Materiały źródłowe

• #1 Understanding Myocarditis – Myocarditis Foundation

  https://www.myocarditisfoundation.org/about-myocarditis/

  Myocarditis is classified as a rare disease but is estimated to affect thousands of adults and children in the U.S. and around the world each year. 1.3 million cases of myocarditis were diagnosed in 2021. […] The majority of cases of myocarditis have no symptoms and are not diagnosed. However, when a person develops symptoms, common tests for myocarditis include the following: […] An Electrocardiogram Electrical activity of your heart is detected by electrodes taped to your skin. This activity is recorded as waves that represent the electrical forces in the different parts of the heart. […] A Chest X-Ray A chest X-ray produces an image on film that outlines your heart, lungs and other structures in your chest. From a chest X-ray, your physician learns information such as the size and shape of your heart.

• #2 Myocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/244

  Myocarditis describes a heterogeneous group of disorders characterised by myocardial inflammation in the absence of predominant acute or chronic ischaemia. […] Myocarditis is clinically and pathologically defined as inflammation of the myocardium in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease. […] Key diagnostic factors include presence of risk factors, viral syndrome (prior), autoimmune disease, infectious disease, and drugs and toxins. […] 1st investigations to order include 12-lead ECG, CXR, serum CK, serum CK-MB, serum troponin (I or T), serum B-type natriuretic peptide, two-dimensional echocardiogram, and 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT). […] Investigations to consider include endomyocardial biopsy (EMB), coronary angiography, cardiac MRI, and viral polymerase chain reaction (PCR). […] Emerging tests include MRI-guided EMB.

• #3 Myocarditis – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/myocarditis-and-pericarditis/myocarditis

  Myocarditis is inflammation of the myocardium with necrosis of cardiac myocytes. […] Diagnosis is based on symptoms and clinical findings of abnormal electrocardiography (ECG), cardiac biomarkers, and cardiac imaging in the absence of cardiovascular risk factors. Endomyocardial biopsy confirms clinical diagnosis of myocarditis. […] Myocarditis should be suspected when otherwise healthy patients with no cardiac risk factors present with symptoms of heart failure or arrhythmias. ECG, cardiac enzymes, and cardiac imaging are not specific for myocarditis but can be diagnostic in the appropriate clinical setting. […] ECG can be normal or abnormal in patients with myocarditis. […] Cardiac enzymes can be abnormal in patients with acute myocarditis. […] Cardiac imaging can be abnormal in patients with myocarditis.

• #4 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  ACC ECDP for Diagnosis and Management of Myocarditis: Key Points […] The following are key points to remember from a 2024 American College of Cardiology (ACC) expert consensus decision pathway (ECDP) on strategies and criteria for the diagnosis and management of myocarditis: […] Acute myocarditis can be asymptomatic or present with nonspecific symptoms. However, having a high index of suspicion is key when patients present with chest pain, arrhythmias, or heart failure (HF), especially in the setting of a recent viral infection, prior myocarditis, autoimmune disease, family history of cardiomyopathy or sudden death, or cardiotoxin exposure. […] […] Electrocardiograms (ECG), echocardiograms, and cardiac troponin assays are common diagnostic tests for suspected myocarditis. They provide useful prognostic information and data to guide management. However, normal testing does not rule out myocarditis in patients where index of suspicion is high. […]

• #5 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  Early diagnosis of myocarditis is important to preventing long-term heart damage. To diagnose myocarditis, a healthcare professional examines you and listens to your heart with a stethoscope. […] Blood and imaging tests may be done to check your heart health. Imaging tests can help confirm myocarditis and determine its severity. […] Tests to diagnose myocarditis include: […] Blood tests are usually done to check for a heart attack, inflammation and infection. A cardiac enzyme test can check for proteins related to heart muscle damage. Antibody blood tests may help learn if you had an infection linked to myocarditis. […] This quick and painless test shows how the heart is beating. Your healthcare professional can look for signal patterns on an ECG to learn if you have irregular heartbeats.

• #6 Myocarditis Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/156330-workup

  Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Cardiac troponin (troponin I or T), in particular, is elevated in at least 50% of patients with biopsy-proven myocarditis. […] In acute myocarditis, inflammatory biomarkers such as CRP and ESR may be elevated, but they are not specific to the condition, and normal values don’t rule it out. […] The following imaging studies may be used to assess patients with suspected myocarditis: […] Cardiac angiography or CCT are often indicated to rule out coronary ischemia as a cause of new-onset heart failure, especially when clinical presentation mimics acute myocardial infarction. […] EMB is the criterion standard for the diagnosis of myocarditis, including the following conditions: […] The presence of viral genome in EMB samples is considered the criterion standard for viral persistence.

• #7 Azthena logo with the word Azthena

  https://www.news-medical.net/news/20230406/Study-reviews-the-diagnosis-and-treatment-of-acute-myocarditis.aspx

  Scientists have recently reviewed and summarized the evidence regarding diagnosing and treating acute myocarditis. This review has been published in the JAMA Network journal. […] Cardiac magnetic resonance (CMR) has been used as a non-invasive diagnosis of acute myocarditis. […] Patients with acute myocarditis have increased inflammatory markers (e.g., C-reactive protein) and troponin levels. Troponin I or T levels were elevated in around 64% to 100% of patients. […] An abnormal electrocardiogram (ECG) finding is obtained in 62% to 96% of patients with acute myocarditis. […] As stated above, acute myocarditis can be diagnosed via cardiac magnetic resistance (CMR) with or without the endomyocardial biopsy (EMB) approach. […] CMR helps detect cardiac edema in patients. […] Coronary computed tomography (CT) and coronary angiography are performed in approximately 46% to 95% of adult patients with acute myocarditis.

• #8 Myocarditis – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/myocarditis-and-pericarditis/myocarditis

  Myocarditis is inflammation of the myocardium with necrosis of cardiac myocytes. […] Diagnosis is based on symptoms and clinical findings of abnormal electrocardiography (ECG), cardiac biomarkers, and cardiac imaging in the absence of cardiovascular risk factors. Endomyocardial biopsy confirms clinical diagnosis of myocarditis. […] Myocarditis should be suspected when otherwise healthy patients with no cardiac risk factors present with symptoms of heart failure or arrhythmias. ECG, cardiac enzymes, and cardiac imaging are not specific for myocarditis but can be diagnostic in the appropriate clinical setting. […] ECG can be normal or abnormal in patients with myocarditis. […] Cardiac enzymes can be abnormal in patients with acute myocarditis. […] Cardiac imaging can be abnormal in patients with myocarditis.

• #9 Myocarditis Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/156330-workup

  Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Cardiac troponin (troponin I or T), in particular, is elevated in at least 50% of patients with biopsy-proven myocarditis. […] In acute myocarditis, inflammatory biomarkers such as CRP and ESR may be elevated, but they are not specific to the condition, and normal values don’t rule it out. […] The following imaging studies may be used to assess patients with suspected myocarditis: […] Cardiac angiography or CCT are often indicated to rule out coronary ischemia as a cause of new-onset heart failure, especially when clinical presentation mimics acute myocardial infarction. […] EMB is the criterion standard for the diagnosis of myocarditis, including the following conditions: […] The presence of viral genome in EMB samples is considered the criterion standard for viral persistence.

• #10 Myocarditis – Cardiovascular Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/cardiovascular-disorders/myocarditis-and-pericarditis/myocarditis

  Myocarditis is inflammation of the myocardium with necrosis of cardiac myocytes. […] Diagnosis is based on symptoms and clinical findings of abnormal electrocardiography (ECG), cardiac biomarkers, and cardiac imaging in the absence of cardiovascular risk factors. Endomyocardial biopsy confirms clinical diagnosis of myocarditis. […] Myocarditis should be suspected when otherwise healthy patients with no cardiac risk factors present with symptoms of heart failure or arrhythmias. ECG, cardiac enzymes, and cardiac imaging are not specific for myocarditis but can be diagnostic in the appropriate clinical setting. […] ECG can be normal or abnormal in patients with myocarditis. […] Cardiac enzymes can be abnormal in patients with acute myocarditis. […] Cardiac imaging can be abnormal in patients with myocarditis.

• #11 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  Early diagnosis of myocarditis is important to preventing long-term heart damage. To diagnose myocarditis, a healthcare professional examines you and listens to your heart with a stethoscope. […] Blood and imaging tests may be done to check your heart health. Imaging tests can help confirm myocarditis and determine its severity. […] Tests to diagnose myocarditis include: […] Blood tests are usually done to check for a heart attack, inflammation and infection. A cardiac enzyme test can check for proteins related to heart muscle damage. Antibody blood tests may help learn if you had an infection linked to myocarditis. […] This quick and painless test shows how the heart is beating. Your healthcare professional can look for signal patterns on an ECG to learn if you have irregular heartbeats.

• #12 Myocarditis – Diagnosis and Treatment : Emergency Care BC

  https://emergencycarebc.ca/clinical_resource/clinical-summary/myocarditis-diagnosis-and-treatment/

  Myocarditis is a challenging and potentially life-threatening condition that is underdiagnosed in the emergency department. […] The gold standard for diagnosis is endomyocardial biopsy (EMB). […] Recommended approach is based on 3 tiered classification as adapted from Sagar et al. 2012 when myocarditis is suspected. […] Recommended investigations include labs: CBC, lytes, renal/liver function, CRP, troponin, BNP. […] Troponin levels are commonly elevated in myocarditis, but their absence is not sensitive in myocarditis and should not be used for prognosis. […] Overall evidence for diagnosis of myocarditis is mixed as there have been multiple proposed definitions with no clear universally agreed upon criteria.

