ISSN: 1524-4539
Copyright © 2006 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online
Diagnosis of Myocarditis
Death of Dallas Criteria
Kenneth L. Baughman, MD
Determining the etiology of cardiac dysfunction ...
with eosinophil and myocyte damage demonstrated by endo-
myocardial biopsy.11–13 These patients respond to treatment
of th...
long-term survival in patients with initially unexplained cardiomyopathy.
N Engl J Med. 2000;342:1077–1084.
2. Dec GW Jr, ...
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Dallas criteria Circulation 2006


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Dallas criteria Circulation 2006

  1. 1. ISSN: 1524-4539 Copyright © 2006 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.105.589663 2006;113;593-595Circulation Kenneth L. Baughman Diagnosis of Myocarditis: Death of Dallas Criteria located on the World Wide Web at: The online version of this article, along with updated information and services, is Reprints: Information about reprints can be found online at 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters Subscriptions: Information about subscribing to Circulation is online at by on October 23, 2008circ.ahajournals.orgDownloaded from
  2. 2. Diagnosis of Myocarditis Death of Dallas Criteria Kenneth L. Baughman, MD Determining the etiology of cardiac dysfunction in pa- tients with heart failure influences management and prognosis.1 Myocarditis, diagnosed by the current histopatho- logical Dallas criteria, accounts for Ϸ10% of patients with new-onset cardiac dysfunction submitted to endomyocardial biopsy.1,2 Despite complete evaluation including history, physical examination, blood work, echocardiography, coro- nary angiography, and endomyocardial biopsy, Ϸ50% of patients with dilated cardiomyopathy have no etiology iden- tified.1 Recent data suggest that patients in the “idiopathic” category may be suffering from myocardial inflammation due to persistent viral replication or autoimmune activation after a viral infection. These studies raise the question of whether the current histopathological criteria for myocardial inflam- mation (the Dallas criteria) are sensitive enough to identify the population with viral or autoimmune-related heart compromise. The Dallas criteria were proposed in 1986 and provided a histopathological categorization by which the diagnosis of myocarditis could be established. Dallas criteria myocarditis requires an inflammatory infiltrate and associated myocyte necrosis or damage not characteristic of an ischemic event. Borderline myocarditis requires a less intense inflammatory infiltrate and no light microscopic evidence of myocyte destruction.3 These criteria have been used exclusively by American investigators over the last 2 decades. Sampling error, variation in expert interpretation, variance with other markers of viral infection and immune activation in the heart, and variance with treatment outcomes all suggest that the Dallas criteria are no longer adequate. Chow et al and Hauck et al4,5 demonstrated by biopsying postmortem hearts of patients who had died with myocarditis that, from a single endomyocardial biopsy, histological myo- carditis could be demonstrated in only 25% of samples. With Ͼ5 biopsies, Dallas criteria myocarditis could be diagnosed in approximately two thirds of subjects. A recent MRI study used focal imaging abnormalities to guide heart biopsy investigation of possible myocarditis. The authors showed that the earliest myocardial inflammatory abnormalities were evident in the lateral wall of the left ventricle, and only these sites revealed myocarditis by histological examination.6 Therefore, there is considerable sampling error associated with establishing the diagnosis of myocarditis. In addition, there are variations in the interpretation of histological samples. Of the 111 patients included in the Myocarditis Treatment Trial diagnosed with myocarditis by heart biopsy,7 only 64% had that diagnosis confirmed by the expert pathology panel who reviewed the histopathological material. In a separate analysis, 7 expert pathologists’ inter- pretations of histopathological findings from endomyocardial biopsies of 16 patients with dilated cardiomyopathy varied remarkably in the assessment of significant fibrosis (25% to 69%), hypertrophy (19% to 88%), nuclear changes (31% to 94%), lymphocyte count per high-power field (0% to 38%), and the diagnosis of myocarditis. Definite or probable myo- carditis was diagnosed in 11 of 16 patients by at least 1 pathologist. However, of the 11 patients, 3 of 7 pathologists agreed on the diagnosis of myocarditis in 3 patients, and 2 of 7 pathologists agreed on the diagnosis of myocarditis in 