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The Prognostic Role of Qtc Interval in Acute Myocarditis

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The Prognostic Role of Qtc Interval in Acute Myocarditis Acta Cardiol Sin 2016;32:223-230 Original Article doi: 10.6515/ACS20150226A General Cardiology The Prognostic Role of QTc Interval in Acute Myocarditis Yuan Hung, Wei-Hsiang Lin, Chin-Sheng Lin, Shu-Meng Cheng, Tsung-Neng Tsai, Shih-Ping Yang and Wen-Yu Lin Background: Acute myocarditis is an inflammatory disease of the myocardium. Although a fulminant course of the disease is difficult to predict, it may lead to acute heart failure and death. Previous studies have demonstrated that reduced left ventricular systolic function and prolonged QRS duration can predict the fulminant course of acute myocarditis. This study aimed to identify whether prolonged QTc interval could also be predictive of fulminant disease in this population. Methods: We retrospectively included 40 patients diagnosed with acute myocarditis who were admitted to our hospital between 2002 and 2013. They were divided into the fulminant group (n = 9) and the non-fulminant group (n = 31). Clinical symptoms, laboratory findings, electrocardiographic, and echocardiographic parameters were analyzed. Multivariate logistic regression analysis was used to identify the independent factors predictive of fulminant disease. Results: Patients with fulminant myocarditis had a higher mortality rate than those with non-fulminant disease (55.6% vs. 0%, p < 0.001). Multivariate analysis revealed that wider QRS durations (133.22 ± 45.85 ms vs. 92.81 ± 15.56 ms, p = 0.030) and longer QTc intervals (482.78 ± 69.76 ms vs. 412.00 ± 33.31 ms, p = 0.016) were significant predictors associated with a fulminant course of myocarditis. Conclusions: Prolonged QRS duration and QTc interval, upon patient admission, may be associated with an increased risk of fulminant disease and increased in-hospital mortality. Therefore, early recognition of fulminant myocarditis and early mechanical support could provide improved patient outcomes. Key Words: Fulminant myocarditis · Predictors · QRS complex · QTc interval INTRODUCTION as non-fulminant or fulminant, based on a comprehen- sive integration of clinical, echocardiographic, hemo- Myocarditis is an inflammation of the myocardium dynamic, and histological findings.5,6 Patients with ful- that results in ventricular systolic dysfunction.1,2 The minant myocarditis may develop rapid and severe he- etiology of acute myocarditis usually involves viral infec- modynamic instability, fetal ventricular arrhythmia, car- tion and typically has three phases: direct viral invasion, diogenic shock with multiple organ dysfunction syn- immune dysregulation, and extensive myocardial injury drome, and often require immediate mechanical circula- and remodeling.3,4 Viral myocarditis may be described tory support.7 Despite the potentially disastrous course of fulminant myocarditis, previous reports have sug- gested that early recognition of a fulminant course and Received: July 17, 2014 Accepted: February 26, 2015 prompt, aggressive intervention, including mechanical Division of Cardiology, Department of Internal Medicine, Tri-Service 6 General Hospital, National Defense Medical Center, Taipei, Taiwan. circulatory support, may result in improved outcomes. Address correspondence and reprint requests to: Dr. Wen-Yu Lin, Many investigators have demonstrated that reduced Division of Cardiology, Department of Internal Medicine, Tri-Service left ventricular function and prolonged QRS duration General Hospital, National Defense Medical Center, No. 325, Cheng- 8-10 Kung Road, Section 2, Neihu 114, Taipei, Taiwan. Tel: 886-2-8792- can predict the fulminant course of viral myocarditis. 7213; Fax: 886-2-8792-7134; E-mail: [email protected] The QT interval represents the time from the onset of 223 Acta Cardiol Sin 2016;32:223-230 Yuan Hung et al. ventricular depolarization to the end of repolarization, symptoms, or according to the Dallas criteria.3 Of these but it varies with heart rate and needs to be corrected. 47 patients, one patient was excluded due to incomplete Previous studies indicated that a prolonged QTc was ob- data, three were excluded due to discharge against served in patients with advanced heart failure; other re- medical advice, and three were excluded because coro- ports have provided support for the concept that pro- nary angiography revealed significant obstructive coro- longation of both the QRS duration and QTc interval is nary artery disease (Figure 1). Therefore, 40 patients predictive of mortality in patients with acute heart fail- with acute viral myocarditis were evaluated. These 40 ure, ischemic heart disease, and idiopathic cardiomyo- patients were divided into the fulminant group (n = 9) pathy.8-11 However, the value of the QTc interval for pre- and the non-fulminant group (n = 31). The definition of dicting a fulminant disease course in patients with acute a fulminant course of acute myocarditis was the pres- myocarditis has not been clearly elucidated. Thus, this ence of severe