Myocarditis and Dilated Cardiomyopathy in Athletes: Diagnosis, Management, and Recommendations for Sport Activity

doi:10.1016/j.ccl.2007.08.008

Cardiology Clinics

Volume 25, Issue 3, August 2007, Pages 423-429

https://doi.org/10.1016/j.ccl.2007.08.008 Get rights and content

This article focuses on uncommon heart diseases associated with an increased risk for sudden death during exercise, namely, myocarditis and dilated cardiomyopathy.

Section snippets

Dilated cardiomyopathy

DCM is a heart muscle disease characterized by left ventricular dilatation and systolic dysfunction with normal left ventricular wall thickness [9]. The estimated prevalence of DCM is 1 case per 2500 population, and it is the third most common cause of heart failure and one of the major diseases requiring cardiac transplantation. DCM is a heterogeneous disease with a multifactorial pathogenesis [2], [10]. It may be familial/genetic, viral, or immune related, which explains why it has been

Myocarditis and dilated cardiomyopathy as causes of sudden death in young athletes

Myocarditis has been traditionally considered an important cause of sudden death in young individuals including athletes, although its importance may be exaggerated because of overinterpretation of histologic data and the lack of standardized morphologic criteria (Fig. 1). It has been shown that intense physical exercise, either as a single episode of exhausting exercise or as persistent overtraining, can increase the susceptibility to upper respiratory infections as a consequence of a

Recommendations for sport activity in athletes affected by myocarditis and dilated cardiomyopathy

The recommendations for sport activity discussed herein are based on recent consensus documents of expert panels of the European Society of Cardiology and the Sports Cardiology Section of the European Association of Cardiovascular Prevention and Rehabilitation [31], [32].

Myocarditis may evolve into a chronic inflammation, often with a subclinical course, and eventually progress into DCM (Fig. 3). It is of utmost importance to respect an adequate period of athletic rest until the disease has

References (32)

E. Burkett et al.
State of the art: clinical and genetic issues in familial dilated cardiomyopathy
J Am Coll Cardiol
(2005)
L. Mestroni et al.
Familial dilated cardiomyopathy: evidence for genetic and phenotypic heterogeneity. Heart Muscle Disease Study Group
J Am Coll Cardiol
(1999)
A.L. Caforio et al.
Evidence from family studies for autoimmunity in dilated cardiomyopathy
Lancet
(1994)
N.G. Ilback et al.
Exercise in coxsackie B3 myocarditis: effects on heart lymphocyte subpopulations and the inflammatory reaction
Am Heart J
(1989)
L. Wesslen et al.
Myocarditis caused by Chlamydia pneumoniae (TWAR) and sudden unexpected death in a Swedish elite orienteer
Lancet
(1992)
K. Nilsson et al.
Association of Rickettsia helvetica with chronic perimyocarditis in sudden cardiac death
Lancet
(1999)
H.T. Aretz et al.
Myocarditis: a histopathologic definition and classification
Am J Cardiovasc Pathol
(1987)
P. Richardson et al.
Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies
Circulation
(1996)
F. Calabrese et al.
Myocarditis and inflammatory cardiomyopathy: microbiological and molecular biological aspects
Cardiovasc Res
(2003)
T. Morgera et al.
Electrocardiography of myocarditis revisited: clinical and prognostic significance of electrocardiographic changes
Am Heart J
(1992)

B. Pianamonti et al.

Echocardiographic findings in myocarditis

Am J Cardiol

(1988)

A. Urhausen et al.

Images in cardiovascular medicine: diagnosis of myocarditis by cardiac tissue velocity imaging in an Olympic athlete

Circulation

(2003)

A.B. Martin et al.

Acute myocarditis rapid diagnosis by PCR in children

Circulation

(1994)

A.L. Caforio et al.

A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis

Eur Heart J

(2007)

B.J. Maron et al.

Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention

Circulation

(2006)

A. Gavazzi et al.

The spectrum of left ventricular size in dilated cardiomyopathy: clinical correlates and prognostic implications

Am Heart J

(1993)

Cited by (53)

Is Exercise Helpful or Harmful in Dealing With Specific Arrhythmia
2021, Current Problems in Cardiology
Exercise is universally known to benefit health by lowering risk for cardiovascular disease and mortality. However, in patients with pre-existing cardiac conditions, including channelopathies, cardiomyopathies and coronary artery disease, exercise can cause sudden cardiac death (SCD). In this review, we explore exercise related risks and current recommendations for specific conditions. The risk of myocardial infarction (MI) during strenuous exercise in asymptomatic individuals with coronary artery disease is decreased with habitual exercise, especially if they have a normal ejection fraction and no ischemia. Furthermore, cardiac rehabilitation has been shown to be beneficial in heart failure. On the other hand, surgery is recommended for certain anomalous coronaries prior to engaging in vigorous activity. In addition, both exercise-induced disease progression and SCD in arrhythmogenic cardiomyopathy restrict ability to engage in competitive sports, as is the case in hypertrophic cardiomyopathy. Other diseases, like myocarditis only cause temporary risk for SCD. Previously considered benign, common conditions like early repolarization do increase SCD risk. Finally, certain gear including thicker chest protectors for athletes engaging in sports with hard, small spherical objects decrease risk of commotio cordis. While significant advances have been achieved in diagnosing and treating previously unrecognized conditions that predispose to sudden cardiac death, more research is needed to further tailor recommendations to allow beneficial exercise in those with rarer conditions that are under-represented in large systemic studies.
Application of Multiparametric Quantitative Cardiac Magnetic Resonance for Detection and Monitoring of Myocardial Injury in Patients with Fulminant Myocarditis
2021, Academic Radiology
Citation Excerpt :
Active inflammatory edema is mainly observed in the acute stage and usually resolves quickly during the healing process of myocarditis. Accurate detection and monitoring of the inflammatory myocardial alterations is essential for clinical decision-making (9,10). Endomyocardial biopsy (EMB) can directly assess myocarditis injury, but was rarely performed due to its invasive nature and possible sampling errors (11).
To investigate whether multiparametric cardiac magnetic resonance (CMR) could detect and monitor inflammatory myocardial alterations in fulminant myocarditis.
Nineteen patients (35 ± 14 years, 37% male) with clinical diagnosis of fulminant myocarditis underwent CMR examinations at 3.0T in the acute phase and at 3-months follow up. The control group consisted of 19 healthy volunteers. The CMR protocol included cine, black blood T2-weighted imaging, T1 mapping, T2 mapping and late gadolinium enhancement (LGE). Cardiac parameters, such as edema ratio, LGE mass, native T1, T2 and extracellular volume were measured.
The left ventricular mass index (67 ± 15 versus 55 ± 12 g/m², p < 0.05) and interventricular septum thickness (10.4 ± 1.5 versus 8.3 ± 1.8 mm, p < 0.001) in acute stage was significantly higher compared to controls, and normalized at the chronic stage. All quantitative inflammation metrics, including edema ratio, LGE mass, native T1, T2 and extracellular volume were significantly (all p < 0.001) decreased in the follow-up scan, but still higher compared to controls. Compared to the controls, all global strain indices including circumferential, longitudinal and radial strain values were significantly impaired in acute stage (all p < 0.001). Native T1 and T2 values led to excellent diagnostic accuracy for discriminating fulminant myocarditis from healed myocarditis, with AUC of 0.947 and 0.931.
Multiparametric CMR could detect and monitor inflammation myocardial injuries in patients with fulminant myocarditis. Native T1 and T2 values achieved excellent diagnostic performance in distinguishing acute from healed myocarditis.
Should we fear infarct-like myocarditis?
2018, Cor et Vasa
Citation Excerpt :
According to the European Society of Cardiology (ESC) recommendations, published in their Position Statement [5], prohibition of physical activity is recommended. However the recommendation is based on the work of Basso et al. [16] and Pelliccia et al. [17], who were making recommendations for athletes. Athletes were allowed to continue sports activity 6 months after disease appearance, depending on follow-up examination results.
Infarct-like myocarditis is the common presentation of acute myocarditis with a good prognosis, mentioned in the literature. The restriction of physical activity for up to 6 months is usually recommended. The aim of our study was to show the characteristic features and specificity of this particular presentation of myocarditis and to evaluate its prognosis, relative to physical activity, after hospital discharge.
From 2012 to 2016, 93 patients were hospitalized with acute myocarditis at the University Hospital of Pilsen, 73 (78%) of them had infarct-like myocarditis and were evaluated by basic diagnostic parameters.
Thirty-two patients with infarct-like myocarditis were involved in our prospective observational study where echocardiography (ECHO), magnetic resonance imaging (MRI) including late gadolinium enhancement (LGE) volume, bicycle ergometry (BE) as well as troponin screening tests were regularly performed. None of the patients were professional athletes.
One month after hospital discharge, all patients underwent bicycle ergometry without any load limitation. After the 1-month follow-up, patients were allowed to increase physical exertion gradually to included job performance.
Initially, mild left ventricular systolic dysfunction was found in 43.8%, that was normalized before the first outpatient follow-up. Other patients had normal systolic function. Initially, all of the patients had significantly elevated troponin level. After 1 and 6 months, hypersensitive troponin values were under the 99th percentile of the healthy population. All of the patients had positive LGE in subepicardial localization. After 1 month, the LGE volume median had decreased by up to 53% and after 6 months it had decreased by up to 40% of the original value. The achieved exertion during BE, at the 6-month follow-up (9.7 ± 2.2 METs) was statistically significantly better than after the 1-month follow-up (8.9 ± 2.1 METs, p = 0.0023). On the last BE follow-ups (9.3 ± 2.1 METs), no significant change was seen (p = 0.2331). The average follow-up time was 2 years.
