Examined group
The examined group comprised of patients hospitalized on the Department of Cardiology of Na Homolce Hospital between the 1st January 2002 and the 31st December 2016 with the diagnosis of myocarditis or perimyocarditis. The patients were identified in the hospital electronic database on the basis of the diagnosis code I 408. Myocarditis and perimyocarditis were in this examined group defined on the grounds of the diagnosis of a cardiologist. In consideration of the fact that EMB was not performed, myocarditis was considered clinically suspicious. All findings and results have been searched in the hospital electronic database.
Findings of serological examinations and aetiology of myocarditis generally were not evaluated in this group of patients. According to the researches, serological examinations in myocarditis have a low significance and are loaded with a number of factors so any practically beneficial conclusions could not be drawn [24, 108]. Furthermore, in a part of patients, the serological examination was performed in an external department and the results of these examinations were not available in the hospital electronic database.
The examined group comprised of 30 patients (24 males and 6 females) of the average age of 35±14 years and average hospitalization duration 7±4 days patients. Diagnosis of perimyocarditis had 8 patients. Researched basic parameters of the examined group were age, gender, weight, height, BMI, blood pressure, heart rate, smokers´ amount, hospitalization duration and previous diseases.
Exclusion criteria are stated in Table.
| Administration | Cardiac conditions | Non-cardiac conditions | Pharmacological and non-pharmacological treatment |
| The electronic database contained just a record of suffered myocarditis or perimyocarditis in anamnesis | Over 50% stenosis of coronary arteries | Pharmacologically uncompensated thyroid disease | Implantable pacemaker or other device adjusting the heart rhythm |
| Ischemic heart disease | Stroke | ||
| SV and V arrhythmias (apart AV block during rheumatic fever, because the disease is sometimes associated with myocarditis [25]) | Chronic obstructive pulmonary disease | ||
| Uncorrected arterial hypertension over 180/110 mmHg | |||
| Cardiomyopathy | |||
| Valvular disease | |||
| Congenital heart defect |
Table: Exclusion criteria used for the examined group in the retrospective study (SV – supraventricular, V – ventricular, AV – atrioventricular).
Definition of terms
Myocarditis/perimyocarditis – defined on the ground of a cardiologist´s diagnosis
Symptoms/anamnesis of an infection – i.e. anamnesis of a cough, running temperature/fever, flu-like symptoms or previously set diagnosis of an infection
Heart failure – defined on the ground of a cardiologist´s diagnosis
Abnormal heart rhythm – i.e. tachycardia, bradycardia, atrial flutter, atrial fibrillation, junctional rhythm, non-specific ventricular line disorders and AV blocks.
Subjective symptoms and objective findings
Subjective symptoms were ascertained on the grounds of a patient´s transmission. The incidence of the following characteristics was researched: chest pain and/or chest pressure, pain propagation in one of the upper limbs, back or jaw, palpitation, dyspnoea, running temperature/fever, rash, headache, symptoms or anamnesis of a recent (in 2 months before the hospitalization) infection (i.e. anamnesis of cough, running temperature/fever, flu-like symptoms or previously set diagnosis of an infection), vomiting, diarrhoea, paleness, pre-collapse/collapse state, nausea, fatigue and peripheral swelling.
In objective finding, which was researched on the ground´s of a cardiologist´s physical examination, incidence of patients with normal objective finding and following characteristics was investigated: heart failure symptoms, picture of coronary artery disease, paleness, jugular vein distention, running temperature/fever, shortness of breath, tachypnoea, tachycardia, hepatomegaly, ascites, irregular heart action, weakening of the 1st heart sound (HS), 3rd or 4th HS, mitral (apex) murmur, pulmonary murmur, tricuspid murmur, aortic murmur, pericardial effusion or pleural effusion murmur, lung base crackles, rash, peripheral swelling, palpation – heart enlargement.
ECG
12-lead ECG was performed in all patients. The researched parameters were – abnormal heart rhythm incidence (bradycardia, tachycardia, atrial flutter, atrial fibrillation, junctional rhythm, ventricular line disorder, AV block I/II/III degree), repolarization changes of ST-segment (ST-segment depression/elevation, inversion/flat T waves), LBBB, RBBB + iRBBB and other findings (in this examined group specifically – QS swing, LV hypertrophy and transitional zone shift).