hemodynamic compromise requiring study aimed to investigate the association of the QTc inotropic agents or ventricular assist devices, such as an interval with a fulminant course of acute viral myo- intra-aortic balloon pump (IABP), left ventricular assist carditis. device, or extracorporeal membrane oxygenation (ECMO). Patient characteristics MATERIALS AND METHODS Clinical presentation, baseline characteristics and serum biochemistry markers were obtained. Initial elec- Study population trocardiography (ECG) results obtained in the emer- This study was approved by the Tri-Service General gency department were also collected, and the rhythm, Hospital Joint Institutional Review Board. Between 2002 heart rate, PR interval, QRS duration, QTc interval, and and 2013, 47 patients with a diagnosis of acute myo- ST segment/T-wave changes were analyzed. All intervals carditis at a tertiary medical center in Taiwan were en- were determined using commercial ECG analysis soft- rolled in a retrospective medical records review; pa- ware (12-Lead Algorithm, Philips, Amsterdam, Nether- tients under the age of 15 years were excluded. A diag- lands). The algorithm in the software analyzes the mor- nosis of acute myocarditis was based on the clinical fea- phology and rhythm in the 12 leads, simultaneously, and tures of acute heart failure following recent flu-like summarizes the results. The QT interval was measured Figure 1. Study cohort. Acta Cardiol Sin 2016;32:223-230 224 QTc Interval & Fulminant Myocarditis from the onset of the QRS complex to the end of the mine the predictors of a fulminant course in patients T-wave. The QTc interval was determined using Bazett’s with acute myocarditis. The variables selected in the Rate-Corrected QT interval formula, which is the com- multivariate logistic analysis were those with a p-value < monly used method for correcting the QT interval for 0.05 in the univariate models. A two-sided p-value < heart rate variations (corrected QT interval = QT/RR1/2).12 0.05 was considered statistically significant. The receiver All patients underwent standard trans-thoracic echo- operating characteristic (ROC) curve analysis and the cardiography at the time of presentation. Various para- area under the ROC curve (AUC) were used to quantify meters, including the left ventricular ejection fraction the ability of the selected parameters for predicting (LVEF), left atrium (LA) diameter, left ventricular end- fulminant myocarditis, where a value of 1.0 indicates systolic dimensions (LVEDs), thicknesses of the left ven- perfect ability and a value of 0.5 represents no ability. tricular post wall (LVPW), and the maximal interventri- All statistical analyses were performed using the SPSS cular septum (IVS), were calculated by using linear mea- statistical package (IBMÒSPSSÒ Statistics, Version 20, surements.13 IBM, Armonk, NY, USA). Statistical analysis All values are presented as means ± standard devia- RESULTS tions. Measurements between groups at baseline were compared using the Student’s t-test; statistical signifi- Baseline characteristics cance was defined as a p-value < 0.05. The chi-square The baseline characteristics, clinical manifestations, test was used for comparisons of frequencies and cate- and laboratory findings of patients with fulminant and gorical variables. A univariate logistic regression analysis non-fulminant myocarditis are noted in Table 1. There of the various clinical variables was performed to deter- were no statistically significant differences in age, gen- Table 1. Comparison of the characteristics and laboratory findings between the fulminant and non-fulminant groups Non-fulminant group (N = 31) Fulminant group (N = 9) p-value Characteristics Male (N, %) 25 (80.6%) 6 (66.7%) 0.38 Age (years) 33.32 ± 16.01 41.56 ± 19.96 0.28 Hypertension 06 (19.4%) 2 (22.2%) 0.85 Diabetes mellitus 1 (3.2%) 1 (11.1%) 0.34 Hyperlipidemia 1 (3.2%) 0 (0%)0.0 0.59 Uremia 1 (3.2%) 0 (0%)0.0 0.59 VHD 1 (3.2%) 0 (0%)0.0 0.59 Prior MI 0 (0%) 0 (0%)0.0 NS Prior CVA 0 (0%)0. 0(0%)0.0 NS Manifestations Chest pain (N, %) 20 (64.5%) 3 (33.3%) 0.10 Fever (N, %) 16 (51.6%) 4 (44.4%) 0.73 Peripheral edema (N, %) 07(22.6%) 0(0%)0.0 0.12 Serum biochemistry data WBC (mm3) 10,386.13 ± 3904.520. 14,911.11 ± 8224.180 0.14 CRP (mg/dL) 5.89 ± 6.73 4.39 ± 4.43 0.58 CK (IU/L) 470.03 ± 630.18 610.44 ± 727.60 0.61 Troponin-I (ng/mL) 4.12 ± 4.95 17.91 ± 26.04 0.15 Na (mmol/L) 137.06 ± 3.6200 136.44 ± 5.3900 0.69 K (mmol/L) 4.08 ± 0.65 3.99 ± 0.53 0.69 GOT (IU/L) 212.42 ± 861.91 0302.22 ± 590.740 0.77 Creatinine (IU/L) 1.24 ± 1.77 1.14 ± 0.34 0.87 BUN, blood urea nitrogen; CK, creatine kinase; CRP, C-reactive protein; CVA, cardiovascular accident; GOT, glutamate oxaloacetate transaminase; K, potassium; MI, myocardial infarction; Na, sodium; NS, not statistically significant; VHD, valvular heart disease; WBC, white blood cell. 225 Acta Cardiol Sin 2016;32:223-230 Yuan Hung et al. der, hypertension, diabetes mellitus, hyperlipidemia, mensions, showed no statistical differences between uremia, or valvular heart disease between both groups.
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