5 patients.8 Therefore, even expert observers do not agree on the interpretation of histopathological material that has un- dergone routine staining. Myocarditis may be associated with a number of condi- tions including HIV/AIDS, ischemia, and inflammatory states such as sarcoidosis and immune disease such as lupus erythematosus. Excluding causes of myocardial inflammation of known etiology allows investigators to address the larger and more important category of patients with “primary” (or postviral) myocarditis. Primary viral myocarditis includes several forms of myocarditis that are defined by their clinical pathological manifestations. These include fulminant, chronic active, eosinophilic, and giant cell myocarditis. Fulminant myocarditis has a distinct onset usually within 2 weeks of presentation. Patients present with profound left ventricular dysfunction but usually not left ventricular dilatation. The endomyocardial biopsy shows multiple foci of active inflam- mation and necrosis. Patients recover or die within 2 weeks with complete histological and functional recovery of the myocardium in survivors.9 Chronic active myocarditis has an indistinct onset with moderate ventricular dysfunction on presentation and active or borderline myocarditis by biopsy. These patients display ongoing inflammation and fibrosis resulting in the development of a restrictive cardiomyopathy usually 2 to 4 years after presentation.10 Eosinophilic myo- carditis may be attributed to eosinophilic syndromes or allergic reactions resulting in left ventricular compromise, From the Advanced Heart Disease Section, Division of Cardiovascular Medicine, Harvard Medical School, Boston, Mass. Correspondence to Kenneth Lee Baughman, MD, Brigham and Women’s Hospital, Cardiovascular Division, 75 Francis St, Boston, MA 02115. E-mail (Circulation. 2006;113:593-595.) © 2006 American Heart Association, Inc. Circulation is available at DOI: 10.1161/CIRCULATIONAHA.105.589663 593 Special Report by on October 23, 2008circ.ahajournals.orgDownloaded from
  3. 3. with eosinophil and myocyte damage demonstrated by endo- myocardial biopsy.11–13 These patients respond to treatment of the eosinophilic disorder and/or withdrawal of the offend- ing agent. Patients with giant cell myocarditis present with congestive heart failure, ventricular arrhythmias, or heart block. Despite institution of medical therapy, patients with giant cell myocarditis continue to have poorly controlled congestive heart failure or ventricular arrhythmias. Untreated, patients will die in Ͻ6 months. Patients have a characteristic endomyocardial biopsy with giant cells and active inflamma- tion that may respond to aggressive immunosuppressive therapy.14,15 Therefore, several forms of myocarditis are characterized by their clinical pathological manifestations. The largest population of patients presenting with subacute myocardial deterioration is indistinct from patients presenting with idiopathic cardiomyopathy. A number of investigators have shown that virus may be present in the myocardium without Dallas criteria myocardi- tis. Martin et al16 demonstrated in 34 children with clinical presentations compatible with myocarditis that 26 heart biopsy samples were positive for viral pathogens, and 13 of the 26 positive samples had no evidence of myocarditis by histopathological examination. Other investigators have con- firmed the presence of viral pathogens in samples of cardiac tissue from patients with cardiomyopathy and myocarditis. Pauschinger et al17 found 24 of 94 patients with idiopathic dilated cardiomyopathy to have either adenoviral or entero- viral polymerase chain reaction positivity. A meta-analysis of polymerase chain reaction studies in patients who had heart biopsies with presumed myocarditis or cardiomyopathy dem- onstrated an odds ratio of 3.8 for viral presence in both categories compared with control patients.18 In a selected sample of 45 patients with left ventricular dysfunction and suspected myocarditis and 26 controls, nonreplicative entero- virus was demonstrated in 18 of 45 patients (40%) compared with none of the controls. Of the 18 patients with nonrepli- cative virus, 10 (56%)19 were found to have active viral replication as well (strand negative). Why et al20 discovered in 120 patients with idiopathic dilated cardiomyopathy that the 34% who were enteroviral positive had a significantly worse outcome over 2 years (Pϭ0.02) compared with those who were enteroviral negative. Therefore, virus can exist in the myocardium (even in a replicative form) in the absence of myocardial inflammation adequate to meet Dallas criteria and may adversely affect outcome. There is also dissociation