key: cord-0724498-0pcterqm
authors: Wang, Si; Wei, Xin; Hu, Hongde
title: STAR evidence evaluation of viral fulminant myocarditis: Specificity, Timeliness, Accessibility, Risk
date: 2020-07-29
journal: Eur Heart J
DOI: 10.1093/eurheartj/ehaa520
sha: c8f0d09ff0ba881f0e7dbf49d76c9f9630e62342
doc_id: 724498
cord_uid: 0pcterqm

nan

Fulminant myocarditis (FM) is defined as an inflammatory myocardium disease with sudden severe haemodynamic disorder. It is a clinical diagnosis more than histological or pathological diagnosis. Therefore, FM diagnosis requires a comprehensive analysis of clinical manifestations, laboratory, and imaging examinations.

Viral infection is the most common cause of FM. The European Society of Cardiology (ESC) statement for the management of myocarditis recommends all patients with clinically suspected myocarditis should be considered endocardial myocardial biopsy (EMB). 1 Tissue obtained from EMB should be analysed by histology, immunohistochemistry, and viral polymerase chain reaction (PCR). 2 American Heart Association (AHA) 2020 statement also recommends EMB for FM. For giant cell myocarditis and eosinophilic myocarditis, immunosuppressive agents should be actively used. And for lymphocytic myocarditis, steroids may be helpful in the absence of cardiotropic viral genome by PCR. 3 However, since FM has an acute onset and develops rapidly, it needs to be diagnosed and treated as soon as possible. Due to the delay and complications of EMB, it is difficult to use EMB to guide treatment in the acute phase of FM. In a cohort of 187 patients with myocarditis, EMB was performed only in 50 patients (27%) and the median time from admission to EMB was 2 days. 4 Waiting for the results of EMB may miss the best treatment time for FM. In addition, a previous study has showed that there is no impact of the presence of a viral genome on the prognosis of patients with histologically proven acute myocarditis. 5 Another case also indicated that the steroid therapy was not banned for lymphocytic myocarditis before excluding viral infection. 6 In 2013, a meta-analysis showed that the left ventricular function improved more obviously in viral myocarditis cases treated with glucocorticoid, replication of the virus did not increase.

In Take home figure, we suggest an evidence evaluation of viral FM, including diagnosis Specificity, Timeliness, Accessibility, and Risk of the obtained/obtaining evidences. Fulminant myocarditis can be clinically diagnosed with virus infection symptoms, severe haemodynamic disorders, obvious elevated myocardial damage markers, severe heart injury echocardiography findings before EMB evidence obtained. Although EMB is still the gold standard for diagnosis of myocarditis, there is still no sufficient evidence to prove that EMB-guided treatment can bring improvement in the prognosis of FM, especially in the first onset days. Clinical earlier diagnosis and treatment of FM are important, EMB is encouraged simultaneously.

National Key R&D Program of China. (Award number: 2017YFC 1307800).

Conflict of interest: none declared.

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), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For commercial re-use, please contact journals

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Take home figure STAR evidence evaluation of viral fulminant myocarditis: Specificity, Timeliness, Accessibility, Risk. CMR, cardiac magnetic resonance

Fulminant myocarditis; IHC, immunohistochemistry

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