In this position statement of the ESC Working Group on Myocardial and Pericardial Diseases an expert consensus group reviews the current knowledge on clinical presentation, diagnosis and treatment of myocarditis, and proposes new diagnostic criteria for clinically suspected myocarditis and its distinct biopsy-proven pathogenetic forms. The aims are to bridge the gap between clinical and tissue-based diagnosis, to improve management and provide a common reference point for future registries and multicentre randomised controlled trials of aetiology-driven treatment in inflammatory heart muscle disease.

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Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases.

Cardiovascular Magnetic Resonance in Myocarditis: A JACC White Paper

The full text of this document is available on the Website of the European Society of Cardiology: www.escardio.org in the section ‘Scientific Information’, Guidelines. Introduction 1809 Pathophysiology 1810 Plaque rupture and erosion 1810 Inflammation 1812 Thrombosis 1812 Vasoconstriction 1812 Myocardium 1813 Diagnosis 1813 Clinical presentation 1813 Physical examination 1813 Electrocardiogram 1813 Biochemical markers of myocardial damage 1814 Recommendations 1815 Risk assessment 1815 Risk factors 1815 Clinical presentation 1815 Electrocardiogram 1816 Markers of myocardial damage 1816 Markers of inflammatory activity 1816 Markers of thrombosis 1817 Echocardiography 1817 Predischarge stress testing 1817 Coronary angiography 1817 Recommendations for risk stratification 1818 Treatment options 1818 Anti-ischaemic agents 1818 Beta-blockers 1818 Nitrates 1818

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Management of acute coronary syndromes in patients presenting without persistent ST-segment elevation

Update on myocarditis.

Recently, the European Society of Cardiology (ESC) and the American College of Cardiology (ACC) convened a conference to discuss refinements in the diagnosis of acute myocardial infarction. The panel on biochemistry considered issues related to the use of marker proteins. We were guided predominantly by the science of the area. We were also cognizant of the impact that changes in the standards would have on epidemiology, clinical trials, education of physicians, and patient care. Our recommendations will be incorporated, with the recommendations of the other panels, into a position paper for the ESC and the ACC. However, the members of the biochemistry group decided to express the opinions we felt were important in this area independently. Our thinking does not represent the position of the ESC, the ACC, or of the conjoint task force.

Many modifications of the original World Health Organization criteria for acute myocardial infarction1 have been accepted and incorporated into the ESC/ACC criteria; some deletions have also occurred. Until recently, most markers were detected using enzymatic activity; detection of the protein concentration now is preferred. Thus, it is more appropriate to refer to molecules released into the circulation as a consequence of cardiac injury as biochemical diagnostic markers or biomarkers. In this editorial, we emphasize issues related to the biochemical diagnosis of acute myocardial infarction. New and improved plasma biomarkers (troponins) with better sensitivity and specificity will be emphasized in preference to markers such as total creatine kinase (CK), CK-MB, lactate dehydrogenase, and aspartate aminotransferase. Rapid assays for the early detection of infarction that may be helpful will be delineated, and the use of the troponin markers to aid in the risk stratification of patients with acute coronary syndromes will be recommended.

### Biomarker Increases

Detectable increases in the biomarkers of cardiac injury are indicative of injury to the …

It’s Time for a Change to a Troponin Standard

Cardiac Troponin T in Patients With Clinically Suspected Myocarditis

Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis.

Chronic inflammation in the myocardium of patients with clinically suspected dilated cardiomyopathy

