Silent myocarditis in systemic sclerosis detected by cardiovascular magnetic resonance using Lake Louise criteria

Abstract

BackgroundSystemic sclerosis (SSc) is an autoimmune disease characterized by microvascular abnormalities, inflammation and fibrosis. We hypothesized that myocarditis may be diagnosed in asymptomatic SSc, undergoing routine cardio-vascular magnetic resonance (CMR) for fibrosis assessment, using the Lake Louise criteria: T2 ratio, early (EGE) and late gadolinium enhanced (LGE) images.MethodsEighty-two asymptomatic SSc, diagnosed according to American College of Rheumatology criteria, aged 43 ± 5 yrs., 62 with diffuse (dSSc) and 20 with localized (lSSc) systemic sclerosis were evaluated by CMR, performed at 1.5 T scanner, according to Lake Louise criteria.ResultsCMR documented normal biventricular function in all SSc. However, 7/62 (11.2%) with dSSc and 2/20 (10%) with lSSc, had CMR signs of myocarditis according to Lake Louise criteria, without any clinical cardiac symptom. In these 9 patients, T2 ratio, EGE ratio and LGE (positive in all 9 SSc) were 2.8 ± 0.5%, 8 ± 3% and 5 ± 3% of LV mass, respectively. No correlation between CMR and blood inflammatory indices (C-reactive protein and erythrocyte sedimentation rate), cardiac troponin T, disease characteristics or type of SSc was identified. A repeat CMR at 6 months, after treatment with prednisone and azathioprine, showed normalisation of the acute inflammation CMR indices.ConclusionsSilent myocarditis may be diagnosed using the Lake Louise paper criteria in SSc patients without cardiac symptoms, has no correlation with blood inflammatory indices, cardiac troponin or disease characteristics. CMR is a promising tool to diagnose silent myocarditis in SSc and monitor the response to immunosuppressive treatment.

Cardiovascular Magnetic Resonance Identifies High-Risk Systemic Sclerosis Patients with Normal Echocardiograms and Provides Incremental Prognostic Value

“…A diffuse subendocardial fibrosis pattern was present in 75% of patients that died and conveyed the worse prognosis [21]. Furthermore, according to other studies, myocarditis is a common finding in SSc patients with recent-onset cardiac involvement [22,23].…”

Clinical and laboratory predictions of myocardial inflammation as detected by cardiac magnetic resonance imaging in patients with systemic sclerosis: A pilot study

“…Myocardial inflammation is commonly found in early‐onset SSc. Early detection and treatment of myocardial inflammation may help to prevent myocardial fibrosis and/or further mortality …”

“…In SSc, there are some limitations of interpretation due to breathing artifacts, arrhythmia, and undistinguished diffuse myocardial inflammation from diffuse fibrosis . Mavrogeni et al reported on myocardial inflammation detection—with a prevalence of 10%—using cardiac MRI and the Lake Louise Criteria in SSc with asymptomatic cardiac involvement, and they found no correlation between myocardial inflammation and blood inflammatory indices, cardiac troponin‐T, disease characteristics, or the SSc subset. There have been no recent studies between the clinical and laboratory associations and the findings of myocardial inflammation on cardiac MRI.…”

Combined Brain-Heart Magnetic Resonance Imaging in Autoimmune Rheumatic Disease Patients with Cardiac Symptoms: Hypothesis Generating Insights from a Cross-Sectional Study

“…As such, this demonstrates the need for a combined brain and heart MRI examination in ARD patients with cardiac symptoms, seeing as disease progression may evolve differently in the two organs. Notably, our group has previously reported that CMR findings are independent of C-reactive protein levels in ARD patients [47,51,52], often rendering biomarker-based pre-selection of patients for CMR examinations problematic. This would explain the current findings and suggests that such inflammatory biomarkers might have greater utility in evaluating brain involvement than cardiac involvement, although this needs to be corroborated by future independent studies.…”