• #13 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  ACC ECDP for Diagnosis and Management of Myocarditis: Key Points […] The following are key points to remember from a 2024 American College of Cardiology (ACC) expert consensus decision pathway (ECDP) on strategies and criteria for the diagnosis and management of myocarditis: […] Acute myocarditis can be asymptomatic or present with nonspecific symptoms. However, having a high index of suspicion is key when patients present with chest pain, arrhythmias, or heart failure (HF), especially in the setting of a recent viral infection, prior myocarditis, autoimmune disease, family history of cardiomyopathy or sudden death, or cardiotoxin exposure. […] […] Electrocardiograms (ECG), echocardiograms, and cardiac troponin assays are common diagnostic tests for suspected myocarditis. They provide useful prognostic information and data to guide management. However, normal testing does not rule out myocarditis in patients where index of suspicion is high. […]

• #14 Myocarditis: Causes, Symptoms, and Treatment | Doctor

  https://patient.info/doctor/myocarditis-pro

  Myocarditis is acute or chronic inflammation of the myocardium – and may present similarly to myocardial infarction. Myocardial destruction may lead to dilated cardiomyopathy. […] The exact incidence of myocarditis is unknown. A primary diagnosis of myocarditis accounted for 0.04% (36.5 per 100,000) of all hospital admissions in England between 1998 and 2017, although this is likely to be an underestimate of the true burden of myocarditis. […] ECG: changes may include ST-segment elevation/depression, T-wave inversion, atrial arrhythmias, transient atrioventricular (AV) block. Blood tests: FBC (leukocytosis in 25%), UE, creatine kinase (often elevated, as are other markers of myocardial cell damage, including troponin I and troponin T), ESR or CRP (elevated in 60%), LFT. […] Endomyocardial biopsy (the gold standard test) is sometimes performed – but has only limited sensitivity and specificity.

• #15 Azthena logo with the word Azthena

  https://www.news-medical.net/news/20230406/Study-reviews-the-diagnosis-and-treatment-of-acute-myocarditis.aspx

  Scientists have recently reviewed and summarized the evidence regarding diagnosing and treating acute myocarditis. This review has been published in the JAMA Network journal. […] Cardiac magnetic resonance (CMR) has been used as a non-invasive diagnosis of acute myocarditis. […] Patients with acute myocarditis have increased inflammatory markers (e.g., C-reactive protein) and troponin levels. Troponin I or T levels were elevated in around 64% to 100% of patients. […] An abnormal electrocardiogram (ECG) finding is obtained in 62% to 96% of patients with acute myocarditis. […] As stated above, acute myocarditis can be diagnosed via cardiac magnetic resistance (CMR) with or without the endomyocardial biopsy (EMB) approach. […] CMR helps detect cardiac edema in patients. […] Coronary computed tomography (CT) and coronary angiography are performed in approximately 46% to 95% of adult patients with acute myocarditis.

• #16 Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

  https://www.mdpi.com/2075-4418/13/19/3073

  Diagnostic includes physical examinations, teleradiography of the heart and lungs, echocardigraphic examination, 24-h ECG Holter monitoring, CMR heart examination, cardiac catheterization, and EMB. […] Non-invasive diagnostic methods such as CMR can be useful in diagnosing myocarditis and monitoring the progression of the disease. […] EMB is the gold standard in the final diagnosis of myocarditis; however, not all patients with suspected myocarditis should undergo EMB, but only patients with an unconfirmed diagnosis, especially with a pseudoinfraction image. […] Changes in the electrocardiogram can be seen in approximately 90% of patients with AM. […] A 12-lead ECG should be performed in all patients with clinically suspected myocarditis despite its low sensitivity for myocarditis.

• #17 Azthena logo with the word Azthena

  https://www.news-medical.net/health/How-is-Myocarditis-Diagnosed.aspx

  Myocarditis represents the inflammatory reaction of the heart due to infectious, autoimmune, or toxic causes. […] Acute myocarditis (one form of myocarditis) represents one of the most challenging diagnoses in cardiology, as currently, no diagnostic test can be considered a gold standard due to the insensitivity of traditional approaches. […] The initial evaluation of acute myocarditis must encompass detailed medical history and a thorough physical examination, searching for any potential features that may provide clues to its etiology. […] Despite its low sensitivity, the electrocardiogram (ECG) is widely used as a screening tool. […] Serum cardiac biomarkers (creatine kinase and troponin) lack specificity but may help confirm myocarditis diagnosis; hence, they are routinely measured in suspected cases.

• #18 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  Early diagnosis of myocarditis is important to preventing long-term heart damage. To diagnose myocarditis, a healthcare professional examines you and listens to your heart with a stethoscope. […] Blood and imaging tests may be done to check your heart health. Imaging tests can help confirm myocarditis and determine its severity. […] Tests to diagnose myocarditis include: […] Blood tests are usually done to check for a heart attack, inflammation and infection. A cardiac enzyme test can check for proteins related to heart muscle damage. Antibody blood tests may help learn if you had an infection linked to myocarditis. […] This quick and painless test shows how the heart is beating. Your healthcare professional can look for signal patterns on an ECG to learn if you have irregular heartbeats.

• #19 Diagnosis and Management of Myocarditis in Children

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

  Myocarditis remains a clinical challenge in pediatrics. Four strata of certainty in the diagnosis of myocarditis include biopsy proven, clinically suspected confirmed by cardiac magnetic resonance (CMR), clinically suspected, and possible myocarditis. […] Clinically suspected myocarditis represents a constellation of findings supportive of the diagnosis of myocarditis when biopsy and CMR cannot be performed or despite their negative results. To date, there are no definitive criteria using clinical features alone to confirm the diagnosis of myocarditis or to differentiate clinical suspicion from possible myocarditis. […] Echocardiography is the first-line and most widely used imaging modality for the evaluation of cardiac structure and function in patients suspected of myocarditis. Echocardiography reliably demonstrates the variable findings associated with myocarditis, including the following: Subtle to profound changes in global left ventricular (LV) or right ventricular systolic function, including regional wall motion abnormalities, variable degrees of LV enlargement, thickened myocardium from wall edema, pericardial effusion, intracardiac thrombus, functional valvar regurgitation.

• #20 Diagnosis and Management of Myocarditis in Children

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

  Myocarditis remains a clinical challenge in pediatrics. Four strata of certainty in the diagnosis of myocarditis include biopsy proven, clinically suspected confirmed by cardiac magnetic resonance (CMR), clinically suspected, and possible myocarditis. […] Clinically suspected myocarditis represents a constellation of findings supportive of the diagnosis of myocarditis when biopsy and CMR cannot be performed or despite their negative results. To date, there are no definitive criteria using clinical features alone to confirm the diagnosis of myocarditis or to differentiate clinical suspicion from possible myocarditis. […] Echocardiography is the first-line and most widely used imaging modality for the evaluation of cardiac structure and function in patients suspected of myocarditis. Echocardiography reliably demonstrates the variable findings associated with myocarditis, including the following: Subtle to profound changes in global left ventricular (LV) or right ventricular systolic function, including regional wall motion abnormalities, variable degrees of LV enlargement, thickened myocardium from wall edema, pericardial effusion, intracardiac thrombus, functional valvar regurgitation.

• #21 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #22 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #23 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #24 Diagnosis and Management of Myocarditis in Children

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

  Myocarditis remains a clinical challenge in pediatrics. Four strata of certainty in the diagnosis of myocarditis include biopsy proven, clinically suspected confirmed by cardiac magnetic resonance (CMR), clinically suspected, and possible myocarditis. […] Clinically suspected myocarditis represents a constellation of findings supportive of the diagnosis of myocarditis when biopsy and CMR cannot be performed or despite their negative results. To date, there are no definitive criteria using clinical features alone to confirm the diagnosis of myocarditis or to differentiate clinical suspicion from possible myocarditis. […] Echocardiography is the first-line and most widely used imaging modality for the evaluation of cardiac structure and function in patients suspected of myocarditis. Echocardiography reliably demonstrates the variable findings associated with myocarditis, including the following: Subtle to profound changes in global left ventricular (LV) or right ventricular systolic function, including regional wall motion abnormalities, variable degrees of LV enlargement, thickened myocardium from wall edema, pericardial effusion, intracardiac thrombus, functional valvar regurgitation.

• #25 Diagnosis and Management of Myocarditis in Children

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

  Myocarditis remains a clinical challenge in pediatrics. Four strata of certainty in the diagnosis of myocarditis include biopsy proven, clinically suspected confirmed by cardiac magnetic resonance (CMR), clinically suspected, and possible myocarditis. […] Clinically suspected myocarditis represents a constellation of findings supportive of the diagnosis of myocarditis when biopsy and CMR cannot be performed or despite their negative results. To date, there are no definitive criteria using clinical features alone to confirm the diagnosis of myocarditis or to differentiate clinical suspicion from possible myocarditis. […] Echocardiography is the first-line and most widely used imaging modality for the evaluation of cardiac structure and function in patients suspected of myocarditis. Echocardiography reliably demonstrates the variable findings associated with myocarditis, including the following: Subtle to profound changes in global left ventricular (LV) or right ventricular systolic function, including regional wall motion abnormalities, variable degrees of LV enlargement, thickened myocardium from wall edema, pericardial effusion, intracardiac thrombus, functional valvar regurgitation.

