The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

Q: What are the key findings of this study?

Multiparametric CMR provided a positive diagnosis in 72% of patients with suspected acute myocarditis, with a 3.5% adverse outcome rate over 674 days in those scanned within 40 days.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Suspected acute myocarditis (n=540). Intervention: Contemporary multiparametric cardiovascular magnetic resonance (CMR) including T1/T2 mapping and LGE vs. Normal CMR findings (within the 40-day presentation subgroup). Primary outcome: Composite of first hospitalisation for heart failure (HF) after CMR or all-cause mortality (HR 0.87, 95% CI 0.80-0.94).

Q: What does this research mean for the field?

Multiparametric cardiovascular magnetic resonance provides a positive diagnosis in 72% of patients presenting with suspected acute myocarditis, with diagnostic yield independently associated with male sex and shorter presentation-to-scan intervals. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Jakub Lagan; Christien Fortune; David Hutchings; Joshua Bradley; Josephine H. Naish; Richard Timoney; Daniel Prescott; Hamish D. C. Bain; Tasneem Bangi; Jerome McIntosh; R Egdell; R. B. Irwin; David Clark; Erik B. Schelbert; Gaetano Nucifora; Matthias Schmitt; Chris Miller

doi:10.3390/diagnostics12010156

January 10, 2022DiagnosticsOpen Access

The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

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Key result

Early multiparametric CMR linked to ~13% lower HF hospitalization or mortality in suspected myocarditis.

HR 0.87
95% CI 0.80-0.94
n=540

Figures

Why the study?

Most supporting data for CMR in suspected acute myocarditis are retrospective, and few studies have included parametric mapping.

What is the diagnostic and prognostic utility of contemporary multiparametric cardiovascular magnetic resonance (CMR) in patients presenting with suspected acute myocarditis?

Key Points

To investigate the diagnostic yield, clinical correlates, and prognostic utility of contemporary multiparametric cardiovascular magnetic resonance (CMR) in patients presenting with suspected acute myocarditis.
Prospective cohort study of 540 consecutive patients presenting with suspected acute myocarditis who underwent contemporary multiparametric CMR including parametric mapping.
A subgroup of 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation was followed for a median of 674 (504–915) days, with 39 undergoing follow-up CMR at 189 (166–209) days.
The primary outcome endpoint was a composite of first hospitalization for heart failure or all-cause mortality.
CMR provided a positive diagnosis in 387 of 540 patients (72%), identifying myocarditis in 40% (215 patients), myocardial infarction in 11% (61 patients), and dilated cardiomyopathy in 11% (57 patients).
In multivariable analysis, male sex (OR 5.73, 95% CI 2.42–13.54, p < 0.001) and shorter presentation-to-scan interval (OR 0.94, 95% CI 0.91–0.98, p = 0.003) independently predicted a myocarditis diagnosis.
Over median follow-up, 4 of 113 patients (3.5%) met the primary endpoint; baseline lower left ventricular ejection fraction predicted follow-up left ventricular dysfunction on multivariable analysis and associated with adverse outcomes (HR 0.87, 95% CI 0.80–0.94).

Study Design

Type

Cohort (n=540)

Blinding

CMR analysis was performed blinded to patient outcomes

Multicenter

No

Structured PICO

What is the diagnostic and prognostic utility of contemporary multiparametric cardiovascular magnetic resonance (CMR) in patients presenting with suspected acute myocarditis?

P

Population

540 consecutive adults (median age 47, 39% female) undergoing clinical CMR for suspected acute myocarditis in the United Kingdom, with 113 diagnosed within 40 days followed for a median of 674 days.

E

Exposure

Contemporary multiparametric cardiovascular magnetic resonance (CMR) on 1.5 T or 3 T scanners including steady-state free precession cine imaging, basal and mid LV short-axis T1 mapping (MOLLI) pre- and 15 min post-gadoterate meglumine (0.15-0.2 mmol/kg), T2 mapping, extracellular volume (ECV) quantification, and late gadolinium enhancement (LGE) imaging.

C

Comparator

Patients with normal CMR findings performed within 40 days of presentation (n=46) for comparative clinical and outcome analyses.

O

Outcome

Composite of first hospitalisation for heart failure (HF) after CMR or all-cause mortality at a median follow-up of 674 (IQR 504-915) days, alongside diagnostic yield of multiparametric CMR.composite

Main Result

Hazard Ratio: 0.87 (95% CI 0.8–0.94)

Absolute Event Rate: 3.5% vs 0%

Contemporary multiparametric CMR yields a positive diagnosis in 72% of patients with suspected acute myocarditis, with higher sensitivity when performed early after presentation, and identifies a low-risk group when scans are normal.

Limitations

Patients did not undergo endomyocardial biopsy as a reference standard.
Myocardial injury may have lessened or resolved in the 40-day window between presentation and CMR.
Survival analysis was limited by a low number of adverse events (4 events).
Single-centre data may not generalise to other populations.
Patients did not undergo endomyocardial biopsy.
Myocardial injury may have lessened or resolved during the 40-day window between hospital presentation and CMR.
Survival analysis was limited by a low number of adverse events (only 4 patients experienced the primary endpoint).
Single-centre study design may limit generalisability.

Ask about this paper

Answers are grounded in this paper and cite their sources.

Implication

Supports multiparametric CMR for suspected acute myocarditis diagnosis; leaves open randomized validation of prognostic utility.

Abstract

Cardiovascular magnetic resonance (CMR) is used to investigate suspected acute myocarditis, however most supporting data is retrospective and few studies have included parametric mapping. We aimed to investigate the utility of contemporary multiparametric CMR in a large prospective cohort of patients with suspected acute myocarditis, the impact of real-world variations in practice, the relationship between clinical characteristics and CMR findings and factors predicting outcome. 540 consecutive patients we recruited. The 113 patients diagnosed with myocarditis on CMR performed within 40 days of presentation were followed-up for 674 (504-915) days. 39 patients underwent follow-up CMR at 189 (166-209) days. CMR provided a positive diagnosis in 72% of patients, including myocarditis (40%) and myocardial infarction (11%). In multivariable analysis, male sex and shorter presentation-to-scan interval were associated with a diagnosis of myocarditis. Presentation with heart failure (HF) was associated with lower left ventricular ejection fraction (LVEF), higher LGE burden and higher extracellular volume fraction. Lower baseline LVEF predicted follow-up LV dysfunction. Multiparametric CMR has a high diagnostic yield in suspected acute myocarditis. CMR should be performed early and include parametric mapping. Patients presenting with HF and reduced LVEF require closer follow-up while those with normal CMR may not require it.

Discussion

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Cite This Study

Lagan et al. (2022) conducted a cohort in Suspected acute myocarditis (n=540). Contemporary multiparametric cardiovascular magnetic resonance (CMR) including T1/T2 mapping and LGE vs. Normal CMR findings (within the 40-day presentation subgroup) was evaluated on Composite of first hospitalisation for heart failure (HF) after CMR or all-cause mortality (HR 0.87, 95% CI 0.80-0.94). Multiparametric CMR provided a positive diagnosis in 72% of patients with suspected acute myocarditis, with a 3.5% adverse outcome rate over 674 days in those scanned within 40 days.

synapsesocial.com/papers/6a7a03698a3ae1c742328a46 https://doi.org/10.3390/diagnostics12010156

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The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

The Diagnostic and Prognostic Utility of Contemporary Cardiac Magnetic Resonance in Suspected Acute Myocarditis

Figures

Key Points

Study Design

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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