Post‐discharge arrhythmic risk stratification of patients with acute myocarditis and life‐threatening ventricular tachyarrhythmias

Gentile, Piero; Merlo, Marco; Peretto, Giovanni; Ammirati, Enrico; Sala, Simone; Bella, Paolo Della; Aquaro, Giovanni Donato; Imazio, Massimo; Potena, Luciano; Campodonico, Jeness; Foà, Alberto; Raafs, Anne; Hazebroek, Mark; Brambatti, Michela; Cercek, Andreja Cerne; Nucifora, Gaetano; Shrivastava, Sanskriti; Huang, Florent; Schmidt, Matthieu; Muser, Daniele; Heyning, Caroline M. Van De; Craenenbroeck, Emeline Van; Aoki, Tatsuo; Sugimura, Koichiro; Shimokawa, Hiroaki; Cannatà, Antonio; Artico, Jessica; Porcari, Aldostefano; Colopi, Marzia; Perkan, Andrea; Bussani, Rossana; Barbati, Giulia; Garascia, Andrea; Cipriani, Manlio; Agostoni, Piergiuseppe; Pereira, Naveen L.; Heymans, Stéphane; Adler, Eric; Camici, Paolo G.; Frigerio, Maria; Sinagra, Gianfranco

doi:10.1002/ejhf.2288

Cited by 22 publications

(30 citation statements)

References 33 publications

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“…In keeping with prior studies, we identified anteroseptal LGE [23][24][25][26] and histological signs suggesting chronic myocarditis [12,13] as factors associated with adverse arrhythmic outcomes, both in the whole cohort and in patients without malignant VA onset. Results are consistent with recently published data [27]. As suggested by Table 3, mild systolic dysfunction (i.e., LVEF < 50%) may play an additional role for primary prevention risk stratification, as already suggested both in myocarditis and other cardiomyopathies [28,29].…”

Section: Arrhythmic Risk Estimationsupporting

confidence: 92%

Continuous Electrical Monitoring in Patients with Arrhythmic Myocarditis: Insights from a Referral Center

Peretto

Mazzone

Paglino

et al. 2021

JCM

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Background. The incidence and burden of arrhythmias in myocarditis are under-reported. Objective. We aimed to assess the diagnostic yield and clinical impact of continuous arrhythmia monitoring (CAM) in patients with arrhythmic myocarditis. Methods. We enrolled consecutive adult patients (n = 104; 71% males, age 47 ± 11 year, mean LVEF 50 ± 13%) with biopsy-proven active myocarditis and de novo ventricular arrhythmias (VAs). All patients underwent prospective monitoring by both sequential 24-h Holter ECGs and CAM, including either ICD (n = 62; 60%) or loop recorder (n = 42; 40%). Results. By 3.7 ± 1.6 year follow up, 45 patients (43%) had VT, 67 (64%) NSVT and 102 (98%) premature ventricular complexes (PVC). As compared to the Holter ECG (average 9.5 exams per patient), CAM identified more patients with VA (VT: 45 vs. 4; NSVT: 64 vs. 45; both p < 0.001), more VA episodes (VT: 100 vs. 4%; NSVT: 91 vs. 12%) and earlier NSVT timing (median 6 vs. 24 months, p < 0.001). The extensive ICD implantation strategy was proven beneficial in 80% of the population. Histological signs of chronically active myocarditis (n = 73, 70%) and anteroseptal late gadolinium enhancement (n = 26, 25%) were significantly associated with the occurrence of VTs during follow up, even in the primary prevention subgroup. Conclusion. In patients with arrhythmic myocarditis, CAM allowed accurate arrhythmia detection and showed a considerable clinical impact.

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Section: Arrhythmic Risk Estimationsupporting

confidence: 92%

Continuous Electrical Monitoring in Patients with Arrhythmic Myocarditis: Insights from a Referral Center

Peretto

Mazzone

Paglino

et al. 2021

JCM

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“…Specifically, ~40% of patients presenting with life-threatening VA can experience a recurrence at a median time of 8 months based on a recent international registry including 156 patients ( 104 ). Factors associated with arrhythmic recurrence were initial presentation with sustained VT, LGE involving ≥2 myocardial segments, and absence of T2-weighted short-tau inversion recovery (STIR) signal suggestive for residual edema on CMRI ( 104 ). In this registry, 98 patients underwent EMB showing in the large majority of cases a lymphocytic myocarditis (88.8%).…”

Section: Specific Subset Of Myocarditismentioning

confidence: 99%

“…In this registry, 98 patients underwent EMB showing in the large majority of cases a lymphocytic myocarditis (88.8%). An immunosuppressive therapy was initiated in 21% of cases and there was no difference in the use of immunosuppressive therapy between patients who subsequently experience an arrhythmic recurrence vs. those who did not ( 104 ). A second registry of 185 patients with VA (including VF/VT, non-sustained VT, and Lown's ≥2 premature ventricular complexes [PVC]) and myocarditis confirmed a 30% of recurrence of malignant VA at 2 years ( 105 ).…”

