Миокардит: диагностика и лечение в период пандемии

Благова О.В., Коган Е.А. Миокардит: диагностика и лечение в период пандемии. Consilium Medicum. 2021; 23 (10): 742–749. DOI: 10.26442/20751753.2021.10.200668

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Blagova OV, Kogan EA. Myocarditis: diagnosis and treatment in a period of pandemic. Consilium Medicum. 2021; 23 (10): 742–749. DOI: 10.26442/20751753.2021.10.200668

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Аннотация

Пандемия новой коронавирусной инфекции, официально объявленная в начале 2020 г. и продолжающаяся до сих пор, привела к существенному росту числа миокардитов, привлекла внимание специалистов широкого профиля к этой проблеме и расставила в ней новые акценты.
В острую фазу COVID-19 частота миокардита у наиболее тяжелых (погибших) больных оценивается на уровне 7,2%, однако его истинная частота при разных вариантах течения болезни неизвестна, прижизненная диагностика затруднена сложностями транспортировки пациентов в экспертные центры с целью выполнения магнитно-резонансной томографии сердца и эндомиокардиальной биопсии. Определение уровня тропонина недостаточно специфично, из клинических признаков поражения сердца чаще всего регистрируются боли в грудной клетке, аритмии, выпот в полости перикарда (до 20%). Сердечно-сосудистые проявления в целом коррелируют с уровнем D-димера и прогнозом. Почти у 3/4 больных в острую фазу болезни выявляются повышенные титры антикардиальных антител, которые отражают системный иммунный ответ и являются одним из важных механизмов повреждения сердца. РНК SARS-CoV-2 обнаруживается в миокарде как во время COVID-19, так и в сроки до 6–8 мес после него, что сопровождается морфологической и клинической картиной подострого/хронического постковидного миокардита. Его основными проявлениями являются аритмии и дилатация камер сердца с падением сократимости. COVID-19 может приводить к существенному утяжелению течения предшествующего миокардита в отсутствие базисной терапии, но у больных, получающих иммуносупрессивную терапию, протекает относительно благоприятно и, как правило, не приводит к обострению миокардита. Коронавирус нового типа (SARS-CoV-2) является этиологическим фактором не только острого миокардита в исходную (собственно инфекционную) фазу болезни, но и подострого (в сроки от 1 до 3 мес), а также хронического постковидного миокардита, обусловленных не только персистенцией вируса в миокарде, но в первую очередь – выраженными аутоиммунными реакциями, что требует определения показаний к иммуносупрессивной терапии, ее объема и длительности.

Ключевые слова: COVID-19, SARS-CoV-2, миокардит, антикардиальные антитела, эндомиокардиальная биопсия, иммуносупрессивная терапия

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The novel coronavirus infection pandemic, officially declared in early 2020 and has been continuing till now, led to a significant increase in the rate of myocarditis, drew the attention of multi-discipline specialist to this problem and set new accents in it. In the acute phase of COVID-19, the rate of myocarditis in the most severe (dead) patients is estimated to be 7.2%, however, its real prevalence in different course of the disease is unknown; life-time diagnostics is complicated by the difficulties of transporting patients to expert centers for cardiac magnetic resonance imaging and endomyocardial biopsy. A troponin test is not sufficiently specific; chest pain, arrhythmias, and pericardial effusion are most common findings indicating heart damage (up to 20%). Cardiovascular signs and symptoms generally correlate with D-dimer levels and prognosis. In the acute phase of the disease, elevated anticardiac antibody titers are detected in almost 3/4 of patients, that reflect the systemic immune response and is one of the important mechanisms of heart damage. SARS-CoV-2 RNA is revealed in the myocardium both during COVID-19 and up to 6–8 months after it, that is accompanied by the morphological and clinical signs of subacute/chronic post-COVID myocarditis. Its main manifestations are arrhythmias and heart chamber dilation with impaired contractility. COVID-19 can lead to a significant worsening of symptoms of pre-existing myocarditis if there is no basic therapy, but in patients taking immunosuppressive therapy, its course is relatively favorable and usually does not lead to an exacerbation of myocarditis. A novel coronavirus (SARS-CoV-2) is an etiological factor not only for acute myocarditis in the initial (infectious) phase of the disease, but also for subacute (within 1 to 3 months) and chronic post-COVID myocarditis, which are due to not only the virus persistence in the myocardium, but, mainly, due to autoimmune reactions, which requires the determination of indications for immunosuppressive therapy, its volume and duration.