• #26 Diagnosis and Management of Myocarditis in Children

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2021/07/09/17/31/diagnosis-and-management-of-myocarditis

  Myocarditis remains a clinical challenge in pediatrics. Four strata of certainty in the diagnosis of myocarditis include biopsy proven, clinically suspected confirmed by cardiac magnetic resonance (CMR), clinically suspected, and possible myocarditis. […] Clinically suspected myocarditis represents a constellation of findings supportive of the diagnosis of myocarditis when biopsy and CMR cannot be performed or despite their negative results. To date, there are no definitive criteria using clinical features alone to confirm the diagnosis of myocarditis or to differentiate clinical suspicion from possible myocarditis. […] Echocardiography is the first-line and most widely used imaging modality for the evaluation of cardiac structure and function in patients suspected of myocarditis. Echocardiography reliably demonstrates the variable findings associated with myocarditis, including the following: Subtle to profound changes in global left ventricular (LV) or right ventricular systolic function, including regional wall motion abnormalities, variable degrees of LV enlargement, thickened myocardium from wall edema, pericardial effusion, intracardiac thrombus, functional valvar regurgitation.

• #27 Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes | Signal Transduction and Targeted Therapy

  https://www.nature.com/articles/s41392-020-00360-y

  ECG tracings demonstrating arrhythmias or tachycardia with sinus rhythm can demonstrate left bundle branch block (LBBB), reduced QRS wave amplitude, ventricular premature beat, and ventricular tachycardia suggestive of severe progression. […] Considering the results of echocardiography can vary according to the state of the FM patients heart function, repeated and close monitoring is recommended. […] In order to differentiate FM from acute coronary disease, emergency angiography should be considered. […] The diagnosis of FM is largely based on the clinical symptoms observed in patients rather than a pathological or pathophysiological diagnosis. […] Importantly, it is critical to differentiate between FM and acute coronary artery disease as the treatment regimens are completely different.

• #28 Acute myocarditis: aetiology, diagnosis and management

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8439515/

  Acute myocarditis is a serious, likely underdiagnosed condition affecting people of all ages and for which the number of UK hospital admissions is rising. […] Clinical features are varied and overlap with other acute cardiac conditions making diagnosis a challenge. Cardiovascular magnetic resonance imaging currently serves as the gold standard non-invasive diagnostic modality. […] The symptoms and signs of acute myocarditis overlap considerably with those of pericarditis, although both can and frequently do occur concomitantly, that is, myopericarditis. […] Cardiovascular magnetic resonance imaging serves as the reference standard non-invasive modality to determine the presence or absence of myocardial inflammation and other associated abnormalities. […] Endomyocardial biopsy has traditionally been the reference standard diagnostic test for myocarditis (with specimens typically sent for histology, immunohistochemistry and polymerase chain reaction (PCR) for potential infectious agents).

• #29 Acute myocarditis: aetiology, diagnosis and management

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8439515/

  Myocarditis is defined as an inflammatory disease of the cardiac muscle, diagnosed on endomyocardial biopsy by established histological, immunological and immunohistochemical criteria. […] Cardiovascular magnetic resonance imaging serves as the reference standard non-invasive test for the diagnosis of myocarditis.

• #30 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #31 Myocarditis Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/156330-workup

  Once the initial evaluation is complete, the second step focuses on confirming myocarditis. Myocarditis often mimics coronary artery disease due to elevated troponin levels and ECG changes, sometimes requiring coronary angiography to rule out ischemic causes. Noninvasive imaging with cardiac magnetic resonance imaging (CMRI) has become the gold standard for diagnosing myocarditis that allows the noninvasive diagnosis of stage B or symptomatic myocarditis. […] EMB, although invasive, remains the definitive diagnostic tool, particularly for high-risk patients, as it can characterize inflammatory cell types and detect viral genomes, potentially guiding treatment decisions. […] The ACC pathway underscores the necessity for regular follow-up, including repeat cardiac imaging and biomarker assessments, to monitor recovery and detect any recurrence or progression of the disease.

• #32 Myocarditis: Background, Etiology, Pathophysiology

  https://emedicine.medscape.com/article/156330-overview

  Myocarditis is diagnosed by CMRI when there is myocardial inflammation demonstrated by T2-based markers for myocardial edema (T2-weighted imaging or T2 mapping) and T1-based markers of myocardial injury/necrosis (late gadolinium enhancement [LGE], T1 mapping, or extracellular volume [ECV]). […] Patients should be advised of the current understanding of the natural history of myocarditis and the strengths and limitations of different diagnostic testing and therapeutic options. […] The availability of CMRI has expanded the ability to detect myocarditis in patients who might otherwise not receive an EMB. Consequently, the reported incidence of myocarditis has risen from roughly 1-10 cases per 100,000 persons to around 9.5-14.4 cases per 100,000, paralleling CMRI’s more widespread use.

• #33 Myocarditis: Background, Etiology, Pathophysiology

  https://emedicine.medscape.com/article/156330-overview

  Myocarditis is diagnosed by CMRI when there is myocardial inflammation demonstrated by T2-based markers for myocardial edema (T2-weighted imaging or T2 mapping) and T1-based markers of myocardial injury/necrosis (late gadolinium enhancement [LGE], T1 mapping, or extracellular volume [ECV]). […] Patients should be advised of the current understanding of the natural history of myocarditis and the strengths and limitations of different diagnostic testing and therapeutic options. […] The availability of CMRI has expanded the ability to detect myocarditis in patients who might otherwise not receive an EMB. Consequently, the reported incidence of myocarditis has risen from roughly 1-10 cases per 100,000 persons to around 9.5-14.4 cases per 100,000, paralleling CMRI’s more widespread use.

• #34 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #35 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #36 Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis – Revista Española de Cardiología (English Edition)

  https://www.revespcardiol.org/en-diagnosis-treatment-myocarditis-inflammatory-cardiomyopathy–articulo-S1885585724001567

  Diagnostic testing should start as soon as myocarditis is suspected. […] The recommended diagnostic algorithm for suspected myocarditis is shown in figure 1. Clinical suspicion is the first step. […] All patients with suspected myocarditis should undergo ECG, laboratory tests, and echocardiography. […] When acute myocarditis is suspected, CMR should be performed rapidly (ideally within 7 days) and include T1/T2 mapping to help establish a confirmatory diagnosis. […] CMR is recommended in all patients with clinical suspicion of myocarditis and who have elevated biomarkers or ECG or echocardiographic changes indicative of myocardial injury. […] EMB with immunohistochemical staining should be performed on suspicion of a specific cause that might benefit from targeted treatment. […] The current indications for EMB according to various international scientific societies are listed in table 2 of the supplementary data.

• #37 Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis – Revista Española de Cardiología (English Edition)

  https://www.revespcardiol.org/en-diagnosis-treatment-myocarditis-inflammatory-cardiomyopathy–articulo-S1885585724001567

  Diagnostic testing should start as soon as myocarditis is suspected. […] The recommended diagnostic algorithm for suspected myocarditis is shown in figure 1. Clinical suspicion is the first step. […] All patients with suspected myocarditis should undergo ECG, laboratory tests, and echocardiography. […] When acute myocarditis is suspected, CMR should be performed rapidly (ideally within 7 days) and include T1/T2 mapping to help establish a confirmatory diagnosis. […] CMR is recommended in all patients with clinical suspicion of myocarditis and who have elevated biomarkers or ECG or echocardiographic changes indicative of myocardial injury. […] EMB with immunohistochemical staining should be performed on suspicion of a specific cause that might benefit from targeted treatment. […] The current indications for EMB according to various international scientific societies are listed in table 2 of the supplementary data.

• #38

  https://journals.lww.com/pidj/fulltext/2025/03000/diagnosis_and_management_of_pediatric_myocarditis.21.aspx

  Myocarditis is a heterogeneous inflammatory disease of the myocardium, causing focal edema and injury, which may result in structural and functional abnormalities. The incidence varies between 0.8 and 2.13 cases per 100,000 with male predominance reported in children older than 6 years (approximately 2.5 times higher risk), and 2 peaks of occurrence: in children 2 years and in adolescents 13-18 years of age. In-hospital mortality is reported at 6.1%. Viruses are the leading cause of myocarditis in children, most commonly parvovirus B19, human herpes virus type 6 (HHV-6), enteroviruses and adenoviruses. Other etiologies include cytomegalovirus (CMV), Epstein Barr virus, hepatitis C, herpes simplex type 2, influenza, parainfluenza, SARS-CoV-2 and HIV, less frequent bacteria or other infectious pathogens, immune-mediated mechanisms and toxin exposure. Diagnosis of myocardial inflammation is based on cardiac magnetic resonance Lake Louis criteria with the presence of both, myocardial edema and late gadolinium enhancement. Dallas criteria (histologic inflammatory infiltrate different than ischemic necrosis), tissue PCR and immunohistochemistry are considered the gold standard for definitive diagnosis. Given the focal nature of myocarditis, multiple EMB samples are recommended to detect viral nucleic acids to minimize the risk of false-negative results. EMB should be performed in children with a severe clinical course for treatment decisions. Initial management depends on the severity of the clinical course regardless of the etiology, and may include management of heart failure, serious arrhythmias and conduction disorders in accordance with the current guidelines. Tailored management strategies, ranging from supportive care to specific antiviral or immunosuppressive therapies are essential for improving patient outcomes. Further studies are needed to enhance the treatment of pediatric myocarditis.

