Myocarditis: The Mysterious Affliction of Young Men

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Rand 20,000 Germans contract heart muscle inflammation (myocarditis) every year – many without noticing it. Everyday symptoms such as tiredness, shortness of breath during exertion or heart palpitations also occur with many other diseases. They are therefore often overlooked as myocarditis warning signs. In addition, they are often so mild that those affected never see a doctor. At least that was the case until now. For a few months, however, the heart condition has suddenly been in the public eye. Not just because it’s caused in part by the coronavirus itself. As a very rare but potentially dangerous side effect, it also brings mRNA vaccines into disrepute.

But this challenge also represents an unexpected opportunity for medical progress. “Covid has given research into myocarditis a boost,” says Carsten Tschöpe, professor of cardiology at the Berlin Charité. It is also urgently needed. Because there is probably no other heart disease that poses so many puzzles for him and his colleagues.

So far, for example, they have not understood why the condition is only really dangerous for a minority of patients. And who belongs to these threatened persons. In addition, the diagnosis is very complex, which also contributes to the fact that many patients are overlooked. As a result, medicine does not even know exactly how large the annual number of victims is. That could now change thanks to the pandemic, one hopes. There are mainly five areas of progress.

1. New triggers found

Medicine has known since the 1950s that viruses can attack the heart. Michael Böhm from the German Society of Cardiology assumes that up to ten percent of all viral infections involve at least a mild inflammation of the heart muscle. Flu and cold pathogens are also capable of this. The same applies to lifelong viruses such as the Epstein-Barr pathogen. Bacteria and fungi can also be dangerous to the heart muscle.

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What is new, however, is the realization that medication can also trigger heart muscle inflammation. These are, for example, among the potential side effects of so-called immune checkpoint inhibitors. These cancer drugs release the brakes on the immune system, which can lead to autoimmune reactions against heart cells, among other things. “The image of the virus-associated disease, which was widespread in the 1990s and 2000s, has corrected itself,” says cardiologist Dirk Westermann from the University Hospital Hamburg-Eppendorf.

2. Not all myocarditis is the same

Whether the disease is severe or mild also depends on who or what triggered it. The past few months have made that clear. “Myocarditis after a Covid vaccination almost always has a good prognosis and heals without consequences,” says the cardiologist Tschöpe. The opposite threatens if a real virus infects the heart muscle. According to studies from Israel and Great Britain, infection with corona leads to additional hospital stays due to heart muscle inflammation four to seven times more often than vaccination.

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Age also influences the symptoms. “In children, the picture of myocarditis differs from that in adults,” explains assistant doctor Franziska Seidel from the German Heart Center Berlin. Together with Daniel Messroghli from the German Heart Center Berlin and Stephan Schubert from the Heart and Diabetes Center NRW, she oversees the world’s largest prospective register for children and adolescents with suspected myocarditis.

“While sick adolescents usually have a good heart function, small children with myocarditis are often seriously ill.” In many cases, the weakened muscle has to be temporarily relieved by a small pump. Some even need a heart transplant.

3. New role for the immune system

Cold viruses invade the heart muscle cells themselves to destroy them. However, this is not the main reason for the damage with all pathogens. A chronic infection with the Epstein-Barr virus can so confuse the immune system that it attacks the heart itself. Almost every German is infected with the pathogen in the course of his life.

Coronaviruses appear to trigger similar autoimmune responses. Severe Covid courses are often accompanied by a so-called cytokine storm. Case reports and tissue samples show that such an overdose of immune messengers can lead to organ failure. But the pathogen also directly infects the cells that are responsible for the pump function.

According to a survey, every ten thousandth Covid 19 patient experiences myocarditis symptoms. It is now known that different inflammatory cells are involved in different viral infections, says the Berlin cardiologist Tschöpe. “With this knowledge, we expect a boost in new diagnostic and therapy options in the coming years.”

Source: Infographic WORLD

So far, doctors have only been able to specifically combat the infection of the heart muscle in a few cases. There are antibiotics for bacteria. However, viruses can only be slowed down to a very limited extent with appropriate medication. Drugs such as cortisone should then at least dampen the excessive immune response in severe cases.