Keywords: COVID-19, SARS-CoV-2, myocarditis, anticardiac antibody, endomyocardial biopsy, immunosuppressive therapy

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Список литературы

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1. Kogan EA, Berezovskiy YS, Blagova OV, et al. Miocarditis in Patients with COVID-19 Confirmed by Immunohistochemical. Kardiologiia. 2020;60(7):4-10 (in Russian). DOI:10.18087/cardio.2020.7.n1209
2. Caforio AL, Pankuweit S, Arbustini E, et al.; European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. 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. Eur Heart J. 2013;34(33):2636-48, 2648a-2648d. DOI:10.1093/eurheartj/eht210
3. Bozkurt B, Colvin M, Cook J, et al.; American Heart Association Committee on Heart Failure and Transplantation of the Council on Clinical Cardiology; Council on Cardiovascular Disease in the Young; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; and Council on Quality of Care and Outcomes Research. Current Diagnostic and Treatment Strategies for Specific Dilated Cardiomyopathies: A Scientific Statement From the American Heart Association. Circulation. 2016;134(23):e579-e646. DOI:10.1161/CIR.0000000000000455
4. Myocarditis. Pathogenesis, Diagnosis and Treatment. Ed. ALP Caforio. Springer Verlag, 2020. DOI:10.1007/978-3-030-35276-9
5. Winter MP, Sulzgruber P, Koller L, et al. Immunomodulatory treatment for lymphocytic myocarditis – a systematic review and meta-analysis. Heart Fail Rev. 2018;23(4):573-81.
DOI:10.1007/s10741-018-9709-9
6. Escher F, Kühl U, Lassner D, et al. Long-term outcome of patients with virus-negative chronic myocarditis or inflammatory cardiomyopathy after immunosuppressive therapy. Clin Res Cardiol. 2016;105(12):1011-20. DOI:10.1007/s00392-016-1011-z
7. Merken J, Hazebroek M, Van Paassen P, et al. Immunosuppressive Therapy Improves Both Short- and Long-Term Prognosis in Patients With Virus-Negative Nonfulminant Inflammatory Cardiomyopathy. Circ Heart Fail. 2018;11(2):e004228. DOI:10.1161/CIRCHEARTFAILURE.117.004228
8. Tschöpe C, Elsanhoury A, Schlieker S, et al. Immunosuppression in inflammatory cardiomyopathy and parvovirus B19 persistence. Eur J Heart Fail. 2019;21(11):1468-9. DOI:10.1002/ejhf.1560
9. Tschöpe C, Ammirati E, Bozkurt B, et al. Myocarditis and inflammatory cardiomyopathy: current evidence and future directions. Nat Rev Cardiol. 2020 Oct 12:1-25. DOI:10.1038/s41569-020-00435-x
10. Rigopoulos AG, Klutt B, Matiakis M, et al. Systematic Review of PCR Proof of Parvovirus B19 Genomes in Endomyocardial Biopsies of Patients Presenting with Myocarditis or Dilated Cardiomyopathy. Viruses. 2019;11(6):566. DOI:10.3390/v11060566
11. Greulich S, Kindermann I, Schumm J, et al. Predictors of outcome in patients with parvovirus B19 positive endomyocardial biopsy. Clin Res Cardiol. 2016;105(1):37-52.
DOI:10.1007/s00392-015-0884-6
12. Pietsch H, Escher FE, Aleshcheva GA, et al. Parvovirus B19 NS1 and VP1/2 mRNAs expression indicates viral activity in endomyocardial biopsy-based diagnosis of patients with unexplained heart failure. Available at: https://esc365.escardio.org/Congress/ESC-CONGRESS-2020-The-Digital-Experience/Myocardial-Disease-ePo.... Accessed: 01.02.2021.
13. Ammirati E, Frigerio M, Adler ED, et al. Management of Acute Myocarditis and Chronic Inflammatory Cardiomyopathy: An Expert Consensus Document. Circ Heart Fail. 2020;13(11):e007405. DOI:10.1161/CIRCHEARTFAILURE.120.007405
14. Fine NM. Giant Cell Myocarditis: Still the Deadly Giant. JACC Case Rep. 2020;2(10):1489-91. DOI:10.1016/j.jaccas.2020.07.001
15. Tavazzi G, Pellegrini C, Maurelli M, et al. Myocardial localization of coronavirus in COVID-19 cardiogenic shock. Eur J Heart Fail. 2020;22(5):911-5. DOI:10.1002/ejhf.1828
