Myocarditis and Immunosuppression in Inflammatory Bowel Disease

Myocarditis secondary to inflammatory bowel disease (IBD) is generally benign, mostly affects young men, and may resolve spontaneously; however, a relevant number of patients experience a chronic, subacute disease course and could benefit from immunosuppression therapy. These findings were published in the International Journal of Cardiology.

Investigators sought to determine the clinical characteristics of patients with both myocarditis and IBD. They conducted a retrospective analysis of 21 consecutive patients followed-up at the outpatient Cardioimmunology and Gastroenterology Clinic of Padua University Hospital, Padua, Italy. Patients with suspected myocarditis or myocarditis diagnosed via endomyocardial biopsy (EMB) that succeeded, preceded, or was concomitant with IBD diagnosis were included.

The investigators also conducted a systematic literature review on case reports of myocarditis in patients with IBD (n=83) using OvidSP and PubMed databases. A qualitative analysis of the overall study population was performed. Reports with a diagnosis of EMB-proven or clinically suspected myocarditis (according to the 2013 ESC Working Group of Myocardial and Pericardial diseases), a diagnosis of IBD (according to the 2018 European Crohn’s and Colitis Organization Criteria), and with at least echocardiographic and/or demographical or cardiovascular magnetic resonance imaging data at the moment of myocarditis diagnosis were included.

In combined data, the investigators found that young men (median age, 31 years; 72% men) were primarily affected by myocarditis in IBD. Patients predominantly presented with infarct-like myocarditis (58%) during an acute phase of IBD (67%) and followed a benign clinical course (87%).

In the single-center patient cohort (76% men; 95% White; median age at diagnosis, 33 years), 29% of patients had family history of immune-mediated disease and 29% of patients had immune-mediated disease. There were 38% of patients with ulcerative colitis and 38% with Crohn’s disease. At the time of myocarditis onset, 60% had IBD activity, 57% had infarct-like myocarditis presentation, 29% had a subacute or chronic course, and 14% died or received a transplant.

In the literature review population (71% men; median age, 39 years) there were 64% with ulcerative colitis and 35% with Crohn’s disease. At myocarditis diagnosis, there were 74% with IBD activity, 58% with infarct-like myocarditis presentation, 8% with subacute course, and 92% with clinical resolution. There were 8% who died or received a transplant.

Study limitations include potential selection bias in the review of literature, and the majority of patients had a clinically suspected myocarditis diagnosis.

Among patients with concomitant IBD and myocarditis, the investigators concluded that myocarditis in IBD usually follows a benign clinical course. “In the majority of cases it [myocarditis] affects young males, presenting with infarct-like chest pain at the time of an IBD flare,” the study authors wrote. “…patients may have a subacute, chronic, or even fatal course, needing advanced cardiological life support measures and prompt execution of EMB to reach a diagnosis of certainty of myocarditis as well as differentiation of infectious and immune-mediated forms.”