• #39 Cardiovascular Magnetic Resonance in Myocarditis

  https://www.mdpi.com/2075-4418/12/2/399

  Furthermore, neither a single clinical nor diagnostic finding can presently confirm or exclude the diagnosis of myocarditis with absolute certainty, which is the reason for using an integrative diagnostic approach. […] CMR can detect changes caused by myocardial inflammation independent of the underlying aetiology, and has thereby altered the clinical decision-making process of many patients. […] The strength of the method lies in its unique multiparametric tissue characterization ability, which, however, relies mainly on parameters exploiting changes in extracellular volume to visualize myocardial inflammation. […] Overall, CMR mapping techniques show an excellent sensitivity, specificity, and diagnostic accuracy in patients with clinically suspected myocarditis. […] The updated LLC proposed a “2 out of 2” approach for the diagnosis of myocardial inflammation, which means that one positive T2-based criterion and one T1-based criterion must be fulfilled. […] CMR is an established and highly valuable clinical tool in the diagnostic work-up of patients with clinically suspected myocarditis.

• #40 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #41 Understanding Myocarditis – Myocarditis Foundation

  https://www.myocarditisfoundation.org/about-myocarditis/

  Myocarditis is classified as a rare disease but is estimated to affect thousands of adults and children in the U.S. and around the world each year. 1.3 million cases of myocarditis were diagnosed in 2021. […] The majority of cases of myocarditis have no symptoms and are not diagnosed. However, when a person develops symptoms, common tests for myocarditis include the following: […] An Electrocardiogram Electrical activity of your heart is detected by electrodes taped to your skin. This activity is recorded as waves that represent the electrical forces in the different parts of the heart. […] A Chest X-Ray A chest X-ray produces an image on film that outlines your heart, lungs and other structures in your chest. From a chest X-ray, your physician learns information such as the size and shape of your heart.

• #42 Myocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/244

  Myocarditis describes a heterogeneous group of disorders characterised by myocardial inflammation in the absence of predominant acute or chronic ischaemia. […] Myocarditis is clinically and pathologically defined as inflammation of the myocardium in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease. […] Key diagnostic factors include presence of risk factors, viral syndrome (prior), autoimmune disease, infectious disease, and drugs and toxins. […] 1st investigations to order include 12-lead ECG, CXR, serum CK, serum CK-MB, serum troponin (I or T), serum B-type natriuretic peptide, two-dimensional echocardiogram, and 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT). […] Investigations to consider include endomyocardial biopsy (EMB), coronary angiography, cardiac MRI, and viral polymerase chain reaction (PCR). […] Emerging tests include MRI-guided EMB.

• #43 Acute myocarditis: aetiology, diagnosis and management

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8439515/

  Acute myocarditis is a serious, likely underdiagnosed condition affecting people of all ages and for which the number of UK hospital admissions is rising. […] Clinical features are varied and overlap with other acute cardiac conditions making diagnosis a challenge. Cardiovascular magnetic resonance imaging currently serves as the gold standard non-invasive diagnostic modality. […] The symptoms and signs of acute myocarditis overlap considerably with those of pericarditis, although both can and frequently do occur concomitantly, that is, myopericarditis. […] Cardiovascular magnetic resonance imaging serves as the reference standard non-invasive modality to determine the presence or absence of myocardial inflammation and other associated abnormalities. […] Endomyocardial biopsy has traditionally been the reference standard diagnostic test for myocarditis (with specimens typically sent for histology, immunohistochemistry and polymerase chain reaction (PCR) for potential infectious agents).

• #44 Diagnostic approach of myocarditis: strike the golden mean

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3967560/

  Myocarditis is a challenging diagnosis due to the extreme diversity of clinical manifestations. The actual incidence of myocarditis is also difficult to determine as endomyocardial biopsy (EMB), the diagnostic gold standard, is used infrequently. […] Nevertheless, in up to 30 % of patients with biopsy-proven myocarditis, progression to dilated cardiomyopathy (DCM) can occur and is associated with a poor prognosis. […] Several non-invasive diagnostic modalities, including cardiac magnetic resonance imaging (CMR), can be helpful in the diagnosis of myocarditis; however we emphasise that EMB remains the gold standard for the diagnosis of definite myocarditis. […] Myocarditis should be suspected in the presence of one or more of the clinical presentations in Table 1, with or without ancillary features and one or more of the diagnostic criteria from different categories (I to IV) in Table 2.

• #45 Myocarditis – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/myocarditis/diagnosis-treatment/drc-20352544

  A chest X-ray shows the size and shape of the heart and lungs. A chest X-ray can tell if there’s fluid in or around the heart that might be related to heart failure. […] This test uses magnetic fields and radio waves to create detailed images of the heart. A cardiac MRI shows the heart’s size, shape and structure. It can help diagnose myocarditis. […] Sound waves create moving images of the beating heart. An echocardiogram can show the heart’s size and how well blood flows through the heart and heart valves. An echocardiogram can see if there’s fluid around the heart. […] A doctor places a thin, flexible tube called a catheter into a blood vessel in the arm or groin. It’s guided to an artery in the heart. Dye flows through the catheter to help the heart arteries show up more clearly on X-rays. A tiny sample of heart muscle tissue may be taken during this test. This is called a biopsy. The sample is sent to a lab to be checked for signs of myocarditis or an infection.

• #46

  https://link.springer.com/article/10.1007/s11936-012-0204-7

  Myocarditis is a condition that can have a very wide clinical spectrum ranging from asymptomatic forms to fatal disease, but mostly presenting as new onset heart failure with reduced left ventricular ejection fraction, with or without viral syndrome. […] The diagnostic work-up may be challenging, but non-invasive imaging, primarily cardiac magnetic resonance, plays an increasingly important role, although endomyocardial biopsy is still considered a gold standard for diagnosis. […] On pathology obtained from endomyocardial biopsy, myocarditis has well-defined features which until recently were the mainstay of the diagnosis. […] Endomyocardial biopsy is still considered the gold standard in diagnosis of myocarditis. […] According to the Dallas criteria proposed in 1986, acute myocarditis is defined by lymphocytic infiltrates in association with myocyte necrosis not characteristic for ischemic damage.

• #47 Azthena logo with the word Azthena

  https://www.news-medical.net/health/How-is-Myocarditis-Diagnosed.aspx

  Echocardiography represents an important part of the initial diagnostic evaluation when evaluating a patient with myocarditis, assessing the function of the left heart ventricle and ruling out other causes of heart failure. […] In recent years cardiovascular magnetic resonance imaging (MRI) has been recognized as a highly sensitive and specific tool for diagnosing myocarditis. […] Histologic examination of heart tissue is necessary to confirm the diagnosis of myocarditis; thus, endomyocardial biopsy still represents one of the key diagnostic steps. […] The standard Dallas pathological criteria, published in 1986, served as the initial attempt to develop standardized diagnostic guidelines for the histopathological classification of myocarditis. […] Therefore, immunohistochemistry which allows quantification, identification, and differentiation of inflammatory cells is gaining further acceptance in diagnosing myocarditis.

• #48 Acute myocarditis: aetiology, diagnosis and management

  https://pmc.ncbi.nlm.nih.gov/articles/PMC8439515/

  Acute myocarditis is a serious, likely underdiagnosed condition affecting people of all ages and for which the number of UK hospital admissions is rising. […] Clinical features are varied and overlap with other acute cardiac conditions making diagnosis a challenge. Cardiovascular magnetic resonance imaging currently serves as the gold standard non-invasive diagnostic modality. […] The symptoms and signs of acute myocarditis overlap considerably with those of pericarditis, although both can and frequently do occur concomitantly, that is, myopericarditis. […] Cardiovascular magnetic resonance imaging serves as the reference standard non-invasive modality to determine the presence or absence of myocardial inflammation and other associated abnormalities. […] Endomyocardial biopsy has traditionally been the reference standard diagnostic test for myocarditis (with specimens typically sent for histology, immunohistochemistry and polymerase chain reaction (PCR) for potential infectious agents).

• #49 Advances in myocarditis management in the light of the latest research and recent guidelines of the European Society of Cardiology | Chabior | Cardiology Journal

  https://journals.viamedica.pl/cardiology_journal/article/view/95175

  A combination of methods including CMR, and troponin levels improves the diagnostic accuracy. It is also necessary to rule out significant coronary artery disease or extra-cardiac causes of symptoms. […] Despite recent advances in non-invasive methods, true myocarditis may only be confirmed by EMB or autopsy. […] Endomyocardial biopsy is a gold standard and provides a definitive diagnosis of myocarditis. The EMB allows for the assessment of the specific histotype, immunologic and virologic status of the myocardium with immunohistochemistry and polymerase chain reaction analysis. […] The latest ESC HF guidelines recommend EMB in patients with severe cardiac impairment and/or serious ventricular arrhythmias or atrioventricular blocks. In patients not responding to standard HF and antiarrhythmic therapy in a short time, EMB should be performed for a better insight of the HF mechanism and the diagnosis of possible ongoing myocarditis.

• #50 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #51 Diagnostic approach of myocarditis: strike the golden mean

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3967560/

  Our suggestions include that all patients with clinically suspected myocarditis should be admitted and considered for selective coronary angiography, in line with the recommendations from the ESC Working Group. […] We differ from the perspective of both the ESC and ACCF/AHA regarding the indication for EMB in patients with suspected myocarditis. […] Therefore, referral for EMB in acute suspected myocarditis patients is recommended in the case of a life-threatening arrhythmia, LV dysfunction that does not improve 45 days after onset of symptoms, LV dysfunction that progressively deteriorates within 45 days after onset of symptoms, or recurrent myocarditis. […] The diagnosis of myocarditis remains challenging and the exact approach varies, as reflected by the different recommendations of both the ESC and ACCF/AHA.

