setting of other autoimmune conditions
There remains lack of broad consensus but myocarditis experts from certain centers advise:
Perform viral PCR on endomyocardial biopsy tissue to exclude active infection prior to initiation of immunosuppressive therapy
Treat chronic lymphocytic myocarditis (with negative viral PCR) with immunosuppressive therapy
Implementation of immunosuppressive therapy
Typically start with methylprednisolone boluses (7–14 mg/kg per day for 3 days) followed by oral prednisone taper (start at 1 mg/kg)
Giant cell myocarditis requires higher level of immunosuppression than IV steroids, typically including a calcineurin inhibitor (cyclosporine or tacrolimus)
Involve other specialty experts in setting of autoimmune conditions (e.g., systemic lupus, vasculitis) as immunosuppressive strategy may be altered based on other organ involvement
when to use IVIG ?
IVIG can be considered in the setting of inflammatory, antibody-mediated, or autoimmune disorders
low risk stage C ?
All the following:
Normal LVEF
No LGE
Hemodynamic and electrical stability
follow up of low risk stage C ?
By 2-4 weeks
Office visit
Echocardiogram
At 6 months : Echocardiogram
follow up of high risk stage C and stage D ?
By 2-4 weeks : Office visit, Biomarkers, ECG
Echocardiogram
Uptitration of GDMT for
HFrEF as appropriate
At 6 months : MRI
Key Risk Factors for Adverse Prognosis in Patients With Myocarditis
Symptomatic HF
Biventricular reduced EF
GCM
Cardiogenic shock
Presence of LGE
Electrical instability
Recurrent ventricular arrhythmia
Advanced AV block
when to return to physical activity ?
after 3-6 months
if no symptoms
if no arrythmia nor ventricular ectopy
if CMR normal
if treadmill test normal at maximal effort
the resume sport,
if not : repeat reevaluation in 3 months
