Early characteristics of fulminant myocarditis vs non-fulminant myocarditis

Abstract

Background: Fulminant myocarditis (FM) is a sub-category myocarditis. Its primary characteristic is a rapidly progressive clinical course that necessitates hemodynamic support. FM can be difficult to predict at the onset of myocarditis. The aim of this meta-analysis was to identify the early characteristics in FM compared to those of non-fulminant myocarditis (NFM). Methods: We searched the databases of MEDLINE, EMBASE, CENTRAL, for studies comparing FM with acute NFM from January 1, 2000 to June 1, 2018. The baseline variables were compared in each study. Mean differences (MD) and relative ratios (RR) were calculated. Results: Seven studies (158 FM patients and 388 NFM patients) were included in the analysis. The FM group had significantly lower systolic blood pressure (SBP), higher creatine kinase (CK), wider QRS duration, lower left ventricular ejection fraction (LVEF), thicker left ventricular posterior wall diameter (LVPWd), higher incidence of ST depression, ventricular tachycardia/ventricular fibrillation (Vt/Vf) and syncope, less incidence of chest pain than the NFM groups. There was no difference in terms of heart rate (HR), c-reactive protein (CRP), fever, dyspnea, white blood cells (WBC), atrioventricular block (AVB), Q waves, ST elevation, interventricular septum diameter (IVSd), or end-diastolic left ventricular diameter (LVEDd) between FM and NFM. Conclusion: We found that the lower SBP, higher CK, wider QRS duration, lower LVEF, thicker LVPWd, higher incidence of ST depression, Vt/Vf and syncope as well as lower incidence of chest pain were early characteristics of FM.

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

“…The presence of wide QRS complex has been associated with a poorer prognosis, particularly in FM, where it can be one of the earliest clinical signs (Elamm et al, 2012;Ginsberg & Parrillo, 2013;Ukena et al, 2011;Wang et al, 2019). A study by Morgera B et al showed that abnormal QRS complexes were associated with more severe left ventricular impairment and with a higher frequency of hypertrophy and fibrosis (according to histologic examination) (Morgera et al, 1992).…”

“…ST depression is less frequent in myocarditis/myopericarditis (with the exception of lead aVR); when present in patients simultaneously displaying ST elevation, it likely represents a reciprocal change and suggests MI (Pollak & Brady, 2012). However, nonspecific ST depression has been reported in FM (Ginsberg & Parrillo, 2013), where it can represent one of the earliest clinical signs (Wang et al, 2019). Moreover, De Winter sign (defined as a 1-3 mm upsloping ST depression in V1-V6 that continues into tall, positive symmetrical T waves, generally associated with ST elevation of 1-2 mm in aVR lead and mild ST depression in inferior leads), a well-described ECG pattern that typically suggests acute occlusion of proximal left anterior descending coronary artery, has also been described in ACS-like myocarditis (de Winter, Verouden, Wellens, & Wilde, 2008;García-Izquierdo, Parra-Esteban, Mirelis, & Fernández-Lozano, 2018).…”

The diagnostic capability of electrocardiography on the cardiogenic shock in the patients with acute myocarditis

“…It has been observed that the different components of electrocardiography (ECG) usually alter in myocarditis patients, such as prolonged PR interval, wide QRS complex, nonspecific ST-T changes, emergence of pathological Q wave [11]. Although many changes are not pathognomonic, a few features are more likely to occur in the FM than NFM [12][13][14][15]. Based on the above findings, we postulate that combination of the various alterations on the ECG might create an useful index for rapid diagnosis of the CS in acute myocarditis patients.…”

A Mini-Thoracotomy Approach for Walking Veno-Arterial Extracorporeal Membranous Oxygenation

“…Patients with fulminant myocarditis require varying platforms of hemodynamic support (1). This group can be differentiated from the more benign uncomplicated myocarditis presentation as they have significantly lower systolic blood pressure, higher creatine kinase, wider QRS duration, lower left ventricular ejection fraction, thicker left ventricular posterior wall diameter, higher incidence of ST depression, and more ventricular tachycardia/ventricular fibrillation (1).…”