• #52 Diagnostic approach of myocarditis: strike the golden mean

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3967560/

  Our suggestions include that all patients with clinically suspected myocarditis should be admitted and considered for selective coronary angiography, in line with the recommendations from the ESC Working Group. […] We differ from the perspective of both the ESC and ACCF/AHA regarding the indication for EMB in patients with suspected myocarditis. […] Therefore, referral for EMB in acute suspected myocarditis patients is recommended in the case of a life-threatening arrhythmia, LV dysfunction that does not improve 45 days after onset of symptoms, LV dysfunction that progressively deteriorates within 45 days after onset of symptoms, or recurrent myocarditis. […] The diagnosis of myocarditis remains challenging and the exact approach varies, as reflected by the different recommendations of both the ESC and ACCF/AHA.

• #53 Diagnostic approach of myocarditis: strike the golden mean

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3967560/

  Our suggestions include that all patients with clinically suspected myocarditis should be admitted and considered for selective coronary angiography, in line with the recommendations from the ESC Working Group. […] We differ from the perspective of both the ESC and ACCF/AHA regarding the indication for EMB in patients with suspected myocarditis. […] Therefore, referral for EMB in acute suspected myocarditis patients is recommended in the case of a life-threatening arrhythmia, LV dysfunction that does not improve 45 days after onset of symptoms, LV dysfunction that progressively deteriorates within 45 days after onset of symptoms, or recurrent myocarditis. […] The diagnosis of myocarditis remains challenging and the exact approach varies, as reflected by the different recommendations of both the ESC and ACCF/AHA.

• #54 Diagnostic approach of myocarditis: strike the golden mean

  https://pmc.ncbi.nlm.nih.gov/articles/PMC3967560/

  Our suggestions include that all patients with clinically suspected myocarditis should be admitted and considered for selective coronary angiography, in line with the recommendations from the ESC Working Group. […] We differ from the perspective of both the ESC and ACCF/AHA regarding the indication for EMB in patients with suspected myocarditis. […] Therefore, referral for EMB in acute suspected myocarditis patients is recommended in the case of a life-threatening arrhythmia, LV dysfunction that does not improve 45 days after onset of symptoms, LV dysfunction that progressively deteriorates within 45 days after onset of symptoms, or recurrent myocarditis. […] The diagnosis of myocarditis remains challenging and the exact approach varies, as reflected by the different recommendations of both the ESC and ACCF/AHA.

• #55 Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis – Revista Española de Cardiología (English Edition)

  https://www.revespcardiol.org/en-diagnosis-treatment-myocarditis-inflammatory-cardiomyopathy–articulo-S1885585724001567

  Diagnostic testing should start as soon as myocarditis is suspected. […] The recommended diagnostic algorithm for suspected myocarditis is shown in figure 1. Clinical suspicion is the first step. […] All patients with suspected myocarditis should undergo ECG, laboratory tests, and echocardiography. […] When acute myocarditis is suspected, CMR should be performed rapidly (ideally within 7 days) and include T1/T2 mapping to help establish a confirmatory diagnosis. […] CMR is recommended in all patients with clinical suspicion of myocarditis and who have elevated biomarkers or ECG or echocardiographic changes indicative of myocardial injury. […] EMB with immunohistochemical staining should be performed on suspicion of a specific cause that might benefit from targeted treatment. […] The current indications for EMB according to various international scientific societies are listed in table 2 of the supplementary data.

• #56 Advances in myocarditis management in the light of the latest research and recent guidelines of the European Society of Cardiology | Chabior | Cardiology Journal

  https://journals.viamedica.pl/cardiology_journal/article/view/95175

  Therefore, an approach with the use of EMB allows for a personalized and specific treatment due to the identification of disease etiology, particularly in case of giant cell myocarditis, eosinophilic myocarditis, cardiac sarcoidosis, and systemic inflammatory disorders. EMB can be repeated in case of unexplained progression of HF or to monitor response to treatment.

• #57

  https://journals.lww.com/pidj/fulltext/2025/03000/diagnosis_and_management_of_pediatric_myocarditis.21.aspx

  Myocarditis is a heterogeneous inflammatory disease of the myocardium, causing focal edema and injury, which may result in structural and functional abnormalities. The incidence varies between 0.8 and 2.13 cases per 100,000 with male predominance reported in children older than 6 years (approximately 2.5 times higher risk), and 2 peaks of occurrence: in children 2 years and in adolescents 13-18 years of age. In-hospital mortality is reported at 6.1%. Viruses are the leading cause of myocarditis in children, most commonly parvovirus B19, human herpes virus type 6 (HHV-6), enteroviruses and adenoviruses. Other etiologies include cytomegalovirus (CMV), Epstein Barr virus, hepatitis C, herpes simplex type 2, influenza, parainfluenza, SARS-CoV-2 and HIV, less frequent bacteria or other infectious pathogens, immune-mediated mechanisms and toxin exposure. Diagnosis of myocardial inflammation is based on cardiac magnetic resonance Lake Louis criteria with the presence of both, myocardial edema and late gadolinium enhancement. Dallas criteria (histologic inflammatory infiltrate different than ischemic necrosis), tissue PCR and immunohistochemistry are considered the gold standard for definitive diagnosis. Given the focal nature of myocarditis, multiple EMB samples are recommended to detect viral nucleic acids to minimize the risk of false-negative results. EMB should be performed in children with a severe clinical course for treatment decisions. Initial management depends on the severity of the clinical course regardless of the etiology, and may include management of heart failure, serious arrhythmias and conduction disorders in accordance with the current guidelines. Tailored management strategies, ranging from supportive care to specific antiviral or immunosuppressive therapies are essential for improving patient outcomes. Further studies are needed to enhance the treatment of pediatric myocarditis.

• #58 Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

  https://www.mdpi.com/2075-4418/13/19/3073

  The presence of anti-cardiac antibodies strongly correlates with the prognosis of patients with myocarditis. […] In AM, their presence may indicate the risk of cardiac death or the need for a heart transplant. […] Myocardial edema is best seen on T2 imagining. CMR can be repeated during patient follow-up, usually after 6–12 months, in order to identify post-inflammatory scars. […] Endomyocardial biopsy (EMB) has long been considered the gold standard, but has variable sensitivity and specificity. […] Although EMB is often indicated for the diagnosis of myocarditis, the sensitivity of this method is debatable given the limited possibility of myocardial sampling. […] EMB provides unique useful information related to diagnosis and prognosis, and its results help in the selection of therapeutic modalities.

• #59 Myocarditis Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/156330-workup

  Elevated cardiac enzymes are an indicator for cardiac myonecrosis. Cardiac troponin (troponin I or T), in particular, is elevated in at least 50% of patients with biopsy-proven myocarditis. […] In acute myocarditis, inflammatory biomarkers such as CRP and ESR may be elevated, but they are not specific to the condition, and normal values don’t rule it out. […] The following imaging studies may be used to assess patients with suspected myocarditis: […] Cardiac angiography or CCT are often indicated to rule out coronary ischemia as a cause of new-onset heart failure, especially when clinical presentation mimics acute myocardial infarction. […] EMB is the criterion standard for the diagnosis of myocarditis, including the following conditions: […] The presence of viral genome in EMB samples is considered the criterion standard for viral persistence.

• #60 Fulminant myocarditis: a comprehensive review from etiology to treatments and outcomes | Signal Transduction and Targeted Therapy

  https://www.nature.com/articles/s41392-020-00360-y

  ECG tracings demonstrating arrhythmias or tachycardia with sinus rhythm can demonstrate left bundle branch block (LBBB), reduced QRS wave amplitude, ventricular premature beat, and ventricular tachycardia suggestive of severe progression. […] Considering the results of echocardiography can vary according to the state of the FM patients heart function, repeated and close monitoring is recommended. […] In order to differentiate FM from acute coronary disease, emergency angiography should be considered. […] The diagnosis of FM is largely based on the clinical symptoms observed in patients rather than a pathological or pathophysiological diagnosis. […] Importantly, it is critical to differentiate between FM and acute coronary artery disease as the treatment regimens are completely different.

• #61 Azthena logo with the word Azthena

  https://www.news-medical.net/news/20230406/Study-reviews-the-diagnosis-and-treatment-of-acute-myocarditis.aspx

  Scientists have recently reviewed and summarized the evidence regarding diagnosing and treating acute myocarditis. This review has been published in the JAMA Network journal. […] Cardiac magnetic resonance (CMR) has been used as a non-invasive diagnosis of acute myocarditis. […] Patients with acute myocarditis have increased inflammatory markers (e.g., C-reactive protein) and troponin levels. Troponin I or T levels were elevated in around 64% to 100% of patients. […] An abnormal electrocardiogram (ECG) finding is obtained in 62% to 96% of patients with acute myocarditis. […] As stated above, acute myocarditis can be diagnosed via cardiac magnetic resistance (CMR) with or without the endomyocardial biopsy (EMB) approach. […] CMR helps detect cardiac edema in patients. […] Coronary computed tomography (CT) and coronary angiography are performed in approximately 46% to 95% of adult patients with acute myocarditis.

• #62 Myocarditis | Diagnosis & Disease Information – The Cardiology Advisor

  https://www.thecardiologyadvisor.com/ddi/myocarditis/

  Myocarditis is characterized by inflammation of the myocardium, which might be caused by a viral infection, another medical condition, or certain medications. […] Diagnostic techniques include laboratory testing, electrocardiography, cardiac imaging, and (in select patients) biopsy. […] According to an older recommendation from a European Society of Cardiology task force, a noninvasive diagnostic workup combined with a patients clinical presentation can be used to establish a myocarditis diagnosis. […] The nonspecific nature of the history and physical examination of patients with myocarditis presents diagnostic challenges. […] Today, tests that are less invasive, including cardiac MRI, are able to identify a wider range of myocarditis patients. […] The European Society of Cardiology also recommends coronary angiography and EMB in all patients who meet diagnostic criteria for myocarditis.

