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Clinical and Imaging Diagnostic Criteria for Myocarditis
Quick Takes
- There is a significant and independent prognostic value of ESC criteria for suspected myocarditis and the updated Lake-Louise criteria (LLC), respectively.
- ESC criteria were positive in a larger proportion of patients, while LLC more specifically indicated high risk for MACE.
- AHA criteria for probable acute myocarditis and expert consensus definitions of acute and complicated myocarditis had moderate overlap to each other and were of limited prognostic value when adjusted for clinical criteria and ESC or LLC.
Study Questions:
What is the comparative predictive value of European Society of Cardiology (ESC) criteria for clinically suspected myocarditis, updated Lake-Louise criteria (LLC), American Heart Association (AHA) criteria for probable acute myocarditis (pAM), and expert consensus criteria for acute myocarditis (AM) and complicated myocarditis (CM)?
Methods:
The investigators enrolled patients with a clinical suspicion of myocarditis referred for cardiac magnetic resonance (CMR) at two centers. Those with any prior cardiomyopathy were excluded. The association of composite outcome events (heart failure hospitalization, recurrent myocarditis, sustained ventricular tachycardia, or death) with ESC diagnostic criteria, LLC, pAM, AM, and CM were compared. Uni- and multivariate Cox regression was used to investigate associations to the composite endpoint and to provide hazard ratios (HRs) and confidence intervals (CIs). Time to event curves were plotted according to the Kaplan-Meier method and groups compared by a log-rank test.
Results:
Among 1,557 consecutive patients referred for CMR with possible myocarditis, 1,050 (62.6% male; 48.9 ± 16.8 years of age) were without an alternative diagnosis. Of those, 938 (89.3%) met ESC criteria for clinically suspected myocarditis, 299 (28.5%) LLC, and 356 (33.9%), 216 (20.6%), and 77 (7.3%) for pAM, AM, and CM, respectively. Adverse events occurred in 161 patients (15.3%) during a median follow-up of 3.4 years. The highest annualized event rates (6.6%) were observed in patients meeting LLC, whereas negative ESC criteria indicated excellent prognosis (0.7% annualized event rate). Among all myocarditis definitions, ESC criteria and LLC were the strongest multivariable outcome predictors and had independent and incremental prognostic value (adjusted HR, 3.87; 95% CI, 1.22-12.2; p = 0.021, and adjusted HR, 2.53; 95% CI, 1.83-3.49; p < 0.001, respectively) when adjusted for clinical characteristics.
Conclusions:
The authors report that in a real-world cohort of patients with possible myocarditis, diagnosis was reached in most patients using ESC criteria, whereas only approximately one-quarter of patients reached a diagnosis with LLC.
Perspective:
This study reports a significant and independent prognostic value of ESC criteria for suspected myocarditis and the updated LLC, respectively. ESC criteria were positive in a larger proportion of patients, while LLC more specifically indicated high risk for MACE. AHA criteria for pAM and expert consensus definitions of acute and complicated myocarditis had moderate overlap to each other and were of limited prognostic value when adjusted for clinical criteria and ESC or LLC. However, the findings of this retrospectively designed observational study should be interpreted in light of several possible limitations. Overall, the study highlights the complementary significance of different diagnostic criteria in risk prediction for myocarditis patients and emphasizes the importance of integrating multiple modalities, including CMR, in the diagnostic workflow of possible myocarditis.
Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Magnetic Resonance Imaging
Keywords: Diagnostic Imaging, Magnetic Resonance Imaging, Myocarditis
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