Comparison of ECG, laboratory and echocardiographic parameters in patients with acute myocarditis at acute attack and clinical remission

Year 2020, , 175 - 180, 01.06.2020

Mehmet İnanır , Müjgan Gürler , Ramazan Kargın Emrah Erdal

https://doi.org/10.21601/ortadogutipdergisi.713846

Abstract

Aim: The pathogenesis of myocarditis, which has high morbidity and mortality in childhood and adolescence, has not been fully elucidated. The pathogenesis of acute myocarditis is a complex process in which multiple agents play a role. We aimed to compare ECG, laboratory and echocardiographic parameters of patients during acute exacerbation of myocarditis and clinical remission.

Material and Method: 144 patients (124 males, 20 females) with an acute myocarditis episode were included in the study (28 ± 5). These patients were called for control during the clinical remission period of 3-12 months. The ECG, laboratory and echocardiographic parameters of the patients were compared during acute exacerbation and clinical remission. QT and Tp-e ECG parameters were measured. In addition to routine biochemistry and hemogram parameters, troponin I, uric acid, CRP, sedimentation, TSH and cholesterol levels were measured. Left ventricular ejection fraction was measured as an echocardiographic parameter.

Results: When compared with the clinical remission Tp-e interval (p: 0.032), QT-max (p=0.014), QT-min (p=0.001), TSH (p<0.001), Trop (p<0.00), Urea (p=0.028), Alt (p=0.010), Ast (p<0.001), Wbc (p<0.001), Hb (p<0.001), Htc (p<0.001), Rdw (p<0.001), Plt (p<0.001), Mpv (p<0.001), Neu (p=0.003), Lym (p=0.013), Mon (p<0.001), Eo (p=0.003), Pdw (p<0.001), CRP (p=0.001), ESR (p<0.001), and HDL-C (p=0.002) were significantly changed in patients with acute attack myocarditis.

Conclusion: ECG parameters, inflammation markers, and HDL cholesterol levels were significantly improved in the clinical remission in addition to the left ventricular ejection fraction during acute exacerbation of the patients. LVEF, ECG parameters, inflammation markers, TSH and HDL cholesterol levels were thought to be important in terms of clinical course and pathogenesis of the disease.

Keywords

biochemical, ECG, echocardiography, myocarditis, remission

Akut atak ve klinik remisyonda akut miyokarditli hastalarda EKG, laboratuvar ve ekokardiyografik parametrelerin karşılaştırılması

Abstract

Amaç: Çocukluk ve ergenlikte yüksek morbidite ve mortaliteye sahip miyokardit patogenezi tam olarak aydınlatılamamıştır. Akut miyokardit patogenezi, çoklu ajanların rol oynadığı karmaşık bir süreçtir. Miyokarditin akut alevlenmesi ve klinik remisyon sırasında EKG, laboratuvar ve ekokardiyografik parametreleri karşılaştırmayı amaçladık.

Materyal ve Yöntem: Akut miyokardit atağı olan 144 hasta (124 erkek, 20 kadın) çalışmaya dahil edildi (28 ± 5). Bu hastalar 3-12 aylık klinik remisyon döneminde kontrol altına alındı. Akut alevlenme ve klinik remisyon sırasında hastaların EKG, laboratuvar ve ekokardiyografik parametreleri karşılaştırıldı. QT ve Tp-e gibi EKG parametreleri ölçüldü. Rutin biyokimya ve hemogram parametrelerine ek olarak troponin I, ürik asit, CRP, sedimantasyon, TSH ve kolesterol düzeyleri ölçüldü. Sol ventrikül ejeksiyon fraksiyonu ekokardiyografik parametre olarak ölçüldü.

Bulgular: Klinik remisyon ile karşılaştırıldığında, akut atak miyokarditli hastalarda Tp-e aralığı (p: 0,032), QT-max (p = 0,014), QT-min (p = 0,001), TSH (p <0,001), Trop (p <0,00), Üre (p = 0,028), Alt (p = 0,010), Ast (p <0,001), Wbc (p <0,001), Hb (p <0,001), Htc (p <0,001), Rdw (p <0,001), Plt (p <0,001), Mpv (p <0,001), Neu (p = 0,003), Lym (p = 0,013), Mon (p <0,001), Eo (p = 0,003), Pdw (p <0,001), CRP (p=0,001), ESR (p<0,001), and HDL-C (p=0,002) önemli ölçüde değişmiştir.

