The Changing Face of Cardiac Inflammation
New Opportunities in the Management of Myocarditis
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See Articles by Berg et al and Müller et al
The search for noninvasive tests to diagnose myocardial inflammation has developed from the use of 67Gallium through antimyosin antibodies to the current standards of 18fluorodeoxyglucose positron emission tomography and cardiac magnetic resonance imaging (CMR).1,2 In CMR, a combination of 2 of 3 signal intensity measurements from native T2-weighted images and T1-weighted images obtained before and after gadolinium contrast provides a reasonable diagnostic performance with an estimated sensitivity of 67% and specificity of 91%.3 Since these original Lake Louise criteria were published, newer mapping techniques that quantify T1 and T2 relaxation times have significantly improved the performance of CMR for the diagnosis of inflammation.4
Early in the course of suspected myocarditis, CMR can predict meaningful clinical outcomes. In most but not all studies, the risk of ventricular arrhythmias is increased in patients with delayed gadolinium enhancement.5–7 CMR sequences that estimate extracellular volume and edema can also inform management decisions. For example, an increase in T2 relaxation time may suggest greater myocardial water content and a greater likelihood of improved cardiac function.8 Because exercise can trigger arrhythmias in the setting of acute myocarditis, current American Heart Association scientific and European Society of Cardiology position …