Grundproblematik und Fragestellung: Die Ergebnisse der routinemasig eingesetzten Laboruntersuchungen zum Nachweis eines Myokardschadens sind bei Patienten mit klinischem Verdacht auf Myokarditis haufig negativ. Mit der vorliegenden Studie wurde untersucht, ob durch Bestimmung von kardialem Troponin T (cTnT) bei diesen Patienten ein myokardialer Zelluntergang sensitiv nachgewiesen werden kann, inwieweit dies mit den Befunden der Endomyokardbiopsate ubereinstimmt und ob durch eine cTnT-Bestimmung eine nicht-invasive Verlaufskontrolle der Myokarditis moglich ist. Patienten und Methodik: Es wurden 80 Patienten (52 Manner, 28 Frauen) mit dem klinischen Verdacht auf eine Myokarditis konsekutiv untersucht. Als klinisch fuhrende Symptome bestanden bei den Patienten eine Herzinsuffizienz (n = 45), Angina pectoris (n = 25) oder Herzrhythmusstorungen (n = 10). Die Symptomatik hatte sich bei der Mehrzahl der Patienten in zeitlichem Zusammenhang mit einem viralen Infekt entwikkelt. Eine koronare Herzkrankheit war bei allen Patienten durch eine Koronarangiographie ausgeschlossen worden. Die vom interventrikularen Septum entnommenen Endomyokardbiopsate wurden histologisch und immunhistologisch aufgearbeitet. cTnT wurde mit einem hochsensitiven Sandwich-Immunoassay bestimmt. Ergebnisse: Erhohte cTnT-Spiegel (> 0,1 ng/ml) wurden bei 28/80 Patienten (35 %) nachgewiesen. Histologisch konnte nur bei funf Patienten eine Myokarditis diagnostiziert werden, immunhistologisch zeigte sich jedoch eine Myokarditis bei 26/28 (93 %) Patienten mit erhohtem cTnT-Spiegel sowie ebenfalls bei 23/52 (44 %) Patienten mit normalen cTnT-Spiegeln. Bei Patienten einer Myokarditis mit nur kurzer Anamnesedauer war der cTnT-Spiegel haufiger erhoht als bei Patienten mit einer langeren Anamnesedauer. Nach 6 Monaten waren die cTnT-Spiegel nur noch bei vier von 28 Patienten mit einer Myokarditis erhoht, die Myokardbiopsate zeigten jedoch eine persistierende Myokarditis bei 14 Patienten. Folgerungen: Durch Bestimmung von cTnT ist sehr sensitiv ein Nachweis einer myokardialen Zellschadigung bei Patienten mit klinischem Verdacht auf eine Myokarditis moglich. Durch die immunhistologische Analyse der Myokardbiopsate kann hierbei haufig auch bei histologisch unauffalligem Befund eine Myokarditis diagnostiziert werden. Die Sensitivitat der cTnT-Bestimmung fur die Diagnostik einer Myokarditis ist am hochsten, wenn die Patienten bereits kurz nach Beginn der Symptomatik untersucht werden. Background and objective: Results of routine laboratory tests for demonstrating myocardial damage in patients suspected of having myocarditis are often negative. This study was undertaken to ascertain (1) whether measuring Tropinin T (cTnT) in these patients can sensitively determine myocardial cell death, (2) to what extent this correlates with the findings of endomyocardial biopsy, and (3) whether measurement of cTnT can provide noninvasive assessment of the course of myocarditis. Patients and methods: 80 consecutive patients (52 men, 28 women) with clinically suspected myocarditis were investigated. The main clinical symptoms were heart failure (n = 45), angina pectoris (n = 25) or cardiac arrhythmias (n = 10). In most patients the symptoms had developed in temporal relation to a viral infection. Coronary heart disease was excluded in all by coronary angiography. Interventricular septal endomyocardial biopsies were examined histologically and immunohistologically. cTnT was measured with a highly sensitive sandwich-Immunoassay. Results: An increased level of cTnT (> 0.1 ng/ml) was demonstrated in 28 of the 80 patients (35 %). Myocarditis was diagnosed histologically in only 5 patients, but immunohistologically in 26 of 28 (93 %) with a raised cTnT level and in 23 of 52 (44 %) with a normal cTnT level. The cTnT level was more frequently elevated in patients with a brief rather than a long history of myocarditis. After 6 months the cTnT level was elevated in only 4 of 28 patients with myocarditis, but the myocardial biopsy showed persisting myocarditis in 14 patients. Conclusion: Measurement of cTnT is a very sensitive way of demonstrating myocardial cell damage in patients clinically suspected of having myocarditis. Immunohistological analysis can often provide positive results even if the histological findings are unremarkable. The sensitivity in diagnosing of cTnT is greatest when the patient is tested shortly after the onset of symptoms.

Kardiales Troponin T zur Diagnostik und Verlaufsbeurteilung bei klinischem Verdacht auf Myokarditis

Background: After myocardial infarction (MI) necrotic cardiomyocytes are irrecoverable and represents a major cause of infarct-related heart failure and death. In experimental infarction in animal ...

Abstract 2432: Increase of Regional Metabolism in the Infarcted Zone and Cardiac Function After Intracoronary Transplantation of Autologous Bone Marrow Cells in Patients with Chronic Myocardial Infarction

Mira Schannwell

Papers

Cardiac Troponin T in Patients With Clinically Suspected Myocarditis

Antimyosin autoantibodies are associated with deterioration of systolic and diastolic left ventricular function in patients with chronic myocarditis.

Chronic inflammation in the myocardium of patients with clinically suspected dilated cardiomyopathy

Kardiales Troponin T zur Diagnostik und Verlaufsbeurteilung bei klinischem Verdacht auf Myokarditis

Abstract 2432: Increase of Regional Metabolism in the Infarcted Zone and Cardiac Function After Intracoronary Transplantation of Autologous Bone Marrow Cells in Patients with Chronic Myocardial Infarction