Prognostic value of early ECG evolution in patients with histologically proven fulminant myocarditis
M Ciabatti, G Cacioli, G Gallone, E Cristiano, G D'amati, A Gasperetti, S Heymans, G Peretto, O De Diego, P Garcia-Pavia, G M De Ferrari, M Merlo, G Sinagra, I Olivotto, M PieroniAbstract
Background
Fulminant myocarditis (FM) is a life-threatening disorder with high rates of death or heart transplantation (Htx). Despite improvement of treatment strategies, outcome remains largely unpredictable and reliable short-term prognostic markers are currently lacking.
Purpose
We aimed to assess the prognostic value of baseline and early follow-up (FU) ECG in a multicentre retrospective cohort of patients with histologically-proven FM.
Methods
We retrospectively collected patients with histology-proven FM from ten European Centers. We evaluated baseline and short-term (3-7 days) FU-ECG, clinical, laboratory and histological variables. Our primary endpoint was a composite of in-hospital mortality and urgent Htx.
Results
We enrolled 94 subjects (53.2% males, median age 48 years) with histologically-proven FM. Cardiac arrest as clinical presentation was documented in 18.1% of cases. Most patients received intensive hemodynamic support including inotropes (94.6%) and/or temporary mechanical support (tMCS, 61.7%). Histology showed the presence of lymphocytic infiltrates in 86.2% of cases, leading to extensive use of steroids (77.7%) or other immunosuppressive (36.1%) therapies. Eighteen patients (19.1%) reached the clinical outcome during hospitalization (11 deaths and 7 Htx). Among ECG parameters, a lower sum of R waves amplitudes in leads II and III at early follow-up (FU-RII+RIII) showed the strongest association with adverse outcomes (AUC 0.868, 95% CI 0.784-0.951, p<0.001) and outperformed baseline RII+RIII (0.868 vs 0.705, p=0.013). At multivariate analysis, FU-RII+RIII was an independent prognostic predictor, even when adjusted for ECG (OR 0.846, 95% CI 0.700–0.988, p=0.033; Model 1 comprising FU-QRS duration and sustained ventricular tachycardia), clinical (OR 0.792, 95% CI 0.640–0.938, p=0.005; Model 2 comprising cardiac arrest at presentation and tMCS), and laboratory variables (OR 0.65, 95% CI 0.41–0.84, p<0.001 Model 3 comprising baseline lactates and neutrophils-to-lymphocytes ratio).
Conclusions
early ECG evolution in patients with FM is an easy bedside tool for identifying high-risk subjects necessitating escalation therapy or early screening for Htx. FU-RII+FU-RIII is the strongest independent ECG predictor of adverse prognosis.For image description, please refer to the figure legend and surrounding text.For image description, please refer to the figure legend and surrounding text.