• #63 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #64 Myocarditis – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/244

  Myocarditis describes a heterogeneous group of disorders characterised by myocardial inflammation in the absence of predominant acute or chronic ischaemia. […] Myocarditis is clinically and pathologically defined as inflammation of the myocardium in the absence of the predominant acute or chronic ischaemia characteristic of coronary artery disease. […] Key diagnostic factors include presence of risk factors, viral syndrome (prior), autoimmune disease, infectious disease, and drugs and toxins. […] 1st investigations to order include 12-lead ECG, CXR, serum CK, serum CK-MB, serum troponin (I or T), serum B-type natriuretic peptide, two-dimensional echocardiogram, and 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET-CT). […] Investigations to consider include endomyocardial biopsy (EMB), coronary angiography, cardiac MRI, and viral polymerase chain reaction (PCR). […] Emerging tests include MRI-guided EMB.

• #65 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #66 Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

  https://www.mdpi.com/2075-4418/13/19/3073

  Diagnostic includes physical examinations, teleradiography of the heart and lungs, echocardigraphic examination, 24-h ECG Holter monitoring, CMR heart examination, cardiac catheterization, and EMB. […] Non-invasive diagnostic methods such as CMR can be useful in diagnosing myocarditis and monitoring the progression of the disease. […] EMB is the gold standard in the final diagnosis of myocarditis; however, not all patients with suspected myocarditis should undergo EMB, but only patients with an unconfirmed diagnosis, especially with a pseudoinfraction image. […] Changes in the electrocardiogram can be seen in approximately 90% of patients with AM. […] A 12-lead ECG should be performed in all patients with clinically suspected myocarditis despite its low sensitivity for myocarditis.

• #67

  https://link.springer.com/article/10.1007/s11936-012-0204-7

  Another diagnostic approach is identification and quantification of viral infection markers with immunohistochemical and polymerase chain reaction techniques. […] The value of diagnostic imaging has grown significantly over the past decade. Cardiac magnetic resonance imaging (CMR), in particular, provides an alternative to invasive tests and plays an important role in the early diagnosis of myocarditis. […] According to a consensus paper and recommendations on the use of CMR for myocarditis, the Lake Louise criteria require that two of the three above-mentioned sequences need to be positive to make the diagnosis. […] In summary, CMR is currently the best non-invasive test for diagnosing myocarditis. […] Studies have also shown that when endomyocardial biopsies are guided by CMR, the diagnostic yield is much higher.

• #68 Update on Myocarditis: From Etiology and Clinical Picture to Modern Diagnostics and Methods of Treatment

  https://www.mdpi.com/2075-4418/13/19/3073

  Myocarditis is a very common disease in children, and due to the heterogeneity of the symptoms of the clinical picture, the diagnosis is made only in 17% of patients during the first examination. […] According to the ESC recommendations, clinically suspected myocarditis requires one or more clinical criteria (acute chest pain or new-onset dyspnea or palpitations/unexplained arrhythmia cardiogenic shock) and ≥1 diagnostic criteria from different categories (ECG features of heart injury, elevated markers of myocardial necrosis, functional/structural abnormalities on echocardiogram/angiogram or CMR) in the absence of an angiographically detectable cause that could explain the existing syndrome. […] The lack of non-invasive tests with high specificity and sensitivity is another reason why the diagnosis of myocarditis is often missed.

• #69

  https://link.springer.com/article/10.1007/s11936-012-0204-7

  Another diagnostic approach is identification and quantification of viral infection markers with immunohistochemical and polymerase chain reaction techniques. […] The value of diagnostic imaging has grown significantly over the past decade. Cardiac magnetic resonance imaging (CMR), in particular, provides an alternative to invasive tests and plays an important role in the early diagnosis of myocarditis. […] According to a consensus paper and recommendations on the use of CMR for myocarditis, the Lake Louise criteria require that two of the three above-mentioned sequences need to be positive to make the diagnosis. […] In summary, CMR is currently the best non-invasive test for diagnosing myocarditis. […] Studies have also shown that when endomyocardial biopsies are guided by CMR, the diagnostic yield is much higher.

• #70 Cardiovascular Magnetic Resonance in Myocarditis

  https://www.mdpi.com/2075-4418/12/2/399

  Furthermore, neither a single clinical nor diagnostic finding can presently confirm or exclude the diagnosis of myocarditis with absolute certainty, which is the reason for using an integrative diagnostic approach. […] CMR can detect changes caused by myocardial inflammation independent of the underlying aetiology, and has thereby altered the clinical decision-making process of many patients. […] The strength of the method lies in its unique multiparametric tissue characterization ability, which, however, relies mainly on parameters exploiting changes in extracellular volume to visualize myocardial inflammation. […] Overall, CMR mapping techniques show an excellent sensitivity, specificity, and diagnostic accuracy in patients with clinically suspected myocarditis. […] The updated LLC proposed a “2 out of 2” approach for the diagnosis of myocardial inflammation, which means that one positive T2-based criterion and one T1-based criterion must be fulfilled. […] CMR is an established and highly valuable clinical tool in the diagnostic work-up of patients with clinically suspected myocarditis.

• #71 Azthena logo with the word Azthena

  https://www.news-medical.net/health/How-is-Myocarditis-Diagnosed.aspx

  Echocardiography represents an important part of the initial diagnostic evaluation when evaluating a patient with myocarditis, assessing the function of the left heart ventricle and ruling out other causes of heart failure. […] In recent years cardiovascular magnetic resonance imaging (MRI) has been recognized as a highly sensitive and specific tool for diagnosing myocarditis. […] Histologic examination of heart tissue is necessary to confirm the diagnosis of myocarditis; thus, endomyocardial biopsy still represents one of the key diagnostic steps. […] The standard Dallas pathological criteria, published in 1986, served as the initial attempt to develop standardized diagnostic guidelines for the histopathological classification of myocarditis. […] Therefore, immunohistochemistry which allows quantification, identification, and differentiation of inflammatory cells is gaining further acceptance in diagnosing myocarditis.

• #72

  https://link.springer.com/article/10.1007/s11936-012-0204-7

  Myocarditis is a condition that can have a very wide clinical spectrum ranging from asymptomatic forms to fatal disease, but mostly presenting as new onset heart failure with reduced left ventricular ejection fraction, with or without viral syndrome. […] The diagnostic work-up may be challenging, but non-invasive imaging, primarily cardiac magnetic resonance, plays an increasingly important role, although endomyocardial biopsy is still considered a gold standard for diagnosis. […] On pathology obtained from endomyocardial biopsy, myocarditis has well-defined features which until recently were the mainstay of the diagnosis. […] Endomyocardial biopsy is still considered the gold standard in diagnosis of myocarditis. […] According to the Dallas criteria proposed in 1986, acute myocarditis is defined by lymphocytic infiltrates in association with myocyte necrosis not characteristic for ischemic damage.

• #73 Strategies and Criteria for the Diagnosis and Management of Myocarditislogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na58268/2024/12/24/strategies-and-criteria-diagnosis-and-management

  The ACC proposes a new 5-step process for evaluation and management and defines a 4-stage spectrum of myocarditis. […] Due to evolving diagnostic modalities, the ACC convened a committee to develop an Expert Consensus Decision Pathway, which proposes a new 5-step diagnostic process and a new clinical staging classification of myocarditis. […] A proposed 5-step care pathway: Recognize clinical scenarios and syndromes compatible with acute myocarditis. High-sensitivity cardiac troponin results establish the diagnosis in most patients but may be below diagnostic threshold in some. […] Pivotal diagnostic tests: cardiac MRI and endomyocardial biopsy. […] A 4-stage classification of myocarditis is defined, with stages linked to treatment strategies and supportive care. The stages are: 1. exposure to risk factors; 2. asymptomatic myocarditis; 3. symptomatic myocarditis; 4. advanced myocarditis, with hemodynamic or electrical instability.

• #74 Myocarditis Workup: Approach Considerations, Laboratory Studies, Imaging Studies

  https://emedicine.medscape.com/article/156330-workup

  The Dallas and the WHO Marburg classifications are commonly used on the basis of patterns in the following histologic characteristics: […] The 2024 ACC expert consensus decision pathway proposed a new four-stage staging framework to categorize myocarditis progression on the basis of clinical presentation:

• #75 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #76 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #77 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #78 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Cardiac magnetic resonance (CMR) imaging provides valuable information in diagnosing myocarditis, characterizing the presence of myocardial edema, hyperemia, necrosis, fibrosis, pericardial inflammation, and left ventricular (LV) dysfunction. Additional imaging with myocardial scintigraphy and inflammation-sensitive radiotracers (e.g., 18F-FDG PET) may be of diagnostic value in select cases. […] […] Endomyocardial biopsy use is generally limited to identifying causes of myocarditis with etiology-directed therapies (e.g., giant cell myocarditis) or ruling out myocarditis mimics. Use in all suspected cases of myocarditis is not routinely performed due to risks of the procedure and factors limiting diagnostic accuracy. […] […] This document proposes a new classification system for myocarditis, which parallels the stages for HF. This new classification includes Stage A (exposure to myocarditis risk factors without symptoms or disease), Stage B (evidence of myocarditis without symptoms), Stage C (symptomatic myocarditis), and Stage D (symptomatic myocarditis with hemodynamic or electrical instability). […]

• #79 Strategies and Criteria for the Diagnosis and Management of Myocarditislogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na58268/2024/12/24/strategies-and-criteria-diagnosis-and-management

  The ACC proposes a new 5-step process for evaluation and management and defines a 4-stage spectrum of myocarditis. […] Due to evolving diagnostic modalities, the ACC convened a committee to develop an Expert Consensus Decision Pathway, which proposes a new 5-step diagnostic process and a new clinical staging classification of myocarditis. […] A proposed 5-step care pathway: Recognize clinical scenarios and syndromes compatible with acute myocarditis. High-sensitivity cardiac troponin results establish the diagnosis in most patients but may be below diagnostic threshold in some. […] Pivotal diagnostic tests: cardiac MRI and endomyocardial biopsy. […] A 4-stage classification of myocarditis is defined, with stages linked to treatment strategies and supportive care. The stages are: 1. exposure to risk factors; 2. asymptomatic myocarditis; 3. symptomatic myocarditis; 4. advanced myocarditis, with hemodynamic or electrical instability.

