Leslie T. Cooper, Jr., MDLeslie T. Cooper, Jr., MDChair, Cardiovascular DepartmentChair, Cardiovascular Department

Mayo Clinic in FloridaMayo Clinic in Florida

Myocarditis in the Emergency Department

May 23rd, 2015

DISCLOSURERelevant Financial

Relationship(s)None

Off Label UsageNone

32 year old man presents to your ED with recent onset

chest pressure and dyspnea

•• He reports a flu-like illness 1 week priorHe reports a flu-like illness 1 week prior

•• Exam: HR 108 regular. BP 105/70.Exam: HR 108 regular. BP 105/70.

•• + Pericardial rub, + basilar rales+ Pericardial rub, + basilar rales

•• JVP 9 cm. No peripheral edema.JVP 9 cm. No peripheral edema.

•• Troponin T 12Troponin T 12

First Electrocardiogram

CP1291921-1

II

IIII

IIIIII

aVRaVR

aVLaVL

aVFaVF

V1V1

V2V2

V3V3

V4V4

V5V5

V6V6

Which of the following is least likely to improve his left ventricular

function over the next 6 months?

•• LisinoprilLisinopril•• CarvedilolCarvedilol•• Prednisone and AzathioprinePrednisone and Azathioprine

And….. avoid competitive sports for at least 3-6 months

Immunosuppression for Chronic iDCM

Inflammatory, Infiltrative, Infectious Cardiomyopthies

•• MyocarditisMyocarditisPost-viral/idiopathic, giant cell, Post-viral/idiopathic, giant cell,

rheumatologic or hypersensitivity- rheumatologic or hypersensitivity- relatedrelated

•• Sarcoidosis- Sarcoidosis- 50% 50% isolated to the heartisolated to the heart•• HIV, Chagas’ and Lyme DiseasesHIV, Chagas’ and Lyme Diseases•• AmyloidosisAmyloidosis

Cumulative Incidence Rates of Death, Heart Transplantation and Left Ventricular Recovery

in Children with Myocarditis

Time to occurrence of event (years)

Eve

nt p

roba

bilit

y

No event

Echocardiographic normalization

Death

Transplant

Foerster et al: Circ Heart Fail, 2010

28 yo woman with same symptoms And the following EKG

CP1304423-1

According to current ESC and AHA scientific statements,

which of the following is a Class I indication for EMB in acute DCM?

•• Failure to improve with GDMT after 2 Failure to improve with GDMT after 2 weeksweeks

•• Sustained or symptomatic VTSustained or symptomatic VT•• Mobitz type 2 or higher heart blockMobitz type 2 or higher heart block•• All of the aboveAll of the above

©2012 MFMER | slide-*

Giant Cell Myocarditis

21%

Cardiac Sarcoidosis

18 yo man with pericardidic chest pain, Troponin 10, normal LVEF and MRI:

According to a recent randomzed clinical trial which of the following are useful to

control his chest pain?

•• Colchicine, dosed by weightColchicine, dosed by weight•• Prednisone 20 mg/dayPrednisone 20 mg/day•• HydrocodoneHydrocodone•• None of the aboveNone of the above

Imazio, M. et al. Circ 2013

No Deaths

Will and CharlieMayo

Questions?Cooper.leslie@mayo.edu

NewNew onset heart failure of onset heart failure of 2 2 weeks to 3 monthsweeks to 3 months duration duration associated with a dilated left associated with a dilated left ventricle…andventricle…and

Class I, LOE B

Cooper, LT, et al Circulation 2007

•Ventricular arrhythmias, or•High degree heart block, or •Failure to respond to usual care within

1 to 2 weeks

Giant Cell versus Lymphocytic Myocarditis Transplant-Free Survival

CP977755-6

Survival (yr)Survival (yr)

Prop

ortio

n su

rviv

ing

Prop

ortio

n su

rviv

ing

LM groupLM groupGCM groupGCM group

Cooper, LT, NEJM 1997

25% of 72 patients 18-55 with initially unexplained AV block had GCM or cardiac sarcoidosis on endomyocardial biopsy

Circ. Arrhy and EP 2011:4(3). 303 -9

21% changed management

Bennett, et al. Circ Heart Fail 2013

Immunohistology Predicts Outcome in Patients with Acute Myocarditis

Free

dom

from

car

diac

deat

h an

d H

Tx

Months after biopsy

Kindermann et al: Circ 118:639, 2008 CP1324648-2

Positive

Negative

P<0.001

ImmunohistologyResults

Histopathological ResultsAccording to DALLAS Criteria

1.0

0.8

0.6

0.4

0.2

0.0

Months after biopsy

DALLAS negative

DALLAS positive

P=0.192

TIMIC Study•• RCT- Biopsy guided therapy in chronic RCT- Biopsy guided therapy in chronic

DCM, n=DCM, n=8585; Screened ; Screened 512512•• AZA and prednisone-mean LVEF AZA and prednisone-mean LVEF

increased from increased from 26% to 46% 26% to 46% at 6 months at 6 months •• Immunosuppression may improve LVEF Immunosuppression may improve LVEF

in select patients with non-viral, in select patients with non-viral, inflammatory DCM that inflammatory DCM that fails to respond fails to respond to usual careto usual care

Frustaci, A, et al. Eur Heart J 2009

Anti-CD3

Anti-CD68HLA-class II antigen

H and E

Select Histological Definitions of Myocarditis

From Staudt et al: Circ 2001