Should We Stay or Should We Go? A Review of Current Management of Non-COVID-19 Acute Myocarditis in a Rural Setting and a Suggested Risk-Based Approach

Abstract

Acute myocarditis (AM) is uncommon but may be associated with significant acute deterioration, requiring emergency high-level tertiary level care. We therefore sought to examine the contemporary management of myocarditis presenting to a rural referral centre, comparing this to a recently proposed “risk-based approach” [[1]Ammirati E. Frigerio M. Adler E.D. Basso C. Birnie D.H. Brambatti M. et al.Management of acute myocarditis and chronic inflammatory cardiomyopathy: an expert consensus document.Circ Heart Fail. 2020; 13 (e007405)Crossref PubMed Scopus (103) Google Scholar], providing a framework based on risk of deterioration, to help select those requiring transfer for tertiary level care. We conducted a retrospective review of all presentations coded as myocarditis to a rural Australian centre, between May 2019 and June 2021. Twenty-four (24) patients were identified. Five of these were transferred for tertiary level care, all of whom had myocarditis confirmed on cardiac magnetic resonance imaging (CMRI). The estimated AM incidence was 43 per million. Factors associated with transfer were younger age (26 vs 49yrs, p=0.03) and higher troponin I rise (30,986 vs 6,124 ng/L, p=0.01). Reasons for transfer included cardiogenic shock, tachyarrhythmias, concern for potential deterioration, and diagnostic uncertainty. There was one mortality, unrelated to myocarditis. Applying the Ammirati risk-based criteria to transferred patients suggested 1 patient was high risk, 1 was medium risk and 3 were low risk but required CMRI for diagnostic clarity. A risk-based model, based on clinical findings, echocardiography, and cardiac monitoring, safely selects patients requiring tertiary care. However, without routine use of CMRI, there may be the tendency to transfer some patients subsequently found to be low risk, thereby over-utilising resources. Planned wider availability of CMRI in rural settings might be expected to ameliorate this difficulty.