ECHO
ECHO was performed in all individuals. Valvular regurgitation was evaluated semiquantitatively with colour and continual Doppler and with PISA method. Pericardial separation/effusion was evaluated with the calliper from the different projection. Hypertrophy of the LV was evaluated from the thickness of the LV in end-diastole. When investigating the disorders of the LV kinetics and systolic function, global LV function (including EF) and regional kinetics disorder were evaluated. LV contractility and systolic function were assessed semIquantitatively and quantitatively, dilatation of the heart chambers visually and on the grounds of the dimensions of the chambers. LV ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV) were measured in the apical four chamber view and evaluated with the Simpson method. Normal EF was considered 55–60 %. Pulmonary hypertension (PH) was evaluated based on the acceleration time of pulmonary artery flow or the gradient between the right atrium and ventricle. Parasternal (long and short axis) and apical (2 and 4-chamber) were used. The investigating parameters were – finding of a mild to severe tricuspid/mitral/pulmonary/aortic regurgitation, pericardial effusion, pericardial separation, LV wall thickness, LV systolic function, presence of thrombus in heart chambers, dilatation of the LV, LV EF, pulmonary hypertension signs, morphology and function of the right ventricle and right/left atrium. All values were, except the presence of thrombus in heart chambers, gained from the 1st performed ECHO examination
X-Ray and CMRI
X-Ray of lungs was performed in 15 individuals. There were evaluated the incidence of normal findings and of the following characteristics – heart dilatation and widened heart shade, pericardial effusion, pulmonary circulation congestion and other findings (specifically bronchopneumonia and accentuation of lung markings)
12 individuals underwent CMRI (Avanto Siemens 1,5 T). Standard views including 2 and 4-chamber and short axis views were recorded. All patients received gadolinium contrast agent Gadovist. Following sequences were used – 3D IR T1 (late gadolinium enhancement, LGE), True FISP (heart function, morphology and heart chambers dimensions), TSE T2 FS (for the evidence of myocardial oedema). Pictures for the LGE evaluation were recorded 5–15 minutes after the contrast agent administration. LGE and edema pictures were evaluated visually, LV EDV, ESV and EF quantitatively, EF with tracing of the left ventricular contours in end-diastolic and end-systolic phase. Kinetics was evaluated with the observation of cine loops and visually. The investigated parameters were – normality of the finding, dilatation and kinetics of the LV and of other heart chambers, LV EF, EDV and ESV, the presence of a pericardial effusion, myocardial oedema, presence of thrombus in heart chambers and LGE.
Laboratory examination
Basic biochemical examination (iontogram, cholesterol, creatinine etc.), blood count and troponin I examination were performed in all individuals. Single investigated characteristics, their units, reference values, used methods and the number of patients in which the researched characteristic was examined, are stated in the table. The main examined laboratory parameters were biomarkers of myocardial necrosis (troponin I, CK-MB, myoglobin), of the heart failure (NT-BNP) and of ongoing inflammation (number of leukocytes, CRP) and substances researched as predictors of the worse prognosis (creatinine, ALT and AST [110]). In all characteristics, the first measured values were used. Cut-off for the classification of individuals in groups with troponin I negative (Trop I –, 7 patients) and troponin I positive (Trop I +, 23 patients) initial level was 0,06 ng/ml what was stated upper limit.
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| Characteristic | Unit | Reference value | Method | No. of patients (n) |
| Sodium | mmol/l | 135-146 | ISE indirect | 30 |
| Potassium | mmol/l | 3,6-5,5 | ISE indirect | 30 |
| Chlorides | mmol/l | 97-115 | ISE indirect | 30 |
| Uric acid | mmol/l | 2,5-8,3 | Enzymatic, conductometric, kinetic method | 30 |
| Creatinine | μmol/l | 57-113 | Reaction with alkaline picrate | 30 |
| ALT | μkat/l | 0,15-0,73 | IFCC with starter, 37 °C | 30 |
| AST | μkat/l | 0,10-0,66 | IFCC with starter, 37 °C | 30 |
| Creatine kinase | μkat/l | 0,41-3,24 | IFCC kinetic, 37 °C | 30 |
| ESR 1 hour | mm/1 h | 3-8 | Sedimentation | 24 |
| ESR 2 hours | mm/2 h | – | Sedimentation | 24 |
| Haemoglobin | g/l | 133-170 | Impedance flow cytometry | 30 |
| Erythrocytes | 4,3-5,5 | Impedance flow cytometry | 30 | |
