Intravenous immunoglobulin for presumed viral myocarditis in children and adults

Robinson J, Hartling L, Vandermeer B, Klassen TP

Published Online:

January 20, 2010

Acute myocarditis involves inflammatory cell infiltration of the myocardium, and is thought to most commonly begin as a viral infection. The disease affects all ages. Based on multiple case reports and case series, IVIG has become part of routine practice for treating patients with acute myocarditis in many centers. Only one randomized controlled trial (RCT) was identified: this trial evaluated 62 adults with acute myocarditis and found no treatment benefit among patients receiving IVIG.

Abstract (click to read)

Background:

Case reports and case series have described dramatic responses to intravenous immunoglobulin (IVIG) in people with presumed viral myocarditis and its administration has become commonplace.

Objectives:

To assess the effects IVIG in people with presumed myocarditis.

Search strategy:

We searched CENTRAL (2009, Issue 3), MEDLINE (1966-September 2009), EMBASE (1988-September 2009), CINAHL (1982-September 2009), Web of Science (1975-September 2009), LILACS (1982-September 2009), trials registries and conference proceedings. We contacted authors of trials and checked reference lists of relevant papers. No language restrictions were applied.

Selection criteria:

Studies were included if: (1) patients had a clinical diagnosis of acute myocarditis with either a left ventricular ejection fraction (LVEF) <= 0.45, LVEDD of >2 SDs above the norm, or a shortening fraction (SF) >2 SDs below the mean and the duration of cardiac symptoms was less than 6 months; (2) patients had no evidence of non-infectious or bacterial cardiac disease; and, (3) patients were randomized to receive at least 1 gm/kg of IVIG versus no IVIG or placebo. Studies were excluded if: (1) patients had received immunosuppression prior to outcome assessment; or, (2) onset of myocarditis was less than 6 months postpartum.

Data collection and analysis:

Searches were screened and data extracted independently by two reviewers. Quality was assessed by two reviewers using the Jadad scale and allocation concealment. Meta-analysis was not possible because only one relevant study was found.

Main results:

The relevant study involved 62 adults with acute myocarditis randomized to receive IVIG or an equivalent volume of 0.1% albumin in a blinded fashion. The incidence of death or requirement for cardiac transplant or placement of a left ventricular assist device was low in both groups (OR for event-free survival was 0.52 ,95% CI 0.12 to 2.30). Follow-up at 6 and 12 months showed equivalent improvement in LVEF (mean difference 0.00, 95% CI -0.07 to 0.07 at 6 months, mean difference 0.01, 95% CI -0.06 to 0.08 at 12 months). Functional capacity as assessed by peak oxygen consumption was equivalent in the two groups at 12 months (mean difference -0.80, 95% CI -4.57 to 2.97). Infusion-related side effects were more common in the treated group, but all appeared to be mild (OR 30.16, 95% CI 1.69 to 539.42).

Authors' conclusions:

Evidence from one trial does not support the use of IVIG for the management of adults with presumed viral myocarditis. There are no randomized paediatric trials. Further studies of the pathophysiology of this entity would lead to improved diagnostic criteria which would facilitate future research.

This record should be cited as:

Robinson J, Hartling L, Vandermeer B, Klassen TP. Intravenous immunoglobulin for presumed viral myocarditis in children and adults. Cochrane Database of Systematic Reviews 2005, Issue 1. Art. No.: CD004370. DOI: 10.1002/14651858.CD004370.pub2

Assessed as up to date:

September 28, 2009

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Primary Review Group:

Heart Group

Health topics:

Infectious disease > Heart diseases > Myocarditis

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Intravenous immunoglobulin for presumed viral myocarditis in children and adults

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