STAR evidence evaluation of viral fulminant myocarditis: Specificity, Timeliness, Accessibility, Risk.

This commentary refers to ‘Coronavirus fulminant myocarditis saved with glucocorticoid and human immunoglobulin’, H. Hu

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). Tissue obtained from EMB should be analysed by histology, immunohistochemistry, and viral polymerase chain reaction (PCR). 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.

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. 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. Another case also indicated that the steroid therapy was not banned for lymphocytic myocarditis before excluding viral infection. 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 , 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.

Take home figure

STAR evidence evaluation of viral fulminant myocarditis: Specificity, Timeliness, Accessibility, Risk. CMR, cardiac magnetic resonance; ECG, electrocardiogram; ECHO, echocardiography; EMB, endocardial myocardial biopsy; FM, Fulminant myocarditis; IHC, immunohistochemistry; LGE, late gadolinium enhancement; PCR, polymerase chain reaction. +, ++, +++, ++++, Score of the evaluated factor. ΔExclude coronary artery disease through selective coronary angiography, etc.

Funding

National Key R&D Program of China. (Award number: 2017YFC1307800).

Conflict of interest: none declared.