| Haematocrit | – | 0,40-0,50 | Impedance flow cytometry | 30 |
| Thrombocytes | 130-350 | Impedance flow cytometry | 30 | |
| Leucocytes | 4,0-10,0 | Impedance flow cytometry | 30 | |
| Neutrophils | % | 50,0-70,0 | Microscopy, flow cytometry | 24 |
| Eosinophils | % | 1,0-5,0 | Microscopy, flow cytometry | 24 |
| Basophils | % | 0,0-1,0 | Microscopy, flow cytometry | 24 |
| Monocytes | % | 3,0-10,0 | Microscopy, flow cytometry | 24 |
| Lymphocytes | % | 18,0-40,0 | Microscopy, flow cytometry | 24 |
| APTT | ratio | 0,8-1,2 | Coagulation | 25 |
| QUICK | INR | 0,8-1,2 | Coagulation | 25 |
| Troponin I | ng/ml | 0,00-0,06 | Chemiluminescence immunoassay | 30 |
| Myoglobin | ng/ml | 20-82 | Chemiluminescence immunoassay | 23 |
| CK-MB | μg/l | 0,6-5,0 | Chemiluminescence immunoassay | 30 |
| CRP | mg/l | 0-5 | Immunoturbidimetry | 30 |
| NT BNP | pmol/l | 0-15 | Chemiluminescence immunoassay | 15 |
————————————————————————————————————————————————————————————————————————————–Table 4: Evaluated laboratory parameters, their units, reference values, methods and number of patients at which the examination was performed (ALT – alanine transaminase, AST – aspartate aminotransferase, ESD – erythrocytes sedimentation rate, APTT – activated partial thromboplastin time, QUICK – prothrombin time, CK-MB – creatine kinase muscle/brain, CRP – C reactive protein, NT BNP – N-terminal brain natriuretic peptide, ISE – ion specific electrode, IFCC – International Federation of Clinical Chemistry and Laboratory Medicine)
Cardiac catheterization
Cardiac catheterization via femoral or upper limb artery was performed in 19 individuals. Changes in coronary arteries (coronarography) and changes in the LV function (ventriculography) were evaluated after the administration of a contrast agent visually and with the computer from different projections. The researched parameters were – the incidence of normal finding, stenosis of a coronary artery under 50 % and incidence of other findings (in this examined group specifically of pericardial effusion, right coronary artery hypoplasia, dilated/border LV dimension, diffuse/regional hypokinesia of the left or right ventricle, mitral regurgitation.
Treatment
In table 5, there is summarised the therapy of patients in the course of the hospitalization, before the hospitalization and during the transfer in the hospital.
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| Medication group | Number of patients taking the medicaments (n) |
| Proton pump inhibitors | 6 (20 %) |
| ATB | 5 (17 %) |
| Analgesics (ibuprofen/mezamizolum natricum monohydricum) | 13 (43 %) |
| Anticoagulants | 12 (40 %) |
| ACE inhibitors/sartans | 19 (63 %) |
| Calcium channel blockers | 2 (7 %) |
| Chemotherapeutic medicament of nonspecific intestinal inflammations | 1 (3 %) |
| Alfa/beta-blockers | 14 (47 %) |
| Antiulcerotic drugs | 1 (3 %) |
| Prednisone | 2 (7 %) |
| Digoxin | 4 (13 %) |
| Hepatoprotective drugs | 2 (7 %) |
| Diuretics | 7 (23 %) |
| Antiagregans | 5 (17 %) |
| Anxiolytic drugs | 2 (7 %) |
| Vazodilatans | 2 (7 %) |
| Azathioprine | 1 (3 %) |
| Hypolipidemic drugs | 3 (10 %) |
| Insulin, p.o. antidiabetic drugs | 2 (7 %) |
| Dobutamine | 1 (3 %) |
| Antiasthmatic drugs, bronchodilatans | 2 (7 %) |
| Anti-hyperuricemic drugs | 2 (7 %) |
| Potassium preparation | 3 (10 %) |
| Thyroid gland hormone | 1 (3 %) |
| Venotonic drugs | 1 (3 %) |
Table 5: The list of medicaments administered to patients from the examined group before and during the course of hospitalization or during the transport.————————————————————————————————————————————————————————————————————————————–
Statistical methods
The practical part has a design of a retrospective study. Categorical variables are expressed in the form of the absolute value and percentage representation. They were evaluated by Fischer exact test. Continuous variables are expressed in the form of mean and standard deviation and were evaluated by Mann-Whitney U test considering the limited number of individuals in the examined group. Statistical significance level was considered p < 0,05. Variables were evaluated in Microsoft Excel 2016 and online calculators: https://www.socscistatistics.com/tests/mannwhitney/ for Mann Whitney U test, and for Fischer exact test in https://www.graphpad.com/quickcalcs/contingency1/.
Authors od the opening picture: (from the left upper side) Johannes Jansson, Agateller – Anthony Atkielski, Department of Paediatrics, 2nd Medical School and Motol Hospital, Sincefalastrum, Kalumet, James Heilman, MD, Bill Branson, Department of Radiology, 2nd Medical School and Motol Hospital (first 2 pictures, 3rd line), KGH