Essentially, therefore, the treatment of myocarditis still consists of protecting the heart. Give him rest until the inflammation has subsided. Doctors still recommend that athletes take a half-year break before they start training again. And a follow-up. “So far we have not achieved a breakthrough in therapy,” says Dirk Westermann.

4. Alternatives to biopsy

However, initial progress is being made in the diagnosis. It is difficult because the most common acute symptoms such as shortness of breath, chest pain and arrhythmia can also result from other heart conditions. They also vary depending on which part of the muscle is affected. In addition: In many cases, the inflammation develops slowly and is initially only noticeable through fever or digestive problems. So by symptoms that do not indicate heart disease.

If there is a suspicion of myocarditis, a tissue sample from the heart is the most reliable proof. Doctors usually perform the biopsy through a catheter. Because of the associated risks, however, samples are only taken from less than one in ten suspected patients.

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Doctors therefore only diagnose the majority of those affected with the help of an ECG and ultrasound, provided they also have the corresponding symptoms. If patients even have to go to the hospital because of their symptoms, a special magnetic resonance imaging, a cardiac MRI, is sometimes added. A contrast medium that accumulates in the area of ​​inflammation then shows the doctors where the heart is affected. So far, however, the devices are only available in specialized clinics.

Franziska Seidel’s team is working on an evaluation scheme that allows a reliable diagnosis in children based on various blood values ​​and imaging findings. “This is one of our goals. So far, however, the biopsy from the heart muscle has been the gold standard,” she says.

However, the dream remains the diagnosis by blood test. Here, too, there are new approaches. Last summer, for example, Spanish researchers showed that blood samples can be used to distinguish patients with acute myocarditis from those who have had a heart attack. The researchers had tracked down tiny snippets of genetic material that produce immune cells that are particularly active in heart muscle inflammation.

5. Immune markers for early detection

Immune markers could actually play a role in diagnostics in the future, confirms cardiologist Tschöpe: “But there will probably not be just one marker, but a whole bunch of them.” The problem: Depending on the trigger, different immune cells are activated in the disease.

A test that helps to predict the course of the disease is also desired. Most myocarditis heals and the organ becomes fully functional again. The arrhythmias also disappear. However, some leave scars that permanently impair the muscle’s conductivity and pumping ability.

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“How do we recognize those 10 to 15 percent of patients in whom the disease does not heal well?” Tschöpe asks. Because they are at risk of developing cardiac insufficiency. In the meantime, it has become clear that the greatest danger is not the infection itself, but the sometimes excessive immune response. “For a prognosis, we therefore need markers that provide information about the balance of the immune reaction.”

The most important gain, however, is the increased public attention. Because it’s always dangerous if you don’t give your heart enough time to heal. Myocarditis scars are the cause of one in ten sudden cardiac deaths in people under the age of 35.

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Background: A young man’s affliction

Many heart muscle inflammations are overlooked because the condition is often mild. In addition, the Diagnosis very difficult. That’s why nobody knew exactly how many people develop myocarditis in the first place. The American medical journal “JAMA” recently provided one of the best estimates. It shows that young men between the ages of 16 and 29 are particularly at risk. In all other age groups and in women, the disease occurs much less frequently. In the study, the researchers calculated the risk of this occurring in the first week after a Covid vaccination develop myocarditis that is not caused by the vaccine itself.

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In order to display embedded content, your revocable consent to the transmission and processing of personal data is required, since the providers of the embedded content as third-party providers require this consent [In diesem Zusammenhang können auch Nutzungsprofile (u.a. auf Basis von Cookie-IDs) gebildet und angereichert werden, auch außerhalb des EWR]. By setting the switch to “on”, you agree to this (which can be revoked at any time). This also includes your consent to the transfer of certain personal data to third countries, including the USA, in accordance with Art. 49 (1) (a) GDPR. You can find more information about this. You can withdraw your consent at any time via the switch and via privacy at the bottom of the page.

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