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Diagnosing and Sports Counselling of Athletes with Myocarditis

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Diagnosing and Sports Counselling of Athletes with Myocarditis Review Swiss Sports & Exercise Medicine, 67 (2), 28–36, 2019 Diagnosing and sports counselling of athletes with myocarditis Eichhorn C 1,2 , Gräni C 1,2 1 Department of Cardiology, Swiss Cardiovascular Center, University Hospital Berne, Switzerland 2 Noninvasive Cardiovascular Imaging Section, Cardiovascular Division, Department of Medicine, Brigham and Womens Hospital, Harvard Medical School, Boston, USA Abstract Zusammenfassung Myocarditis is dened as an inammation of the heart mus- Myokarditis ist eine Herzmuskelentzündung mit heterogener cle and its presentation, especially in athletes, is heterogene- klinischer Präsentation, dies insbesondere bei Athleten. Die ous. Underlying causes include in most of the cases viruses, häugsten Ursachen umfassen Virusinfektionen, oder weni- and less often bacteria, toxins, vasculitic diseases or pharma- ger häug bakterielle Infektionen, Vaskulitis, Toxine oder ceutical agents. Cardiac magnetic resonance (CMR) imaging Medikamente. Neben den laborchemischen Untersuchungen, is the primary imaging tool to diagnose myocarditis follow- dem Elektrokardiogramm und der Echokardiographie, ist die ing laboratory test, electrocardiogram and echocardiography. kardiovaskuläre Magnet-Resonanz-Tomographie (MRT) ak- In certain cases, endomyocardial biopsy is required, espe- tuell die primäre Untersuchungsmethode in diesem klini- cially in unclear cases with reduced systolic left ventricular schen Zusammenhang. Bei gewissen Patienten mit Verdacht ejection fraction. Although, athletes and sport physicians auf Myokarditis, insbesondere wenn sich eine unklar redu- face the dilemma of signicant performance decline in com- zierte systolische Ejektionsfraktion zeigt, ist die endomyo- petitive athletes against the risk of adverse cardiac events, kardiale Biopsie ein weiteres wichtiges Diagnoseinstrument. currently abstinence from competitive sports is recommend- Aktuell ist bei Athleten mit einer Myokarditis mindestens ed for at least 3–6 months in myocarditis. Sports recommen- 3–6 Monate kompetitive Trainingspause empfohlen, was der dations are currently based mainly on autopsy studies and Wettbewerbsfähigkeit eines Athleten nachhaltig schaden experts’ opinions and better risk stratication tools are im- kann. Diese Empfehlungen sind hauptsächlich basierend auf peratively needed. New tissue characterization methods, Autopsiestudien und Expertenmeinungen entstanden. Neue namely T1 mapping and T2 mapping in CMR continue to Gewebecharakterisierungs-Methoden im kardiovaskulären improve sensitivity and specicity of diagnosing myocarditis MRT, namentlich T1 mapping und T2 mapping, verbessern and may further enhance individual risk assessment. In the die Sensitivität und Spezizität der Myokarditis-Diagnostik. future, sports physicians may be able to rely more on these Zukünftig werden Sportmediziner ihre Athleten mit Ver- novel noninvasive tissue characterisation methods in risk dacht auf eine Myokarditis besser risikostratizieren können stratication and sports restriction recommendations of ath- und bezüglich Sportverhaltens je nach Befund der nichtinva- letes with suspected myocarditis. siven kardialen Bildgebung besser beraten können. Keywords: myocarditis, cardiac magnetic resonance imag- Schlüsselwörter: Myokarditis, kardiale Magnetresonanz- ing, sports restriction, risk stratication, athletes, competitive tomographie, Sportbeschränkung, Risikostratizierung, Sportler, Wettkampf 28 Eichhorn, Gräni Introduction cal setting using Cardiac magnetic resonance (CMR) imag- ing (see Figure 1) . The presented ow-chart incorporates Myocarditis, dened as inammation of the myocardium, clinical, laboratory and imaging markers with the aim to bet- presents the third most common cause of sudden cardiac ter diagnose and risk stratify athletes with suspected myo - death (SCD) in young athletes after autopsy-negative sudden carditis. unexplained death and coronary artery anomalies in the USA and Italy [1,2]. Also in post-mortem studies of athletes in Switzerland, we could recently show that myocarditis was Contributing effect of exercise on pathogenesis one of the underlying causes of SCD [3,4]. However, wheth- er exercise is a trigger of fatal arrhythmias is an unanswered Intense endurance training, compared to moderate exercise, question as the majority of SCD occurs at rest and not during which is generally protective, can predispose to viral upper or immediately after physical activity [1]. While exercise is respiratory tract infection and increases the chance of a sys- undeniably benecial for cardiovascular health [5], excessive temic inammatory response [13]. Murine studies have exercise has been shown to predispose athletes