• #80 ACC Offers ‘Practical Document’ for Myocarditis Diagnosis and Care | tctmd.com

  https://www.tctmd.com/news/acc-offers-practical-document-myocarditis-diagnosis-and-care

  A new expert consensus decision pathway from the American College of Cardiology (ACC) provides guidance around the management of myocarditis from diagnosis to follow-up. […] The pathway outlined in the document has five main steps, starting with recognition of the three classic presentations of myocarditis—chest pain, heart failure/cardiogenic shock, and symptoms related to arrhythmias, like palpitations and presyncope or syncope—and the initial workup. […] Pivotal diagnostic testing that includes cardiac magnetic resonance (CMR) imaging and endomyocardial biopsy comes next in the pathway, after which appropriate treatment is provided. […] In the paper, the authors stress that follow-up of these patients doesn’t end when symptoms resolve and recommend two cardiac imaging studies after the acute issue is addressed—a repeat echocardiogram at 2 to 4 weeks to look for new or progressive deterioration of LV function and, depending on the severity of the initial myocarditis, either a CMR scan or second echocardiogram at 6 months.

• #81 Difficulties in myocarditis diagnosis: a case report – Poteshkina – Digital Diagnostics

  https://jdigitaldiagnostics.com/DD/article/view/546163

  Myocarditis is often difficult to diagnose. The diagnostic difficulties include nonspecific symptoms or a vague clinical picture, absence of pathognomonic signs during physical examination, and endomyocardial biopsy, which is the gold standard of diagnosis of myocarditis, being an invasive procedure that is performed under strict indications in certain patients. […] Nevertheless, as radiology is rapidly developing, clinicians are now able to noninvasively diagnose symptoms of inflammatory myocardial damage, including edema and myocardial fibrosis, using cardiac magnetic resonance imaging. […] Thus, this case study demonstrates the role of imaging techniques in the differential diagnosis of ischemic and inflammatory heart diseases. […] Poorly defined symptoms at onset, lack of specific clinical signs of myocarditis, minimal changes on physical examination, and infrequent use of endomyocardial biopsy as the gold standard for diagnosis lead to the underdiagnosis of this disease in real-world practice.

• #82 Questions to Ask Your Doctor About Myocarditis

  https://www.myocarditisfoundation.org/questions-to-ask-your-doctor-when-suspecting-myocarditis/

  Classified as a rare disease, myocarditis is misdiagnosed by physicians and is the 3rd leading cause of sudden death in young people. […] One of the reasons that myocarditis is underdiagnosed is because of its absence of symptoms specific to the disease. […] While there is not a diagnostic test specific to myocarditis, there are tests that can be utilized to help in ruling it out depending on the symptoms. Common tests include blood tests for Troponins (proteins in the blood which are released when the heart muscle has been damaged), BNP (a blood test that measures levels of a protein that is made by your heart and blood vessels.) […] Other tests can include an electrocardiogram, a chest X-ray, and echocardiogram, and sometimes an MRI scan. […] Occasionally a heart, or myocardial biopsy is required to confirm the diagnosis and determine the diagnosis, especially when thought to be Giant Cell Myocarditis.

• #83 Difficulties in myocarditis diagnosis: a case report – Poteshkina – Digital Diagnostics

  https://jdigitaldiagnostics.com/DD/article/view/546163

  Myocarditis is often difficult to diagnose. The diagnostic difficulties include nonspecific symptoms or a vague clinical picture, absence of pathognomonic signs during physical examination, and endomyocardial biopsy, which is the gold standard of diagnosis of myocarditis, being an invasive procedure that is performed under strict indications in certain patients. […] Nevertheless, as radiology is rapidly developing, clinicians are now able to noninvasively diagnose symptoms of inflammatory myocardial damage, including edema and myocardial fibrosis, using cardiac magnetic resonance imaging. […] Thus, this case study demonstrates the role of imaging techniques in the differential diagnosis of ischemic and inflammatory heart diseases. […] Poorly defined symptoms at onset, lack of specific clinical signs of myocarditis, minimal changes on physical examination, and infrequent use of endomyocardial biopsy as the gold standard for diagnosis lead to the underdiagnosis of this disease in real-world practice.

• #84 Questions to Ask Your Doctor About Myocarditis

  https://www.myocarditisfoundation.org/questions-to-ask-your-doctor-when-suspecting-myocarditis/

  It’s important to know the full scope of what can be done to diagnose myocarditis. […] Below is a list of symptoms and diagnostic tests that may help the doctors to rule out if you have myocarditis. […] Even with these tests, diagnosing myocarditis is still a very complex and difficult task. […] What Can Diagnose Myocarditis? Electrocardiogram, Echocardiogram, Chest X-ray, Heart Biopsy, MRI Scan, Blood tests. […] Cardiac Biopsies are not a commonly ordered test and are very risky when done. Biopsies of the heart are only done at hospitals that perform transplants, so they are not a frequently ordered test. Plus, there is a high risk of false negative results if done for viral myocarditis.

• #85 Myocarditis in Children | Symptoms, Causes, Treatment & Prognosis

  https://www.cincinnatichildrens.org/health/m/myocarditis

  Myocarditis is a condition where the muscular walls of the heart become inflamed. Myocarditis typically results in poor heart function. […] Unfortunately, to the frustration of parents and doctors, there is no specific test for myocarditis. It is mostly a clinical diagnosis where the doctor must rely on the history provided by the family and physical examination of the child. […] There are many tests that can be performed that help with making a diagnosis of myocarditis. […] The most precise way to make the diagnosis of myocarditis is by doing a heart biopsy during a cardiac catheterization. This involves the use of a long catheter that is passed up a large blood vessel in the leg. Once the catheter is in the heart, a tiny piece of heart muscle is taken and sent to the pathologist to look at under the microscope. […] Results vary but the diagnosis of myocarditis is made by this method up to 65 percent of the time. The results of the biopsy are not 100 percent because the areas of the heart affected by the inflammation are often patchy and may be missed.

• #86 Questions to Ask Your Doctor About Myocarditis

  https://www.myocarditisfoundation.org/questions-to-ask-your-doctor-when-suspecting-myocarditis/

  Classified as a rare disease, myocarditis is misdiagnosed by physicians and is the 3rd leading cause of sudden death in young people. […] One of the reasons that myocarditis is underdiagnosed is because of its absence of symptoms specific to the disease. […] While there is not a diagnostic test specific to myocarditis, there are tests that can be utilized to help in ruling it out depending on the symptoms. Common tests include blood tests for Troponins (proteins in the blood which are released when the heart muscle has been damaged), BNP (a blood test that measures levels of a protein that is made by your heart and blood vessels.) […] Other tests can include an electrocardiogram, a chest X-ray, and echocardiogram, and sometimes an MRI scan. […] Occasionally a heart, or myocardial biopsy is required to confirm the diagnosis and determine the diagnosis, especially when thought to be Giant Cell Myocarditis.

• #87 Myocarditis – causes, symptoms & treatments – BHF

  https://www.bhf.org.uk/informationsupport/conditions/myocarditis

  Myocarditis is inflammation of the heart muscle, usually following a virus. […] If you think you have symptoms of myocarditis, contact your doctor straightaway, or call NHS 111. Getting diagnosed and treated early can help you feel better and lower your risk of long-term complications from myocarditis. […] Your doctor will examine you physically and ask you questions, including important information such as: recent illnesses, any history of auto-immune problems, exposure to toxins/drugs, other risk factors, for example if you’ve recently had a baby. […] You may have tests, including: an ECG (electrocardiogram), an echo (echocardiogram), a chest X-ray, blood tests. […] These tests will help your doctor with your diagnosis. […] BHF-funded researchers are developing the first-ever blood test for myocarditis, which they hope will lead to speedy diagnosis.

• #88

  https://www.cnic.es/en/noticias/nejm-first-blood-biomarker-distinguish-between-myocarditis-and-acute-myocardial-infarction

  The diagnosis of acute myocarditis is challenging, and the availability of a sensitive and specific early marker of acute myocardial inflammation could have a major impact on its clinical diagnosis. […] Nevertheless, the diagnosis of myocarditis continues to be challenging in clinical practice. […] CNIC General Director Dr. Valentn Fuster emphasizes that these results of paramount importance because they establish the first validated blood marker with high sensitivity and specifity (90%) for myocarditis. This will allow clinicians to distinguish between this disease and other cardiomyopathies like acute myocardial infarction, myocardial infarction with nonobstructive coronary arteries (MINOCA), and other inflammatory diseases with an autoimmune origin. […] The diagnosis of myocarditis is challenging, and the availability of a sensitive and specific marker of acute myocardial inflammation could have a major clinical impact, improving the diagnosis of myocarditis both generally and particularly in its early phases.