Infarct-like myocarditis was the most common presentation of acute myocarditis during the observation time. No patient had an early recurrence of the disease (i.e., within 1 year) and no left ventricular (LV) systolic dysfunction was developed. Infarct-like myocarditis has a specific feature that differs from other types of myocarditis. It has good prognosis, which is independent of physical exertion starting 1 month after hospital discharge.
Approximation of the Incidence of Myocarditis by Systematic Screening With Cardiac Magnetic Resonance Imaging
2018, JACC: Heart Failure
Citation Excerpt :
Up to this point, numerous studies evaluated the incidence of myocarditis based on CMR data. However, due to discrepancy in the results and a lack of a shared standardized diagnostic approach the true incidence of myocarditis has remained uncertain (5,8,9,11,14–16). In that regard Pitts et al. (1) and Karjalainen and Heikkilä (9) showed that clinically diagnosed myocarditis in young men was present in 99 patients of 672,672 Finnish military conscripts over a period of 20 years with an incidence rate of 0.17 per 1,000 man-years.
This study sought to obtain an approximation of the true incidence of myocarditis by systematic screening of patients at risk using cardiac magnetic resonance imaging (CMR) in a tertiary care center.
Underdiagnosis of myocarditis and resulting uncertainty about its incidence remain a clinical dilemma. The authors hypothesized that systematic screening of patients presenting with angina-like symptoms, elevated troponin T, and no significant coronary artery disease using CMR will provide an approximation of the true incidence of myocarditis.
The authors performed a retrospective chart review of patients presenting with angina-like symptoms and elevated high-sensitivity troponin T (TnT-hs ≥14 ng/l) in 2015 and 2016. During the year 2015, only patients with elevated TnT-hs, no significant coronary artery disease, and moderate-to-high clinical likelihood of myocarditis underwent CMR. Starting in 2016, CMR was obtained in patients with similar presentation, but independent of clinical likelihood of myocarditis.
A total of 1,788 patients (74% male, age 69 ± 14 years) qualified for our analysis. In 2015, 521 patients presented with angina-like symptoms and TnT-hs elevation. In 2016, the number increased to 1,267 patients. Although in the year 2015, a total of 4 of 88 (5%) CMRs were positive for myocarditis, the percentage of positive CMRs doubled (26 of 199; 13%; p = 0.03) in 2016.
A novel diagnostic screening algorithm led to a 6.3-fold increase of the incidence of myocarditis in our hospital. Furthermore, the percentage of CMRs positive for myocarditis doubled, supporting the diagnostic value of this method. Considering the potentially lethal adverse events of myocarditis if left untreated, we recommend a low threshold for the use of CMR in patients with angina-like symptoms and elevated TnT-hs after exclusion of coronary artery disease.
Sudden Cardiac Death in Athletes
2018, JACC: Heart Failure
Citation Excerpt :
Primary, inherited electrical cardiac abnormalities were implicated in ≤5% of confirmed SCD events in the U.S. Registry (8) and <4% in NCAA athletes (6,7), and 0% were identified in studies from the United Kingdom (36) and Australia and New Zealand (37). Acquired abnormalities such as commotio cordis, which is increasingly reported in the United States and worldwide (38,39); myocarditis, which may have multiple causes (40); and environmental factors and performance-enhancing drugs have been linked with SCD in athletes (41,42). Anomalous coronary artery origins, particularly a coronary artery originating from the wrong aortic sinus, is a frequent cause of SCD, ranging from 7% to 17% of athlete cases (8,36,43).
Sudden cardiac death is a tragedy at any age and under any circumstances but is perhaps most tragic when it claims the life of the athlete, the individual who epitomizes health and a healthy lifestyle. Sports cardiologists from around the world have worked to quantitate the incidence of sudden cardiac death (SCD) in the athlete, to identify risk factors, to develop pre-participation screening tools, and to formulate plans to deal with on-field SCD. Progress has been made, but much remains to be done in order to make both competitive and recreational sports safer for both patients with known cardiac disease and athletes without known or suspected cardiac abnormalities.
Organ-Specific Autoimmune Myocardial Diseases: From Pathogenesis to Diagnosis and Management
2017, The Heart in Rheumatic, Autoimmune and Inflammatory Diseases: Pathophysiology, Clinical Aspects and Therapeutic Approaches
Autoimmune disease must fulfill at least two of the major criteria proposed by Witebsky and later modified by Rose. Organ-specific autoimmune diseases develop as a result of both genetic predisposition and environmental factors. The inheritance of susceptibility is usually polygenic, mediated by human leukocyte antigens (HLA) and non-HLA genes. Autoimmune disease is characterized by the presence of circulating autoantibodies, which are not always pathogenic but represent markers of ongoing tissue damage. In nonorgan-specific autoimmune disease the autoantibodies are against ubiquitous autoantigens and tissue damage is generalized. In organ-specific autoimmune disease, immunopathology is restricted to one organ or apparatus within the body, and the autoimmune process, antibody- and/or cell-mediated, is directed against autoantigens that are unique to the affected organ. Organ- and disease-specific antibodies are found in the affected patients and in asymptomatic family members at risk of disease development. Involvement of organ-specific autoimmunity has been suspected in several heart diseases, but currently the Rose–Witebski criteria for organ-specific autoimmunity are entirely fulfilled in infection-negative biopsy-proven myocarditis and in inflammatory cardiomyopathy (eg, defined as myocarditis with myocardial dysfunction) that are covered in this chapter from diagnosis to management.

