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Biomarkers in Inflammatory and Noninflammatory Cardiomyopathy

Biomarker bei inflammatorischer und nichtinflammatorischer Kardiomyopathie

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Abstract

Acute myocarditis (AMC) and its sequela, dilated cardiomyopathy (DCM), are most often caused by cardiotropic viral infections in the Western world. Inflammatory cardiomyopathy (DCMi) is a specific cardiomyopathy entity of DCM, being defined by the proof of intramyocardial inflammation and/or viral infection in endomyocardial biopsies (EMBs). Diagnostic procedures of EMBs are indispensable for the etiopathogenic differentiation of the disease. Experienced cardiology centers have reported low complication rates of EMB obtainment. The histological Dallas criteria are prone to substantial sampling error and interobserver variability, have no prognostic impact and, moreover, are not suitable to select AMC/DCMi patients who favorably respond to immunosuppression. Immunohistological detection of myocarditis and viral persistence have proven adverse prognostic impact in AMC and DCM patients, respectively. This contemporary diagnostic repertoire on EMBs is essential for the selection of DCMi patients who will likely benefit from immunomodulatory treatment, which has been addressed in randomized trials. During the past decade, cardiac magnetic resonance (CMR) has developed as a valuable noninvasive diagnostic approach for the detection and localization of intramyocardial inflammation, and CMR guidelines for AMC have been elaborated. Late gadolinium enhancement (LGE) has been associated with adverse prognostic outcome in DCM patients. CMR techniques, however, are not suitable to specifically detect myocardial viral infections. To date, no classic biomarker has been shown to differentiate between DCMi and noninflammatory cardiomyopathies.

Zusammenfassung

Die akute Myokarditis (AMC) und ihre Folgeerkrankung, die dilatative Kardiomyopathie (DCM), werden in der westlichen Welt am häufigsten durch kardiotrope Viren hervorgerufen. Die „inflammatorische Kardiomyopathie“ (DCMi) ist eine spezifische Kardiomyopathieentität, definiert durch den Nachweis einer Herzmuskelentzündung und/oder einer Virusinfektion in Endomyokardbiopsien (EMBs). Diagnostische Untersuchungen an EMBs sind unabdingbar für die ätiopathogenetische Differenzierung der Erkrankung. Die Komplikationsrate der EMBs ist in erfahrenen Zentren sehr gering. Die histologischen Dallas-Kriterien unterliegen einem erheblichen „Probefehler“ und einer Interobservervariabilität, haben keine prognostische Aussagekraft und taugen vor allem nicht zur Auswahl geeigneter AMC-/DCMi-Patienten für die Immunsuppression. Die immunhistologische Diagnostik der DCMi und der molekularbiologische Nachweis von Virusgenomen haben eine nachgewiesene prognostische Bedeutung bei AMC- und DCM-Patienten. Dieses zeitgemäße und umfassende diagnostische Repertoire an EMBs ist für die Selektion von DCMi-Patienten wichtig, die wahrscheinlich von einem immunmodulatorischen Regime profitieren, wie in randomisierten Studien bereits gezeigt. Die kardiale Magnetresonanztomographie (CMR) hat sich in der vergangenen Dekade als ein wichtiges nichtinvasives diagnostisches Verfahren für die sensitive Detektion und Lokalisation der Entzündungsreaktion im Myokard entwickelt. Entsprechende Richtlinien sind bereits erarbeitet worden. Late Gadolinium-Enhancement (LGE) ist mit einer schlechteren Prognose von DCM-Patienten assoziiert. CMR kann jedoch nicht spezifisch die myokardialen Virusinfektionen darstellen. Bislang hat keiner der bekannten kardialen Biomarker eine Differenzierung zwischen DCMi und nichtinflammatorischen Kardiomyopathien ermöglicht.

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  1. Department of Internal Medicine – Cardiology, University Hospital of Marburg and Gießen/UKGM GmbH, Faculty of Medicine, Philipps University of Marburg, Marburg, Germany

    Michel Noutsias FESC, Sabine Pankuweit & Bernhard Maisch

  2. Department of Internal Medicine – Cardiology, University Hospital of Marburg and Gießen/ UKGM GmbH Faculty of Medicine Philipps University of Marburg, Baldinger Straße, 35033, Marburg, Germany

    Michel Noutsias FESC

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Noutsias, M., Pankuweit, S. & Maisch, B. Biomarkers in Inflammatory and Noninflammatory Cardiomyopathy. Herz 34, 614–623 (2009). https://doi.org/10.1007/s00059-009-3318-2

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