Section: Specific Subset Of Myocarditismentioning

confidence: 99%

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

et al. 2022

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The field of inflammatory disease of the heart or “cardio-immunology” is rapidly evolving due to the wider use of non-invasive diagnostic tools able to detect and monitor myocardial inflammation. In acute myocarditis, recent data on the use of immunomodulating therapies have been reported both in the setting of systemic autoimmune disorders and in the setting of isolated forms, especially in patients with specific histology (e.g., eosinophilic myocarditis) or with an arrhythmicburden. A role for immunosuppressive therapies has been also shown in severe cases of coronavirus disease 2019 (COVID-19), a condition that can be associated with cardiac injury and acute myocarditis. Furthermore, ongoing clinical trials are assessing the role of high dosage methylprednisolone in the context of acute myocarditis complicated by heart failure or fulminant presentation or the role of anakinra to treat patients with acute myocarditis excluding patients with hemodynamically unstable conditions. In addition, the explosion of immune-mediated therapies in oncology has introduced new pathophysiological entities, such as immune-checkpoint inhibitor-associated myocarditis and new basic research models to understand the interaction between the cardiac and immune systems. Here we provide a broad overview of evolving areas in cardio-immunology. We summarize the use of new imaging tools in combination with endomyocardial biopsy and laboratory parameters such as high sensitivity troponin to monitor the response to immunomodulating therapies based on recent evidence and clinical experience. Concerning pericarditis, the normal composition of pericardial fluid has been recently elucidated, allowing to assess the actual presence of inflammation; indeed, normal pericardial fluid is rich in nucleated cells, protein, albumin, LDH, at levels consistent with inflammatory exudates in other biological fluids. Importantly, recent findings showed how innate immunity plays a pivotal role in the pathogenesis of recurrent pericarditis with raised C-reactive protein, with inflammasome and IL-1 overproduction as drivers for systemic inflammatory response. In the era of tailored medicine, anti-IL-1 agents such as anakinra and rilonacept have been demonstrated highly effective in patients with recurrent pericarditis associated with an inflammatory phenotype.

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“…Outcomes of acute myocarditis are not clearly defined. 3,22,23 A total of 466 consecutive patients, with clinically suspected or biopsy-proven myocarditis, were enrolled in a single centre prospective study from 1992 to 2012. Survival free from death or heart transplantation at 10 years was 83% and was lower in biopsy-proven versus clinically suspected myocarditis (76% vs. 94%, p < 0.001).…”

Section: Acute Myocarditismentioning

confidence: 99%

June 2022 at a glance: prevention, outcomes and treatment

Tomasoni

Adamo

Metra

2022

European J of Heart Fail

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Myocardial infarction (MI) is a major cause of heart failure (HF). [1][2][3] Rastogi et al. 4 showed different characteristics associated with the progression to HF in patients with or without a history of MI in the HOMAGE (Heart 'OMics' in AGEing) cohort. Older age, male sex and higher heart rate were associated with an increased risk of HF in all subjects, whereas lower renal function had a stronger association with HF in patients with a history of MI, and higher body mass index, hypertension and blood glucose were significant only in patients without a history of MI. These data were confirmed in the UK Biobank (validation cohort). 4 Chronic kidney disease (CKD) is a major risk factor for HF. 2,5 Janus et al. 6 investigated the usefulness of biomarkers to predict the risk of HF in 3182 patients with CKD in the Chronic Renal Insufficiency Cohort (CRIC). Four biomarkers -B-type natriuretic peptide, fibroblast growth factor-23, fibrinogen and high-sensitivity troponin T -were associated with incident HF after adjustment for other risk factors and their inclusion allowed a better risk stratification for incident HF. Acute myocarditisOutcomes of acute myocarditis are not clearly defined. 3,22,23 A total of 466 consecutive patients, with clinically suspected or biopsy-proven myocarditis, were enrolled in a single centre prospective study from 1992 to 2012. Survival free from death or heart transplantation at 10 years was 83% and was lower in biopsy-proven versus clinically suspected myocarditis (76% vs. 94%, p < 0.001). Female gender, fulminant presentation, anti-nuclear antibodies and lower LVEF were predictors of death or heart transplantation. 24

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Post‐discharge arrhythmic risk stratification of patients with acute myocarditis and life‐threatening ventricular tachyarrhythmias

Abstract: The outcomes of patients presenting with acute myocarditis and life-threatening ventricular arrhythmias (LT-VA) are unclear. The aim of this study was to assess the incidence and predictors of recurrent major arrhythmic events (MAEs) after hospital discharge in this patient population.

Cited by 22 publications

References 33 publications

Continuous Electrical Monitoring in Patients with Arrhythmic Myocarditis: Insights from a Referral Center

Continuous Electrical Monitoring in Patients with Arrhythmic Myocarditis: Insights from a Referral Center

Immunomodulating Therapies in Acute Myocarditis and Recurrent/Acute Pericarditis

June 2022 at a glance: prevention, outcomes and treatment

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