to infection shown that this inammatory response in athletes is associ- and exacerbate it [2]. Commonly, myocarditis is caused by ated with a higher propensity to arrhythmogenicity [14]. In viral infection such as enterovirus, Coxsackie B, Parvovirus addition to that, in athletes affected by myocarditis, infec- B19 and Human Herpes Virus 6 [6,7]. Non-infectious causes, tious agents attack the myocardium directly and cause a sub- which are generally rare, include toxins, vasculitic diseases sequent autoimmune response that leads to myocardial re- or pharmaceutical agents and illicit drugs [8]. The question modelling through three phases: acute viral, subacute amongst primary care physicians, sports physicians and car- immune and chronic phase, where severe cases develop into diologists alike is how we can best identify athletes who may a dilated cardiomyopathy [15]. be suffering from myocarditis, which inevitably predisposes In summary, the interaction between an environmental them to a higher risk of SCD, and how we risk stratify these trigger and the host’s immune system creates a subacute and athletes. Currently, based on animal and autopsy studies, ex- chronic inammatory state. This leads to death of myocar- pert opinions recommend an abstinence from competitive dial tissue and causes scarring of the heart, which further sports for 3 to 6 months after an episode of myocarditis predisposes individuals to arrhythmias. Even beyond an ep- [9–12]. This, however, can be of great inconvenience to ath- isode of myocarditis, it is believed that chronic myocardial letes due to deconditioning and an inability to compete. This inammation secondary to pathogenic autoimmunity can review aims to present the current challenges in diagnosing persist due to the continued presence of cytokines, which myocarditis and further propose how to approach this clini- exert pro-arrhythmic effect [16]. Figure 1: Diagnostic ow-chart and sports counselling of athletes with suspected myocarditis. Adapted from Eichhorn C. et al. JACC Cardiovasc Imaging, 2019. Diagnosing and sports counselling of athletes with myocarditis 29 Clinical presentation and initial clinical work-up Previous studies have shown that viral serology has a very of athletes with suspected myocarditis low sensitivity and intermediate specicity with myocardial biopsy inltrates conrming myocarditis [17]. Viral serology The typical clinical scenario is an athlete with atypical chest may be of use in ruling out hepatitis C, human immunode- pain, aggravated when leaning forward with the upper body, ciency virus, Lyme disease or rickettsia if there is a high history of a recent upper respiratory tract infection or gastro- suspicion. Myocarditis has been shown to be the second most intestinal infection, elevated inammatory and myocardial common cause of high troponin levels in the young and mid- biomarkers, diffuse elevated ST-elevations and PQ depres- dle-aged (< 50 years) [18], warranting further investigations sion in the electrocardiogram (ECG) and absence of coronary once myocardial infarction has been ruled out. A dilemma is artery disease. However, this is only in the minority of the presented by the fact that endurance training can raise tro- presentations the case. Myocarditis in athletes can present in ponin levels as demonstrated by a meta-analysis totalling a variety of ways. Beside chest pain as a leading symptom, 1045 patients where troponin levels were raised above the patients can present with palpitations, performance drop or cut-off in 83% of participants [19]. This means that repeat even be asymptomatic. Biomarkers, ECG and echocardiog- troponins in athletes are key in making the diagnosis of my- raphy might be abnormal, however, its sensitivity and speci- ocarditis as the raised troponin levels due to exercise resolve city is low. As myocarditis may clinically resemble to an faster and are less prominent as well as monophasic in com- acute coronary event, it is important to rule out coronary parison to the troponin proles found in myocarditis and my- artery disease (CAD) rst in these patients. ocardial infarction. Therefore, performing a troponin test in athletes suspected with myocarditis is important but it must be kept in mind that troponin levels do not sufciently cor- Biomarkers and Electrocardiogram relate with the level of oedema and scarring or recovery that can be observed on imaging modalities, such as cardiac mag- There are no specic biomarkers for myocarditis other than netic resonance (CMR) imaging [20]. ECG abnormalities possible increased inammation parameters C-reactive pro- like PR depression, ST-elevations, T-wave inversion, Q-wave tein, leucocytes, elevated blood sedimentation rate and ele- presence, prolonged QRS or QTc may be present but are nei- vated myocardial biomarkers like troponin/creatin-kinase. ther sensitive nor specic
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