• #89 Viral myocarditis—diagnosis, treatment options, and current controversies | Nature Reviews Cardiology

  https://www.nature.com/articles/nrcardio.2015.108

  Myocarditis is a frequent cause of dilated cardiomyopathy with heterogeneous clinical presentations and a wide range of clinical outcomes […] Advances in our diagnostic capabilities using cardiac MRI as well as molecular detection of viruses by endomyocardial biopsy have improved our understanding and ability to characterize the disease […] Advances in cardiac MRI and molecular detection of viruses by endomyocardial biopsy have improved our ability to diagnose and understand the pathophysiological mechanisms of this elusive disease […] However, therapeutic options are currently limited for both the acute and chronic phases of myocarditis […] In this Review, we explore the pathophysiology, natural history, and modes of diagnosis of myocarditis, as well as evidence-based treatment strategies

• #90 CNN-KCL: Automatic myocarditis diagnosis using convolutional neural network combined with k-means clustering

  https://www.aimspress.com/article/doi/10.3934/mbe.2022110

  Myocarditis is the form of an inflammation of the middle layer of the heart wall which is caused by a viral infection and can affect the heart muscle and its electrical system. It has remained one of the most challenging diagnoses in cardiology. […] Cardiac MRI (CMR) has been considered a noninvasive and golden standard diagnostic tool for suspected myocarditis and plays an indispensable role in diagnosing various cardiac diseases. However, the performance of CMR depends heavily on the clinical presentation and features such as chest pain, arrhythmia, and heart failure. […] This paper introduces a new deep learning-based model called Convolutional Neural Network-Clustering (CNN-KCL) to diagnose Myocarditis. […] Our results demonstrate that the proposed method achieves an accuracy of 97.41% based on 10 fold-cross validation technique with 4 clusters for diagnosis of Myocarditis. To the best of our knowledge, this research is the first to use deep learning algorithms for the diagnosis of myocarditis.

• #91 Viral myocarditis—diagnosis, treatment options, and current controversies | Nature Reviews Cardiology

  https://www.nature.com/articles/nrcardio.2015.108

  Role of cardiovascular magnetic resonance imaging (CMR) in the diagnosis of acute and chronic myocarditis […] Diagnostic performance of cardiovascular magnetic resonance in patients with suspected acute myocarditis: comparison of different approaches […] Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology […] Diagnostic synergy of non-invasive cardiovascular magnetic resonance and invasive endomyocardial biopsy in troponin-positive patients without coronary artery disease […] Visualization of immune cell infiltration in experimental viral myocarditis by 19F MRI in vivo […] The role of endomyocardial biopsy in the management of cardiovascular disease: a scientific statement from the American Heart Association, the American College of Cardiology, and the European Society of Cardiology.

• #92 Diagnosis and treatment of myocarditis and inflammatory cardiomyopathy. Consensus document of the SEC-Working Group on Myocarditis – Revista Española de Cardiología (English Edition)

  https://www.revespcardiol.org/en-diagnosis-treatment-myocarditis-inflammatory-cardiomyopathy–articulo-S1885585724001567

  Myocarditis associated with isolated cases of nonsevere SARS-CoV-2 infection or vaccination-induced symptoms does not require any specific treatment other than standard COVID-19 treatment or the recommendation to avoid another vaccine dose. […] The treatment of chronic inflammatory myocarditis or cardiomyopathy should be individualized based on EMB findings and the identification of specific viruses or specific systemic inflammatory/autoimmune causes. […] Myocarditis in pediatric patients has a range of causes, including autoimmune diseases, infections, hypersensitivity, and toxicity. […] A diagnosis should always be followed by risk stratification and a structured follow-up plan.

• #93 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Outcomes in patients with biopsy-proven myocarditis vary, with approximately 50% having resolution in 2-4 weeks, 25% developing persistent cardiac dysfunction, and 12-25% progressing to end-stage HF or death. Predictors of poor outcomes include biventricular dysfunction, Stage D presentation, late gadolinium enhancement (LGE) on CMR, and specific etiologies (e.g., giant cell myocarditis). Transfer to an advanced HF center is recommended for patients with increased risk. […] […] Pharmacological treatment of myocarditis is based on presentation and etiology. Nonsteroidal anti-inflammatory drugs and colchicine are uses for pericardial-type chest pain but should be avoided in cases of symptomatic HF. Immunosuppression is generally used in cases of eosinophilic, giant cell, cardiac sarcoid, and immune checkpoint inhibitor-associated myocarditis. […]

• #94 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Outcomes in patients with biopsy-proven myocarditis vary, with approximately 50% having resolution in 2-4 weeks, 25% developing persistent cardiac dysfunction, and 12-25% progressing to end-stage HF or death. Predictors of poor outcomes include biventricular dysfunction, Stage D presentation, late gadolinium enhancement (LGE) on CMR, and specific etiologies (e.g., giant cell myocarditis). Transfer to an advanced HF center is recommended for patients with increased risk. […] […] Pharmacological treatment of myocarditis is based on presentation and etiology. Nonsteroidal anti-inflammatory drugs and colchicine are uses for pericardial-type chest pain but should be avoided in cases of symptomatic HF. Immunosuppression is generally used in cases of eosinophilic, giant cell, cardiac sarcoid, and immune checkpoint inhibitor-associated myocarditis. […]

• #95 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Outcomes in patients with biopsy-proven myocarditis vary, with approximately 50% having resolution in 2-4 weeks, 25% developing persistent cardiac dysfunction, and 12-25% progressing to end-stage HF or death. Predictors of poor outcomes include biventricular dysfunction, Stage D presentation, late gadolinium enhancement (LGE) on CMR, and specific etiologies (e.g., giant cell myocarditis). Transfer to an advanced HF center is recommended for patients with increased risk. […] […] Pharmacological treatment of myocarditis is based on presentation and etiology. Nonsteroidal anti-inflammatory drugs and colchicine are uses for pericardial-type chest pain but should be avoided in cases of symptomatic HF. Immunosuppression is generally used in cases of eosinophilic, giant cell, cardiac sarcoid, and immune checkpoint inhibitor-associated myocarditis. […]

• #96 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  Outcomes in patients with biopsy-proven myocarditis vary, with approximately 50% having resolution in 2-4 weeks, 25% developing persistent cardiac dysfunction, and 12-25% progressing to end-stage HF or death. Predictors of poor outcomes include biventricular dysfunction, Stage D presentation, late gadolinium enhancement (LGE) on CMR, and specific etiologies (e.g., giant cell myocarditis). Transfer to an advanced HF center is recommended for patients with increased risk. […] […] Pharmacological treatment of myocarditis is based on presentation and etiology. Nonsteroidal anti-inflammatory drugs and colchicine are uses for pericardial-type chest pain but should be avoided in cases of symptomatic HF. Immunosuppression is generally used in cases of eosinophilic, giant cell, cardiac sarcoid, and immune checkpoint inhibitor-associated myocarditis. […]

• #97 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  In patients with Stage C or D myocarditis, it is recommended to avoid strenuous physical activity for 3-6 months. Follow-up with CMR or echocardiography, 24-hour ECG monitoring, and exercise stress testing at the end of this time frame is advisable prior to returning to strenuous exercise. […] […] Many patients with myocarditis have a genetic predisposition. Genetic counseling and testing for all patients is recommended if possible. […] […] Longitudinal follow-up with imaging is important to assess for disease resolution or progression. Patients with Stage C or D myocarditis should have a repeat echocardiogram at 2-4 weeks with an office visit. At 6 months, low-risk patients (normal LV ejection fraction, no LGE on CMR, no electrical/hemodynamic instability) should get a repeat echocardiogram and higher-risk patients should get a CMR. Biomarkers also may be used to assess for evidence of subclinical deterioration.

• #98 ACC Offers ‘Practical Document’ for Myocarditis Diagnosis and Care | tctmd.com

  https://www.tctmd.com/news/acc-offers-practical-document-myocarditis-diagnosis-and-care

  A new expert consensus decision pathway from the American College of Cardiology (ACC) provides guidance around the management of myocarditis from diagnosis to follow-up. […] The pathway outlined in the document has five main steps, starting with recognition of the three classic presentations of myocarditis—chest pain, heart failure/cardiogenic shock, and symptoms related to arrhythmias, like palpitations and presyncope or syncope—and the initial workup. […] Pivotal diagnostic testing that includes cardiac magnetic resonance (CMR) imaging and endomyocardial biopsy comes next in the pathway, after which appropriate treatment is provided. […] In the paper, the authors stress that follow-up of these patients doesn’t end when symptoms resolve and recommend two cardiac imaging studies after the acute issue is addressed—a repeat echocardiogram at 2 to 4 weeks to look for new or progressive deterioration of LV function and, depending on the severity of the initial myocarditis, either a CMR scan or second echocardiogram at 6 months.

• #99 ACC ECDP for Diagnosis and Management of Myocarditis: Key Points

  https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2024/12/09/21/53/2024-acc-ecdp-on-myocarditis

  In patients with Stage C or D myocarditis, it is recommended to avoid strenuous physical activity for 3-6 months. Follow-up with CMR or echocardiography, 24-hour ECG monitoring, and exercise stress testing at the end of this time frame is advisable prior to returning to strenuous exercise. […] […] Many patients with myocarditis have a genetic predisposition. Genetic counseling and testing for all patients is recommended if possible. […] […] Longitudinal follow-up with imaging is important to assess for disease resolution or progression. Patients with Stage C or D myocarditis should have a repeat echocardiogram at 2-4 weeks with an office visit. At 6 months, low-risk patients (normal LV ejection fraction, no LGE on CMR, no electrical/hemodynamic instability) should get a repeat echocardiogram and higher-risk patients should get a CMR. Biomarkers also may be used to assess for evidence of subclinical deterioration.

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