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Acute and Fulminant Myocarditis: a Pragmatic Clinical Approach to Diagnosis and Treatment

  • Myocardial Disease (A Abbate, Section Editor)
  • Published:
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Abstract

Purpose of Review

To review the clinical features of acute myocarditis, including its fulminant presentation, and present a pragmatic approach to the diagnosis and treatment, considering indications of American and European Scientific Statements and recent data derived by large contemporary registries.

Recent Findings

Patients presenting with acute uncomplicated myocarditis (i.e., without left ventricular dysfunction, heart failure, or ventricular arrhythmias) have a favorable short- and long-term prognosis: these findings do not support the indication to endomyocardial biopsy in this clinical scenario. Conversely, patients with complicated presentations, especially those with fulminant myocarditis, require an aggressive and comprehensive management, including endomyocardial biopsy and availability of advanced therapies for circulatory support. Although several immunomodulatory or immunosuppressive therapies have been studied and are actually prescribed in the real-world practice, their effectiveness has not been clearly demonstrated. Patients with specific histological subtypes of acute myocarditis (i.e., giant cell and eosinophilic myocarditis) or those affected by sarcoidosis or systemic autoimmune disorders seem to benefit most from immunosuppression. On the other hand, no clear evidence supports the use of immunosuppressive agents in patients with lymphocytic acute myocarditis, even though small series suggest a potential benefit.

Summary

Acute myocarditis is a heterogeneous condition with distinct pathophysiological pathways. Further research is mandatory to identify factors and mechanisms that may trigger/maintain or counteract/repair the myocardial damage, in order to provide a rational for future evidence-based treatment of patients affected by this condition.

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Abbreviations

MRI:

Magnetic resonance imaging

FM:

Fulminant myocarditis

GCM:

Giant cell myocarditis

Hs-Tn:

High-sensitivity troponin

CRP:

C-reactive protein

LV:

Left ventricular

EF:

Ejection fraction

MCS:

Mechanical circulatory supports

CK:

Creatine kinase

EMB:

Endomyocardial biopsy

HES:

Hypereosinophilic syndromes

EGPA:

Eosinophilic granulomatosis with polyangiitis

HF:

Heart failure

HTx:

Heart transplantation

EDD:

End-diastolic diameter

ESC:

The European Society of Cardiology

AHA:

The American Heart Association

ACC:

The American College of Cardiology

AV:

Atrioventricular

EDV:

End-diastolic volume

va-ECMO:

Veno-arterial extracorporeal membrane oxygenator

STIR:

Short tau inversion recovery

MTT:

Myocarditis Treatment Trial

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Acknowledgments

The authors thank Federico Landi for his contribution to the graphic design of Fig. 1.

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Authors and Affiliations

  1. “De Gasperis” Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy

    Enrico Ammirati, Giacomo Veronese, Manlio Cipriani, Andrea Garascia & Maria Frigerio

  2. School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy

    Giacomo Veronese

  3. Vita-Salute San Raffaele University and Hospital, Milan, Italy

    Francesco Moroni

  4. Division of Cardiology, Department of Medicine, University of California San Diego, San Diego, CA, USA

    Michela Brambatti & Eric D. Adler

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  1. Enrico Ammirati
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Correspondence to Enrico Ammirati.

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Enrico Ammirati, Giacomo Veronese, Manlio Cipriani, Francesco Moroni, Andrea Garascia, Michela Brambatti, Eric D. Adler, and Maria Frigerio declare that they have no conflict of interest.

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Ammirati, E., Veronese, G., Cipriani, M. et al. Acute and Fulminant Myocarditis: a Pragmatic Clinical Approach to Diagnosis and Treatment. Curr Cardiol Rep 20, 114 (2018). https://doi.org/10.1007/s11886-018-1054-z

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