View all citing articles on Scopus

: This work was supported by the Veneto Region, Venice, Italy; Cariparo Foundation, Pedove, Italy; Ministry of Health, Rome, Italy.

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Myocarditis and Dilated Cardiomyopathy in Athletes: Diagnosis, Management, and Recommendations for Sport Activity

Section snippets

Dilated cardiomyopathy

Myocarditis and dilated cardiomyopathy as causes of sudden death in young athletes

Recommendations for sport activity in athletes affected by myocarditis and dilated cardiomyopathy

J Am Coll Cardiol

J Am Coll Cardiol

Lancet

Am Heart J

Lancet

Lancet

Myocarditis: a histopathologic definition and classification

Am J Cardiovasc Pathol

Report of the 1995 World Health Organization/International Society and Federation of Cardiology Task Force on the Definition and Classification of Cardiomyopathies

Circulation

Myocarditis and inflammatory cardiomyopathy: microbiological and molecular biological aspects

Cardiovasc Res

Electrocardiography of myocarditis revisited: clinical and prognostic significance of electrocardiographic changes

Am Heart J

Echocardiographic findings in myocarditis

Am J Cardiol

Images in cardiovascular medicine: diagnosis of myocarditis by cardiac tissue velocity imaging in an Olympic athlete

Circulation

Acute myocarditis rapid diagnosis by PCR in children

Circulation

A prospective study of biopsy-proven myocarditis: prognostic relevance of clinical and aetiopathogenetic features at diagnosis

Eur Heart J

Circulation

The spectrum of left ventricular size in dilated cardiomyopathy: clinical correlates and prognostic implications

Am Heart J