between Dallas criteria myocar- ditis and response to immune modulation therapy. In the Myocarditis Treatment Trial, there was no difference in the 1- or 5-year survival or 28-week ejection fraction in patients with Dallas criteria myocarditis treated with immunosuppres- sive therapy or placebo.7 Other authors have used alternative criteria to diagnose immune-related heart disease. Wojnicz et al21 found 84 of 202 patients with new-onset cardiomyopathy to be HLA positive, while only 27% were positive by Dallas criteria for myocarditis. HLA has previously been shown to be upregulated in patients with myocarditis and is less “focal” than lymphocytic infiltration. HLA-identified patients were treated with immunosuppressive therapy or placebo. Al- though there was no difference in primary outcome (death, transplant, or hospitalization), the ejection fraction in the immunosuppressive group increased from 24% to 36%, whereas it remained stagnant in the placebo group (25% to 27%). Even in patients demonstrating Dallas criteria myocar- ditis, response to treatment may be influenced by the presence of virus or immunological response to infection. Frustaci et al22 identified Dallas criteria myocarditis in 112 of 652 patients with new-onset heart failure. Forty-one of the 112 had progressive congestive heart failure despite standard medical therapy. These patients were treated with prednisone and azathioprine for 6 months. Twenty responded, and 21 failed to respond. Those responding increased their ejection fraction from 23% to 47%, whereas the ejection fraction of the nonresponders remained stable. Those who responded had evidence of antiheart antibodies (90%) verses nonresponders (0%). Those who failed to respond displayed viral persistence in heart tissue (84% of patients), whereas only 13% of responders had viral persistence. Therefore, the presence of Dallas criteria myocarditis does not identify patients who respond to immune modulation therapy. Evidence of viral persistence may imply a worse prognosis and identify pa- tients who fail to respond to immunosuppressive therapy. Alternatively, patients with immune activation, demonstrated by HLA upregulation or antiheart antibodies, may respond to immunosuppressive therapy despite absence of Dallas criteria myocarditis. Defining the etiology of the 50% of patients currently labeled as idiopathic with new-onset heart failure is critical to determining their outcome and treatment options. We must now redefine the diagnosis of viral and postviral immune- related heart dysfunction. This classification should include clinicopathological entities such as fulminant, chronic persis- tent, eosinophilic, and giant cell myocarditis that are easily recognized by their clinical course and/or histology on heart biopsy. Those without distinct clinical pathological manifes- tations encompass a much broader category and will include patients with viral persistence and immune upregulation. With this approach, we may identify clinical pathological correlates and natural history of disease specific for a given virus. McNamara et al23 and Mason et al7 demonstrated that some patients with new-onset left ventricular compromise display significant recovery of ventricular function with or without histological evidence of myocardial inflammation by the Dallas criteria. The ability to modify the outcome of those who fail to improve spontaneously or to enhance the recovery of those who increase their ejection fraction may significantly alter the prognosis of this population and lessen the burden of chronic disabling heart failure that they otherwise will face. The time has come to redefine viral and autoimmune heart disease with the use of methodologies available in the 21st century. Clinicians, pathologists, immunologists, and molec- ular cardiologists must contribute to the new criteria, which should include clinical presentation, histopathology, immu- nohistochemistry, viral polymerase chain reaction, cardiac antibody assessment, and imaging results. References 1. Felker GM, Thompson RE, Hare JM, Hruban RH, Clemetson DE, Howard DL, Baughman KL, Kasper EK. Underlying causes and 594 Circulation January 31, 2006 by on October 23, 2008circ.ahajournals.orgDownloaded from