Sonuç: EKG parametreleri, inflamasyon belirteçleri ve HDL kolesterol düzeyleri, hastaların akut alevlenmesi sırasında sol ventrikül ejeksiyon fraksiyonuna ek olarak klinik remisyonda önemli ölçüde iyileşti. LVEF, EKG parametreleri, inflamasyon belirteçleri, TSH ve HDL kolesterol düzeylerinin hastalığın klinik seyri ve patogenezi açısından önemli olduğu düşünülmektedir.

Keywords

biyokimyasal, EKG, ekokardiyografi, miyokardit, remisyon

References

• Al-Akchar M, Kiel J. Acute Myocarditis. 2019 Dec 16. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from http://www.ncbi.nlm.nih.gov/books/NBK441847/ PubMed PMID: 28722877.
• Feldman AM, McNamara D: Myocarditis. N Engl J Med 2000; 343: 1388-98.
• Batra AS, Epstein D, Silka MJ. The clinical course of acquired complete heart block in children with acute myocarditis. Pediatr Cardiol 2003; 24(5): 495-7. (doi: 10.1007/s00246-002-0402-2).
• Chang YJ, Chao HC, Hsia SH, Yan DC. Myocarditis presenting as gastritis in children. Pediatr Emerg Care 2006; 22(6): 439-40. (doi: 10.1097/01.pec.0000221346.64991.e7).
• Durani Y, Egan M, Baffa J, Selbst SM, Nager AL. Pediatric myocarditis: presenting clinical characteristics. Am J Emerg Med 2009; 27(8): 942-7. (doi: 10.1016/j.ajem.2008.07.032).
• Jois A, Zannino D, Curtis N, Cheung M, Burgner DP, Chen KYH. Arterial Structure and Function Following Viral Myocarditis. Pediatr Cardiol. 2019 Jan; 40(1): 133-7.
• Leslie TC, Kirk UK. Part VIII. Disease of the heart, pericardium, and pulmonary vasculature bed.67; Myocarditis. Edited by: Douglas LM, Douglas PZ, Peter L, Robert O. Bonow. Founding editor and online editor: Eugene B. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. Tenth edition. Philadelphia; 2015. pp. 1591.
• Lang RM, Bierig M, Devereux RB, et al. Recommendations for chamber quantification: a report from the American Society of Echocardiography’s Guidelines and Standards Committee and the Chamber Quantification Writing Group, developed in conjunction with the European Association of Echocardiography, a branch of the European Society of Cardiology. J Am Soc Echocardiogr 2005; 18: 440-63.
• Savla J, Lin KY, Lefkowitz DS, Paridon SM, Gaynor JW, Hammond R, Shaddy RE, Rossano JW (2014) Adolescent age and heart transplantation outcomes in myocarditis or congenital heart disease. J Heart Lung Transplant 33(9): 943-9. (doi: 10.1016/j.healun.2014.04.018).
• Al-Khatib SM, Stevenson WG, Ackerman MJ, Bryant WJ, Callans DJ, Curtis AB, et al. 2017 AHA/ACC/HRS guideline for management of patients with ventricular arrhythmias and the prevention of sudden cardiac death: Executive summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Heart Rhythm. 2018 Oct;15(10):e190-e252. (doi: 10.1016/j.hrthm.2017.10.035). Epub 2017 Oct 30. Review. Erratum in: Heart Rhythm. 2018 Sep 26. PMID: 29097320.
• Fischer K, Marggraf M, Stark AW, Kaneko K, Aghayev A, Guensch DP, et al. Association of ECG parameters with late gadolinium enhancement and outcome in patients with clinical suspicion of acute or subacute myocarditis referred for CMR imaging. PLoS One. 2020 Jan 10; 15(1): e0227134. (doi: 10.1371/journal.pone.0227134). eCollection 2020. PubMed PMID: 31923225; PubMed Central PMCID: PMC6953836.
