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Pediatric Acute Myocarditis: Predicting Hemodynamic Compromise at Presentation to Health Care
Ashley E Wolf1, Bradley S Marino2,3, Ahmad Sami Chaouki4
1Division of Critical Care Medicine, Seattle Children's Hospital, Seattle, Washington ashley.wolf@seattlechildrens.org.
Insights
Predicting hemodynamic compromise in pediatric acute myocarditis is possible using initial presentation factors. Early identification aids in timely intervention and patient disposition for critical care.
Area of Science:
- Pediatric Cardiology
- Critical Care Medicine
- Cardiovascular Research
Background:
- Pediatric acute myocarditis presents with a wide clinical spectrum, from mild symptoms to life-threatening cardiovascular collapse.
- Identifying early indicators of hemodynamic compromise is crucial for timely management.
Purpose of the Study:
- To identify factors present at initial presentation that predict subsequent hemodynamic compromise in children with acute myocarditis.
- To develop predictive models for patient stratification.
Main Methods:
- Retrospective cohort study of 74 pediatric patients diagnosed with acute myocarditis (2007-2016).
- Patients were categorized into high-acuity (requiring advanced support or resulting in death) and low-acuity groups.
- Multivariable logistic regression models were used to identify predictive factors from initial clinical, laboratory, and imaging data.
Main Results:
- Significant differences in demographics, symptoms, and initial findings were observed between high- and low-acuity cohorts.
- A model including tachycardia, tachypnea, creatinine, and cardiomegaly predicted high acuity (AUC=0.913).
- Adding pericardial effusion to the model further improved prediction (AUC=0.964).
Conclusions:
- Initial presentation factors effectively predict subsequent hemodynamic compromise in pediatric acute myocarditis.
- Validated predictive models could guide patient disposition to specialized centers for advanced cardiac support and transplant evaluation.
Background:
The clinical spectrum of pediatric acute myocarditis ranges from minimal symptoms with intact hemodynamics to rapid cardiovascular collapse and death. We sought to identify factors on initial presentation associated with subsequent hemodynamic compromise.
Methods:
We performed a retrospective cohort study of patients with acute myocarditis at a freestanding pediatric hospital from 2007 to 2016. We defined 2 cohorts: high-acuity patients with hemodynamic compromise defined as requiring inotropic or vasoactive medications, cardiopulmonary resuscitation, extracorporeal membrane oxygenation, ventricular assist devices, or transplant or who died and low-acuity patients without these interventions. We collected the first recorded set of vital signs, symptoms, laboratory values, and chest radiograph, electrocardiogram, and echocardiography results. Univariate analysis was performed, and 2 multivariable logistic regression models were created to discriminate between cohorts.
Results:
A total of 74 patients were included: 33 high acuity and 41 low acuity. There were significant differences in demographics, symptoms, and physical examination, laboratory, electrocardiogram, and echocardiography findings between high- and low-acuity cohorts. Multivariable logistic regression models were highly discriminate in predicting those in the high-acuity cohort. The first model included presence of tachycardia, tachypnea, creatinine, and cardiomegaly on chest radiograph (area under the curve = 0.913). The second model added the presence of pericardial effusion to the above variables (area under the curve = 0.964).
Conclusions:
Models based on factors available at initial presentation with acute myocarditis are predictive of subsequent hemodynamic compromise. If our results can be validated in a multicenter study, these models may help disposition patients with suspected acute myocarditis (with those who meet model criteria being admitted to centers capable of rapidly providing extracorporeal membrane oxygenation, ventricular assist devices, and heart transplant evaluation).
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