Diagnosis of myocarditis belongs to one of the most challenging in cardiology because of many reasons. One of them is, for example, an enormous variability of symptoms and manifestations of the disease including asymptomatic individuals, heart failure, cardiogenic shock, sudden death and patients with myocarditis mimicking ischemic heart disease [97]. There is no single examination which could confirm the diagnosis with 100% certainty. There are examinations which have a high specificity, however on the other side, low sensitivity, like EMB. Diagnosis is thus very frequently based on a process of elimination [96], when other possible causes of patients´ symptoms and cardiac dysfunction (like ischemic heart disease, valvular or congenital heart disease) are excluded by different examination methods (ECHO, cardiac catheterization), [24, 96, 98, 99, 100]. There are all kinds of examinations used for the diagnosis of myocarditis and ICMP – ECG, ECHO, laboratory examination of the myocardial damage, CMRI and EMB.

The disease may affect all age groups, even though its higher prevalence is in younger patients [19].

The latest diagnostical criteria are based on the statement of the European Society of Cardiology ([24], or table 2) when clinically suspect myocarditis is confirmed by the presence of at least one clinical and one diagnostic criterion, alternatively of two diagnostic criteria in asymptomatic patients, at the same time other possible causes of patients´ symptoms are excluded. Myocarditis and ICMP are definitely confirmed by an analysis of the myocardial samples from EMB. Its indication however abides by the recommendations of cardiological societies [43, 96].

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CLINICAL CRITERIA

Chest pain New-onset, subacute or chronic dyspnoea at rest or exercise, fatigue, with or without heart failure signs Palpitation or other symptoms of arrhythmias, syncope or sudden cardiac death Unexplained cardiogenic shock

DIAGNOSTIC CRITERIA

I. Changes of ECG, Holter monitoring or stress test (AV block of the 1st to 3rd degree, bundle branch block, ST-T segment changes, T wave inversion, ventricular tachycardia or fibrillation, atrial fibrillation, asystole, sinus arresr, widened QRS complex, reduced R wave, pathological Q wave, low voltage, supraventricular tachycardia, premature beats) II. Elevation of the myocardial necrosis markers (troponin I or T) III. Functional and structural abnormalities on cardiac imaging (new, otherwise unexplained left and/or right ventricular structure and function abnormalities; global or regional systolic or diastolic dysfunction with or without the ventricular dilatation; with or without increased wall thickness; with or without pericardial effusion; with or without endocavitary thrombi) IV. Tissues characterization by CMRI (oedema and/or LGE of the myocardium)

Table 2: Clinical and diagnostical criteria for suspected myocarditis by European Society of Cardiology when clinically suspected myocarditis is confirmed by the presence of at least one clinical and one diagnostic criterion, alternatively of two diagnostic criteria in asymptomatic patients and at the same time other possible causes of patients´ symptoms are excluded [24]————————————————————————————————————————————————————————————————————————————–

Author of the opening picture: Part of the web template

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References:

19) MÜLLEROVÁ J., NOVÁK M. a VÍTOVEC J. Myokarditidy. Kardiologická revue. 2003, -(2), 56-59.

24) CAFORIO, A.L.P, PANKUWEIT S., ARBUSTINI E., et al. Current state knowledge on aetiology, diagnosis, management, and Therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Disease. European Heart Journal. 2013, 34(-), 2636–2648.

43) M, HOLICKÁ a ŠPINAR J. Myokarditidy. ACTA MEDICINAE. 2013, 2013(7), 68-74.

96) Onemocnění myokardu: Myokarditida, zánětlivá kardiomyopatie. ECardio.cz [online]. -: -, – [cit. 2017-01-30].

97) KUCHYNKA P. Kapitola 8.1. Akutní myokarditida. In: MOŤOVSKÁ, Z. a et al. Novinky v akutní kardiologii. Praha: Mladá fronta, 2016. pp. 292–303. ISBN 978-80-204-3903-1.

98) KINDERMANN, I. a et al. Update on Myocarditis. Journal of the American College of Cardiology. 2012, 59(9), 779-792.

99) KUCHYNKA, P. a et al. Myokarditida a zánětlivá kardiomyopatie. Kapitoly z kardiologie. 2013, 3(-), 87-91.

100) KREJČÍ, J. Myokarditidy a zánětlivé kardiomyopatie. Kardiologická Revue Interní Medicína. 2015, 17(4), 288-294.