16. Sala S, Peretto G, Gramegna M, et al. Acute Myocarditis Presenting as a Reverse Tako-Tsubo Syndrome in a Patient With SARS-CoV-2 Respiratory Infection. Eur Heart J. 2020;41(19):1861-2. DOI:10.1093/eurheartj/ehaa286
17. Craver R, Huber S, Sandomirsky M, et al. Fatal Eosinophilic Myocarditis in a Healthy 17-Year-Old Male with Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2c). Fetal Pediatr Pathol. 2020;39(3):263-8. DOI:10.1080/15513815.2020.1761491
18. Van Linthout S, Klingel K, Tschöpe C. SARS-CoV-2-related myocarditis-like syndromes Shakespeare's question: what's in a name? Eur J Heart Fail. 2020;22(6):922-5. DOI:10.1002/ejhf.1899
19. Escher F, Pietsch H, Aleshcheva G, et al. Detection of viral SARS-CoV-2 genomes and histopathological changes in endomyocardial biopsies. ESC Heart Fail. 2020;7(5):2440-7. DOI:10.1002/ehf2.12805
20. Wenzel P, Kopp S, Göbel S, et al. Evidence of SARS-CoV-2 mRNA in endomyocardial biopsies of patients with clinically suspected myocarditis tested negative for COVID-19 in nasopharyngeal swab. Cardiovasc Res. 2020;116(10):1661-3. DOI:10.1093/cvr/cvaa160
21. Kogan EA, Berezovskii IuS, Kukleva AD, et al. Limfotsitarnyi miokardit u patsientov s COVID-19 (4 autopsiinykh nabliudeniia). Arkhiv patologii. 2020;82(5):57-62 (in Russian). DOI:10.17116/patol20208205157
22. Blagova OV, Varionchik NV, Zaydenov VA, et al. Anticardiac antibodies in patients with severe and moderate COVID-19 (correlations with the clinical performance and prognosis). Russian Journal of Cardiology. 2020;25(11):4054 (in Russian). DOI:10.15829/29/1560-4071-2020-4054
23. Imazio M, Klingel K, Kindermann I, et al. COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis? Heart. 2020;106(15):1127-31.
DOI:10.1136/heartjnl-2020-317186
24. Inciardi RM, Lupi L, Zaccone G, et al. Cardiac Involvement in a Patient With Coronavirus Disease 2019 (COVID-19). JAMA Cardiol. 2020;5(7):819-24. DOI:10.1001/jamacardio.2020.1096
25. Agdamag ACC, Edmiston JB, Charpentier V, et al. Update on COVID-19 Myocarditis. Medicina (Kaunas). 2020;56(12):678. DOI:10.3390/medicina56120678
26. Ozieranski K, Tyminska A, Jonik S, et al. Clinically Suspected Myocarditis in the Course of Severe Acute Respiratory Syndrome Novel Coronavirus-2 Infection: Fact or Fiction? J Card Fail. 2021;27(1):92-6. DOI:10.1016/j.cardfail.2020.11.002
27. Halushka MK, Vander Heide RS. Myocarditis is rare in COVID-19 autopsies: cardiovascular findings across 277 postmortem examinations. Cardiovasc Pathol. 2021;50:107300. DOI:10.1016/j.carpath.2020.107300
28. Tissières P, Teboul JL. SARS-CoV-2 post-infective myocarditis: the tip of COVID-19 immune complications? Ann Intensive Care. 2020;10(1):98. DOI:10.1186/s13613-020-00717-0
29. Pietsch H, Escher F, Aleshcheva G, et al. Proof of SARS-CoV-2 genomes in endomyocardial biopsy with latency after acute infection. Int J Infect Dis. 2021;102:70-2. DOI:10.1016/j.ijid.2020.10.012
30. Nicol M, Cacoub L, Baudet M, et al. Delayed acute myocarditis and COVID-19-related multisystem inflammatory syndrome. ESC Heart Fail. 2020;7(6):4371-6. DOI:10.1002/ehf2.13047
31. Hudowenz O, Klemm P, Lange U, et al. Case report of severe PCR-confirmed COVID-19 myocarditis in a European patient manifesting in mid January 2020. Eur Heart J Case Rep. 2020;4(6):1-6. DOI:10.1093/ehjcr/ytaa286
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Авторы

О.В. Благова*, Е.А. Коган

ФГАОУ ВО «Первый Московский государственный медицинский университет им. И.М. Сеченова» Минздрава России (Сеченовский Университет), Москва, Россия
*blagovao@mail.ru

________________________________________________

Olga V. Blagova*, Evgenyia A. Kogan

Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
*blagovao@mail.ru

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