  4. 4. long-term survival in patients with initially unexplained cardiomyopathy. N Engl J Med. 2000;342:1077–1084. 2. Dec GW Jr, Palacios IF, Fallon JT, Aretz HT, Mills J, Lee DC, Johnson RA. Active myocarditis in the spectrum of acute dilated cardiomyopa- thies: clinical features, histologic correlates, and clinical outcome. N Engl J Med. 1985;312:885–890. 3. Aretz HT, Billingham ME, Edwards WD, Factor SM, Fallon JT, Fenoglio JJ Jr, Olsen EG, Schoen FJ. Myocarditis: a histopathologic definition and classification. Am J Cardiovasc Pathol. 1987;1:3–14. 4. Chow LH, Radio SJ, Sears TD, McManus BM. Insensitivity of right ventricular endomyocardial biopsy in the diagnosis of myocarditis. J Am Coll Cardiol. 1989;14:915–920. 5. Hauck AJ, Kearney DL, Edwards WD. Evaluation of postmortem endo- myocardial biopsy specimens from 38 patients with lymphocytic myo- carditis: implications for role of sampling error. Mayo Clin Proc. 1989; 64:1235–1245. 6. Mahrholdt H, Goedecke C, Wagner A, Meinhardt G, Athanasiadis A, Vogelsberg H, Fritz P, Klingel K, Kandolf R, Sechtem U. Cardiovascular magnetic resonance assessment of human myocarditis: a comparison to histology and molecular pathology. Circulation. 2004;109:1250–1258. 7. Mason JW, O’Connell JB, Herskowitz A, Rose NR, McManus BM, Billingham ME, Moon TE, for the Myocarditis Treatment Trial Investi- gators. A clinical trial of immunosuppressive therapy for myocarditis. N Engl J Med. 1995;333:269–275. 8. Shanes JG, Ghali J, Billingham ME, Ferrans VJ, Fenoglio JJ, Edwards WD, Tsai CC, Saffitz JE, Isner J, Furner S, Subramanian R. Interobserver variability in the pathologic interpretation of endomyocardial biopsy results. Circulation. 1987;75:401–405. 9. McCarthy RE III, Boehmer JP, Hruban RH, Hutchins GM, Kasper EK, Hare JM, Baughman KL. Long-term outcome of fulminant myocarditis as compared with acute (nonfulminant) myocarditis. N Engl J Med. 2000; 342:690–695. 10. Lieberman EB, Hutchins GM, Herskowitz A, Rose NR, Baughman KL. Clinicopathologic description of myocarditis. J Am Coll Cardiol. 1991; 18:1617–1626. 11. Burke AP, Saenger J, Mullick F, Virmani R. Hypersensitivity myo- carditis. Arch Pathol Lab Med. 1991;115:764–769. 12. Getz MA, Subramanian R, Logemann T, Ballantyne F. Acute necrotizing eosinophilic myocarditis as a manifestation of severe hypersensitivity myocarditis: antemortem diagnosis and successful treatment. Ann Intern Med. 1991;115:201–202. 13. Galiuto L, Enriquez-Sarano M, Reeder GS, Tazelaar HD, Li JT, Miller FA Jr, Gleich GJ. Eosinophilic myocarditis manifesting as myocardial infarction: early diagnosis and successful treatment. Mayo Clin Proc. 1997;72:603–610. 14. Cooper LT Jr, Berry GJ, Shabetai R, for the Multicenter Giant Cell Myocarditis Study Group Investigators. Idiopathic giant-cell myocarditis- –natural history and treatment. N Engl J Med. 1997;336:1860–1866. 15. Menghini VV, Savcenko V, Olson LJ, Tazelaar HD, Dec GW, Kao A, Cooper LT Jr. Combined immunosuppression for the treatment of idio- pathic giant cell myocarditis. Mayo Clin Proc. 1999;74:1221–1226. 16. Martin AB, Webber S, Fricker FJ, Jaffe R, Demmler G, Kearney D, Zhang YH, Bodurtha J, Gelb B, Ni J, Bricker JT, Towbin JA. Acute myocarditis: rapid diagnosis by PCR in children. Circulation. 1994;90: 330–339. 17. Pauschinger M, Bowles NE, Fuentes-Garcia FJ, Pham V, Kuhl U, Schwimmbeck PL, Schultheiss HP, Towbin JA. Detection of adenoviral genome in the myocardium of adult patients with idiopathic left ventric- ular dysfunction. Circulation. 1999;99:1348–1354. 18. Baboonian C, Treasure T. Meta-analysis of the association of entero- viruses with human heart disease. Heart. 1997;78:539–543. 19. Pauschinger M, Doerner A, Kuehl U, Schwimmbeck PL, Poller W, Kandolf R, Schultheiss HP. Enteroviral RNA replication in the myocar- dium of patients with left ventricular dysfunction and clinically suspected myocarditis. Circulation. 1999;99:889–895. 20. Why HJ, Meany BT, Richardson PJ, Olsen EG, Bowles NE, Cunningham L, Freeke CA, Archard LC. Clinical and prognostic significance of detection of enteroviral RNA in the myocardium of patients with myo- carditis or dilated cardiomyopathy. Circulation. 1994;89:2582–2589. 21. Wojnicz R, Nowalany-Kozielska E, Wojciechowska C, Glanowska G, Wilczewski P, Niklewski T, Zembala M, Polonski L, Rozek MM, Wod- niecki J. Randomized, placebo-controlled study for immunosuppressive treatment of inflammatory dilated cardiomyopathy: two-year follow-up results. Circulation. 2001;104:39–45. 22. Frustaci A, Chimenti C, Calabrese F, Pieroni M, Thiene G, Maseri A. Immunosuppressive therapy for active lymphocytic myocarditis: viro- logical and immunologic profile of responders versus nonresponders. Circulation. 2003;107:857–863. 23. McNamara DM, Holubkov R, Starling RC, Dec GW, Loh E, Torre- Amione G, Gass A, Janosko K, Tokarczyk T, Kessler P, Mann DL, Feldman AM. Controlled trial of intravenous immune globulin in recent-onset dilated cardiomyopathy. Circulation. 2001;103:2254–2259. KEY WORDS: cardiomyopathy Ⅲ heart failure Ⅲ myocarditis Ⅲ pathology Ⅲ biopsy Baughman Myocarditis Diagnosis 595 by on October 23, 2008circ.ahajournals.orgDownloaded from