• Buttà C, Zappia L, Laterra G, Roberto M. Diagnostic and prognostic role ofelectrocardiogram in acute myocarditis: A comprehensive review. Ann NoninvasiveElectrocardiol. 2019 Nov 28. (doi: 10.1111/anec.12726). [Epub ahead of print] Review. PubMed PMID: 31778001.
• Shabetai R: Acute myopericarditis. Cardiol Clin 1990; 8: 39-44.
• Castro-Torres Y. Tpeak-Tend/QT: unnuevo predictor electro-cardiográfico de muerte súbita cardíaca. Cardiocore 2014; 49: 86-7.
• Acar G, Yorgun H, Inci MF, Akkoyun M, Bakan B, Nacar AB, et al. Evaluation of Tp-e interval and Tp-e/QT ratio in patients with ankylosing spondylitis. Mod Rheumatol 2014; 24: 27-30.
• Antzelevitch C, Oliva A. Amplification of spatial dispersion of repolarization underlies sudden cardiac death associated with catecholaminergic polymorphic VT, long QT, short QT and Brugada syndromes. J Intern Med 2006; 259: 48-58.
• Antzelevitch C, Shimizu W. Cellular mechanisms underlying the long QT syndrome. Curr Opin Cardiol 2002; 17: 43-51.
• Castro-Torres Y. Tpeak-Tend/QT: unnuevo predictor electro cardiográfico de muerte súbita cardíaca. Cardiocore 2014; 49: 86-7.
• Schouten EG, Dekker JM, Meppelink P, et al. QT interval prolongation predicts cardiovascular mortality in an apparently healthy population. Circulation 1991; 84: 1516-23.
• Aaronson KD, Schwartz JS, Chen TM, et al. Development and prospective validation of a clinical index to predict survival in ambulatory patients referred for cardiac transplant evaluation. Circulation 1997; 95: 2660-7.
• Ucar FM, Ozturk C, Yılmaztepe MA. Evaluation of Tp-e interval, Tp-e/QT ratioand Tp-e/QTc ratio in patients with acute myocarditis. BMC CardiovascDisord.2019 Oct 22; 19(1): 232. (doi: 10.1186/s12872-019-1207-z). PubMed PMID: 31640548; PubMed Central PMCID: PMC6805629.
• Assessment of repolarization abnormalities in baseline electrocardiograms of patients with myocarditis. Güneş HM, Babur Güler G, Güler E, et al. Turk J Med Sci. 2017 Nov 13; 47(5): 1333-9. (doi: 10.3906/sag-1612-39).
• Sharma AN, Stultz JR, Bellamkonda N, Amsterdam EA. Fulminant Myocarditis: Epidemiology, Pathogenesis, Diagnosis, and Management. Am J Cardiol. 2019; 124(12): 1954-60. (doi: 10.1016/j.amjcard.2019.09.017).
• Kato S, Morimoto S, Hiramitsu S, et al. Risk factors for patients developing a fulminant course with acute myocarditis. Circ J 2004; 68: 34-9.
• Crişan S, Tint D, Petrescu L. Therapeutic Advances in Emergency Cardiology: A Focus on Acute Myocarditis. Am J Ther. 2019 Mar/Apr; 26(2): e294-e300. (doi: 10.1097/MJT.0000000000000921). Review. PubMed PMID: 30839378.
• Gironès N, Carbajosa S, Guerrero NA, Poveda C, Chillón-Marinas C, Fresno M. Global metabolomic profiling of acute myocarditis caused by Trypanosoma cruzi infection. PLoS Negl Trop Dis. 2014 Nov 20; 8(11): e3337. (doi: 10.1371/journal.pntd.0003337). eCollection 2014 Nov. PubMed PMID: 25412247; PubMed Central PMCID: PMC4239010.
• Dominguez F, Kühl U, Pieske B, et al. Update on myocarditis and inflammatory cardiomyopathy: reemergence of endomyocardial biopsy. Rev Esp Cardiol (Engl Ed). 2016; 69: 178-87.