LAUSR

AIMS Outcome predictors in myocarditis are not well defined; we aimed at identifying predictors of death, heart transplantation (HTx) and relapse before the introduction of immunosuppression. METHODS AND RESULTS From 1992 to 2012 we consecutively included 466 patients (68% male, 37±17 years, single centre recruitment, median follow-up 50 months), 216 with clinically suspected and 250 with biopsy (Bx)-proven myocarditis. Serum anti heart (AHA) and antiintercalated disk (AIDA) auto-antibodies were measured by indirect immunofluorescence. We performed univariable and multivariable analysis of clinical and diagnostic features at diagnosis. Survival free from death or HTx at 10 years was 83% in the whole group and was lower in Bx- proven vs. clinically suspected myocarditis (76% vs 94% respectively, p<0.001). Female gender (hazard ratio (HR) 2.7, 95% Confidence Intervals (CI) 1.1-6.5), fulminant presentation (HR 13.77, CI 9.7-261.73), high-titre organ-specific AHA (HR 4.2, CI 1.2-14.7) and anti-nuclear antibodies (ANA) (HR 5.2, CI 2.1-12.8) were independent predictors of death or HTx; higher echocardiographic left ventricular ejection fraction (LVEF) at diagnosis was protective, with a 0.93 times risk reduction for each 1% LVEF increase (CI 0.89-0.96). History of myocarditis at diagnosis (HR 8.5, CI 3.5-20.7) was independent predictor of myocarditis relapse at follow-up; older age was protective (HR 0.95, CI 0.91-0.99). Predictors of death, HTx and relapse did not differ in Bx-proven vs. clinically suspected myocarditis. CONCLUSIONS Young age and a previous myocarditis were independent relapse predictors; female gender, fulminant onset, lower LVEF at presentation and high-titre organ-specific AHA and ANA were independent predictors of death and HTx, suggesting that autoimmune features predict worse prognosis.