Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document
Enrico Ammirati, Maria Frigerio, Eric D Adler, Cristina Basso, David H Birnie, Michela Brambatti, Matthias G Friedrich, Karin Klingel, Jukka Lehtonen, Javid J Moslehi, Patrizia Pedrotti, Ornella E Rimoldi, Heinz-Peter Schultheiss, Carsten Tschöpe, Leslie T Cooper Jr, Paolo G Camici, Enrico Ammirati, Maria Frigerio, Eric D Adler, Cristina Basso, David H Birnie, Michela Brambatti, Matthias G Friedrich, Karin Klingel, Jukka Lehtonen, Javid J Moslehi, Patrizia Pedrotti, Ornella E Rimoldi, Heinz-Peter Schultheiss, Carsten Tschöpe, Leslie T Cooper Jr, Paolo G Camici
Abstract
Myocarditis is an inflammatory disease of the heart that may occur because of infections, immune system activation, or exposure to drugs. The diagnosis of myocarditis has changed due to the introduction of cardiac magnetic resonance imaging. We present an expert consensus document aimed to summarize the common terminology related to myocarditis meanwhile highlighting some areas of controversies and uncertainties and the unmet clinical needs. In fact, controversies persist regarding mechanisms that determine the transition from the initial trigger to myocardial inflammation and from acute myocardial damage to chronic ventricular dysfunction. It is still uncertain which viruses (besides enteroviruses) cause direct tissue damage, act as triggers for immune-mediated damage, or both. Regarding terminology, myocarditis can be characterized according to etiology, phase, and severity of the disease, predominant symptoms, and pathological findings. Clinically, acute myocarditis (AM) implies a short time elapsed from the onset of symptoms and diagnosis (generally <1 month). In contrast, chronic inflammatory cardiomyopathy indicates myocardial inflammation with established dilated cardiomyopathy or hypokinetic nondilated phenotype, which in the advanced stages evolves into fibrosis without detectable inflammation. Suggested diagnostic and treatment recommendations for AM and chronic inflammatory cardiomyopathy are mainly based on expert opinion given the lack of well-designed contemporary clinical studies in the field. We will provide a shared and practical approach to patient diagnosis and management, underlying differences between the European and US scientific statements on this topic. We explain the role of histology that defines subtypes of myocarditis and its prognostic and therapeutic implications.
Keywords: cardiac magnetic resonance imaging; endomyocardial biopsy; inflammatory cardiomyopathy; myocarditis; viruses.
Conflict of interest statement
Dr Adler is a consultant for Abbott, Abiomed, AstraZeneca, Endotronix, Ionis, Medtronic, and Novartis, is on the board of directors of Genstem Therapeutics, and is a shareholder of Rocket Pharmaceuticals. Dr Brambatti is an employee at Ionis Pharmaceuticals. Dr Moslehi has served on advisory boards for Pfizer, Novartis, Bristol-Myers Squibb, Deciphera, Audentes Pharmaceuticals, Nektar, Takeda, Ipsen, Myokardia, AstraZeneca, GlaxoSmithKline, Intrexon, and Regeneron and has been supported by National Institutes of Health grants R56 HL141466 and R01 HL141466. Dr Tschöpe is a consultant at Cardiotropic Labs, Miami, FL. Dr Camici is a consultant at Servier. The other authors report no conflicts.
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Source: PubMed