Highlights
- •The diagnosis of myocarditis is challenging at Emergency Department.
- •D.A.M.E. score may provide fast identification of patients with myocarditis.
- •DAME score is composed by fever, chest pain, ESR, hs-CRP, troponin, and LVEF.
- •A score>7 showed higher sensibility, specificity and NPV in myocarditis diagnosis.
Abstract
Purpose
. The final diagnosis of myocarditis is challenging. The aim of our study was to provide
the D.A.M.E. (Diagnosis of Acute Myocarditis in Emergency) Score for the fast identification of patients suffering from myocarditis
at Emergency Department (ED).
Methods
. This was a multicenter, retrospective study involving three centers. All medical
records from January 2010 to December 2014 reporting a final discharge diagnosis of
myocarditis were considered. One hundred-four patients (mean age: 40.2±16.5 years)
were enrolled. Clinical, biochemical and instrumental data were gathered. Data were
analysed by means of logistic regression model and factorial analysis. A validation
cohort from a fourth center was enrolled.
Results
. The final determinants of the DAME score were six: fever, chest pain, erythrocyte
sedimentation rate (ESR) > 20 mm/h, C-reactive protein (hs-CRP) >3 mg/L, troponin
serum levels >3 ng/L, and left ventricle ejection fraction < 50%. All of them received
a specified score ranging from 0 to 4. A score > 4 was related to 75% probability
of myocarditis; a final score ranging between 1 and 4 was related to 57% probability
of myocarditis. ROC curve on the validation cohort (289 patients, 27 with myocarditis)
demonstrated the best cut-off to be 7: AUC 0.958 (p< 0.001), sensibility: 100%, specificity:
85.11%, PPV: 40.9%, NPV: 100% (LR+: 6.72; LR-: 0.00). Logistic regression analysis
revealed Odds Ratio equal to 2.83 (95% CI 1.90 – 4.20, p < 0.0001).
Conclusions
. DAME score can offer a reliable tool in ED setting for the evaluation of patients
suffering from suspected myocarditis.
Keywords
Abbreviations:
AUC (area under the curve), BNP (brain natriuretic peptide), CMR (Cardiac magnetic resonance), ECG (electrocardiogram), ED (Emergency Department), ESR (erythrocyte sedimentation rate), hs-CRP (high sensitive C-reactive protein), hs-TnI (high sensitive Troponin I), LR (likelihood ratio), LVEF (left ventricle ejection fraction), NPV (negative predictive value), NT-proBNP (N-terminal prohormone of brain natriuretic peptide), NYHA (New York Heart Association), OR (odds ratio), PPV (positive predictive value), ROC (receiver-operating characteristic)To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to European Journal of Internal MedicineAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- 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: 2636-2648
- Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2013; 386 (2015): 743-800
- Incidence of fatal myocarditis: a population-based study in Finland.Am J Epidemiol. 2007; 165: 570-574
- Prevalence of myocarditis at autopsy in Turin, Italy.Arch Pathol Lab Med. 1997; 121: 619-622
- Survival and Left Ventricular Function Changes in Fulminant Versus Nonfulminant Acute Myocarditis.Circulation. 2017; 136: 529-545
- National survey of fulminant myocarditis in Japan: therapeutic guidelines and long-term prognosis of using percutaneous cardiopulmonary support for fulminant myocarditis (special report from a scientific committee).Circ J. 2002; 66: 133-144
- Myocarditis: emergency department recognition and management.Emerg Med Clin North Am. 2004; 22: 865-885
- The global burden of myocarditis: part 1: a systematic literature review for the Global Burden of Diseases, Injuries, and Risk Factors 2010 study.Glob Heart. 2014; 9: 121-129
- Chest pain in the emergency department: risk stratification with Manchester triage system and HEART score.BMC Cardiovasc Disord. 2015; 15: 48
- Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2015; 28: 1-39
- Recommendations for the Evaluation of Left Ventricular Diastolic Function by Echocardiography: An Update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.J Am Soc Echocardiogr. 2016; 29: 277-314
- Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group.JAMA. 1994; 271: 703-707
- Evaluation of postmortem endomyocardial biopsy specimens from 38 patients with lymphocytic myocarditis: implications for role of sampling error.Mayo Clin Proc. 1989; 64: 1235-1245
- Nationwide but still inhomogeneous distribution of certified chest pain units across Germany: Need to strengthen rural regions.Herz. 2018; 43: 78-86
- Investigations, findings, and follow-up in patients with chest pain and elevated high-sensitivity cardiac troponin T levels but no myocardial infarction.Int J Cardiol. 2017; 232: 111-116
- Predictors of outcome in patients with suspected myocarditis.Circulation. 2008; 118: 639-648
- Long-term evolution and prognostic stratification of biopsy-proven active myocarditis.Circulation. 2013; 128: 2384-2394
- Risk factors for patients developing a fulminant course with acute myocarditis.Circ J. 2004; 68: 734-739
- Predictors of Mortality in Paediatric Myocarditis.J Clin Diagn Res. 2016; 10 (SC12-6)
- Circulating cardiac troponins levels and cardiac dysfunction in children with acute and fulminant viral myocarditis.Acta Paediatr. 2010; 99: 1510-1516
- Acute myocardial infarction or acute myocarditis? Discharge registry-based study of likelihood and associated features in hospitalised patients.BMJ Open. 2015; 5e007555
- Serum cardiac troponin T and creatine kinase-MB elevations in murine autoimmune myocarditis.Circulation. 1995; 92: 1927-1932
- Cardiac troponin I but not cardiac troponin T induces severe autoimmune inflammation in the myocardium.Circulation. 2006; 114: 1693-1702
- C-reactive protein as a prognostic marker in lymphocytic myocarditis.Jpn Heart J. 2000; 41: 41-47
- Myocardial inflammation and non-ischaemic heart failure: is there a role for C-reactive protein?.Basic Res Cardiol. 2009; 104: 591-599
- Detection of cardiac troponin and high-sensitivity C reactive protein in children with viral myocarditis.Nan Fang Yi Ke Da Xue Xue Bao. 2008; 28: 1076-1077
- Fulminant Peripartum myocarditis associated with sudden cardiac death: a case report.Cardiovasc Pathol. 2016; 25: 87-89
- Clinicopathological correlates can predict acute myocarditis in patients with recent-onset heart failure: preliminary data.Ital Heart J. 2002; 3: 188-193
- Predictors of poor clinical outcomes in patients with acute myocardial infarction and non-obstructed coronary arteries (MINOCA).Int J Cardiol. 2018; 267: 41-45
- Guidelines for the Appropriate Use of Bedside General and Cardiac Ultrasonography in the Evaluation of Critically Ill Patients-Part II: Cardiac Ultrasonography.Crit Care Med. 2016; 44: 1206-1227
- Focused cardiac ultrasound in the emergent setting: a consensus statement of the American Society of Echocardiography and American College of Emergency Physicians.J Am Soc Echocardiogr. 2010; 23: 1225-1230
- Accuracy of handheld echocardiography for bedside diagnostic evaluation in a tertiary cardiology center: comparison with standard echocardiography.Echocardiography. 2011; 28: 136-141
Article info
Publication history
Published online: January 24, 2021
Accepted:
January 11,
2021
Received in revised form:
January 5,
2021
Received:
October 27,
2020
Identification
Copyright
© 2021 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
